Neck pain is almost as common a complaint as low back pain.
Most cases of neck pain are due to minor muscular or ligament stresses. But there could be many other causes including the serious ones.
Most of the neck pain cases are short-lasting and often can be managed at home. But a chronic pain in the neck or pain that worsens with time can point to some underlying cause and often requires a consultation with a physician.
The neck consists of the cervical spine and other tissues and any abnormality in any structure can cause neck pain.
The cervical spine is a mobile region of the spine that bears the weight of the head and is attached at the other end to an immobile thorax.
Causes of Neck Pain
Most of the neck pains in the adult are caused by musculoskeletal issues. For sake of completion, other causes are also included but these are not discussed further in the article. Only musculoskeletal causes and presentations are further discussed.
Here is a list of conditions that might cause neck pain due to direct or indirect involvement. The list involves both musculoskeletal and non-musculoskeletal causes.
Musculoskeletal Causes
- Cervical spine injury
- Fractures of vertebrae
- Whiplash injury
- Neck sprain and strain
- Lesions of vertebrae
- Infection [osteomylitis]
- Benign and malignant lesions including metastasis
- Herniated intervertebral disc
- Degenerative changes leading to cervical spondylosis
- Meningeal infection or tumors
- Diseases of the muscles
- Myofascial pain syndrome
- Viral myalgia
- Hematoma
- Calcific tendinitis of the musculus longus Colli
- Reflex spasm (meningitis, adenitis, acute pharyngitis)
- Torticollis acquired or congenital
- Lesions of mandible – fracture, infection etc
Non-Musculoskeletal Causes
- Pharynx lesions
- Pharyngitis
- Ludwig’s angina
- Pharyngeal cyst which is inflamed
- Tonsillar lesions
- Lesions of tongue – ulcers and malignancy
- Esophagitis
- SKin lesions furuncle
- Lesions of salivary gland
- Thyroid lesions
- Lymph node swelling
- Carotid body tumor
- Subclavian artery aneurysm
- Referred Pain as in bronchial tumor or pancoast’s tumor
Diagnosis
Neck pain is a symptom and not the disease in itself. Therefore, a patient presenting with pain in the neck region needs to be evaluated for all the probable causes.
Minor acute pains resolve with local therapy. However, chronic pain indicates an underlying problem that requires more detailed evaluation.
Musculoskeletal neck pain can present as acute or chronic pain in the affected region of the neck. The pain is often worsened by neck movements.
There are associated symptoms and findings which may suggest a probable cause. These are
- Numbness or tingling sensation [paraesthesias] in front of the chest or back or upper limb
- Dysphagia[difficulty swallowing]
- Giddiness
- lightheadedness
- Swelling
- Referred pain that leads to
- Headache
- Facial pain
- Shoulder pain
- Pain in the arm or forearm or hand
The patient should be enquired for the following history
- Associated pain in the lower back or other joints [rheumatoid or other arthropathies]
- Trauma
- Sprain
- Fever
- Pain at night
- Morning stiffness
- Movements and postures that worsen the pain
- Movements and postures that make it better
- Professional history like the use of computers, reading, etc.
- Sleeping habits and postures
The patient’s neck is examined for
- Tenderness
- Tautness of structures
- Swelling
- Redness
- Muscle spasm
- Range of movement
Neurological examination is done to know muscle reflexes, muscle power and sensation.
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.
Imaging
Anteroposterior and lateral views x-rays 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 or in chronic instability of the neck.
X-rays should be assessed not only for bone damage but for soft-tissue injury as well.
Most of the neck pain cases do not require x-rays. Very few patients require imaging beyond the x-rays of the neck.
CT and MRI provide better images and an in-depth study of the structures.
MRI is the preferred modality of the imaging and is indicated where neural symptoms are present and the patient ins not showing any improvement in spite of the treatment.
MRI is also able to show any space-occupying lesion like abscess, tumor. It is the imaging of choice to visualize disc herniation and nerve root compression.
CT is better at showing bony pathologies and is better at finding fractures of the vertebrae or ossification of posterior longitudinal ligament.
Bone scan is important in cases of malignancy.
Treatment of Neck Pain
Treatment of the neck pain involves providing comfort to the pain and at the same time addressing the cause of pain if discernable.
Most neck pains can be treated with nonoperative methods. Quite a lot are amenable to self care measures whereas for others consultation with a physician becomes necessary.
Nonoperative Treatment for Neck Pains
Nonoperative treatment includes both – selfcare measures and other treatments.
Minor neck pains can be dealt at home with selfcare. The measures include
- Rest to the part
- Ice or heat application
- Gentle stretches
- Over the counter pain relief drugs like Acetaminophen
- Neck massage
There are certain measures that include lifestyle changes and long term benefits in neck pain and other kinds of musculoskeletal pain. These are
- Active lifestyle
- Quitting smoking
- Posture improvement
- Ergonomic measures
If a few days of self-care do not result in an improvement, a consultation with a doctor may be sought and the advice followed.
The following approaches are used for musculoskeletal neck pain.
Physical therapy
- Cervical orthoses
- Stretch exercises
- Neck muscle strengthening exercises
- Done under the supervision of physical therapist and physician
- Later, the exercises can be continued at home
Drugs
- Other NSAIDs like ibuprofen
- Muscle relaxants like chlorzoxazone, thiocolchicoside
- Gabapentin, pregabalin
- Opioid drugs
Invasive Treatments and Surgery
Injections
- Cervical epidural steroid injection
- For pains of cervical origin
- Instillation of steroid solution into the cervical epidural space,
- Radiofrequency ablation
- For pains of facet joint origin
- Done under fluoroscopy
- Uses heat probe to destruct sensory nerves at the join
The injections provide only temporary relief.
Surgery
Surgery is considered in patients who do not respond to non-operative treatment. Injections may be tried before the surgery.
The surgical procedure would depend on the cause of the pain.
For example, in cervical disc herniation, disc removal and fusion of the segment is carried.
