Management Of Neck Pain
Tai Q. Nguyen, M.D.
Tai Q. Nguyen, M.D. is Associate Professor of Neurosurgery at the
University of Florida Health Science Center / Jacksonville.
Introduction
Neck pain is a ubiquitous and recurring symptom that is usually of short duration and
does not require medical attention. When neck pain is persistent enough to prompt a visit
to the doctor, it deserves a systematic physical examination to determine the presence of
structural damage and/or neural involvement.
History And Physical Examination
A history of trauma is important to determine at the initial visit, including its
relation to the onset of neck pain, for diagnostic as well as for medico-legal purposes.
The exact location of the pain, whether it is associated with shoulder and/or arm pain and
paresthesia, and whether there is limitation of the range of motion of the neck or the
shoulders are factors that will help in the differential diagnosis. When the pain involves
both neck and shoulder, it is important to determine whether the pain comes primarily from
the neck, the shoulder or both. Severe pain with muscle spasm may limit the range of
motion of the neck or the shoulders, but this limitation can be overcome, with
encouragement, by the patient. Real limitation of the range of motion of the neck or the
shoulders indicates the presence of structural damages within the corresponding joints. A
neurological examination will determine the presence or absence of myelopathy and nerve
root dysfunction. Signs that suggest the presence of a radiculopathy: a focal muscle
weakness or decreased sensation in the distribution of a cervical nerve root; a
paresthesia affecting one or two digits of one hand; a decrease or absence of a deep
tendon reflex. Myelopathy is denoted by hyperreflexia, the presence of clonus or a
Babinski sign, spasticity of the lower extremities, sensory loss and disturbance in
bladder function. The emotional condition of the patient should also be assessed as part
of the initial examination to determine psychological factors that might contribute to the
experience of pain.1
Differential Diagnosis
Neck pain may arise from affections of the cervical musculature or the cervical
vertebral column and its surrounding neurovascular structures or from diseases of other
organs with pain irradiation to the neck. A number of diseases presenting with neck pain
require immediate intervention: myocardial infarction and aortic dissection where the pain
is more typically located in the anterior neck, throat or tongue and the range of motion
of the neck is not compromised; meningeal irritation from infection or subarachnoid
hemorrhage, causing neck stiffness; severe arterial hypertension, where the pain is
usually suboccipital.2
Degenerative changes in cervical spines are visible radiographically in 40% of the
adult population and its frequency can reach 90% by the age of 603.
Degenerative changes are most frequently observed in the C5-6 and C6-7 discs. The disc
narrows as nuclear material desiccates, and osteophytes develop at the outer margins of
the bony end-plate. These bony spurs can encroach on the cervical spinal canal and the
neural foramen, causing compression of the spinal cord and the nerve roots, and more
rarely the vertebral arteries. Degeneration of the facet joints often accompanies disc
degeneration. The joint of Luschka are similarly involved.
Fracture of vertebrae, disruption of ligaments, dislocation of joints and ruptures of
intervertebral discs may be seen after falls or traffic accidents. These injuries may or
may not cause neural injuries, and may not even cause enough pain at the initial visit to
the emergency room so that they may be missed by a cursory examination. When the nature of
the accident is such that a severe injury to the cervical spine is suspected, a careful
radiographic investigation must be conducted, with review by an experienced radiologist of
the complete series of plain radiographs of the spine, supplemented if necessary by CT
scan of the suspected region. Tumoral and infectious processes may have an insidious or an
acute onset. Although rare, the possibility of tumor must be considered in the
differential diagnosis of persistent neck pain, with or without neurological symptoms.
Diagnostic Studies
Imaging studies
Plain radiography of the cervical spine is indicated when there is suspicion of
traumatic injuries (fracture, dislocation), or a tumoral or infectious process. Dynamic
studies (lateral views with flexion and extension of the cervical spine) may be performed
in patients without neurological deficits to demonstrate spinal instability when a spinal
injury is suspected and routine cervical-spine series is negative. CT scan of the spine
will show linear fractures of the vertebrae where plain radiographs may not be able to
detect. It also allows the assessment of the spinal canal (spinal canal stenosis) and the
neural foramen (neural foramen narrowing). For the diagnosis of intervertebral disc
rupture and herniation, or intraspinal soft tissue processes (such as epidural and
intradural abscesses and hematomas, intraspinal tumors), MRI scanning is an excellent tool
because it gives a better definition of soft tissues. Myelogram and CT scan with
intrathecal contract are still useful in the surgical planning because they allow the best
visualization of the relationship between the bony structures and the neural tissues. When
all other imaging studies fail to produce an anatomical explanation for the patient's
symptoms, provocative discography has been advocated to produce the precipitation or
exacerbation of the very symptoms that cause the patient to seek medical attention.
Discography has also been shown to demonstrate disc annular tears when MRI scanning was
negative.4 Even in experienced hands, the incidence of complication is still
significant,5 and with the questionable value of its efficacy in identifying
the site of the cervical symptomatology,6 discography is not a routine
diagnostic procedure.
Nerve blocks
Nerve blocks for the diagnosis of cervical joint pain have been used with some success,7
and should be done carefully in a double-blind manner.
Electrodiagnostic studies
Electromyography and nerve conduction velocity tests are helpful in confirming cervical
radiculopathies when the presence of a peripheral neuropathy compounds the symptoms. The
absence of abnormal electrodiagnostic findings does not however rule out a radiculopathy.
Etiologies
Identifiable etiologies of neck pain include: Chronic inflammatory processes, such as
rheumatoid arthritis; tumors of the spine (primary or metastatic), or tumors of the neural
structures (spinal cord tumors: astrocytomas or ependymomas) or of their coverings
(meningiomas, also metastatic tumors); infectious processes such as osteomyelitis,
epidural or subdural abscesses; intervertebral disc herniation or prominent spondylotic
spurs causing spinal cord and/or nerve root compression.
Unless the symptoms are typical of a radiculopathy or radiographic investigations
reveal an acute traumatic, tumoral or infectious process, it is often times difficult to
ascribe neck pain to a particular anatomical abnormality. Ligamental tenderness and muscle
spasm may be the result of direct injuries but may also be secondary to referred pain.
Degenerative changes in the cervical spine are so prevalent that the presence of such
abnormalities cannot be taken as prima facie evidence of their causality. In a study of
individuals between 20 and 65 years of age, disc degeneration was associated with neck
pain in men but not in women. Osteoarthritis was not related to neck pain, either in the
men or in the women. The presence of degenerative changes on the cervical spine
radiographs therefore does not indicate the etiology of the neck pain. Neuroticism was
found to be a more powerful determinant of neck pain than radiological signs of disc
degeneration or osteoarthritis in the general population.8 Recurrent neck pain
with intermittent symptoms of cervical nerve root irritation however has been attributed
to recurrent inflammation of the facet joints or the uncovertebral joints, causing
transient irritation of the nerve roots.
Management Of Neck Pain
The management of neck pain without an obvious identifiable cause is therefore best
treated conservatively. Narcotic analgesics may be used but only for a short period of
time. Nonsteroidal anti-inflammatory agents often offer significant relief.
The effectiveness of physical therapy in reducing neck pain has been and still is a
subject of debate. At best, physical therapy provides a degree of short-term pain relief,
and encourages the patient to resume the normal motion of the neck. In acute neck pain
after road traffic accidents, a home exercise program has been shown to be as effective in
reducing pain and improve cervical movements as outpatient physiotherapy.9
Moist heat and gentle massage done at home with help from a family member, may be
palliative and therefore advised. Cervical traction has been used as a form of physical
therapy for neck pain. It may reduce pain during its application and for a short period
thereafter. Its efficacy in affecting the likelihood and the rate of improvement is still
under question. Soft collars often provided some comfort to the patient with neck pain and
are therefore often prescribed, although their benefit has not been statistically proven.10
Manipulation of the spine may give short-term benefits for some patients with neck pain.
Although the rate of complications of cervical manipulation has been shown to be small,
11 the potential of permanent impairment or death makes its risks outweigh its
possible benefits. Acupuncture as an alternative modality of treatment of neck pain has
not yet been studied on a large scale to assess its effectiveness in shortening the period
of recovery or the rate of permanent pain relief.
Neck pain is a frequent complaint after motor vehicle accidents, especially after
rear-end collisions. The pain may not be experienced immediately, but sometime later when
neck motion precipitates muscle spasm. Sixty-two percents of patients attending hospital
following road traffic accidents state that they have suffered pain in the neck at some
time following their accident, compared with 31% who were noted to have neck pain when
examined soon after the accident.12 The majority of neck pain after traffic
accidents subsides however, and in one study of over 200 individuals where medico-legal
implications are not relevant, the prevalence of chronic symptoms are not higher than in
the general population. Expectation of disability, a family history and attribution of
pre-existing symptoms to the trauma are important determinants for the chronicity of the
neck pain.13 The outcome of acute neck pain after traffic accidents is better
for patients who are encouraged to continue to engage in their normal activities as usual
than for patients who are given sick leave and immobilized in a soft collar during the
first 14 days after the accident.14
Surgical Treatment
Neck pain will benefit from surgical treatments when it is due either to neural
compression and/or spinal instability. Radicular pain will be relieved by decompression of
the nerve root(s) involved. Instability is corrected by reduction and fusion of the
involved vertebrae. Decompression of the nerve root may be accomplished via a posterior
laminotomy and foraminotomy, or an anterior discectomy with or without fusion of the
vertebral bodies. Oftentimes, a fusion is necessary to re-establish the spinal stability
or to prevent a future deformity due to the weakening of the supportive structure after
the decompression. Controversy still surrounds the indications for operating on
degenerated discs without demonstrated neural compression. A recent study showed that
surgical fusion of cervical discs may bring relief of neck pain to a certain number of
selected cases. Only in cases in which radiographic changes correlate with the results of
diagnostic nerve blocks should surgical fusion be considered as a last therapeutic means
to resolve the painful condition.
A Case Presentation
The patient was a 35-year old woman who presented with complaints of posterior neck
pain, right shoulder and arm pain, and occasional paresthesia in the right arm and in the
first two digits of the right hand. The patient dated the onset of her symptoms to a motor
vehicle accident occurring one year before, when her car, which was stationary, was hit
head-on by another car. There was however no pending litigation. The pain had gotten more
intense and more frequent over the previous few months, with an intensity of 7 over 10 on
a 0 to 10 scale. It affected the patient's sleep and required acetaminophen with codeine
for pain control. Past medical history was remarkable for hypothyroidism. Review of
systems was otherwise negative. The patient smoked a pack of cigarettes a day for the
previous 20 years and consumed alcohol moderately. The patient had undergone physical
therapy three times a week for 6 weeks with transient pain relief. She had continued to
work as a computer operator. She was single and had 3 children. Physical examination was
remarkable for an increase in pain in the posterior aspect of the neck going down the
spine on neck flexion. Shoulder movements were not limited and did not elicit any
discomfort. Motor examination revealed a weakness of the right elbow flexion of 4 over 5
on a 0 to 5 scale. Sensory examination showed a decreased sensation to touch and pinprick
over the C6 dermatome distribution. Deep tendon reflexes were symmetrical. There were no
pathological reflexes. The rest of the neurological examination was negative. Plain
radiographs of the cervical spine showed degenerative disc disease at the C5-6 level with
a 2-mm retrolisthesis of C5 vertebra on C6 (Figure 1). MRI scan subsequently revealed an
intervertebral disc herniation at C5-6 on the right side, compressing the right C6 nerve
root (Figure 2). Because the patient had persistent and severe pain, a surgical
decompression by anterior discectomy and interbody fusion with allograft was recommended
to relieve the pressure off the C6 nerve root and to prevent compression of the spinal
cord. The patient was asked to stop smoking.15 She underwent the operation
without complications. Post-operative radiographs of the cervical spine showed good fusion
at the graft site (Figure 3). The neck and arm pain subsided completely. Muscle strength
returned to normal. The patient resumed her occupation without any problem.
Conclusion
Neck pain without evidence of acute structural damage and without neural compression is
best treated with reassurance, non-narcotic analgesics and nonsteroidal anti-inflammatory
medication. The patients (including those with post-traumatic neck pain) should be also
encouraged to maintain or resume normal neck motion with a home program of exercises and
physical therapy. A soft cervical collar should be used only for a short period of time to
allow the patient to initiate the above recommended measures. When acute structural
damages to the spine or an infection are suspected, imaging studies are warranted.
Degenerative changes will be seen on most plain radiographs of patients of over 30 years
of age and are of limited value in the differential diagnosis. In patients with acute
structural damage caused by trauma or an infectious / inflammatory or tumoral process, and
those with compressive myelopathy and/or radiculopathy confirmed by diagnostic studies,
surgical intervention is warranted. Therefore, the initial investigation should be aimed
at distinguishing these two groups. Early assessment of the emotional make-up of the
patient will help to avoid unnecessary diagnostic and surgical procedures.
References
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- Hadler NM. Medical management of the regional musculoskeletal diseases. Grune
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- Lawrence JS. Disc degeneration: Its frequency and relationship to symptoms. Ann
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- Zeidman SM, Thompson K, Ducker TB. Complications of cervical discography:
analysis of 4400 diagnostic disc injections. Neurosurgery. 1995;37:414-7.
- Shinomiya K, Nakao K, Shindoh S, et al. Evaluation of cervical diskography in
pain origin and provocation. J Spinal Disord. 1993; 6:422-6.
- Barnsley L, Bogduk N. Medial branch blocks are specific for the diagnosis of
cervical zygapophyseal joint pain. Reg Anesth. 1993; 18:343-50.
- van der Donk J, Schouten JS, Passchier J, et al. The associations of neck pain
with radiological abnormalities of the cervical spine and personality traits in a general
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- McKinney LA, Doman JO, Ryan M. The role of physiotherapy in the management of
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- British Association of Physical Medicine. Pain in the neck and arm: A
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- Hurtwiz EL, Aker PD, Adams AH, et al. Manipulation and mobilization of the
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- Dean GT, Maggalliard JN, Kerr M, et al. Neck sprain—a major cause of
disability following car accidents. Injury. 1987; 18:10-2.
- Schrader H, Obelieniene D, Bovimm G, et al. Natural evolution of late whiplash
syndrome outside the medicolegal context. Lancet. 1996; 347:1207-11.
- Borchegrevink GE, Kaasa A, McDonald D, et al. Acute treatment of whiplash neck
sprain injuries. A randomized trial of treatment during the first 14 days after a car
accident. Spine. 1998; 23: 25-31.
- Hadley MN, Reddy SV. Smoking and the human vertebral column: a review of the
impact of cigarette use on vertebral bone metabolism and spinal fusion. Neurosurgery.
1997; 41:116-24.
Jacksonville Medicine / June, 1999
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