Neck Solutions

From: BMJ 10 march 2007; Volume 334; 527-531

Most patients who present with neck pain have non specific (simple) neck pain, with a postural or mechanical basis. Causative factors are poorly understood and are usually multifactorial, including poor posture, anxiety, depression, neck strain, and sporting or occupational activities. Neck pain after whiplash injury also fits into this category, provided no bony injury or neurological deficit is present. When mechanical factors are prominent, the condition is often referred to as “cervical spondylosis,” although the term is often applied to all non-specific neck pain. Mechanical and degenerative factors are more likely to be present in chronic neck pain.

In cervical spondylosis, degenerative changes start in the intervertebral discs with osteophyte formation and involvement of adjacent soft tissue structures. Many people over 30 show similar abnormalities on plain radiographs of the cervical spine, however, so the boundary between normal ageing and disease is difficult to define. Even severe degenerative changes are often asymptomatic, but can lead to neck pain, stiffness, or neurological complications.

Plain radiographs of the cervical spine may show a loss of normal cervical lordosis, suggesting muscle spasm, but most other features of degenerative disease are found in asymptomatic people and correlate poorly with clinical symptoms. Magnetic resonance imaging of the cervical spine is the investigation of choice if more serious pathology is suspected, as it gives detailed information about the spinal cord, bones, discs, and soft tissue structures.

Summmmary points:

• The diagnosis of cervical spondylosis is usually based on clinical symptoms
• Patients need detailed neurological assessment of upper and lower limbs as cervical degeneration is often asymptomatic, but can lead to pain, myelopathy, or radiculopathy
• Red flag symptoms identify the small number of patients who need magnetic resonance imaging, blood tests, and other investigations
• The best treatments are exercise, manipulation, and mobilisation, or combinations thereof
• Radiculopathy has a good prognosis and may respond to conservative measures
• Results of neck surgery for myelopathy or intractable pain are often disappointing

Symptoms

• Cervical pain aggravated by movement
• Referred pain (occiput, between the shoulder blades, upper limbs)
• Retro-orbital or temporal pain (from C1 to C2)
• Cervical stiffness—reversible or irreversible
• Vague numbness, tingling, or weakness in upper limbs
• Dizziness or vertigo
• Poor balance
• Rarely, syncope, triggers migraine, “pseudo-angina”

Signs

• Poorly localised tenderness
• Limited range of movement (forward flexion, backward extension, lateral flexion, and rotation to both sides)
• Minor neurological changes like inverted supinator jerks (unless complicated by myelopathy or radiculopathy)

Differential diagnosis of cervical spondylosis

• Other non-specific neck pain lesions—acute neck strain, postural neck ache, or whiplash
• Fibromyalgia and psychogenic neck pain
• Mechanical lesions—disc prolapse or diffuse idiopathic skeletal hyperostosis
• Inflammatory disease—rheumatoid arthritis, ankylosing spondylitis, or polymyalgia rheumatica
• Metabolic diseases—Paget’s disease, osteoporosis, gout, or pseudo-gout
• Infections—osteomyelitis or tuberculosis
• Malignancy—primary tumours, secondary deposits, or myeloma

Red flag features and the conditions they may suggest:

Malignancy, infection, or inflammation
• Fever, night sweats
• Unexpected weight loss
• History of inflammatory arthritis, malignancy, infection, tuberculosis, HIV infection, drug dependency, or immunosuppression
• Excruciating pain
• Intractable night pain
• Cervical lymphadenopathy
• Exquisite tenderness over a vertebral body

Myelopathy

• Gait disturbance or clumsy hands, or both
• Objective neurological deficit—upper motor neurone signs in the legs and lower motor neurone signs in the arms
• Sudden onset in a young patient suggests disc prolapse

Other

• History of severe osteoporosis
• History of neck surgery
• Drop attacks, especially when moving the neck, suggest vascular disease
• Intractable or increasing pain