Neck Pain

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Neck pain is less common than low back pain but still a relatively common reason for seeing a primary care physician. Therefore, it is necessary for the primary care physician to be comfortable with salient points in the history and to be able to perform a basic neurologic examination. Important aspects of the history and physical examination are reviewed. Important clinical syndromes and treatment options are also reviewed.

Section snippets

What is the prevalence of neck pain?

The lifetime prevalence of neck pain is less than that of low back pain. At the same time, there are fewer epidemiologic studies on neck pain available for review.1, 2 Studies suggest that perhaps two thirds of individuals experience neck pain at least once during their lifetime.3, 4 Visits to a primary care physician for the treatment of neck pain, particularly in the geriatric population, is not uncommon.1, 5 The prevalence of neck pain increases with age and is more common in women than men.6

What are the risk factors for neck pain?

Risk factors are better established for low back pain than neck pain, but many risk factors probably are common to both (see the article on low back pain elsewhere in this issue). As noted in the discussion on whiplash to follow, gender and rear-end automobile accidents are risk factors. Older age also is a risk factor.7, 8

What anatomic essentials does a primary care physician need to know to diagnose and treat the causes of neck pain?

The spinal column must be rigid enough to support the trunk and the extremities, strong enough to protect the spinal cord and cauda equina and to anchor the erector spinae and other muscles, and yet sufficiently flexible to allow for movement of the head and trunk in multiple directions. The anatomic organization of the spinal column and related structures allows for all of this, but at a price because the combined properties of rigidity and mobility can lead to many problems. The spine is most

What are the essentials in the history that help to define the nature of neck pain?

Although the approach to history taking for neck pain is similar in many respects to that for low back pain there are enough differences to warrant a separate discussion (see also the article on low back pain elsewhere in this issue). Patients with cervical disorders of one type or another may present with lower extremity and bladder or bowel symptoms often with only minimal neck pain. It is important in patients with suspected neck disorders to ask about symptoms referable to lower extremities

What are the essentials of the physical examination?

On inspection of the head and neck, findings of reduced spontaneous head movement, head tilt, and neck deformity all raise the possibility of an underlying vertebral column disorder or deformity. Palpation and percussion of the neck/cervical spine, as with low back pain, have a low yield with regard to identifying a specific process. However, paracervical tenderness or other changes such as palpation of a mass do offer support for the diagnosis of a vertebral column disorder.

A gait assessment

What is the cause and what is the best treatment approach for patients who present with nonradiating neck pain?

The causes and treatment approach to neck pain are similar to the causes and treatment approach to low back pain (see article on low back pain). Patients presenting with acute and chronic neck pain generally also complain of neck stiffness and reduced mobility. The pain typically is reduced when the patient is recumbent. As with low back pain, if the pain is not reduced by recumbency, vertebral column infections and metastatic cancer should be considered.1, 11, 12

The precise generator of pain

How common are cervical radiculopathies, and how do they present?

Although there are many causes of cervical radiculopathy, the most common is intervertebral disk herniation and cervical spondylosis.17 People in their 40s and 50s are particularly at risk for disk herniation. According to one study, the annual incidence of disk herniation is 83.2 per 100,000, an incidence substantially lower than lumbosacral disk herniation.18 Risk factors include heavy manual jobs, operation of vibrating equipment, lifting heavy objects, frequent automobile travel, smoking,

How do patients with cervical canal stenosis present?

Cervical stenosis may be clinically silent for long periods, sometimes throughout life. Although cervical stenosis and resultant myelopathy can be caused by many pathologic processes, including trauma with resultant hyperextension in the presence of congenital stenosis (a concern in contact sports) and central disk herniation, the most common cause is spondylosis (degeneration).19 About 80% of people by age 50 and virtually 100% of people by age 70 have cervical spondylosis to some degree.1

What is whiplash and how should it be treated?

There are few spinal disorders that are more controversial and contentious than whiplash. Approximately 1 million whiplash (flexion-extension) neck injuries occur annually in the United States, 85% of which are the result of rear-end automobile collisions.1, 23 In contrast to most other injuries, there is a female preponderance of 2:1.1, 23 Some authors have speculated that this gender difference reflects a woman's smaller, less muscular, neck.1, 23

Whiplash can result in a variety of symptoms

What is the role of the facet joint in neck (spine) pain?

The role of the facet (zygapophyseal) joint in the pathogenesis of neck (and low back) pain is controversial.1, 33, 34, 35 The lack of localizing specificity of neck pain from the history and physical examination can contribute to this confusion. Although degeneration of the facet joint probably produces pain in some, every clinician is aware of the patient with severe degenerative spine/facet joint disease with no associated pain. Nonetheless, there still is considerable clinical evidence

Can fibromyalgia present as neck and shoulder pain?

Fibromyalgia is a chronic widespread musculoskeletal pain syndrome of unknown etiology, present by definition for at least 3 months. At its zenith, it usually is generalized to such a degree that it is not confused easily with pain secondary to a localized spine disorder. Early in the evolution of fibromyalgia, however, neck, shoulder, and low back pain may predominate. In addition to aching pain, symptoms include depression, fatigue, malaise, stiffness, disturbed sleep, headache, paresthesia,

How is an acute cervical radiculopathy caused by disk herniation/spondylosis best managed?

Treatment approaches to cervical radiculopathy are similar to lumbar radiculopathy (see the article on low back pain elsewhere in this issue). As with nonspecific acute spine pain, acute radiculopathy is often a self-limiting disorder with recovery expected over a period of weeks.40, 41 The initial management of acute radiculopathy need not differ from the treatment of acute nonradiating neck pain. This is particularly true in the absence of significant weakness. In this setting, relative

Is chiropractic manipulation useful in treatment of neck pain?

Chiropractic manipulation for the treatment of spine symptoms including neck pain is a common practice in the United States. Chiropractic treatment is approved by many insurance companies. Chiropractic is the invention of Daniel David Palmer in 1895. At that time, he was a dry goods grocer and part-time magnetotherapist. Chiropractic is based on a theory that all disease is a result of interference with the body's “innate intelligence” by misaligned vertebrae. Some studies have shown marginal

Are there any other complementary and alternative medical treatments that might be of value for patients with neck pain?

There are a variety of complementary and alternative medical (CAM) treatments available for most medical/neurologic conditions. With regard to the treatment of neck pain, the most common CAM treatments, other than chiropractic manipulation, are massage therapy and acupuncture. There is some evidence to suggest that therapeutic massage may be of value in patients with neck pain, in particular nonradiating neck pain.47 Although scientific validation is limited, massage is safe and appears to

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