Most of the times, neck pain occurs with an unknown cause. Potentially serious causes of neck problems usually result from injuries or degenerative or inflammatory diseases of the cervical joints. Given the proximity of the nerve and joint structures (of the joints and nerves) in the spine of the neck, joint disease has the potential to result in neurological pain, generally the most serious of cervical pathology.
Severe cervical pathology produces symptoms beyond the confines of the cervical region, sometimes without symptoms in the neck itself, and these symptoms are typically neurological in nature. Any disorder associated with cartilage or disc wear, rheumatoid arthritis, polymyalgia rheumatica, spondyloarthropathies, and fibromyalgia are associated with symptoms in the neck region.
To address this problem, the three most important pieces of information are duration, history, and musculoskeletal symptoms in other parts of the body. When the pain is of recent appearance, without previous injuries, is limited to the neck, and there are no other specific indications, a simple symptomatic therapy should be offered. When there is a history of trauma or injury, often as neck hyperextension, a conservative evaluation and diagnosis should be initiated.
Neck pain associated with general musculoskeletal pain leads to fibromyalgia, while neck pain with synovitis (inflammation of the synovium) of the peripheral joints suggests rheumatoid arthritis or other inflammatory arthropathy. In these cases, the cervical spine will probably not be the best place to investigate. When the problem is more chronic and confined to the neck and shoulder region, especially in older subjects, degenerative diseases are more likely, and simple X-rays can aid in the diagnosis.
Physical exam and diagnosis
The persistence of severe neck symptoms and neurological abnormalities of cervical origin require further investigation. Physical exams should be done covering range of motion and pain during flexion and extension, lateral flexion, and rotation movements. The physical exam may also indicate pain or spasms in the paravertebral muscles of the neck.
Limitations or pain associated with rotational movement generally reflects joint pathology in the C1-C2 cervical vertebrae, since most of the rotation results from movement in these joints.
Plain radiographs of the cervical vertebrae, including open C1-C2 and oblique views that allow visualization of the intervertebral neural foramin, can demonstrate degenerative disease and subluxations resulting from inflammatory arthritis or serious trauma. Computed tomography (CT) may be helpful when flat radiographs are inadequate and a fracture is considered. The role of magnetic resonance imaging (MRI) is limited and is most helpful in identifying the cause of a neurological syndrome (such as a compression of a nerve).
Conservative therapies may be beneficial in treating uncomplicated joint diseases, soft tissue injuries, and other painful neck syndromes. Many patients can benefit from the use of cervical collars for evening and night use as well as ergonomic pillows. Physical therapy, including local application of heat, massage, and ultrasound modalities can help, but interrupted traction (performed at home) is generally the most favorable therapy, and in rare cases is contraindicated (significant subluxations). Other appliances that go over the doors with hydraulic weights are inexpensive and easy to use.
Nonsteroidal anti-inflammatory drugs are rarely studied in the setting of neck pain, but benefit can be expected in patients with inflammatory arthropathies. Few studies have evaluated agents marketed as muscle relaxants in patients with neck pain presumably of muscle origin, but agents such as cyclobenzaprine are reliable and can help promote sleep.
Special Neck Pain Syndromes
Whiplash Injury: Soft tissue injury syndrome, called whiplash, often results from rear-end motor vehicle crashes, often when the seat belt is fastened. The head first flexes and then hyper-extends with great force beyond its normal range of motion. Structures affected can include muscles, tendons, joints, ligaments, and perhaps even nerve roots. Pain in the neck and interscapulum area are generally benign within a few hours of the accident. Headaches frequently accompany neck and shoulder symptoms. There are no specific physical findings, loss of cervical lordosis is the only expected radiographic abnormality, and its significance is doubtful.
When symptoms persist for more than 6 months, evidence of pre-existing degenerative disease is usually found. The course of the disease is also influenced by psychological and occupational factors.
Symptomatic therapy with rest and a soft collar is recommended, but there are controlled studies that suggest significant benefits from early mobilization. Physical therapy, including interrupted traction, has been used with variable success, but there is no evidence that any treatment, except for early mobilization, affects the results.
Degenerative disc and joint disease
In young individuals, herniation of the nucleus pulposus of the cervical discs can cause radiculopathies with severe pain in the area of the affected nerve root. The syndrome is characteristically aggravated by forced lateral flexion to the side of the injury and by pressure applied to the top of the head, and is relieved by manual traction. Herniated disc (also called cervical or lumbar radiculopathy; prolapsed intervertebral disc; or ruptured disc) is an unlikely cause of radiculopathy in an older individual, as the nucleus pulposus is generally lost after age 40 to 45.
In middle and elderly patients, cervical problems related to vertebral discs and joint degeneration usually result from compression of nerve structures by osteophytes. Cervical spondylosis myelopathy (degenerative disc disease) is the most common cause of spinal cord dysfunction in older people. A large osteophyte in the upper region of the cervical spine compressing a vertebral artery can result in temporary ischemic attacks, autonomic symptoms, vertigo, and headaches associated with head movement.
Symptoms suggesting compression of the nerve root, spinal cord, or vertebral artery should be investigated with radiographs, including lateral and oblique, to demonstrate disc and joint disease and the resulting osteophytes. Cervical MRI is the best technique to demonstrate compression of a nerve structure. Once compression is demonstrated, surgical intervention is not necessarily required. Conservative therapy can be as effective as surgery in most cases of radiculopathies.
The most common syndrome that can result from degenerative disc disease and degenerative neck disease is pain in the neck, shoulder, and arm, often prevailing on one side and aggravated or caused by lateral flexion of the head to that side. The syndrome probably results from the entrapment of the nerve roots exiting the intervertebral neural foramina by osteophytes at various levels, but most patients with chronic neck pain do not have radiographically demonstrable osteophytes and the degenerative changes shown on radiographs do not. they are necessarily symptomatic, especially in women. Neck and shoulder pain can be reduced with a cervical collar or ergonomic sleeping pillow, simple pain relievers, or interrupted cervical traction. Head weights should be worn for about 30 minutes twice a day. Most patients respond to treatment within a few days and surgical intervention is rarely necessary.
Cervical spine involvement is important in RA, ankylosing spondylitis, and juvenile polyarthritis. The neck may be affected in patients with other spondyloarthropathies but rarely with crystalline arthropathies. In general, there are two separate problems: pain resulting from the inflammatory process, usually without danger of neurological injury, and disorder or deformity derived from joint damage, typically with risk of deterioration to nerve structures. The highest risk of spinal cord compression occurs with diseases that predominate in the area of the C1-C2 vertebrae, where there are two different synovial joints: the two lateral articular facets and the joint between the odontoid process of C2 (called the axis) and the anterior part of the ring of bone that is C1 (called atlas). The transverse ligament forms the posterior aspect of the atlas-odontoid joint, and is the weakest part of that joint. Subluxations commonly occur at this location, but subaxial subluxations also occur alone or in combination with those at C1-C2.
RA (Rheumatoid Arthritis) is the most common inflammatory arthropathy and the one that can most affect the cervical spine. Half or more of the patients with RA will be affected in the neck, predominantly in the C1-C2 vertebrae. Inflammation of the three synovial joints at this site typically causes pain when rotating the head, often felt in the occipital area. Synovitis can sometimes compress nerves – usually a superior cervical nerve – but pain is more commonly articular in nature and results from inflammation of the synovium. The therapy of choice is some type of anti-inflammatory agent, although a soft cervical collar often helps temporarily.
Later in the course of RA, approximately one third of patients will develop neck disorders, often in the upper cervical area, usually C1-C2. Anterior subluxation is the most common of these disorders; It results from the sliding of the skull and C1 forward in the C2 vertebra with head flexion, as a result of the relaxation in the lateral articular facets and the weakness of the transverse ligament. The lesion is usually demonstrated in a lateral film of the cervical spine with the head in inflection, the space between the odontoid process and the anterior surface of C1 is enlarged 4 or more millimeters.
Most patients with anterior subluxation are well tolerated and have no neurologic complications, but more advanced and unstable lesions can result in myelopathies. Surgical fusion for asymptomatic subluxations is controversial.
Other patients will develop severe erosions in one or both lateral articular facets, resulting in occipital pain with cranial rotation, deformation in the inclination when rotating the head if the injury is predominantly unilateral, or a myelopathy with severe bilateral erosions with a tendency to carry the odontoid superiorly. to the foramen magnum (superior subluxation).
Ankylosing Spondylitis: Of the other inflammatory arthropathies, ankylosing spondylitis is the one that can most affect the cervical spine and cause neck pain. The cervical manifestation is typically late, many times after years of thoracic-lumbar involvement. Final inflammation and ankylosis tend to proceed from inferior to superior, so that the C1-C2 region is generally the last affected.
In the early development of cervical disease, pain and limitation of movement primarily result from inflammation in the facet joints and must respond to anti-inflammatory agents. Later, as the disease progresses, restricted mobility becomes irreversible, although with less pain. The association of C1-C2 in patterns similar to those seen in RA has been reported, but is unusual.
During the course of cervical disease, occasional radiographs showing bone ankylosis or its absence can help predict response to physical therapy aimed at improving function. The neurologic damage in ankylosing spondylitis is perhaps most commonly the result of a cervical fracture of the syndesmophytes and resulting pseudo-articulation. This may require surgery.
Juvenile polyarthritis: The polyarticular form of juvenile arthritis tends to affect the cervical spine. It can cause ankylosis similar to that of ankylosing spondylitis or cervical disease in the C1-C2 area similar to that of adult RA.