Posterior Neck Pain
Evaluation and Treatment of Posterior Neck Pain in Family Practice
From: J Am Board Fam Pract 2004;17:S13–22
The human neck is a complex structure that is highly susceptible to irritation. In fact, 10% of people will have neck pain in any given month. Potential pain generators include bones, muscles, ligaments, facet joints, and intervertebral discs. Almost any injury or disease process within the neck or adjacent structures will result in reflexive protective muscle spasm and loss of motion. Gradual collapse of the intervertebral discs and degeneration of the facet joints is a universal part of the aging process and, in some people, can lead to nerve or spinal cord impingement. Further, neck mobility is so important to normal human functioning that any disruption in its normal function is quickly noticed.
Neck pain is an extremely common but nonspecific symptom. In a population-specific study, Cote et al found that 66% of Saskatchewan adults experienced neck pain at some point in their lifetimes, 54% in the most recent 6 months. The prevalence of neck pain at any point in time is approximately 9%. Prevalence increases with age and is higher in women than in men. Neck pain accounts for almost 1% of all visits to primary care physicians in the United States.
Axial neck pain is the most common cause of neck pain and has a high rate of spontaneous resolution. In one study, after 3 months of nonoperative care, 70% had complete or partial relief. With time, most patients achieve relief. In another study, at the 10- to 25-year follow-up, 43% experienced complete resolution, 25% mild residual pain, and 32% moderate or severe residual pain.
In the United States, 1 million cases of whiplash associated disorder occur annually as a result of motor vehicle accidents. Prognostic data are variable, but in one large study, 60% of patient symptoms resolved within 1 month. The incidence of chronic symptoms after acute whiplash associated disorder varies widely among cultures and countries, and lively medical debate is ongoing about the diagnosis of chronic whiplash associated disorder.
There is sparse evidence for a causal link between the mechanism of whiplash associated disorder injury and chronic symptoms. Some authors feel that the symptoms of whiplash associated disorder are often reinforced by legal and social factors. It is interesting that in Lithuania, where there is little involvement of insurance companies or the legal system in motor vehicle injuries, no difference was found in persistent neck symptoms between rear-end-crash victims and uninjured controls. Nonetheless, in 11 high-quality studies, 19% to 60% (mean, 33%) of patients with whiplash associated disorder reported chronic symptoms. Overall, 7% of people who are asymptomatic 3 months after an accident will have symptoms after 2 years. On the other hand, 85% of people who are symptomatic 3 months after an accident will remain so after 2 years.
A large, population-based study in Rochester, Minnesota, noted the annual incidence of cervical radicular symptoms to be 83.2 per 100,000 population, peaking in the 50- to 54-year age-group. Many patients will have resolution of symptoms without surgery. In the Rochester study at a mean follow-up of 5.9 years, 90% of patients were asymptomatic or only mildly incapacitated. Referral center-based studies have shown somewhat less positive outcomes.
The overall prevalence of cervical myelopathy is unknown, but it is relatively rare and the natural history of the disorder in any one person is unpredictable. However, a number of studies have documented progressive deterioration without surgery. In one recent study of patients who underwent laminectomy and posterior fusion, 80% had good outcomes, 76% had improvement in myelopathy scores, and no late neurological deterioration in any group was documented at mean follow-up of 4 years.
Axial neck pain and whiplash associated disorder typically present as pain or soreness in the posterior paramedian neck muscles, with radiation to the occiput, shoulder, or parascapular region. Stiffness in one or more directions of motion and headache are common. Axial neck pain and whiplash associated disorder can be associated with local warmth or tingling. Localized areas of muscle tenderness (trigger points) may develop.
Radicular pain is sharp, tingling, or burning in a specific dermatomal distribution in the upper extremity. In clinical practice it is often confused with radiating pain. However, because there are specific treatments indicated only for radicular pain, an accurate distinction must be made. True radicular pain follows dermatomal patterns which can be somewhat variable among patients and is
usually, but not always, unilateral. Onset is often insidious but may be abrupt. It is frequently aggravated by arm position and extension or lateral rotation of the head. In one study of 736 patients, 99% had arm pain, 85% had sensory deficits, 79% had neck pain, 71% had reflex deficits, 68% had motor deficits, and 52% had scapular pain.
Cervical myelopathy has a subtle and varied presentation necessitating a high degree of clinical suspicion. Patients may present with subtle findings that have been present for years, or with acute paresis. They typically complain of insidious clumsiness,
weakness, or stiffness in the upper and lower extremities. Deep, aching pain in the neck, shoulder, or arm and neck stiffness are common but occur in less than half of patients. Associated radicular symptoms occur in one third of patients. Arm or leg dysfunction and gait and balance difficulties are common. Nonspecific urinary complaints, such as urgency or hesitancy, can occur, but frank urinary or fecal incontinence is unusual.
Neck pain is an almost universal human condition and is among the most common complaints presented to family physicians. Although the differential diagnosis of neck pain is extensive, most symptoms are produced by biomechanical sources, such as axial neck pain, whiplash associated disorder, and cervical radiculopathy. Most symptoms will abate in a timely fashion with little intervention.
There is relatively little high-quality evidence available that is specific to the treatment of neck pain, and there is a dearth of long-term outcomes data. This article presents a consensus on the management of axial neck pain and cervical radiculopathy.
Straightforward guidelines are available on the management of whiplash associated disorder, and a number of general pain management guidelines that are applicable to neck pain are also available.
Patient history and physical examination are important in distinguishing potential etiologies and immediately identifying red flags for more serious conditions. Distinguishing between radicular and nonradicular neck pain is particularly important. Diagnostic imaging should be ordered only when truly necessary because of the high incidence of cervical radiographic abnormalities in asymptomatic persons.
Recommended first-line drug treatment should be with acetaminophen, COX-2–specific inhibitors, or NSAIDs. Short-term muscle relaxants may be considered, but their sedative properties and addictive potential must be taken into account. Opioids should be used if other treatments have been insufficiently effective and continued if there is evidence of improved function that outweighs any impairment caused by adverse effects. Adjuvant antidepressants and anticonvulsants should be considered, especially in chronic or neuropathic pain and when coincident depression is suspected. Epidural steroid injections should be considered only in cervical radiculopathy. Physical modalities supported by evidence of benefit should be used, including early return to usual activities, neck exercises, electromagnetic therapy, manipulation, and mobilization. If symptoms have not resolved within 4- to 6-weeks, re-evaluation and additional diagnostic workup should be considered. The study noted little evidence for neck traction, although positive neck traction studies are numerous and has been proven effective in many cases of radiculopathy.
