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Neck Pain

  • In adults:
    • Common
    • Usually secondary to degenerative disc disease and arthritis
  • In children and adolescents:
    • Less common
    • When it does occur, the pain often is secondary to a neoplasm or infection.
  • Neck pain also occurs after trauma and is extremely common after motor vehicle accidents.
General Prevention
  • No definite methods of prevention are known.
  • General measures such as the use of seat belts and avoidance of motorcycles are recommended.
  • Neck pain occurs in 10% of the population at any given time.
  • In a 1994 survey of Norwegian adults, nearly 35% of respondents reported experiencing neck pain within the last year.
  • A 1991 study of adults in Finland showed that 9.5% of males and 13.5% of females suffer chronic neck pain.
Risk Factors
Congenital fusions of the spine (Klippel-Feil syndrome) are risk factors.
  • The many different causes can be divided broadly into atraumatic and traumatic types.
    • Atraumatic neck pain usually is a secondary symptom of inflammation, degenerative disc disease, arthritis, infection, or a neoplasm.
    • Traumatic neck pain often is caused by soft-tissue sprains, fractures, subluxations, dislocations, and herniated discs conditions that can exist in elderly patients without any occurrence of trauma.
Signs and Symptoms
  • Pain well localized to the neck
  • Stiffness
  • Cervical radiculopathy
Physical Exam
  • Routine cervical spine examination differs from examination of cervical spine trauma patients.
  • Routine examinations should focus on ROM, regions of tenderness, and neurologic assessment.
    • Note loss of flexion, extension, and rotation.
    • Palpate the posterior ligamentous structures to detect tenderness and the paraspinal muscles for spasm.
    • Perform a careful neurologic examination, including motor testing, deep tendon reflexes, and sensation.
    • Look for upper motor neuron signs and assess muscle strength.
  • Examination of a trauma patient must include the following:
    • Immobilization until neurologic testing rules out neurologic deficit
    • A full neurologic examination, including the anal wink and bulbocavernosus reflex tests
    • Radiographic studies to evaluate the extent of cervical spine trauma
The Spurling maneuver tests for cervical radiculopathy.
  • Laboratory studies are indicated if spine abnormality is not present.
  • For suspected infection, white blood cell count and ESR should be obtained.
  • Conventional radiographs:
    • Indicated in patients with history of neck trauma and those >50 years old
    • AP and lateral radiographs are the 1st step in imaging.
    • Other useful views include:
      • Oblique views to evaluate the neural foramen if osteophytic nerve root impingement or facet dislocation/subluxation is suspected
      • Open mouth view to evaluate for C1 fractures (atlas) or odontoid fractures
      • Flexion/extension views to evaluate for segmental instability
  • MRI and CT are indicated in the presence of neurologic abnormalities and to evaluate for occult fractures and ligamentous injuries.
    • Both are sensitive and specific modalities with which to detect structural abnormalities.
    • May be used independently or in combination
    • CT is the most useful for detecting osseous abnormalities such as fractures, facet dislocations, and osteoid osteomas.
    • MRI is useful for detecting abnormalities in the marrow or soft-tissue structures, such as nerve root impingement or spinal cord compression, as well as disc herniation and foraminal stenosis.
Differential Diagnosis
  • Adults:
    • Atraumatic:
      • Degenerative disc disease
      • Inflammatory arthritis (rheumatoid arthritis, AS)
      • Infection (discitis, vertebral osteomyelitis, meningitis)
      • Herniated disc
      • Neoplasm
    • Traumatic:
      • Ligament sprain
      • Fracture
      • Subluxation and dislocation
      • Herniated disc
  • Children:
    • Atraumatic:
      • Rotatory subluxation
      • Abscess
      • Osteomyelitis
      • Neoplasm
    • Traumatic:
      • Ligament disruption
      • Fracture
      • SCIWORA
    • SCIWORA:
      • Occurs in 19-34% of pediatric spinal cord injuries
      • Neurologic deficits after trauma may be delayed up to 4 days in young children, and a 2nd such injury may occur as many as 10 weeks after the trauma.
      • Transient posttraumatic neurologic symptoms in the arms or legs should be evaluated carefully.
General Measures
  • Most patients with neck pain suffer from an inflammatory process.
  • Rest and NSAIDs are the mainstays of treatment.
  • Soft cervical collars are useful for support and to prevent additional injury, but the clinician should avoid prolonged immobilization to prevent deconditioning of the cervical paraspinal musculature.
  • Posture modification and changes in sleep position are important nonsurgical treatments that may be beneficial in treating neck pain.
  • Exercise can be important in maintaining ROM and strength of the cervical paraspinal musculature.
Special Therapy
Physical Therapy
  • Physical therapy is useful for regaining ROM and strength of the paraspinal muscles.
  • Gentle traction of the spine can be useful for decreasing nerve root irritation.
  • NSAIDs are the drug of choice for decreasing inflammation.
    • Usually prescribed initially for 4-6 weeks
    • If the pain has resolved at that time, the medication may be discontinued.
  • All efforts should be made to treat axial neck pain nonoperatively because surgery for isolated axial neck pain has worse outcomes than surgery for other causes (e.g., cervical spinal stenosis).
  • Most commonly, surgery is performed to remove nerve root or spinal cord compression from degenerative disease, trauma, and neoplastic disorders.
  • Relieving localized neck pain often is a difficult task because of the diversity of its causes, including idiopathic origins.
  • A combination of physical therapy, occupational therapy, and NSAIDs is the best course of treatment for neck pain not caused by a tumor or an infection or not associated with neurologic deficits.
  • The prognosis for nonoperative treatment usually is good unless the cause is a malignant bone tumor.
  • The major complication is progressive neural deficit from nerve root or spinal cord compression.
  • Symptoms of nerve root or spinal cord compression include:
    • Weakness in the arms and hands
    • Sensory deficits in the upper extremities
    • Difficulty in walking
    • Bladder and bowel abnormalities
Patient Monitoring
Patients are followed at 4-6-week intervals until the discomfort resolves.
723.1 Cervicalgia
Patient Teaching
  • Patients with neck strains (whiplash injuries) are counseled that full recovery can be expected in the motivated patient.
  • Patients with severe cervical degenerative disease generally improve but may have chronic, mild to moderate symptoms after treatment.
  • Patients who spend a substantial amount of time using a computer should be counseled to take breaks often and to attempt to maintain appropriate posture.
Q: What is SCIWORA, and in which patient population is it most commonly seen?
A: SCIWORA is an acronym for spinal cord injury without radiographic abnormality, and it is usually seen after trauma in children.
Q: In which infectious disease is neck stiffness a common symptom?
A: Meningitis.

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