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 but situated between an immobile thorax and relatively weighty head, and thus it is subject to 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 vary. Many result in pain that may be self-limited but some causes of neck pain, may cause significant morbidity and require immediate intervention.
Causes of Neck Pain
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.
Non-Musculoskeletal Causes
Pharynx
- Pharyngitis
- Ludwig’s angina
- Inflamed pharyngeal cyst (branchial cleft remnants)
Tonsils
- Tonsillitis
- Neoplasm of the tonsil
Tongue
- Ulcers
- Neoplasm
Esophagus
- Inflamed diverticulum
- Esophagitis
Skin and Subcutaneous Tissues
- Furuncle
- Carbuncle
- Erysipelas
Glands
- Thyroid gland – acute suppurative thyroiditis, subacute thyroiditis, hemorrhage
- Salivary gland – Mumps, suppurative protitis, calculus in the duct
Lymph nodes
- Acute adenitis
- Hodgkin’s disease
- Metastases
Blood Vessels
- Carotid body tumor
- Subclavian artery aneurysm
Musculoskeletal Causes
Mandible
- Fracture of mandible
- Osteomyelitis
- Periodonitis
Cervical spine
- Vertebral Injury
- Tumor
- Osteomyelitis
- Metastasis
- Ligament rupture
- Sprain
- Herniated intervertebral disc
- Facet joint syndrome
- Spinal-cord tumor
- Epidural abscess or hematoma,
Muscles
- Myofascial pain syndrome
- Viral myalgia
- Transient stiff neck
- Hematoma
- Intramuscular gummas
- Calcific tendinitis of the musculus longus colli
- Reflex spasm (meningitis, adenitis, acute pharyngitis)
- Torticollis (acquired, congenital)
Referred Pain
- Bronchial tumor
- Pancoast’s tumor
Miscellaneous
- Occipital neuralgia
- Anterior scalenus syndrome
- Costoclavicular syndrome
- Pectoralis minor (hyperabduction) syndrome
Presentation and Diagnosis
Muscle strains, worn joints, nerve compression, and injuries are the most common causes of musculoskeletal neck pain.
A patient presenting with pain in the neck region needs to be evaluated for all the probable causes.
Neck pain is commonly associated with a dull ache in the region affected. The pain may be worsened by neck movements. Numbness, tingling sensation [paraesthesias], dysphagia[difficulty swallowing], giddiness, lightheadedness, and swelling may be associated.
Sometimes the referred pain may lead to headache, facial pain, shoulder pain, and pain in the arm. Numbness or tingling in the upper extremity may be present.
The patient may complain of associated pain in the lower back or other joints.
Depending upon the causation, the neck pain may be acute as in case of trauma, sprain or disc prolapsed. Minor acute pains resolve with local therapy.
A chronic pain indicates underlying problem that requires more detailed evaluation.
Diagnosis of neck pain begins with patient history and examination followed by relevant investigations.
In history type of pain is evaluated
- Whether acute or chronic
- Whether spontaneous or preceded by some kind of trauma
- Any other associated symptom like pain in shoulder or arm or paraesthesiae
- Whether it was causing pain at night
- Whether it caused morning stiffness
- What makes the patient [movements, postures] feel better, what worsens
- Personal history of the patient like profession, computer use, reading habits etc.
- Sleeping habits and postures
- Any known disease like hypertension and diabetes
Patient is examined to know any tender points, any tautness of structures, swelling, redness, muscle spasm . Neurological examinationis done to know muscle reflexes, muscle power and sensation.
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.
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.
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.
Imaging in Neck Pain
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.
Bone scan is important in cases of malignancy.
Treatment
Analgesics
Acetaminophen and other non steroidal anti-inflammatory drugs like brufen, aspirin are commonly prescribed. In case of antibiotics oral or parental antibiotics are started as the need may be. Patient may be advised to use cervical collar or prescribed rest if needed. Heat and cold application may also be used. Topical anesthetic creams, topical pain patches and muscle relaxants are also used.
local steroid injections are used in cases like fibromyalgia and trigger points.
Physical Therapy
This is prescribed in musculoskeltal causes of pain. It involves strengthening exercises, ultrasound therapy, massage and range of motion exercises. Patient may be advised to improve his reading habits and use ergonomical settings.
Surgery
Patients who do not respond to non operative treatment or have some anatomic abnormality may be a candidate for surgery.
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