Neck Pain
Samir Khan and Valentine Chukwuma
Background
- Most common cause of neck pain in adults: Degenerative changes of the cervical spine
- Most atraumatic neck pain does not require imaging
Presentation
- Cervical muscle strain: pain + stiffness with movement due to muscular injury
- Degenerative disc disease/osteoarthritis: pain + stiffness with movement from derangement in disc architecture leads to inability to distribute pressure in the joint
- Cervical radiculopathy: neuropathic pain, sensory abnormalities, and/or weakness in an upper extremity (often radiating to hand)
- Cervical myelopathy: spinal cord compression causing neurologic dysfunction
- Earliest symptom is gait disturbance. Pain is uncommon
- Non-cervical conditions: shoulder pathology, migraine/headaches, occipital neuralgia, torticollis, thoracic outlet syndrome, angina pectoris/MI, bony metastases, vertebral artery or carotid artery dissection, fibromyalgia, meningitis, transverse myelitis
- Posterior neck pain
- Axial only à MSK (sprain vs degenerative disc disease)
- Axial + Extremity Pain à Radiculopathy - Anterior neck pain
- Common sources: esophageal, thyroiditis, carotidynia, lymphadenitis, Ludwig’s angina
- Red flags: recent rauma, lower extremity weakness, gait abnormality, bowel/bladder incontinence, fever, weight loss
Evaluation
- Determine MSK (axial pain) vs. radiculopathy/myelopathy vs non-spinal
Provocation Tests of the Neck | |||
|---|---|---|---|
Test | Isolates | Action | Positive if |
| Spurling’s test | Cervical radiculopathy | Downward pressure applied to top of head with extended neck and rotates to affected side | Reproducible pain beyond shoulder Neck pain alone is not specific |
| Elvey's upper limb tension test | Cervical radiculopathy | Head turn contralaterally, arm is abducted while the elbow extended | Reproduction of symptoms |
| Hoffman sign | Corticospinal lesion (UMN) | Loosely hold middle finger and flick the fingernail downward, allowing the middle finger to flick upward reflex ively | There is flexion & adduction of thumb/index finger on the same hand |
- Imaging indications: neuro deficits, red flag symptoms, persistent pain (> 6 weeks)
- Cervical X-ray: 2-view (AP and lateral)
- Cervical MRI: Visualizes spinal cord, nerve roots, bone marrow, discs and soft tissues
- Usually w/o contrast; can consider contrast if malignancy or infection suspected
- EMG/Nerve Conduction Studies: Not routinely used for neck pain evaluation, but can be used to distinguish cervical radicular pain from peripheral causes of extremity dysesthesia
Management
- First line: conservative therapy for 4 to 6 weeks,
- Refer to Spine PT program at VUMC
- Medications: Tylenol +/- muscle relaxer (Robaxin / Flexiril)
- Steroids (Medrol Dosepak) often prescribed
- Indications to refer to Orthopedics or PM&R spine specialist
- Refractory to conservative treatment
- Severe, debilitating pain at the outset / unable to tolerate PT
- Cervical myelopathy requires urgent surgical evaluation