Neck Pain


Symptoms and History Associated with Neck Pain:
Group 1: Cervical Problems Arising Mainly from Neck Joints and Associated Ligaments and Muscles Group 2: Cervical Problems Involving the Cervical Nerve Roots or the Spinal Cord
Patients complain of pain and stiffness. Pain is a deep, dull aching sensation and often episodic.

Patients have a history of excessive or unaccustomed activity or of sustaining an awkward posture.

There is no history of specific injury. Ligament and muscle pain are localized and asymmetric.

Pain from upper cervical segments is referred toward the head; pain from lower segments, to the upper limb girdle. Symptoms are aggravated by neck movement and relieved by rest.
Patients complain of significant root pain, typically sharp, intense, and may be described as "burning."

Pain may radiate to the trapezial and periscapular areas or down the arm. Patients complain of numbness and motor weakness in a myotomal distribution.

Headache may occur if the upper cervical roots are involved.

Symptoms often become more severe with neck hyperextension (especially when the head is toward the affected extremity).

Patients may experience gradual onset of shocklike sensations spreading down spine to extremities.

Most common myelopathy at the level of the fifth cervical vertebra and affects shoulder abduction (deltoid) and external rotation (infraspinous).

Signs and Symptoms of Cervical Radiculopathy:
Disk Space Cervical Root Pain Complaint Sensory Abnormality Motor Weakness Altered Reflex
C1-C2 C2 Neck, scalp Scalp    
C4-C5 C5 Neck, shoulder, upper arm Shoulder Infraspinatus, deltoid, biceps Reduced biceps reflex
C5-C6 C6 Neck, shoulder, upper medial, scapular area, proximal forearm, thumb, index finger Thumb and index finger, lateral forearm Deltoid, biceps, pronator teres, wrist extensors Reduced biceps and brachioradialis reflex
C6-C7 C7 Neck, posterior arm, dorsum proximal forearm, chest, medial third of scapula, middle finger Middle finger, forearm Triceps, pronator teres Reduced triceps reflex
C7-T1 C8 Neck, posterior arm, ulnar side of forearm, medial inferior scapular border, medial hand, ring, and little fingers Ring and little fingers Triceps, flexor carpi ulnaris, hand intrinsics Reduced triceps reflex

Physical Examination

Imaging Studies in Neck Pain

Differential Diagnosis:

Cervical Strain/Sprain:
  • Neck strain, neck sprain, hyperextension strain, acceleration-deceleration injury, hyperextension-hyperflexion injury, and whiplash are mechanical neck disorders.
  • Motor vehicle collisions, falls, sports injuries, and work-related injuries precipitate most cases.
  • EXAM: localized tenderness of cervical spine; decreased ROM of the cervical spine, no signs of neurological compromise
  • 1st Test: Clinical dx, X-ray, MRI?
  • Tx: Rest, Ice, Compressions, Elevation, Analgesia, PT
Whiplash Injury
  • Whiplash injury results from sudden acceleration-deceleration trauma that occurs when an unaware victim in a stationary vehicle is struck from behind.
  • EXAM: Patients often complain of pain and stiffness, and examination may reveal tender paracervical muscles with decreased range of motion. Typically, pain is delayed for a number of hours following an accident. No signs of neurologic compromise.
  • 1st Test: Cervical Spine X-ray (No abnormalities/Fx/Dislocation)
  • Tx: NSAID, +/- opioid, PT
Hyperflexion-Hyperextension Injury
  • The most devastating complication of hyperflexion-hyperextension injury is the central cord syndrome, which may occur in the presence of cervical spondylosis, spinal stenosis, ankylosing spondylitis, or disk herniation.
  • There may be no radiographic evidence of spinal trauma.
  • Physical examination findings of central cord syndrome include weakness that is greater in upper extremities than the lower extremities, accompanied by variable sensory loss.
Cervical Disk Herniations
  • The symptoms of an acute cervical disk prolapse include neck pain, headache, pain referred to the shoulder and along the medial scapular border, and dermatome pain and dysesthesia in the spinal root distribution to the shoulder and arm.
  • Motor signs include fasciculations, atrophy and weakness in the dermatome distribution of the spinal root, loss of deep tendon reflexes, and, with cervical myelopathy, lower extremity hyperreflexia, Babinski sign, and rarely, loss of sphincter control.
  • A thorough physical examination, including strength, sensory, and reflex testing, easily delineates the level of root involvement.
  • MRI is necessary for diagnosis.
Cervical Spondylosis and Stenosis
  • Cervical spondylosis is a progressive, degenerative condition that often presents either as a loss of cervical flexibility, neck pain, occipital neuralgia, radicular pain, or, occasionally, as progressive myelopathy. There is progressive degeneration of the disks, ligaments, facet joints (zygapophyseal joints), and uncovertebral joints (joints of Luschka). Osteoarthritis of the neck and degenerative disk disease are common clinical terms used for this condition. Osteophytes, disk space narrowing, or facet disease on cervical radiographs in the setting of symptoms makes the diagnosis of cervical spondylosis.7 However, there is a high prevalence of cervical spondylosis in asymptomatic individuals, and spondylosis may not be responsible for symptoms.6 Degenerative disk disease predisposes to progressive osteoarthrosis of the cervical spine, joint instability, and incongruous joint motion during neck movement. Spondylosis most commonly occurs at the C5-C6 and C6-C7 levels.

    Osteophytic spurs can encroach posteriorly on the spinal canal, producing cervical myelopathy; laterally on the intervertebral foramen, producing cervical radiculopathy; and anteriorly on the esophagus, producing dysphagia. Spurious osteophytes or a cervical rib may also produce Horner syndrome, vertebrobasilar symptoms, severe radicular symptoms without associated neck pain, painless upper extremity myotome weakness, and chest pain mimicking angina. Neurologic findings (radiculopathy or myelopathy) may be gradual in onset unless there is a history of recent trauma.

    The combination of a congenitally narrowed spinal canal further compromised by a vertebral osteophytic bar anteriorly and a buckling ligamentum flavum posteriorly increases the risk of myelopathy secondary to cervical spinal stenosis as the diameter of the spinal canal is reduced to <13 mm. Cervical spinal stenosis can also occur in approximately 20% of patients with lumbar spinal stenosis.
Cancer
  • Metastatic cancer should be in the differential diagnosis of chronic neck pain, even though a past history of cancer is lacking. The first sign of cancer can be spinal cord compression.10 The complaint of unremitting night pain may be indicative of a malignant process.6 Lung, breast, and prostate cancers as well as lymphoma and multiple myeloma may involve the cervical spine and cause neck pain.5,11 Although most cases of epidural cord compression occur in the thoracic spine (70%), approximately 10% involve the cervical spine and lesions at multiple levels are not unusual.12 Myelopathy, which is commonly caused by disk or degenerative disease, is rarely caused by metastatic tumors.5

    Plain films have poor sensitivity and a 10% to 17% false negative rate in detecting spinal metastases10 but may reveal destruction of the vertebral bodies, lytic lesions of the pedicles, and pathologic compression fractures.5 MRI is the gold standard in detecting spinal metastatic disease and cord compression.10 Cancer patients with radiographic evidence of bone or disk margin destruction should undergo MRI.7 See the section on Special Situations at the end of this chapter.
Myofascial Pain Syndrome
  • Myofascial pain syndrome is a cause of chronic neck pain and is often confused with radiculopathy. Although it has been defined as pain persisting more than several months, myofascial pain syndrome may present acutely, especially after trauma, with typical clinical characteristics.13 Psychological distress and specific personality traits contribute to the conversion of emotional distress into bodily complaints and focus on the body so that nonpainful sensations are perceived as painful.13

    The location of pain may help in discriminating myofascial pain syndrome from true radicular pain. Myofascial pain syndrome patients often complain of pain in the neck, scapula, and shoulder, and pain is not described in a dermatomal pattern. The neurologic examination is normal. "Trigger points" of pain may be identified on palpation of the head, neck, shoulder, and scapular region. Imaging demonstrates either nonspecific degenerative or disk changes that do not correlate with the clinically suspected site (see Chapter 42, Adults with Chronic Pain).
Other Causes of Neck Pain in Adults
  • Epidural abscess, vertebral osteomyelitis, and transverse myelitis occur more commonly in the thoracic and lumbar spinal regions and are covered in Back Pain: The Thoracic and Lumbar Pain Syndromes later in this chapter. Temporal arteritis is an inflammatory cause of neck pain. Cervical spinal epidural hematoma often presents with neck pain followed by symptoms and signs of cord compression and should be considered in the patient taking anticoagulants or in the child with hemophilia.14 Pain from ischemic heart disease may radiate into the neck and shoulder. Peripheral nerve involvement, such as carpal tunnel syndrome, may present as a C6-C7 sensory radiculopathy, while multiple sclerosis, amyotrophic lateral sclerosis, subacute combined degeneration, and syrinx are in the differential of myelopathy.
Neck Pain in Children
  • In children, causes of neck pain include trauma and infections (meningitis, pneumonia, otitis media, tonsillitis, cervical adenitis, retropharyngeal abscess, mumps, cerebral abscess).15 Other less common but important considerations of neck pain in children include hemophilia resulting in a spinal epidural hematoma,14 juvenile chronic arthritis, Arnold-Chiari malformations, posterior fossa and cervical spinal tumors, vertebral anomalies, cervical osteomyelitis, spondyloarthropathies, and myositis ossificans progressiva.

 

Treatment in ED and Disposition:

  1. pt with neck and back pain that have progressive neurologic deficits, myelopathy, or intractable pain should be imaged as indicated (typically MRI) & admitted to appropriate service for further management. Dexamethasone 10 mg IV should be given prior to imaging for suspected epidural compression.
  2. Pt with a stable or mild radiculopathy may be managed conservatively with pain medication, routine activity, & strict return precautions for worsening symptoms. Outpt. MRI & neurosurgical follow-up should be considered for pt who have failed conservative treatment.
  3. Pain management may include NSAIDs (if no contractions), acetaminophen, or muscle relaxants (eg, diazepam 5mg or 10mg PO tid), used singly or in combination; all have been shown to be effective with no agent proved superior. A short course of oral opioids may be prescribed for pt with moderate to severe pain, but long-term use is discouraged. Other treatments such as manipulation or corticosteroids have limited benefits & should not be prescribed in the ED.
  4. The majority of pt with nect or back pain will have benign courses and improve with time. These pts may be prescribed pain medicine as appropriate & reassurance should be provided.