Simple or Sinister?
When to Seek Attention for Neck Pain
Introduction
The neck is amazing in allowing us to look around with a high degree of freedom. Neck pain, like low-back pain is a common complaint in my office but doesn’t seem to get the same attention from researchers and the media. Those of you who have experienced it will know that neck pain should not be taken lightly—and it turns out that at least 50% of individuals will experience it at some point in their lives(1). In most cases, non-operative treatment will help, but some may require surgery—this is because neck pain is generally more serious than low-back pain. In this article, we will discuss common conditions such as neck strain, but also more serious conditions such as cervical myelopathy and cervical radiculopathy, which may require surgery. I cover many of these topics in my book The Spine Encyclopedia, so if you are interested in learning more, please check it out.
Anatomy:
The term “cervical spine” is used to collectively describe the bones in the neck. There are 7 in total, ranging from the top (C1) to the bottom (C7). Each vertebra is linked by a disc in the front and two small facet joints, also known as zygophyseal joints, in the back. Motion is generated from these connections, and thus a problem affecting one area can typically affect all areas. The two top bones of the cervical spine, known as the Atlas (C1) and the Axis (C2), are special. Most of your neck motion originates from these two bones. Inside the bones of the cervical spine lies a very important structure called the spinal cord. This is the information superhighway that brings sensory input to and motor output from your body, making the cervical spine extremely important. There are small nerves that branch off the spinal cord and exit the cervical spine to supply motor and sensory function to your arms. When things go wrong in the cervical spine, the spinal cord is at risk. Damage to the spinal cord is usually permanent and can result in numbness and loss of bodily function, including paralysis.
Who Gets Neck Pain?
Neck pain can affect almost anyone but seems to be slightly more common in women. Risk factors include a history of neck trauma, lifting/carrying numerous children, depression, smoking, and poor psychological status(2,3). Researchers have also found that obesity and a lack of physical activity or exercise also increase the risk of neck pain (4). Certain high-impact sports such as ice hockey and wrestling seem to cause a higher amount of neck pain(5). Finally, working in an awkward position, such as repetitive computer viewing or precision work, can negatively affect the neck via poor posture. Interestingly, workers who have poor job satisfaction have a higher rate of neck pain(6).
What Should I Do If I Have Neck Pain?
The first thing to do is see your doctor, especially if the pain has been persistent or is associated with neurological symptoms such as numbness, weakness, or loss of coordination. Your doctor will likely order an MRI scan, which is useful for examining the soft tissues of the spine and can identify pinched nerves. However, I find that many patients frequently panic reading their MRI reports, which are really designed to be read by doctors. Many asymptomatic patients will have abnormal MRI reports, and many symptomatic reports will have false positives for injury (7,8). Although it is tempting to try to analyze your own MRI report, understanding the results requires the expertise of your doctor.
It is also critical to be aware of so-called red flag symptoms, which warn of serious conditions that require timely treatment. Do not ignore these symptoms. These include signs of infection (fever, nausea, vomiting, severe neck stiffness/locked neck), or neurological signs (incontinence, weakness, numbness, new sudden headache, inability to walk or balance, sensitivity to light). This list is not comprehensive, so if you are concerned about any symptom, make sure you are seen by a doctor immediately.
Cervical Radiculopathy:
Cervical radiculopathy is a syndrome that results from compression of a nerve in the neck. It typically results in knife-like pain that radiates from the neck to the shoulder and down the arm. If severe, it can also result in numbness and weakness of the muscles connected to the nerve. Typically, motion of the neck will trigger both neck and arm pain. Cervical radiculopathy occurs when a nerve exiting the spine becomes pinched. This is commonly caused by a disc herniation or bone spurs from arthritis.
Cervical radiculopathy can be successfully treated with physical therapy and anti-inflammatories, and most cases will resolve with time. The good news is that 90% of cervical radiculopathy patients will improve with non-operative care alone(9). In certain cases, when the pain is particularly severe or if conservative treatments (like those mentioned above) are not successful, more invasive procedures such as epidurals or surgery may be considered. Weakness of the arm may be an indication for surgery, as nerve damage can quickly become permanent. Surgery generally consists of either an artificial disc replacement, a micro decompression, or a cervical fusion. In general, all of these procedures are effective, and you must discuss with your surgeon which one is right for you(10). Surgery is useful for patients with arm-pain-dominant symptoms, compared to patients with only neck-pain symptoms(11).
Many conditions can mimic cervical radiculopathy, so it’s important that your spine surgeon or physician make this diagnosis.
Cervical Myelopathy
Cervical myelopathy is a devastating condition that is frequently ignored or misdiagnosed. Cervical myelopathy results from direct spinal cord compression in the neck (versus nerve compression in cervical radiculopathy). It is, unfortunately, very common and frequently misdiagnosed by physicians or unrecognized by patients who just feel they are merely aging. Cervical myelopathy can be a tricky diagnosis because it may remain dormant for years followed by a sudden decline in neurologic function. Patients will have neck pain but also worsening balance and gait problems, and hand clumsiness (for example be unable to button their shirt or write their name properly). In addition, your movement may become spastic instead of smooth, and you can develop weakness and numbness of the extremities. You may think, “I’m just getting old,” but actually your spinal cord is being pinched.
Cervical myelopathy is generally caused by degeneration of the vertebrae and discs. Bone spurs and ruptured discs crowd the spinal canal and compress the spinal cord. Furthermore, some people may be predisposed to cervical myelopathy by being born with a smaller spinal canal diameter. There are many other causes, including anything that can take up space in the spinal canal, such as a tumor, fracture, or infection.
Advanced imagining, including MRI and CT of the neck, is a must in these situations. An MRI will show compression of the spinal cord, which looks like a vice clamp on a garden hose. Cases of cervical myelopathy do not improve without surgical intervention and can rapidly progress, leading to permanent disability(12). However, it is important to note that only 23% of asymptomatic individuals with evidence of spinal cord compression on MRI will develop the cervical myelopathy syndrome within 4 years, so it is critical to be evaluated by a trained spine surgeon who can help determine if you actually need surgery now(13). For these reasons, cervical myelopathy is treated much more seriously and urgently than cervical radiculopathy.
There are quite a few ways of treating cervical myelopathy, consisting of either anterior (through the front) or posterior (through the back) surgical approaches. The goal is to alleviate the pressure on the spinal cord. This can be accomplished with decompression alone in many cases, but in some cases will require a spinal fusion with hardware implantation. Cervical myelopathy can affect more levels than cervical radiculopathy and thus tends to require more levels of treatment.
Muscle or Ligament Strain (Whiplash)
Muscle strain is very common and can be caused by repetitive work, whiplash, or a strenuous work environment. Stress can also contribute significantly to muscular neck pain. Muscle strain can result in pain or soreness of the neck with motion. Classically, muscle strain causes the muscles to spasm and shorten, making the neck very tender and stiff.
Whiplash occurs typically in motor vehicle accidents when there is a sudden acceleration and then deceleration, causing the neck to whip back and forward. Whiplash typically affects the soft tissue of the neck, including muscle, joints capsules, and ligaments to create neck pain. Unfortunately, whiplash can become a chronic source of pain in 50% of individuals who experience it. Risk factors for chronic pain seem to be a passive coping behavior and depression. Those who suffer more severe initial symptoms seem to be at a greater risk for chronic progression(14).
The treatment for whiplash and muscle strain is non-operative, with ice, exercise, physical therapy (PT), and massage.
Cervical Disc Disease
Cervical disc disease occurs when the intervertebral discs lose their gel-like consistency over time, causing them to shrink and flatten. As the desiccation process continues, the strong outer ring of the disc can tear, allowing the disc to bulge and herniate. Torn and ruptured discs are highly inflammatory and can cause severe neck pain as well as cervical radiculopathy/myelopathy(15).
Degenerative disc disease occurs because the discs themselves have limited biological activity and blood supply, and thus a limited potential to heal from injury. For this reason, smokers and those who must perform repetitive neck movements are at greater risk for disc disease because these behaviors further limit the disc’s healing potential. Cervical disc disease happens to everyone over time with aging, yet there is a strong genetic link to degenerative disc disease, and some patients may develop early or more extensive cases.
Degenerative disc disease can cause neck and shoulder pain. As noted above, it can also contribute to more serious conditions such as cervical radiculopathy and myelopathy.
Cervical Facet Disease
Cervical facet disease occurs when the small, linked joints in the back of the vertebrae wear down and become arthritic. The facet joints have several confusing names, including zygapophyseal joints or apophyseal joints. Facet-mediated pain has been estimated to be the cause of 66% of chronic neck pain (16). These joints are richly innervated by a branch of the spinal nerve called the medial branch, which becomes irritated and painful. Common risk factors include a history of motor vehicle collision or whiplash. The C2–C3 and C5–C6 facet joints are commonly implicated as the source of pain following a whiplash injury in 50% of cases(17,18). Cervical facet disease can present with neck pain that typically affects one side more than the other, but also with referred pain to the head and shoulders(5). Facet pain does not travel down the arm(19). Headaches can occur from referred pain from the C2–C3 facet joint(17).
Facet-mediated pain can be treated with icing, massage, and physical therapy. In chronic cases, a procedure to anesthetize the medial branch nerve may be effective. Surgery is the last choice for cases that fail to improve with the treatments mentioned above.
Atlantoaxial Arthritis (AAA)
The two top bones of the cervical spine are called the Atlas and the Axis, and are the most important for neck motion. Arthritis (destruction of the smooth cartilage between bones) is surprisingly common with the Atlas and Axis, causing the usually smooth motion between these joints to become painful and stiff. The condition increases with age, affecting about 5% of those in their 60s to 18% of those in their 90s(20). Think of two gears gliding smoothly on one another. Now imagine those same gears become rusty, interlocked, and inseparable.
Typically, patients will present with pain on one side of the neck and difficulty turning the neck to that side. The pain is typically behind the ear or on the back of the head. It can be so bad as to feel as if you have a block preventing you from looking one way, and you have pain anytime you move your neck. The diagnosis is commonly missed by many physicians who attribute the stiffness to other reasons. It can become a debilitating problem, and treatment with injections or surgery may be necessary. These treatments are usually very effective, eliminating pain in 97% of cases of AAA(21).
Summary
Neck pain is common, and most will have to deal with it at some point in their lives. In general, neck pain can be more serious than low-back pain because any issue with the spinal cord can mean permanent disability. If you are experiencing neurologic symptoms combined with neck pain, please get evaluated immediately. If you want to learn more about these topics, please check out my book The Spine Encyclopedia.
References:
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