Neck Pain

See Also

Epidemiology

Prevalence: As high as 20-30% per year
1. However, only one in five present for medical evaluation for acute Neck Pain
Gender: Females
Age
1. Peaks in middle age

History
General

See Neck Pain Red Flag
Timing: Acute or Chronic
1. Acute Neck Pain <6 weeks
2. Subacute Neck Pain 6 to 12 weeks
3. Chronic Neck Pain >12 weeks
Age
1. Age <20 years old
  1. Congenital abnormalities (e.g. cervical Spina bifida, Scheuermann Disease)
  2. Spinal Infection
2. Age 20 to 50 years old
  1. Cervical Disc Herniation
  2. Cervical Neck Strain
3. Age >50 years old
  1. Cervical Spondylosis
  2. Tumors of the Spine
  3. Vertebral Fracture
  4. Vascular Neck Pain
    1. See Vertebral Artery Injury in Blunt Neck Trauma
    2. See Traumatic Carotid Dissection
Pain characteristics
1. Shooting, stabbing, burning or electrical-like pain (often with numbness or Paresthesias)
  1. Neuropathic Neck Pain (central spinal stenosis, Cervical Disc Herniation)
2. Throbbing or aching pain
  1. Mechanical Neck Pain
Pain Distribution
1. Radicular pain is most common at C6 and C7 (pain in first 3 fingers)
Pain, Paresthesias or weakness into Shoulder and arm
1. Cervical Disc Disease (Cervical Radiculopathy)
2. Thoracic Outlet Syndrome
3. Brachial Plexopathy
4. Peripheral Nerve Injury (Neuropraxia)
  1. See Overuse Syndromes of the Hand and Wrist
Provocative Factors
1. Rotating or bending the neck TOWARD the painful side (ipsilateral)
  1. Cervical Radiculopathy
  2. Facet Joint Pain
2. Rotating or bending the neck AWAY from the painful side (contralateral)
  1. Myofascial Pain
3. Neck extension
  1. Central spinal stenosis
4. Neck flexion
  1. Cervical Disc Disease
5. Coughing, sneezing, or straining
  1. Cervical Disc Disease (Cervical Radiculopathy)
  2. Epidural Abscess
Palliative Factors
1. Abduction of arm on painful, ipsilateral side (abduction relief sign)
  1. Cervical Radiculopathy
Associated symptoms
1. Headaches
2. Back Pain
3. Arthralgias
4. Depressed Mood

History
Red Flags

Intractable, unrelenting pain
1. Tumors of the Spine
2. Primary neurologic conditions
3. Spinal Infections
Fever
1. Spinal Infection (e.g. Spinal Osteomyelitis, Spinal Epidural Abscess, Discitis)
2. Meningitis
3. Tumors of the Spine (e.g. Spine Metastases, Multiple Myeloma, chordoma)
Morning Stiffness or Polyarthritits
Upper Motor Neuron Deficit (hyperreflexia, Clasp-knife spasticity, positive Babinski Reflex), Ataxia, bowel/Bladder dysfunction
1. Myelopathy (spinal tract related neurologic defects)
2. See Transverse Myelitis
3. See Spinal Cord Syndrome
4. See Central Cord Syndrome
5. See Amyotrophic Lateral Sclerosis
Central Neurologic Symptoms (TIA, Drop Attacks, Vertigo, Diplopia, Headache)
1. See Vertebral Artery Injury in Blunt Neck Trauma
2. See Traumatic Carotid Dissection

Risk Factors
General

Obesity
Cervical Spine Injury
Traumatic Brain Injury
Sports associated with neck injury
1. Wrestling
2. Ice hockey
3. Football
Occupations associated with neck injury
1. Office and computer work
2. Manual labor
3. Healthcare
Lifestyle and mental health
1. Major Depression
2. Anxiety Disorder
3. Somatization
4. Tobacco Abuse
5. Sleep Disorders
6. Low job satisfaction or perceived poor work environment

Risk Factors
Serious Neck Pain Causes

Comorbidity associated with more serious neck injuries (including Vertebral Fractures)
1. See Cervical Spine Injury
2. Rheumatoid Arthritis
3. Trisomy 21 (Atlantoaxial Instability)
4. Marfan Syndrome
5. Elderly patient with fall from standing
Conditions Associated with Spinal Infection
1. Intravenous Drug Abuse
2. Immunodeficiency (e.g. AIDS, Diabetes Mellitus, AIDS, Alcoholism, Malignancy)
3. Recent spinal procedure (Spinal surgery, Epidural Anesthesia)
4. Concurrent other infections (Parapharyngeal Abscess, Genitourinary infection, Skin Infection)
5. Hemodialysis
6. Poor Dentition

Causes

See Neck Pain Causes (includes Neck Pain Red Flag)
Cervical Disc Related Symptoms
1. Neck tight or stiff
2. Radicular pain, Paresthesias or weakness into Shoulder and arm
3. Worse with activity, on awakening, with neck extension and with coughing, sneezing, or straining
Spondylosis
1. Older patients with disc Degeneration, disc space narrowing with osteophytes and nerve root compression
2. Disc pain is worse with Cervical Spine flexion, while facet pain is worse with extension
Cervical Neck Strain (or Whiplash)
Vertebral Compression Fracture

Exam

See Neck Exam

Imaging

See Cervical Spine Imaging in Neck Pain

Labs

Not routinely indicated
Indicated in Neck Pain Red Flags (esp. Spinal Infection, Tumors of the Spine, Spondyloarthropathy)
1. C-Reactive Protein (C-RP)
2. Erythrocyte Sedimentation Rate (ESR)
3. Complete Blood Count (CBC)
4. Blood Cultures

Management

Symptomatic management for suspected musculoskeletal causes
1. NSAIDs
2. Acetaminophen
3. Maintain Cervical Spine range of motion
Follow protocols for specific causes
1. See Cervical Disc Disease

Prognosis

Most patients improve over time
1. Cervical Radiculopathy significantly improves without deficit and without surgery in 80-90% by 4 weeks
2. Radhakrishnan (1994) Brain 117: 325-35 [PubMed]
Acute Neck Pain persists or frequently recurs in 50% of patients
1. Women
2. Older Age
3. Mental Illness
4. Cervical Radiculopathy

References