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Neck pain

Cervicalgia or Neck pain is very common

Most mobile part of spine , supports the weight of head Complex structure- bone disc , joint , muscle and ligament interact to provide stability and motion 7 cervical vertebrae
○ C1 and C2 atlas and axis ( no IV disc between them )
○ C3-7 connected superiorly and inferiorly to IV discs and articulate with adjacent vertebrae through 
 Uncovertebral jts ( joints of Lushka )
 Zygopophyseal joints ( Z joints or facet joints) Facet joints are diarthroses ie have synovium and hence can get involved in systemic inflammatory processes
Often sites of OA changes , osteophyte formation

Affects 15.1 % of the US general population every 3 months and ranks
fourth in global disability ( after back pain , depression and other MSK disorders High prevalence in developed countries Women affected more than men- the highest prevalence in middle age Can be recurrent and vary in disability Significant socioeconomic impact Few clinical trials dedicated solely to neck pain ie not well studied Most patients have ” non-specific ” ( simple ) neck pain where symptoms have a postural or mechanical basis

Significant trauma or skeletal injury Symptom suggestive of compression of the spinal cord ( myelopathy ) Symptoms that suggest cancer, infection or inflammation New symptoms before age of 20 or after 55 Intractable or increasing pain H/O osteoporosis H/O rheumatoid arthritis ( atlantoaxial disruption ) Neurological findings ( radiculopathy ) Dizziness drop attacks, blackouts H/O cancer Ripping tearing neck sensation

Cervical spondylosis-Degenerative changes start in the IV discs with osteophyte formation and involvement of adjacent tissue structures Changes in XR common in people over 30- changes weakly correlated with pain Most people do not need further investigations C spine XR may show ” loss of normal cervical lordosis ” suggesting muscle spasm Interpret scans with care as normal people may show imp pathological abnormalities on scanning ( MRI ) Complications of cervical spondylosis include myelopathy or radiculopathy Treatment is conservative Optimal treatment in uncomplicated neck pain – not established yet

Cervical radiculopathy-Constellation of symptoms caused by dysfunction of 1 or more cervical spinal nerve roots Usually due to compression or injury to a nerve root May manifest as pain, motor dysfunction, sensory deficits or alteration in tendon reflexes in the distribution of a specific nerve root Pain may approximate dermatomal distribution- usually unilateral but may be bilateral
Sig dermatomal overlap usual Levels C5-T1 most commonly affected XR has no value in the diagnosis of radiculopathy Most patients improve (the result of a study from CR due to herniated disc ) within 6 months ie prognosis is usually good to Refer for MRI if present + 4-6 weeks or more OR there are objective neurological signs

Cervical myopathy-Results from disease ( eg myelitis ) or injury ( eg trauma or syrinx ) affecting the spinal cord which causes UMN signs UMN signs in a distribution below the level of compression Trauma common cause in young and spondylosis in later life commonest cause is a combination of a congenitally narrow spinal canal and progressive cervical spondylosis Course highly variable – periods of dormancy and stepwise progression Although considered an indication for surgery -studies comparing surgical and non-surgical interventions have been mixed Suspect amyotrophic lateral sclerosis if fasciculations and bulbar signs present

Whiplash injury-Described as an acceleration-deceleration mechanism of energy transfer to the neck Often from rear or side impact RTA Attributed to facet jts in about 50 % people Pain often referred to the trapezius , shoulder , mid back and to a lesser extent face Up to 80 % start experiencing neck pain within 1 day and about 50 % continue to suffer a year after the initial injury Late whiplash syndrome – a variety of symptoms that persist for > 6 mts after an acute injury. May include
○ neck pain and stiffness
○ persistent headache
○ dizziness
○ upper limb paraesthesia
○ psychological and emotional symptoms

Lack of evidence – in treatment of non-specific neck pain Physiotherapy ( evidence generally favourable or neutral ) Exercise, Posture Encourage to be active and avoid neck immobilisation Try and exclude red and yellow flags Reassess psychological factors Non-opioid based analgesia first line Tricyclic antidepressants Consider topical NSAIDs Muscle relaxant in acute non-radicular pain Intra-articular injections sometimes used to treat cervical fact jt pain- but high technical failure rate and no evidence of benefit

References

  1. Cervical spondylosis and neck pain BMJ 2007 ; 334 :527-31
  2. The anatomy and pathophysiology of neck pain Nikolai Bogduk , MD , PhD Phys <ed Rehabi Clin N Am 14 ( 2003 ) 455-472
  3. Non-specific neck pain : diagnosis and treatment KCE reports-Belgian Healthcare Knowledge  Centre Tsakitzidis Giannoula, Remmen Roy, Peremans Lieve, Van Royen Paul, Duchesne’s Christiane, Paulus Dominique, Eyssen Marijke https://kce.fgov.be/en/non-specific-neck-pain-diagnosis-and-treatment
  4. Cervical Discogenic Pain Syndrome E-medicine July 2014
  5. Neck pain – Whiplash injury CKS NHS April 2015
  6. Neck pain Cervical radiculopathy CKS NHS April 2015
  7. Advances in the diagnosis and management of neck pain Steven P Cohen et al BMJ 2017; 358 :j 3221
  8. Poitras V, Khangura S, Ford C. Physiotherapy Interventions for the Management of Neck and/or Back Pain: A Review of Clinical and Cost-Effectiveness [Internet]. Ottawa (ON): Canadian Agency for Drugs and Technologies in Health; 2017 Jun 29. Available from: https://www.ncbi.nlm.nih.gov/books/NBK524926/( Abstract )
  9. An approach to neck pain for the family physician AFP Rheumatology Nov 2013 Volume 42 , No 11https://www.racgp.org.au/afp/2013/november/neck-pain/
  10. Identifying and Treating the Causes of Neck Pain Ginger Evans , MD Med Clin N Am 98 (2014) 645–661
    http://dx.doi.org/10.1016/j.mcna.2014.01.015
  11. Neck pain : management in primary care Krysia Dzeidzic et al Arthritis Research UK https://prs.csp.org.uk/system/files/krysia_dziedzic_arthritis_research_uk_presentation.pdf
  12. Reports on the Rheumatic Disease Series 6 Spring 2011 Hands-on No 8 Rheumatology in Practice J A Pereira et al Springer Verlag
  13. Hoy DG, Protani M, De R, Buchbinder R. The epidemiology of neck pain. Best Pract Res Clin Rheumatol. 2010;24(6):783-792. doi:10.1016/j.berh.2011.01.019 ( abstract ) https://pubmed.ncbi.nlm.nih.gov/21665126/
  14. Diagnostic Imaging Pathways – Neck Pain (Non-Traumatic) Govt of Western Australia via http://www.imagingpathways.health.wa.gov.au/
  15. Neck Pain in Changi General Hospital: An Observational StudyJayamoorthy Jacob Praveen, PG Dip (Manip Phy), PGDGC, Ting Jun Lim, BPhty, Aileen O’Brien, BPhtyDepartment of Rehabilitative Services, Changi General Hospital, Singapore https://journals.sagepub.com/doi/pdf/10.1177/201010581402300306
  16. Neck Pain: Diagnosis And Management Practical Pain Management Gerald A Malanga et al https://www.practicalpainmanagement.com/pain/spine/neck-pain-diagnosis-management

  17. Neck pain pathway http://www.rotherhamccg.nhs.uk/Downloads/Top%20Tips%20and%20Therapeutic%20Guidelines/Cervical%20spine%20pathway%202016.pdf
  18. Cohen SP. Epidemiology, diagnosis, and treatment of neck pain. Mayo Clin Proc. 2015;90(2):284-299. doi:10.1016/j.mayocp.2014.09.008 https://pubmed.ncbi.nlm.nih.gov/25659245/
  19. Conservative interventions provide short-term relief for non-specific neck pain: a systematic review Journal of Physiotherapy Volume 56, Issue 2, 2010, Pages 73-85

 

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