Neck Pain is a common problem but is not as disabling as back pain even though it occurs just as often as back pain. It can be divided into two types;
1. Inflammatory Neck Pain
2. Structural Neck Pain
Inflammatory Neck Pain:
1. becomes worse with rest and at night
2. often improves with activity, stretching, and exercise
3. is associated with stiffness in the morning and at night
4. can be associated with severe pain at night
5. occurs in patients with personal or family history of Colitis or Psoriasis
6. usually improves dramatically with NSAIDs such as Voltaren or Indocin and all of the pain comes back off of these medications.
7. can be associated with HLA-B27 in 25% of cases, mild to moderate elevation of ESR in 60% of cases.
8. low titer rheumatoid factor is seen in 10% of cases and positive low titer ANA is seen in 16% of cases
9. is related to an autoimmune disease
Structural Neck Pain:
1. occurs with degenerative arthritis
2. associated with herniated disc
3. can be due to spinal stenosis
4. can be caused by radiculopathy and myelopathy
5. is also caused by muscle spasm such as torticollis
6. can be a referred pain from the heart attack, shoulder impingement, lung cancer, esophagus, blood vessel dissection, infection and tumor
7. can be associated with systemic diseases such as infections, malignancy, infection such as herpes zoster
8. is associated with trauma and injury
9. can be as a result of myelopathy with difficulty with use of upper and lower extremities and loss of bowel and bladder function
10. is also caused by Diffuse Skeletal Hyperostosis
11. it can be from thoracic outlet syndrome
Evaluation:
1. X-rays. This is done when:
a. Pain appears to be structural
b. There is limited range of motion in cervical spine
c. There is history of trauma
d. Only lateral view is needed to initially screen for instability after trauma
2. MRI examination. This is helpful:
a. To rule out spinal cord injuries, infection, and malignancy
b. If the pain appears structural especially with symptoms and signs of radiculopathy or myelopathy
c. History of trauma
d. If there is question of of instability
e. If there is ongoing symptoms over 4-6 weeks or worsening of symptoms despite negative x-rays and CT Scan.
3. CT Scan should be done if:
a. There is concern about fracture as Helical CT is better than x-rays in terms of ruling out fractures after trauma
b. Soft tissue CT Scan of the neck can look for tumors or masses and can be done as a first step. MRI is obviously better for soft tissue but is not as practical as CT Scan.
c. There is significant tenderness and muscle spasm on examination
d. There is a need to look at bony structures and facet joints
4. EMG/NCS. This is to evaluate for nerve impingement when there is complaints of numbness and weakness in the upper extremities.
5. Blood Testing: ESR, Rheumatoid factor, anti-CCP, and HLA-B27 to look at inflammatory causes of neck pain
6. Bone Scan. This is helpful in case of occult fractures and malignancy
Treatment depends on the cause of Neck pain:
1. Spondyloarthritis: NSAIDs as tolerated, Muscle Relaxants, Exercise / Physical therapy for mild cases. May need biologic therapy if evidence for Ankylosing Spondylitis.
2. Radiculopathy with mild to moderate symptoms: NSAIDs as tolerated, at times Steroids, Muscle Relaxants, Exercise / Physical therapy.
3. Radiculopathy with moderate to severe symptoms: In addition to above, may need to be evaluated by Neurosurgery early and may need a referral to pain management for possible injections if pain is severe.
4. Trauma: Need to rule out fractures and spinal instability. Then as #2 and #3.
5. Spinal Stenosis. This may respond to steroid injections. Otherwise, would need surgery.
6. NSAIDs that can be helpful here include: Diclofenac, Indomethacin, Motrin, Celebrex, and others in order of efficacy.
7. Muscle relaxants commonly used are Cyclobenzaprine, Tizanidine, Baclofen, Methocarbamol in order of efficacy.
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