Canadian Medical Association Journal 2001;164(8):1182-7
Neck pain is a common problem in ambulatory medical practice. Slightly more than 50% of adults experience neck pain at some time. In daily practice, it is useful and practical to deal with every patient with neck pain using an organized approach. I have found that thinking through the following series of points is helpful in organizing the management of patients with neck pain. In most cases of neck pain, no clear-cut underlying definable pathology can be identified. These patients should be managed conservatively, with the aim of preventing disability and controlling symptoms. In a minority of cases, pain can be the result of varied pathology. It is important to identify the pathology early so that these patients can be managed properly without undue consequence.
Cervical problems can be divided into 2 main groups: those arising mainly from the joints and associated ligaments and muscles of the neck and those involving the cervical nerve roots or the spinal cord.
The pathologic causes of these problems are
- injury or degeneration affecting muscles or ligaments, soft-tissue strain (the term cervical spondylosis is commonly used for these conditions)
- inflammation, for example, rheumatoid arthritis, ankylosing spondylitis
- infection, for example, discitis, epidural abscess, meningitis
- infiltration, for example, metastatic carcinoma, osteoid osteoma, spinal cord tumours
Group 1: Cervical problems arising mainly from neck joints and associated ligaments and muscles:
- Patients complain of pain and stiffness
- Pain is a deep, dull aching sensation and often episodic
- Patients have a history of excessive or unaccustomed activity or of sustaining an awkward posture
- There is no history of specific injury
- Ligament and muscle pain are localized and asymmetric
- Pain from upper cervical segments is referred toward the head; pain from lower segments, to the upper limb girdle
- Symptoms are aggravated by neck movement and relieved by rest
Group 2: Cervical problems involving the cervical nerve roots or the spinal cord
- Patients complain of significant root pain
- Pain is sharp and intense and is often described as a burning sensation
- Pain may radiate to the trapezial and periscapular areas or down the arm
- Patients complain of numbness and motor weakness in a myotomal distribution
- Headache may occur if the upper cervical roots are involved
- Symptoms often become more severe with neck hyperextension
Group 1: Problems arising mainly from the neck joints and associated ligaments and muscles
Most patients in this group complain of pain and stiffness. They usually have a history of excessive or unaccustomed activity or of sustaining an awkward posture (e.g., as in painting a ceiling). In general, there is no history of a specific injury. Ligament and muscle pain tend to be localized and asymmetric. Pain that arises from joints or discs is usually described as a deep, dull aching sensation. Pain from the upper cervical segments is referred toward the head, and pain from the lower segments is referred to the
upper limb girdle.
Symptoms are usually aggravated by neck movement and relieved by rest. The pain is often episodic, which is a reassuring feature, because sinister pathologic processes often produce symptoms that are relentless and progressive.
The C2–3 facet joints may be the source of occipital headache. It is usually dull and may be a referred pain through the occipital nerve. The prevalence of this phenomenon is unclear. The pathology is likely to be a degenerative process.
Group 2: Problems involving the cervical nerve roots or the spinal cord
Patients with nerve root involvement complain of significant root pain, which is usually sharp, intense and often described as a burning sensation. It can radiate out to the trapezial and periscapular areas or down the arm in a dermatomal distribution. Many patients also complain of numbness and motor weakness in a myotomal distribution. Headache may occur if the upper cervical roots are involved. The symptoms often correlate with specific head positions; they become more severe with neck hyperextension, particularly when the head is tilted toward the affected extremity.
Myelopathy is an uncommon complication of cervical spondylosis that is usually not recognized until late in the course of disease. Patients with spinal cord compression may suffer many years of neck, shoulder and arm pain before their condition is diagnosed correctly. It is often accompanied by the gradual onset of shock-like sensation spreading down the spine and possibly into all 4 extremities. There may be lower motor neuron weakness at the level of the lesion. Myelopathy commonly occurs at the level of the fifth cervical vertebra and affects shoulder abduction (deltoid muscle) and external rotation (infraspinous muscle). It may also be associated with Hoffmann’s sign (finger jerk), difficulty in walking and clumsiness of hand movement.
Key points
- Slightly more than 50% of adults experience neck pain at some time
- In cases of neck pain, a physician must first determine whether it arises from the joints, ligaments and muscles of the neck (group 1) or from the cervical nerve roots and the spinal cord (group 2)
- The second step is to identify the underlying pathology, which may include injury or degeneration, inflammation, infection or infiltration. This step is important, even though in the majority of cases no definable underlying pathology can be identified
- Physical examination should include a general assessment, because neck pain may be part of a systemic medical problem
- Further examination should include assessment of the position of the head and neck, checking for tenderness, and investigation of active and passive neck movement
- When the problem is neurologic, the physician should determine the level of the spine from which it originates
- A history of injury, recent weight loss and prolonged or extensive morning stiffness will alert the clinician to the possibility of injury, infection or inflammation
- Rheumatoid arthritis, temporal arteritis, carpal tunnel syndrome and whiplash-associated disorders must be considered in the differential diagnosis
- When patients have neck pain that lasts for more than a few weeks, nerve root or spinal cord involvement, or a history of injury, the physician should order radiographs to check for instability or pathologic changes in the cervical spine
- Although degeneration in the spine is common in individuals over 50 years of age, such changes become symptomatic only when additional factors such as soft-tissue sprain or nerve root irritation occur
- About two-thirds of group 1 patients with neck pain will have a favourable long-term outcome; group 2 patients often do not achieve complete pain relief
- Acute or chronic neck pain is commonly treated with physical or manual therapies, including ultrasonography, ice or hot packs, electrical stimulation, avoidance of activities that produce pain, traction and passive mobilization
- The physician should continue to see patients who are receiving physiotherapy to reassure them about their progress, ensure that they are remaining active and watch for neurologic signs and systemic illness
