Neck pain is almost as common a compliant as low back pain. The neck contains many pain-sensitive tissues, which are vulnerable to a variety of painful conditions. The cervical spine is quite mobile; situated between an immobile thorax and relatively weighty head, and thus it is subject varying degrees of trauma.
A patient with minor, self-limited neck pain may never consult a physician. Most of the patients who present with neck pain to a physician can be helped by conservative management. Patients with severe and chronic neck pain usually can be helped by the other therapeutic modalities.
The causes of neck pain are multiple and varies. Many result in pain that may be self-limited but some causes of neck pain, may cause significant morbidity and require immediate intervention.
Acute trauma requires careful neurologic examination as well as radiologic investigation. A history of significant or progressive arm weakness or long-tract signs indicates a cord or nerve root injury. The presence of meningeal signs in the appropriate setting mandates hospitalization, and often the empiric dosing of antibiotics.
It is important to ascertain from the patient any history of precipitating events and associated conditions (e.g., trauma, infection, other illnesses, emotional stress, or use of medications). The duration of symptoms (i.e., acute, subacute, or chronic); points of origin and radiation; and character of pain (i.e., sharp, dull, burning, or throbbing) may aid in diagnosis.
The presence of neurologic symptoms (e.g., weakness, numbness, clumsiness, long-tract signs, or evidence of bladder and bowel dysfunction) requires expeditious investigation. The presence medical symptoms (e.g., constitutional symptoms, dyspnea, fever, or chest tightness) other bony or muscular pain, may lead to a diagnosis of systemic disease or malignancy.
A complete physical examination is essential for evaluation of the patient with neck pain. The neck region should be inspected for normal characteristics as well as pathology, including masses, muscular asymmetries, scars, discolorations, and cutaneous lesions.
Palpation of the neck is best performed on the supine patient.
The anterior bony structures of the neck (the hyoid bone, thyroid cartilage, cricoid cartilage, and the first-cricoid ring) are assessed for normal contour and motion.
The thyroid gland is assessed for enlargement, tenderness, nodules, and bruits. The carotid arteries are assessed for bruits, tenderness, carotodynia, and carotid body tumors.
Lymphadenopahty may indicate infection or malignancy. Parotitis should be ruled out.
The sternocleidomastoid is palpated for trigger points as in myofascial pain syndrome, hypertrophy , tenderness, and swelling.
The supraclavicular fossa is assessed for masses.
To examine the cervical spine, each vertebral spinous process is palpated, beginning with C2; tenderness, irregularity, malaginment, and “step-offs” (i.e., when one spinous process protrudes more than the adjacent one) are noted.
Pain localized to the facet joint on rotation and extension of the neck supports the diagnosis of facet-joint syndrome.
Soft tissues of the posterior neck are examined next.
If there is no evidence of an unstable cervical spine, full range of motion as well as cervical-muscle strength should be tested.
Neurologic examination is critical in evaluating the patient with neck pain, as radicular symptoms and neurologic deficits localize the areas of pathology.The pattern of radicular symptoms and the motor, sensory, and reflex deficits localize the nerve root involved.
Anteroposterior and lateral views of the cervical spine are the basic x-ray film studies.All seven cervical vertebrae must be visualized.
A lateral flexion and extension view could be ordered for flexion-extension injuries e.g., whiplash once an unstable cervical spine has been ruled out.
X-rays should be assessed not only for bone damage but for soft-tissue injury as well.
Neurologic or chronic symptoms may warrant further investigation, possibly including a computed tomography (CT), magnetic resonance imaging, or myelography.