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Neck Pain

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Ovid: 5-Minute Orthopaedic Consult

Editors: Frassica, Frank J.; Sponseller, Paul D.; Wilckens, John H.
Title: 5-Minute Orthopaedic Consult, 2nd Edition
> Table of Contents > Neck Pain

Neck Pain
Karl A. Soderlund BS
Sanjog Mathur MD
A. Jay Khanna MD
Basics
Description
  • In adults:
    • Common
    • Usually secondary to degenerative disc disease and arthritis
  • In children and adolescents:
    • Less common
    • When it does occur, the pain often is secondary to a neoplasm or infection.
  • Neck pain also occurs after trauma and is extremely common after motor vehicle accidents.
General Prevention
  • No definite methods of prevention are known.
  • General measures such as the use of seat belts and avoidance of motorcycles are recommended.
Epidemiology
Incidence
  • Neck pain occurs in 10% of the population at any given time (1).
  • In a 1994 survey of Norwegian adults, nearly 35% of respondents reported experiencing neck pain within the last year (2).
  • A 1991 study of adults in Finland showed that 9.5% of males and 13.5% of females suffer chronic neck pain (3).
Risk Factors
Congenital fusions of the spine (Klippel-Feil syndrome) are risk factors.
Etiology
  • The many different causes can be divided broadly into atraumatic and traumatic types.
    • Atraumatic neck pain usually is a
      secondary symptom of inflammation, degenerative disc disease,
      arthritis, infection, or a neoplasm.
    • Traumatic neck pain often is caused by
      soft-tissue sprains, fractures, subluxations, dislocations, and
      herniated discs—conditions that can exist in elderly patients without
      any occurrence of trauma.
Diagnosis
Signs and Symptoms
  • Pain well localized to the neck
  • Stiffness
  • Cervical radiculopathy
Physical Exam
  • Routine cervical spine examination differs from examination of cervical spine trauma patients.
  • Routine examinations should focus on ROM, regions of tenderness, and neurologic assessment.
    • Note loss of flexion, extension, and rotation.
    • Palpate the posterior ligamentous structures to detect tenderness and the paraspinal muscles for spasm.
    • Perform a careful neurologic examination, including motor testing, deep tendon reflexes, and sensation.
    • Look for upper motor neuron signs and assess muscle strength.
  • Examination of a trauma patient must include the following:
    • Immobilization until neurologic testing rules out neurologic deficit
    • A full neurologic examination, including the anal wink and bulbocavernosus reflex tests
    • Radiographic studies to evaluate the extent of cervical spine trauma
Tests
The Spurling maneuver tests for cervical radiculopathy.
Lab
  • Laboratory studies are indicated if spine abnormality is not present.
  • For suspected infection, white blood cell count and ESR should be obtained.
Imaging
  • Conventional radiographs:
    • Indicated in patients with history of neck trauma and those >50 years old
    • AP and lateral radiographs are the 1st step in imaging.
    • Other useful views include:
      • Oblique views to evaluate the neural foramen if osteophytic nerve root impingement or facet dislocation/subluxation is suspected
      • Open mouth view to evaluate for C1 fractures (atlas) or odontoid fractures
      • Flexion/extension views to evaluate for segmental instability
  • MRI and CT are indicated in the presence
    of neurologic abnormalities and to evaluate for occult fractures and
    ligamentous injuries.
    • Both are sensitive and specific modalities with which to detect structural abnormalities.
    • May be used independently or in combination
    • CT is the most useful for detecting osseous abnormalities such as fractures, facet dislocations, and osteoid osteomas.
    • MRI is useful for detecting abnormalities
      in the marrow or soft-tissue structures, such as nerve root impingement
      or spinal cord compression, as well as disc herniation and foraminal
      stenosis.
Differential Diagnosis
  • Adults:
    • Atraumatic:
      • Degenerative disc disease
      • Inflammatory arthritis (rheumatoid arthritis, AS)
      • Infection (discitis, vertebral osteomyelitis, meningitis)
      • Herniated disc
      • Neoplasm
    • Traumatic:
      • Ligament sprain
      • Fracture
      • Subluxation and dislocation
      • Herniated disc
  • Children:
    • Atraumatic:
      • Rotatory subluxation
      • Abscess
      • Osteomyelitis
      • Neoplasm
    • Traumatic:
      • Ligament disruption
      • Fracture
      • SCIWORA
    • SCIWORA:
      • Occurs in 19–34% of pediatric spinal cord injuries (4)
      • Neurologic deficits after trauma may be
        delayed up to 4 days in young children, and a 2nd such injury may occur
        as many as 10 weeks after the trauma (5).
      • Transient posttraumatic neurologic symptoms in the arms or legs should be evaluated carefully.

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Treatment
General Measures
  • Most patients with neck pain suffer from an inflammatory process.
  • Rest and NSAIDs are the mainstays of treatment.
  • Soft cervical collars are useful for
    support and to prevent additional injury, but the clinician should
    avoid prolonged immobilization to prevent deconditioning of the
    cervical paraspinal musculature (6).
  • Posture modification and changes in sleep
    position are important nonsurgical treatments that may be beneficial in
    treating neck pain.
  • Exercise can be important in maintaining ROM and strength of the cervical paraspinal musculature.
Special Therapy
Physical Therapy
  • Physical therapy is useful for regaining ROM and strength of the paraspinal muscles.
  • Gentle traction of the spine can be useful for decreasing nerve root irritation.
Medication
  • NSAIDs are the drug of choice for decreasing inflammation.
    • Usually prescribed initially for 4–6 weeks
    • If the pain has resolved at that time, the medication may be discontinued.
Surgery
  • All efforts should be made to treat axial
    neck pain nonoperatively because surgery for isolated axial neck pain
    has worse outcomes than surgery for other causes (e.g., cervical spinal
    stenosis).
  • Most commonly, surgery is performed to
    remove nerve root or spinal cord compression from degenerative disease,
    trauma, and neoplastic disorders.
Follow-up
Prognosis
  • Relieving localized neck pain often is a difficult task because of the diversity of its causes, including idiopathic origins.
  • A combination of physical therapy,
    occupational therapy, and NSAIDs is the best course of treatment for
    neck pain not caused by a tumor or an infection or not associated with
    neurologic deficits.
  • The prognosis for nonoperative treatment usually is good unless the cause is a malignant bone tumor.
Complications
  • The major complication is progressive neural deficit from nerve root or spinal cord compression.
  • Symptoms of nerve root or spinal cord compression include:
    • Weakness in the arms and hands
    • Sensory deficits in the upper extremities
    • Difficulty in walking
    • Bladder and bowel abnormalities
Patient Monitoring
Patients are followed at 4–6-week intervals until the discomfort resolves.
References
1. Hadler NM. Illness in the workplace: the challenge of musculoskeletal symptoms. J Hand Surg 1985;10A:451–456.
2. Bovim G, Schrader H, Sand T. Neck pain in the general population. Spine 1994;19:1307–1309.
3. Makela M, Heliovaara M, Sievers K, et al. Prevalence, determinants, and consequences of chronic neck pain in Finland. Am J Epidemiol 1991;134:1356–1367.
4. Launay F, Leet AI, Sponseller PD. Pediatric spinal cord injury without radiographic abnormality: a meta analysis. Clin Orthop Relat Res 2005;433: 166–170.
5. Pang D, Pollack IF. Spinal cord injury without radiographic abnormality in children—the SCIWORA syndrome. J Trauma 1989;29:654–664.
6. Rosenfeld
M, Gunnarsson R, Borenstein P. Early intervention in
whiplash-associated disorders: a comparison of two treatment protocols.
Spine 2000;25:1782–1787.
Additional Reading
Hardin JG, Halla JT. Cervical spine syndromes. In: McCarty DJ, Koopman WJ, eds. Arthritis and Allied Conditions. A Textbook of Rheumatology, 4th ed. Malvern, PA: Lea & Febiger, 1993:1563–1572.
Miscellaneous
Codes
ICD9-CM
723.1 Cervicalgia
Patient Teaching
  • Patients with neck strains (whiplash injuries) are counseled that full recovery can be expected in the motivated patient.
  • Patients with severe cervical
    degenerative disease generally improve but may have chronic, mild to
    moderate symptoms after treatment.
  • Patients who spend a substantial amount
    of time using a computer should be counseled to take breaks often and
    to attempt to maintain appropriate posture.
FAQ
Q: What is SCIWORA, and in which patient population is it most commonly seen?
A:
SCIWORA is an acronym for spinal cord injury without radiographic
abnormality, and it is usually seen after trauma in children.
Q: In which infectious disease is neck stiffness a common symptom?
A: Meningitis.

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