Neck Pain

Department of the Navy
Bureau of Medicine and Surgery

Cervical pain is nearly as common as low back pain. In the working population between the ages of 25 to 29, nearly 30 percent will have one or more acute attacks of neck pain. Usually it is less disabling than low back pain. Neck pain with radiation to the arm increases with age and has been experienced by nearly one quarter of working men by age 45.

The HPI should include the following points:

The review of systems must include cardiac, respiratory, rheumatologic, psychological, and gastrointestinal complaints.

Physical examination

Even though the physical exam is centered on the neck, a more systematic comprehensive examination should also be performed.

Laboratory and radiological studies

Laboratory testing may be limited to a CBC and erythrocyte sedimentation rate in certain circumstances. X-rays should include an AP and lateral cervical spine, with additional open-mouth odontoid view and obliques, when neurologic symptoms are noted. Flexion-extension views occasionally will reveal instability. Only the consultant should order a myelogram, computerized tomography (CT), and magnetic resonance imaging (MRI).

The differential diagnosis is quite broad and can include congenital and developmental problems (partial fusions), post-traumatic and degenerative problems, and rarely neoplastic, inflammatory, (rheumatoid arthritis or ankylosing spondylitis), infective, or metabolic abnormalities. Most commonly, the problem relates to normal aging changes, disc degeneration, postural and over-use difficulties.

Occasionally, visceral pain is referred to the neck, arm, and shoulder. Anginal pain is referred to the jaw, neck, left shoulder and arm and should always be considered. Vascular, gall bladder, pancreatic, and pulmonary problems can include radiating pain to the posterior thorax, neck, shoulder, and arm. Toxic and metabolic neuropathies can simulate cervical radicular pain. Psychological disorders, such as depression, can exacerbate neck pain; or through postural manifestations can be causally related.

Usually after a thorough evaluation (history, physical exam, CBC/ESR and x-rays), a worrisome diagnoses can be ruled out and treatment can be tailored to the common neck complaints. Mild to moderate nonradicular or mild radicular pain and stiffness can be treated with activity modification (light duty to exclude heavy lifting, hard pulling, overhead work, etc.), neck rest, medication acetaminophen, aspirin, or other non-steroidal anti-inflammatory (NSAID) medication, light massage, and ice or heat.

More severe pain or a significant radicular component may require greater activity restriction and addition of a soft cervical collar and time-limited (3-5 days) use of acetaminophen with codeine. Discussion about appropriate neck mechanics is helpful. For mild or chronic symptoms, a physical therapy evaluation with treatment can be helpful to encourage proper posture and proper work positioning to decrease neck stresses. Neck isometric exercises are useful for maintaining tone and strength.

Neck range of motion exercises may aggravate symptoms and probably should not be emphasized. With radicular symptoms, avoidance of neck extension is recommended. Proper pillow selection and use are very helpful since large or firm pillows force neck flexion and increase pain. A soft pillow filling the "hollow" of the neck is beneficial. A pillow pulled into position when turning onto the side may help avoid painful and unprotected lateral neck bending.

Indications for immediate referral to orthopedics or neurosurgery include the following findings:

• Constitutional symptoms or studies (leukocytosis or elevated erythrocyte sedimentation rate) suggesting tumor or infection.

• Evidence of spinal cord compression and myelopathy (gait disturbance, Babinski, leg weakness or sphincter disturbance), severe and unremitting arm pain, or progressive neurologic deficit.

• Expeditious referral should occur with complaints of pain out-of-proportion, significant nighttime pain, significant arm pain or persistent weakness.

• A routine consult should be obtained for chronic neck pain, pain with no objective findings, pain with mild or intermittent paresthesias with normal motor, sensory, and reflex examination. Patients with these problems should be exempted from those portions of the physical readiness program that directly aggravate symptoms (eg. sit-ups, push-ups, etc.).

References

1. Hoppenfeld, S. Physical Examination of the Spine and Extremities, Appleton-Century-Crotts, 1976.

2. Sherk, H. & Cervical Spine Research Society Editorial Committee. The Cervical Spine. Lippincott. 1989.