Board-certified orthopedic spine surgeon
CSRS President, 2010
Neck pain is a common condition that can affect more than 30% of the general population every year. In fact, it is the fourth leading cause of disability behind lower back pain, depression, and arthralgias (joint pain). Approximately half of all individuals will experience a noticeable neck pain episode over the course of their lifetime. More women than men have neck pain, and it peaks during the middle aged years (40-60 years).
Individuals who get neck pain tend to have other muscle and bone conditions. Unique risk factors for neck pain include trauma (e.g. traumatic brain and whiplash injuries) and certain sports injuries (e.g. wrestling, ice hockey, football). However, many patients without risk factors can still get neck pain.
There are different ways of categorizing neck pain. One method is according to the duration of pain, in which the duration of pain can be divided into three phases: acute (less than 6 weeks), subacute (less than 3 months), and chronic (more than 3 months).
Duration is important because the shorter the duration of neck pain, the better the prognosis, or the likely outcome. Most cases of acute neck pain will resolve to a large extent within 2 months.
Neck pain can also be categorized by how and why it happens. “Mechanical” pain refers to pain originating from spinal structures such as discs or joints. When discs degenerate, they can sometimes be associated with neck pain.
Similarly, the facet joints in the spine can cause neck pain when they degenerate and produce arthritic changes. However, it is important to understand that degenerative changes within discs and facet joints are universal in everyone with increasing age, and their mere presence on an x-ray or MRI does not necessarily mean that they are the cause of the pain. Other causes of mechanical neck pain include strains and sprains of the muscles and ligaments that surround the cervical spine.
Compression of neurologic structures, such as the spinal cord or nerve roots, can also cause isolated neck pain. However, in addition to neck pain alone, compression of neurologic structures within the cervical spine is often (but not always) associated with other neurologic symptoms, such as radiating pain down the arm, numbness, weakness, difficulty controlling the arms, or difficulty with gait and balance. Differentiating pain arising from neurologic compression from mechanical pain is important since the treatment may be different.
Other causes of neck pain include tumors/cancers, infections, and certain fractures. These causes are relatively rare compared to the mechanical causes, but require more urgent attention. A deformity of the cervical spine, such as kyphosis (an abnormal amount forward bending of the neck) can also cause neck pain.
Non-spinal causes of neck pain can also occur. For example, sometimes a heart attack can manifest itself as neck pain with spread of that pain to the left arm. Problems in and around the shoulder joint can cause neck pain near the shoulder.
A comprehensive history can provide important clues regarding the cause of neck pain and help distinguish mechanical neck pain from other causes. Upon completion of history taking, a detailed physical and neurologic examination is performed to confirm findings from the history, identify serious or treatable causes, and make plans for further testing, if needed.
Depending on the circumstances, imaging and other diagnostic studies may be ordered. Not every case of neck pain requires imaging, and, even when imaging is indicated, not every type of imaging modality needs to be obtained.
Radiographs (“x-rays”) may reveal evidence of disc degeneration, with collapse of the disc spaces and bone spur formation, as well as diagnose many fractures. The side (“lateral”) radiograph allows for examination of the facet joints in the back of the neck, again looking for bone spur formation. X-rays also can also show the presence of kyphosis. In addition, special x-rays taken with the neck in full forward flexion and then in full backward extension may demonstrate any instability or abnormal movement of the cervical spine.
Further imaging with magnetic resonance imaging (MRI) may be requested in some cases.
Cases of neck pain accompanied by neurologic symptoms (e.g. arm pain, numbness, weakness, etc.) may require MRI to evaluate for spinal cord compression or nerve root compression. In cases of purely isolated neck pain without neurological complaints, an MRI may not add much to the diagnosis and treatment and, as such, may not be ordered. Similarly, computed tomography (CT) scans may be ordered to evaluate for changes to the shape or architecture of the bone in the cervical spine. In general, MRI is useful for examining soft tissues and nerves, whereas CT is more useful for examining bone. CT is associated with some radiation exposure to the patient, so these are often withheld unless definitely needed. In some cases, the actual cause of the neck pain may not be clear even after history, physical, and imaging have been obtained. If so, and the symptoms have not gone away with time or routine symptomatic care, different types of spinal injections may be recommended in order to identify the source of pain. For example, facet joint injections (aka “blocks”) may be directed to the facet joint(s) felt to be the culprit for pain. If the injection provides either temporary or long lasting relief, then the cause of the pain is likely to be the injected joint(s). Trigger point injections can be given into muscular areas of pain - they can offer similar diagnostic information and potentially relieve pain long term as well. Epidural steroid injections and nerve root injections are usually performed in patients with associated neurologic symptoms, but they may sometimes be recommended in patients with isolated neck pain as well. Blood tests are not commonly employed in the diagnostic workup of neck pain but may be ordered when tumor, infection, or inflammatory disease (e.g. rheumatoid arthritis) are suspected. Similarly, electromyograms (EMG/”nerve conduction study”) are rarely obtained for isolated neck pain in the absence of neurologic symptoms.
