Neck pain

Overview

Neck pain is defined as pain that originates in the neck and radiates down one or both arms. Neck discomfort can be caused by a variety of conditions or diseases that affect any of the tissues in the neck, including nerves, bones, joints, ligaments, and muscles. The cervical spine, or neck part of the spinal column, is made up of seven bones (C1-C7) that are separated from one another by intervertebral discs. During exercise, these discs allow the spine to move freely and function as shock absorbers.

Each vertebral bone contains an aperture that creates a continuous hollow longitudinal cavity that traverses the length of the spine. The spinal canal is the space through which the spinal cord and nerve bundles flow. The spinal cord is encased by a protective covering called the dura, a leathery sac, and is bathed in cerebrospinal fluid (CSF).

Neck pain definition

Vertebrae are tiny bones that make up your neck and back. The spinal column is formed by stacking them on top of each other. The spinal column protects the spinal cord and supports your head. This is the major structure that connects your body's neural network. Messages move throughout this network, sending feelings to your brain such as discomfort.

The cervical vertebrae are the top seven bones in the spinal column that make up your neck. Facet joints bind the bones together. These are microscopic joints between your vertebrae that allow you to move your head in any direction by working with your neck muscles.

There are cartilage discs between the vertebrae. The discs operate as shock absorbers and provide flexibility to the spine. When one of these discs moves slightly out of its normal place in the spine, it is called a slipped disc. Non-specific neck discomfort is pain with a postural or mechanical cause, often known as cervical spondylosis. It excludes discomfort linked with fibromyalgia.

Non-specific neck discomfort has a postural or mechanical foundation and affects around two-thirds of the population at some point, particularly in middle age.

• Acute neck discomfort usually fades within a few days or weeks, but in around 10% of cases, it remains persistent.
• Whiplash injuries occur as a result of a quick acceleration–deceleration of the neck, such as in a car accident or a sporting mishap. Up to 40% of persons still report symptoms 15 years after the injury.

Neck discomfort is frequently associated with restricted mobility and poorly characterized neurological symptoms affecting the upper limbs. The pain might be intense and uncontrollable, and it can be caused by radiculopathy or myelopathy. Under the section on neck pain with radiculopathy, we have included research involving persons who have mostly radicular symptoms arising in the cervical spine.

Epidemiology

Neck discomfort is getting more widespread all around the world. It has a significant influence on people and their families, communities, health-care systems, and enterprises. There is significant variation across neck pain epidemiological research, making it difficult to compare or pool data from various studies.

According to existing research, the one-year incidence of neck discomfort ranges between 10.4 percent and 21.3 percent, with a greater prevalence observed in office and computer workers. While some studies claim that between 33% and 66% of patients have healed from an episode of neck discomfort after a year, most instances have an episodic course across a person's lifetime, and hence relapses are likely.

Prevalence is typically greater among women, higher in high-income nations than in low- and middle-income countries, and higher in cities than in rural regions. The start and progression of neck discomfort are influenced by a variety of environmental and personal variables. Most studies show that women have a greater incidence of neck pain and a higher risk of getting neck pain until the age of 35-49, when the risk begins to drop. The Worldwide Burden of Disease 2005 Study is now estimating the global burden of neck pain in terms of disability and activity constraint, with findings expected in 2011.

Etiology 

The cause of simple neck discomfort is unknown. The most common causes of simple neck discomfort include poor posture, anxiety and melancholy, neck strain, work injuries, or athletic injuries. Mechanical and degenerative causes (often referred to as cervical spondylosis) are more probable in chronic pain. Some neck discomfort is caused by soft-tissue damage, which is most commonly observed in whiplash injuries. Disc prolapse and inflammatory, infectious, or malignant disorders seldom damage the cervical spine and cause neck discomfort with or without neurological symptoms.

Symptoms

The most common symptoms are:

Pain and stiffness

• Pain may be felt in the centre or on either side of your neck, but it may also spread to your shoulder or upper chest.
• You may have arm discomfort or weakness.
• You may get tension headaches, in which the discomfort travels to the back of your head and, on occasion, into your ear or behind your eye.
• Moving your neck may be unpleasant, and your muscles may feel stiff, especially if you've been sitting or sleeping in one position for a long period.
• You may notice that your neck does not turn as far as it regularly does, such as while reversing the automobile and trying to see over your shoulder.

If you experience pain and stiffness in your neck that started suddenly, maybe overnight, and you have trouble moving both arms over your head, you may have polymyalgia rheumatica (PMR). This is a muscular inflammatory disorder. People over the age of 65 are more likely to suffer from it. If you suspect you have this illness, consult a doctor as soon as possible.

Numbness or tingling

When the muscles, bones, or tissues around a nerve put too much pressure on it, it can get pinched. As a result, you may have numbness, pins and needles, or a tingling feeling down your arm, occasionally all the way to your fingertips.

When the problem is resolved, the numbness and tingling will go away. If your symptoms are severe, consult your doctor; he or she may be able to prescribe medicines that target the pinched nerve, such as gabapentin or pregabalin.

Clicking and grating noises

As you move your head, you may hear or feel clicking or grating. This is known as crepitus, and it can be produced by air bubbles popping in the joint or tissues and bones sliding over one other. Other joints frequently do this as well, but vibrations from your neck are generally louder since they are closer to your ears. They may also be more obvious at night. While this is a frequent symptom and may appear to be worrisome, it is not.

Dizziness and blackouts

If you feel dizzy when looking up or rotating your head, it might be due to a pinching of the vertebral arteries, which run alongside the spine. This can occur as a result of alterations in the vertebrae. When these vertebral arteries are pinched, blood flow is briefly limited, resulting in blackouts. However, blackouts may be caused by a variety of factors, so it's critical to get medical attention if this is occurring to you.

Muscle spasms

Muscle spasms are abrupt stiffenings of one or more muscles in your body. There is frequently no recognized reason, and they can be quite uncomfortable. When it happens in the neck, it generally produces discomfort and stiffness along one side, making turning your head difficult.

It normally only lasts a few hours or days, although it might last for several weeks in exceptional cases. You can try to relieve the discomfort at home by using mild stretches, over-the-counter pain relievers, and heat or cold packs. Heat is very comforting for people who have muscular spasms.

Diagnosis

Physical Examination

To assess neck discomfort, a neuroskeletal-muscular examination is performed. Inspection and palpation, like with any physical examinations, are the first steps. A quick check is conducted to discover cranial nerve anomalies. The examiner will next evaluate the range of motion (ROM) of the neck and extremities, as well as perform a sensory examination, manual muscle testing, and the elicitation of normal and atypical reflexes.

A reflex hammer, a safety pin, and a marking pen are all required items. The finest reflex hammer is hefty at the end and long enough to provide a quick tap on the tendon. Pin-prick sensory testing and mapping of any sensory loss may be accomplished using a simple safety pin that is sharp enough for proper testing but dull enough to prevent breaking the skin. A safety pin also features a blunt end for evaluating sharp and dull edges.

The examiner begins by looking at the patient's walk. When the patient enters the room, this can be done. If an aberrant walking pattern is seen, the patient must be observed further after disrobing. Any deviations are noticed and thoroughly discussed. The following phase in the observation process is to search for skin lesions and characterize their features and distribution.

Muscle atrophy and fasciculations should be noted by the examiner, and if any or both are present, the exact region and individual muscles affected should be described. Finally, the patient is examined for unique facial traits, head posture, involuntary movements, and neck or body abnormalities. The patient's eyes are examined, and any eyelid drooping, aberrant pupillary contractions, or asymmetric facial traits are noted.

Tenderness may be elicited by palpation. If this is the case, the exact region as well as the amount of pressure required to cause discomfort are documented. Furthermore, nonverbal responses to palpation, such as retreat or facial grimaces, should be examined. The initial sensory examination's goal is to discover if feeling is affected in any manner. The examiner assesses the patient's capacity to discriminate between dull and acute sensations as well as temperature variations.

Practical ROM testing may be performed quickly and easily; the examiner should note whether or not the motion is smooth and painless. It is important to record any obvious restriction and/or discomfort in any direction of mobility. The examiner must also be aware of passive motion limitations in the extremities, which may impair the patient's ability to comply with and respond to additional tests.

Strength Evaluation

Muscle strength is assessed by manual resistance applied by the examiner . The examiner uses resistance to assess if there is unilateral or bilateral participation and compares it to the opposing side. Because the classification was created for use in poliomyelitis patients with significant weakness, the numerical muscle grading given in most general textbooks has minimal utility in modern clinical contexts.

Sometimes there is evident weakness, which may be clearly detected and evaluated, but more often than not, just moderate weakness is present. If a numerical grading system is employed, the majority of upper extremity weakness caused by cervical disc degeneration would be evaluated as a 4. Because this is a large category, more explanation is required.

All major upper-extremity muscle groups, including those responsible for shoulder elevation, abduction, flexion, extension, and rotation; elbow flexion, extension, supination, and pronation; wrist flexion, extension, and radial and ulnar deviation; and, finally, all finger motions, must be tested first. Individual muscle testing should be undertaken if weakness is identified in order to pinpoint the exact location and amount of the loss.

Reflexes

Deep-tendon and aberrant reflexes are tested during reflex testing. Deep-tendon responses are induced by slightly tensing the muscle and its tendon and then tapping the tendon vigorously with a reflex hammer. This causes a modest yet rapid stretch of the tendon, which results in a reflex muscular contraction. Deep-tendon reflexes at the elbow (biceps and triceps), wrist (brachioradialis), knee (quadriceps), and ankle (gastrocnemius) are investigated, and clonus is noticed.

Babinski's sign, Hoffmann's sign, and inverted radial reflex are three aberrant reflexes of particular interest. The existence of dorsiflexion of the great toe when the bottom of the foot is stroked is Babinski's sign . When a fast movement of the thumb into flexion and adduction is evoked by flicking the nail of the patient's long finger, Hoffmann's sign is positive.

Pain Distribution

The precise location of the patient's discomfort, as well as any paresthesias or feelings of weakness, not only aid in the direction of the physical examination, but also provide the examiner with an indication of the anatomic cause of the pain. The patterns and physical findings of particular nerve root compression are described in. Furthermore, pain features such as onset, duration, and intensity aid in determining the underlying disease.

Disc disease is typically the source of pain that appears suddenly and is not caused by significant trauma. Intervertebral disc herniation is frequently, but not always, linked with radicular pain, which is discomfort in the distribution of a nerve root. A posterior lateral disc protrusion compresses the nerve corresponding to the lower vertebral body's number. A disc protrusion in the C5-6 interspace, for example, affects the 6th nerve root.

C5-6 is the most prevalent site for a disc protrusion, followed by C6-7 and C4-5. Protrusions at C2-3 and C7-T1 are possible but uncommon. Although C3-4 disc protrusions are uncommon, when they do occur, the fourth nerve root is compressed, and pain is sent to the superior portion of the shoulder rather than the arm, forearm, or hand.

Degenerative diseases of the disc without protrusion that produce neck discomfort can also generate radicular pain, although the onset is generally delayed and the pain pattern is more difficult to locate.

Imaging examinations may be required to pinpoint the specific location of the nerve root compression, especially if the pain pattern is unique. Chronic and acute illnesses are distinguished by the length and consistency of the pain. A degenerative process is characterized by long-term pain that gradually worsens and becomes quite persistent.

A disc protrusion, on the other hand, is distinguished by sudden onset of intense discomfort that gradually fades over a few weeks. Pain with a slow but increasing beginning that is persistent and not alleviated by rest, and is especially bad at night, is diagnostic of a neoplastic process, which is generally of metastatic origin in the neck. Pain that is unrelenting, persistent, and unpleasant raises the likelihood of an infectious process.

Radicular discomfort is described by patients as shooting or scorching pain that begins in the neck and extends into the upper extremity. When the neck is stretched, the discomfort worsens because the size of the neural foramen shrinks. Elevating the injured upper extremity may help to alleviate discomfort. This is performed by gripping the opposite side of the head with the hand, releasing tension from the nerve root.

Numbness, tingling, and a sense of weakness may accompany the pain complaint, and if of cervical origin, it is likely to be in the distribution of the afflicted nerve root. Upper extremity peripheral nerve entrapments can resemble cervical illness.

Management

Simple self-help therapies and a day or two of rest are frequently enough to cure a bout of neck discomfort. However, if you have a more complicated or ongoing neck condition, a healthcare practitioner can offer alternative treatments and therapies that should assist. If your pain isn't going away, your doctor may be able to prescribe stronger pain relievers, however, these aren't for everyone.

Physical treatments

Neck pain can be treated by physiotherapists, chiropractors, and osteopaths. Treatment from one of these therapists, together with home exercises, is frequently all that is required. They might recommend general or particular neck stretching and strengthening activities. It is critical to ensure that any physical therapies are administered by skilled practitioners who are registered with the appropriate agency.

Manipulation

Manipulation is a sort of manual treatment in which portions of your body are adjusted to cure stiffness. It might be uncomfortable at times, so it's critical to understand what's going on. Make sure you talk to your therapist about your problem and describe the symptoms you've been having. This will allow them to make a better educated judgment about the treatments you are likely to benefit from.

It's also a good idea to consult with a healthcare practitioner before attempting manipulation since, while some individuals claim to have benefited from it, it's not ideal for everyone. Some therapies will not be advised if you have a disease such as osteoporosis.

Collars

In situations of more significant or complex health concerns, some people find a customized collar useful for supporting the neck. They are not necessary on a regular basis.

Acupuncture

During an acupuncture treatment, very fine needles are placed into a variety of locations on the skin almost painlessly. These are not always in the painful area. Acupuncture appears to reduce pain in the short term by interfering with brain impulses and promoting the production of endorphins, which are natural analgesics.

Injections

A long-acting local anaesthetic or steroid injection may assist in a very tiny proportion of cases, particularly if you experience ongoing discomfort in the back of your head or arm. The injection is frequently administered into your neck's tiny facet joints. These injections are often administered in an x-ray department so that the expert can properly position the needle.

Surgical treatment for neck pain

If nonsurgical therapies fail to relieve neck discomfort and accompanying signs and symptoms, particularly those caused by spinal cord or nerve root compression, surgery may be considered.

Indications for Neck Surgery

Surgery to relieve neck-related pain is typically performed for one or more of the following reasons:

• To alleviate discomfort caused by a pinched nerve root caused by bone spurs or debris from a ruptured or herniated disk, a disease known as cervical radiculopathy. More than 9 out of 10 people who have a herniated disk removed have complete or considerable pain relief.
• To relieve spinal stenosis, or pressure on the spinal cord caused by bone spurs. This is a more difficult procedure, with a success rate ranging from 50 to 90 percent depending on the conditions involved.
• To prevent vertebrae from grinding together due to degenerative disk disease, which causes neck discomfort from pinched nerves.
• If imaging and diagnostic testing cannot identify one of these causes of neck discomfort and/or accompanying signs and symptoms, such as pain, tingling, or arm weakness, surgery is unlikely to help and is not suggested.

Common Types of Surgery for Neck Pain

The two most popular neck pain surgical methods are meant to remove a damaged disc and restore normal space within the vertebral level in order to decompress a nerve root and/or the spinal cord.

Anterior cervical discectomy and fusion (ACDF)

A discectomy, or the removal of a troublesome disc in the cervical spine, is the most frequent operation for neck discomfort. Typically, the procedure, known as anterior cervical discectomy, is performed through the front of the neck. To maintain spinal stability where the disc was removed, this operation is performed in combination with a cervical spinal fusion.

A discectomy can also be performed through the rear of the neck, known as posterior cervical decompression or microdiscectomy, in which just a portion of the disc is removed and no spinal fusion is required. The area of the cervical disc herniation must be accessible with little spinal cord manipulation. If the position is too central, the ACDF method is preferable.

Cervical artificial disc replacement (ADR)

Discectomy with artificial disc replacement is a fairly recent approach. Rather than a fusion, this procedure includes the removal of the injured disc and replacement with an artificial disc.

A possible advantage of cervical ADR over ACDF is that it preserves more natural neck motion. However, because it is a newer procedure, it is used by fewer surgeons than ACDF, and long-term effects are still being examined.

Although ACDF is still considered the gold standard for neck pain treatment, cervical ADR is gaining favor. ACDF may still be a possibility in some circumstances, such as when extensive spinal degeneration is present, but not cervical ADR.

Neck Surgery: Risks and Complications

Because neck surgery is conducted near the spinal cord and around the throat, there is a tiny but genuine danger of extremely catastrophic consequences. These are some examples:

• One of the main arteries and veins that go through the neck and into the brain is damaged.
• Injuries to the nerves or the spinal cord
• Infection of a bone transplant or the surrounding region of the spine
• Displacement of the bone graft before to fusion is possible.
• Two vertebrae fail to fuse together

Prognosis  

Neck discomfort normally goes away in a few days or weeks, but it might reoccur or become persistent. Neck-related diseases account for as much time away from work as low back discomfort in some sectors (see review on low back pain [acute]). The amount of individuals who get chronic neck pain varies on the reason, but it is estimated to be around 10%, which is similar to the proportion of people who develop chronic low back pain. Neck discomfort causes significant impairment in 5% of those who suffer from it.

Whiplash injuries are more likely to result in impairment than other types of neck pain: up to 40% of whiplash victims reported symptoms even after 15 years of follow-up. The factors that contribute to a bad result following whiplash are not fully established. The prevalence of persistent impairment following whiplash varies by country, although the causes for this difference are unknown.

Conclusion 

With an annual incidence rate of more than 30%, neck discomfort is the fourth largest cause of disability. Most bouts of acute neck pain will disappear on their own or with therapy, but almost half of people will continue to suffer some level of discomfort or recurrent recurrence. History and physical examination can help determine if the pain is neuropathic or mechanical, as well as detect "red flags" that may indicate severe disease, such as myelopathy, atlantoaxial subluxation, and metastases.

Although magnetic resonance imaging has a high incidence of aberrant results in asymptomatic persons, it should be evaluated in situations with focal neurologic symptoms, pain that is resistant to conventional therapy, and when recommending a patient for interventional treatment. Few clinical studies have been conducted to test therapies for neck discomfort.

Exercise appears to be effective in the treatment of neck discomfort in patients. There is limited evidence to support the use of muscle relaxants in acute neck discomfort caused by muscular spasms, inconsistent data for epidural corticosteroid injections for radiculopathy, and weak positive evidence for cervical facet joint radiofrequency denervation.

Surgery appears to be more successful than nonsurgical treatment in the short term but not in the long run in individuals with radiculopathy or myelopathy.