Article about neck pain.
The neck is the part of the body that supports the head and serves as a passageway between the head (and brain) and the rest of the body. The neck contains many important structures: the spinal cord (which carries nerve impulses to and from the brain); the trachea (windpipe); the larynx (voice-box); the oesophagus (gullet); the thyroid and parathyroid glands; lymph nodes; and several major blood vessels. Seven spinal vertebrae are located in the neck; they are surrounded by a complex system of muscles.
Torticollis (wry neck), in which the head is twisted to one side, may result from injury to a neck muscle or from skin contracture (shrinkage) after burns or other injuries. Fractures and dislocations of vertebrae in the neck, as well as whiplash injury, can cause injury to the spinal cord, causing paralysis or even death (see spinal injury).
Degeneration of the joints between the neck vertebrae may occur as a result of cervical osteoarthritis, resulting in neck pain, stiffness, and sometimes tingling and weakness in the arm and hand. Similar symptoms may also be caused by a disc prolapse. In ankylosing spondylitis, fusion of the vertebrae may result in permanent neck rigidity.
Cervical rib is a rare congenital defect in which there is a small extra rib in the neck. This condition often causes no symptoms until middle age, when it may result in pain, numbness, and a pins-and-needles sensation in the forearm and hand.
Neck pain of unknown origin is very common. However, as long as there are no neurological symptoms (such as loss of sensation or a decrease in muscle power), the condition is unlikely to be serious and usually disappears over the course of a few weeks. However, any condition causing a large swelling in the neck (such as enlargement of the thyroid gland) may interfere with breathing or swallowing.
Neck pain in detail -technical article
Neck pain is a very common symptom. In a recent large epidemiological survey from Norway, 34.4% of adult respondents reported troublesome neck pain in the previous year, with 13.8% reporting pain lasting more than 6 months. As for low back pain, neck pain can rarely be attributed to a specific anatomical source, and most patients presenting with this symptom should be diagnosed as suffering from ‘nonspecific neck pain’ or ‘cervical spinal pain of unknown origin’, rather than applying nonvalidated diagnostic labels. Trauma, in particular acceleration–deceleration (whiplash) injuries, increasing age, lower education, and psychosocial factors are the most common risk factors associated with the development of neck pain.
The clinical approach to the patient with neck pain should follow the same principles as described for low back pain. Signs of nerve root and/or spinal cord compression should always be looked for, particularly in patients complaining of associated pain, numbness, or weakness in their arms or legs. Older patients with cervical spinal stenosis due to severe osteoarthritis may present with wasting and lower motor neuron weakness in the arms or hands and spastic weakness and sensory disturbance in the legs.
A number of diseases of the pharynx (pharyngitis, retropharyngeal abscess), larynx (laryngitis), trachea (tracheitis), thyroid (acute thyroiditis), lymph nodes (lymphadenitis), carotids (carotidynia), lungs (Pancoast tumour), heart (myocardial infarction), pericardium (pericarditis), aorta (dissecting aneurysm), and diaphragm (subphrenic abscess) can refer pain to the neck and should be considered. These conditions will usually have other clinical manifestations to alert the physician to the proper diagnosis. The neoplastic, infectious, inflammatory, and metabolic conditions which cause back pain are enumerated in Table 1 can also affect the cervical spine. In addition, rheumatoid arthritis and diffuse idiopathic skeletal hyperostosis should be considered in the differential diagnosis, as both can involve the cervical spine and cause spinal cord compression.
A special task force proposed a classification of cervical disorders associated with whiplash injury that takes into account both the severity and duration of symptoms (Table 2). Although specifically designed to address problems related to whiplash injuries, it can be very useful in classifying and guiding management of patients presenting with nonspecific neck pain unrelated to trauma.
|Table 1 Causes of back (and neck) pain|
|Surgical emergencies||Cauda equina syndrome (disc, tumour mass, abscess)|
|Aortic aneurysm (ruptured, dissected)|
|Sciatica with neurological signs||Ruptured intervertebral disc|
|Spinal stenosis (the neurological examination is often normal)|
|Spinal cord tumours (extradural, intradural–extramedullary/intramedullary)|
|Neoplastic||Benign: osteoid osteoma|
|Malignant: primary (multiple myeloma), secondary (metastasis)|
|Infectious||Acute: pyogenic discitis, osteomyelitis|
|Inflammatory bowel diseases|
|Metabolic||Osteoporosis (with fractures)|
|Paget’s disease of bone|
|Visceral||Pelvic organs (endometriosis, prostatitis)|
|Renal disease (pyelonephritis, renal colic)|
|Nonspecific low back pain||Muscle|
Investigation of patients with neck pain—who and how?
Guidelines are only available for patients presenting with whiplash injuries. Patients with grade I whiplash-associated disorder do not usually require radiographic evaluation. Those with grade II to IV whiplash-associated disorder need a baseline radiological examination consisting of plain films with anteroposterior, lateral, and open-mouth views. Radiographs are usually unhelpful in patients with nonspecific neck pain. Degenerative changes in the discs and zygapophyseal joints increase with age and do not correlate with symptoms of neck pain. CT is helpful for evaluating the bony structures of the neck, but it must be combined with myelography to adequately visualize the neural tissues. MRI is therefore preferred in most cases with spinal cord or nerve root compromise. Fifty per cent of patients with chronic neck pain after motor vehicle accidents respond to diagnostic zygapophyseal joint injection, suggesting that these joints are responsible for their pain.
Management of patients with neck pain
Most treatments recommended for the management of patients with neck pain have not been evaluated in a scientifically rigorous manner. Those that have been have shown very little, if any, evidence of efficacy. These include soft cervical collars, zygapophyseal joint injections and acupuncture. Patients with acute neck pain should be encouraged to maintain their usual level of activity. There is evidence that non-narcotic analgesics, NSAIDs, mobilization, and manipulation are effective, whereas the promotion of rest and soft collars tends to prolong disability. Surgery is indicated only for patients with severe radiculopathy not responsive to 6 to 12 weeks of conservative management.
|Table 1 Classification of whiplash-associated disorders|
|I||Neck complaint of pain, stiffness, or tenderness only; no physical signs|
|II||Neck complaint and musculoskeletal signsa|
|III||Neck complaint and neurological signsb|
|IV||Neck complaint and fracture or dislocation|
Acute, less than 4 days and 4 to 21 days; subacute, 22 to 45 days and 46 to 180 days; chronic, more than 180 days.
Symptoms and disorders that can manifest in all grades include deafness, dizziness, tinnitus, headache, memory loss, dysphagia, and temporomandibular joint pain.
a Musculoskeletal signs include decreased range of motion and point tenderness.
b Neurological signs include decreased or absent deep tendon reflexes, weakness, and sensory deficits. Adapted from Spitzer et al. Scientific monograph of the Quebec Task Force on Whiplash-Associated Disorders (WAD): Redefining “whiplash” and its management. Spine 1995. 20 (supp) pS1–73.
There is no consensus as to how best to manage patients with chronic neck pain.