NECK PAIN : PAIN PHYSICIAN’S PERSPECTIVE
One of the early milestone in development of a new born is head control and this signals the development of neck muscles. In today’s era, neck pain is one of the most common complaints in clinical practice. work ergonomics and poor posture are the important causative factors. With the advent of technology computers and digital technology has become an inseparable part of common man’s life. Fear of pain is disabling than pain itself, hence patient education must be part of treatment. The three main concern changes are :
- lifestyle changes
- posture in day to day activities
- ergonomics at work place
DEFINITION: Neck pain is defined as “pain perceived anywhere in posterior region of cervical spine from superior nuchal line to first thoracic spinous process. Neck pain is one of the most common complaint and a major health issue. It is more common in adult population with an incidence of 15% in males and 25% in females in age group of 21 years to 55 years. Chronic neck pain can be defined as widespread sensation and hyperalgesia in the skin, muscles, ligaments in both active and passive movements in neck and shoulder region.
APPLIED ANATOMY AND PHYSIOLOGY OF CERVICAL SPINE
Neck pain is the second most common type of spine pain after low back pain. Several structures in the cervical spine can be the source of pain. Hence it is important to understand the anatomy of these structures which can aid in diagnosing painful conditions of the neck. Risk factors for developing neck pain include stress, heavy work or work in prolonged neck flexion, depression and anxiety.
CERVICAL VERTEBRAE
There are seven cervical vertebrae out of which three are atypical and four are typical vertebrae. The cervical spine is convex anteriorly. The typical vertebrae are from C3-6 having similar anatomical characteristics.1The atypical vertebrae are C1, C2 and C7 vertebrae, which have unique characteristics that make them different from each other and also from the typical vertebrae.
The cervical vertebrae also are supported by numerous ligaments just like in the lumbar region such as anterior and posterior longitudinal ligaments, interspinous, supraspinous ligaments and ligamentum flavum. The cervical spine is also supported by numerous muscles.
INTERVERTEBRAL DISCS
Intervertebral disc is absent between C1 and C2 vertebrae and is present at all other levels.It has annulus fibrosus, nucleus pulposus and end plates. There are some differences between cervical and lumbar intervertebral discs. The cervical discs are much contained within the vertebral bodies than in the lumbar area due to the concavity on the upper surface. The annulus is also much thicker posteriorly than in the lumbar region. The nucleus pulposus is located more anteriorly within the disc as compared to the lumbar discs and disappears early in life than their lumbar counterparts. Hence cervical disc prolapse is uncommon after the age of thirty.
THE VERTEBRAL CANAL, INTERVERTEBRAL FORAMEN AND THE NEURAL STRUCTURES (SPINAL CANAL)
Image of cervical vertebrae with cervical epidural space and structures traversing the epidural space
The spinal canal in the cervical region is formed by vertebral foramina of all the cervical vertebrae. The normal antero posterior spinal canal diameter in cervical region is 14± 1.5mm.5 When the canal diameter is reduced to less than 10mm, the spinal cord gets compressed leading to quadriparesis or quadriplegia, sensory loss from the level of neck below, bowel and bladder disturbances. This condition is called as cervical myelopathy which is a surgical emergency. The spinal cord with each cervical spinal nerve exits via the intervertebral foramen which is directed antero laterally and slightly inferiorly. Each cervical spinal nerve runs above their respective vertebra except for the C8 nerve which runs above T1 and below the C7 vertebra as there is no eighth cervical vertebra.
FACET JOINTS: The zygapophyseal facet joints are true joints with cartilaginous surfaces lined with synovium, containing synovial fluid. They provide a guiding and gliding movement between the adjacent cervical joint. Each facet joint is formed by the articulation of superior articular process of one vertebra and inferior articular process of the immediate upper vertebra. Facet joints are supplied by medial branch of the dorsal rami of the spinal nerve of that level and also the medial branch from the immediate upper spinal nerve. The unique anatomy of cervical spine and upper extremity balances the attributes of strength and stability with those of flexibility and range of motion.
RED FLAGS:Though chronic neck pain is commonly due to myofascial pain syndrome or facet joint arthropathy, red flags should be rule out. As cervical canal is almost completely occupied by spinal cord, minor reduction in canal diameter will lead to cervical myelopathy, hence careful assessment is important to identify early signs of myelopathy. Occasional patients develop high spinal cord compression leading to quadriparesis, respiratory insufficiency, and death.
RED FLAGS
1. History of trauma- Fracture leading to unstable spine, cord compression, myelopathy, vertebral body fracture.
2.Fever, malaise, nuchal rigidity- meningitis, epidural abscess.
3. Sudden weight loss, anorexia, night pain- cervical tumors, metastatic lesions, SOL leading to cord compression, vertebral compression fractures.
4. Progressive disturbance of gait, progressive motor or sensory deficits, bladder bowel incontinence- cervical myelopathy.
5. Acute progressive neurologic and cognitive deficits accompanied by hemodynamic instability- Dissecting vertebral artery aneurysms. Dissecting extra cranial carotid artery aneurysms.
6. Associated chest pain, tachycardia, and breathlessness on exertion- Ischemic heart disease, Cervical angina syndrome.
7. Associated Horner’s syndrome- Pancoast tumor of the lung.
8. History of Rheumatoid arthritis, morning stiffness >30 mins.
HISTORY OF THE PATIENT
1. AGE OF ONSET:
In pediatric and adolescent patients, trauma or sports injuries are common causes for neck pain. Congenital defects such as Chari I malformations, short neck syndromes can also lead to neck pain in these age groups1. In middle aged adults inflammatory arthritis such as rheumatoid arthritis, seronegative spondyloarthropathies like ankylosing spondylitis, psoriatic arthritis, and reactive arthritis should be consider in differential diagnosis. Degenerative changes are common in older patients.
2. LOCATION OF PAIN:
It helps us to know the underlying pain generator. Pain generators in joints and muscles are usually localized. Nerve root compression pain is dermatomally distributed and pain along the peripheral dermatomal distribution suggests lesions of the cervical or brachial plexus or their branches. Axial neck pain is due to internal disc disruption, bilateral facet joint. Paramedial pain suggestive of facet joint and its referred pain, myofascial pain or other neck pathologies. Widespread pain can be seen in fibromyalgia, osteoarthritis, rheumatoid arthritis, SLE, hypothyroidism or somatization in severe depression. Infections and neoplasms can cause axial neck pain through bone destruction with irritation of vertebral body periosteal nerves and altered biomechanics of the facet joints and cervical discs3.
3. REFERRED PAIN:
Cervical and brachial referral patterns may be secondary to myofascial trigger points or referred pain from cervical facet joints. Pain commonly is referred from the shoulder, heart, lungs, viscera, or temporomandibular joint to the neck region owing to overlapping nerve distribution. Referred pain to the occiput usually indicates pathologic changes in the upper cervical spine and may radiate down the neck and to the ear.If the face, head, or tongue is involved, the upper three nerve roots of the cervical plexus may be affected. Numbness of the neck, shoulder, arm, forearm, or fingers indicates involvement of C5-T1.
4. DURATION OF PAIN:
Acute pain due to trauma, infection, disc prolapse with neurodeficit, vascular dissection with hemodynamic instabilities must be aggressively investigated and treated to avoid major complications and death. More gradual or insidious onset is common in progressive degenerative, inflammatory or malignant process.
5. CHARACTER OF PAIN:
Musculoskeletal pain is dull, aching, deep, throbbing in nature. Neuropathic pain are sharp, shooting, electric shock like with tingling and numbness. Nerve root involvement pain is dermatomally distributed and describes along these areas. Articular symptoms arise from the facet and vertebral joints causing stiffness and localized pain. Poorly localized, burning pain characters are seen in sympathetically mediate pain. Hyperesthesia, allodynia and burning pain suggests Complex Regional Pain Syndrome (CRPS).
6. PROGRESSION OF NEURO DEFICITS:
Any progression of sensory or motor dysfunctions due to nerve root or cord compression must be considered as red flags and treated accordingly. Myelopathy can be due to mass effect from a tumor or infection or instability owing to systemic arthritis or connective tissue disorders, but it is often a result of advanced degenerative changes within the cervical spine and large central PIVD.There can be bladder and bowel disturbances with loss of proprioception due to dorsal column compression leading to gait disturbance. Upper motor type of lesion in lower limb, described as stiffness in lower limbs and lower motor type of lesion in upper limb at the level of compression, described as weakness and looseness in upper limb.
7. AGGRAVATING AND RELIEVING FACTORS:
Pain due to spine involvement will be aggravated during movements. Facet joint pain will be aggravated by neck extension, lateral flexion and lateral rotation. Atlanto-occipital joints arthritis is worsened with provocative neck flexion and extension, whereas atlantoaxial arthritis is worsened with rotation.Discogenic pain will be more in forward flexion. Myofascial pain will be aggravated by muscle stretching and over tender points palpation. Radiculopathy pain will be relieved by arm abducted and externally rotated over head. Chronic inflammatory pain is often worse after a period of inactivity and improves with exercise. Degenerative arthritis is often exacerbated by exercise and improves with rest1.
8. ASSOCIATED SYMPTOMS:
Inflammatory arthritis manifests as morning stiffness, polyarthritis, rigidity and skin manifestations.
Rheumatoid arthritis often involves the cervical spine, initially causing stiffness and later causing pain. After the hands and feet, the cervical spine is the most common site of disease involvement in rheumatoid arthritis.
Ankylosing spondylitis often affects the entire axial skeleton with early limitation of lumbar motion and chest expansion and later involvement of the cervical spine3
Fever night pain and weight loss suggestive of infectious etiology.
Dyspnea can be related to a deficit in the C3-C5 innervations of the diaphragm. Palpitations and tachycardia secondary to cervical spine pathology can be differentiated from other causes by the fact that these symptoms are associated with unusual positions or hyperextension of the neck. This hyperextension is caused by irritation of C4 innervation of the diaphragm and pericardium or by irritation of the cardiac sympathetic nerve supply. Drop attacks suggest posterior circulation insufficiency. Sever night pain, anorexia, progressive myelopathy is associated with malignancy. Eye and ear symptoms may arise from irritation of the plexus surrounding the vertebral and internal carotid arteries. Eye symptoms can manifest with blurring of vision relieved by changing neck position. Altered equilibrium with associated gait disturbances may result from irritation of the surrounding sympathetic plexus or from vertebral insufficiency.
.OCCUPATIONAL HISTORY:
Jobs requiring hyperextension of neck for overhead work are prone for occipital neuralgia and cervicogenic headache due to upper cervical spine involvement, where as job requiring prolonged neck flexion such as computer work are prone for interspinous ligament sprain and lower cervical spine involvement.
FAMILY HISTORY:
Rheumatoid arthritis, ankylosing spondylitis, Reiter’s syndrome and psoriatic arthritis runs in a family and also tumors like schwanoma, neurofibromas, compressing cervical cord seen in familial neurofibromatosis type . Family history of diabetes, hypothyroidism will help to identify diabetic neuropathy and widespread pain
INSPECTION:
a. Skin-skin over neck and upper limb is inspected for post herpetic vesicular scaring which will be dermatomally distributed and do not cross midline in cases of post herpetic neuralgia. Psoriatic skin eruptions can be seen in psoriatic arthropathy. Signs of inflammation like erythema, swelling, redness can be present in local pathologies of neck.
b. Head and neck posture – Patient with neck pain tries to stabilize joint by surrounding muscle contraction to avoid movement aggravating pain.
c. Shoulder symmetry-In cases of shoulder pathologies or neck muscles contraction in myofascial pain, shoulder joints will be drooped or pulled upward.
d. Muscle wasting-Gross muscle wasting can be seen on inspection suggestive of motor nerve fiber involvement like brachial plexopathy. It will be present in both upper and lower limb in case on myelopathy.
RANGE OF MOTION: It may reveal pain or limitations in flexion-extension, lateral bending, and rotation. extension, There is a natural decrease in range of motion with age, even in healthy individuals. It is also reduced in the presence of cervical spinal muscular spasm or pain. Lateral flexion is the earliest and most impaired movement in degenerative diseases with rotation first impaired in rheumatoid arthritis owing to involvement of the odontoid peg. A uniformly stiff neck may be caused by diffuse idiopathic skeletal hyperostosis, which is present in a quarter of elderly patients, but also may be due to ankylosing spondylitis or recent trauma to the neck . If articular signs are found, the examiner must evaluate the entire vertebral column and peripheral joints for evidence of further arthritis and search for extra-articular manifestations
TREATMENT OF NECK PAIN
TREATMENT OF ACUTE NECK PAIN-
Just like acute low back pain, acute neck pain also has a favorable prognosis, where up to 40% of patients recover fully from neck pain and about 30% of patients will continue to have mild symptoms.1 Hence the treatment of acute neck pain should not be aggressive in the absence of red flags. In fact a multivariate analysis showed that the highest rate of recovery from the neck pain was seen in those cases where the treating general practitioners adapted a conservative “wait and see” approach than in those cases where the cases were referred to a specialist for additional management. 2
Pharmacological management
Although the evidence is poor, analgesics have been used for the symptomatic treatment of neck pain. Paracetamol, NSAIDs like Ibuprofen, Naproxen are used to reduce pain and inflammation .Muscle relaxants are used to reduce spasm and spasticity. Opioids like tramadol ,codeine are the frequently used drugs in debilitating conditions. Other drugs used are antispastic agents and antidepressants.
Local transdermal patches
Non-pharmacological management
Patients should be advised to stay active and to resume to the normal activities. Staying active helps in speedy recovery compared to the use of cervical collar and rest.
Conventional treatment like physical therapy which includes strengthening and stretching exercises promote an increased range of motion and elasticity in neck muscles.
Gentle neck exercises , active release techniques which are performed at home are quiet effective and should be encouraged.
MANAGEMENT OF RED FLAG SYMPTOMS
Presence of red flags indicates serious underlying pathology and hence there is no role for conservative management. Hence one should not miss to identify the red flags. In case of red flags, imaging of the spine is a must and urgent neurosurgical referral is warranted for surgical management like decompression of the space-occupying lesion such as abscess, hematoma, tumor, huge disc prolapse or fixation of vertebral fractures in case of neurodeficits , dislocations and trauma
TREATMENT OF CHRONIC NECK PAIN.
Neck pain persisting for more than 3 months with or without treatment, is labelled as chronic neck pain. Chronic neck pain responds poorly to conservative treatment and hence invasive treatment like percutaneous interventions are recommended.
1.Medial branch block for facet joint pain
Facet joint arthropathy in the cervical region is a common cause of neck pain than in the lumbar region. The pain is usually unilateral, paramedian, aggravated on neck extension and lateral rotation3. Paramedian tenderness over the facet joints is present. As in lumbar region, x-ray or MRI is not diagnostic. Fluoroscopy aided medial branch block with > 50% (80% according to some studies) pain relief is diagnostic. This can be followed by radiofrequency ablation of themedial branches for long term pain relief.
2.Cervical epidural steroid for cervical radicular pain4
Cervical radiculopathy is usually caused by prolapsed cervical intervertebral disc. The pain is usually dermatomal depending on the nerve root affected with electric shock like sensation. It is usually associated with tingling and numbness. Cervical interlaminar epidural steroid injection under fluoroscopy is the commonly done procedure for the cervical radicular pain.it providesgood pain relief to the patient by reducing inflammation and pain.
3.Interventions for myofascial pain
Myofascial pain of the trapezius muscle is again a common cause of neck pain. The pain is aching type, aggravated by passively stretching the muscle (contralateral neck flexion). Trigger points, taut bands can be palpated within the muscle. Trigger point injection using local anaesthetic and steroid produces dramatic relief . Dry needling or Intramuscular Stimulation are the treatment of choice in chronic cases of muscle spasm and stiffness of neck muscles. Botox injections are also nelpful in relieving trigger point pain.
ADVANCED PROCEDURES
1: Radiofrequency Denervation of spinal nerves if neuropathic element is the cause of pain.
2: Vertebroplasty for fractured vertebra
3: Spinal Cord Stimulation and drug delivery systems are used to treat neck pain in resistant and debilitating cases
4:Surgical interventions – in presence of red flags.
Neck pain is a potentially disabling condition which if not treated early can land in chronic stage. A number of novel approaches as described can reduce the pain effectively. Neck and shoulder exercises to improve the strength and range of motion are effective in relieving pain. Exercises also help in improving posture. All patients suffering from neck pain must seriously follow exercise program.
EXERCISES: Physical activity and in graded form exercise must be incorporated as an important lifestyle change in all patients and rest for long time must be reserved only for acute cases. The exercise program includes 5 main type of exercises: stretching exercises, strengthening exercises to improve the circulation, endurance , Aerobic exercises and mobilisation and ROM . Heat therapy and ice pack play an important role as they relax the muscles spasms . Not every pain in the neck is necessarily cervical in origin. One needs to assess and diagnose accurately with targeted history and physical examination .
NECK STRETCHES AND STRENTHENING EXERCISES
POINTS TO REMEMBER;
1.MRI of the cervical spine is indicated only in the presence of red flags. This is a commonest myth among the treating physicians and the patients that MRI of the cervical spine can detect the cause of the neck pain and hence should be done in each case of neck pain.
2-A normal MRI scan in a symptomatic patient doesn’t mean that there is no spinal pathology. In fact, MRI cannot reliably identify the source of neck pain particularly the discogenic pain, cervical facet pain and myofascial pain. In these cases the diagnostic interventions are more helpful in confirming the diagnosis rather than imaging moda
3.Prolonged bed rest is not indicated in low back pain. Similarly complete rest is also not indicated in cases of neck pain. Active neck movements within the limit of pain help in faster recovery than prolonged rest.
4.Use of cervical collar is not mandatory as it may be harmful if used for prolonged duratipn. Initial transient pain relief can be obtained due to immobilization but on a long term use, disuse atrophy of the neck muscles which are the important support for the cervical spine has been reported. Hard and rigid cervical collars are useful in stabilizing the cervical spine in cases of cervical spine fracture or subluxation/ dislocations to prevent further damage .
5. There is insufficient evidence to support the need for cervical traction in cases of cervical radiculopathy. In my experience cervical traction has increased the severity of pain and also tingling numbness when advised by treating physicians.
REFFERENCE
1. Fauci AS, Braunwald E, Kasper DL, Hauser SL, Longo DL, Jameson JL, et al., editors. Harrison’s principles of internal medicine;18th ed; New York; McGraw Hill; 2012.p.140.
2. Gary S. Firestein GS, Ralph C. Budd, Gabriel SE, O’Dell JR, McInnes LD;Kelley’s Textbook of Rheumatology; 9th Edition; Philadelphia; Elsevier; 2013.p.628-637.
3. Crockard HA. Surgical management of cervical rheumatoid problems. Spine. 1995; 20: 2584-2590.
4. Van Zundert J, Huntoon M, Patijn J, Arno Lataster A, Nagy Mekhail N, van Kleef M. Cervical radicular pain. Pain Practice. 2010; 10(1): 1-17.
5. Sforza C, Grassi G, et al. Three-dimensional analysis of active head and cervical spine range of motion: Effect of age in healthy male subjects; Clin Biomech (Bristol, Avon) 2002; 17: 611-614.
6. Waldman SD. Pain Management. 2nd ed. Philadelphia; Elsevier ,Saunders; 2011; p.526.
7.Evidence based management of acute musculoskeletal pain. A guide for clinicians. Australian, Passchier J, Koes BW. Clinical Course and Prognostic Factors in Acute
8. Van Eerd M, Patijn J, Lataster A, Rosenquist RW, van Kleef M, Mekhail N, et al. Cervical Facet Pain. Pain Practice. 2010; 10 (2):113–123. academic press. Bowen Hills. 2004. 9.Vos CJ, Verhagen AP REFERENCES Neck Pain: An Inception Cohort Study in General Practice. Pain Medicine. 2008; 9 (5): 572-580.
.
By Dr. Sunita Lawange
Consultant Physician,
Director, Ashwini Pain and Spine Center
President Elect, ISSP, Nagpur
