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Neck Pain

Samir Khan

Background

  • Most common cause of neck pain in adults: degenerative changes of the cervical spine

  • Most atraumatic neck pain does not require imaging

Presentation

  • Cervical muscle strain:  pain + stiffness with movement 2/2 muscular injury

  • Degenerative disc disease/osteoarthritis: pain + stiffness with movement from derangement in disc architecture leads to inability to distribute pressure in the joint

  • Cervical radiculopathy: neuropathic pain, sensory abnormalities, and/or weakness in an upper extremity (often radiating to hand)

  • Cervical myelopathy: spinal cord compression causing neurologic dysfunction

    • Earliest symptom is gait disturbance. Pain is uncommon

  • Non-cervical conditions: shoulder pathology, migraine/headaches, occipital neuralgia, torticollis, thoracic outlet syndrome, angina pectoris/MI, bony metastases, vertebral artery or carotid artery dissection, fibromyalgia, meningitis, transverse myelitis 

  • Posterior neck pain 

    • Axial only à MSK (sprain vs degenerative disc disease) 

    • Axial + Extremity Pain  Radiculopathy 

  • Anterior neck pain 

    • Common sources: esophageal, thyroiditis, carotidynia, lymphadenitis, Ludwig’s angina

    • Red flags: recent trauma, lower extremity weakness, gait abnormality, bowel/bladder incontinence, fever, weight loss 

Evaluation

  • Determine MSK (axial pain) vs Radiculopathy/Myelopathy vs Non-spinal 
 Provocation Tests of the Neck
Test Isolates Action Positive if
Spurling’s test  Cervical radiculopathy  Downward pressure applied to top of head with extended neck and rotates to affected side 

Reproducible pain beyond shoulder

Neck pain alone is not specific

Elvey's upper limb 

tension test 

 Cervical radiculopathy  Head turn contralaterally, arm is abducted while the elbow extended   Reproduction of symptoms 
Hoffman sign  Corticospinal lesion (UMN)  Loosely hold middle finger and flick the fingernail downward, allowing the middle finger to flick upward reflexively There is flexion & adduction of thumb/index finger on the same hand

  • Imaging indications: Neuro deficits, Red flags, persistent pain (> 6 weeks) 

    • Cervical Plain films, 2-view (AP and lateral) 

    • Cervical MRI: visualizes spinal cord, nerve roots, bone marrow, discs and soft tissues

      • Usually w/o contrast; can consider contrast if malignancy or infection suspected

  • EMG/Nerve Conduction Studies: not routinely used for neck pain evaluation, but can be used to distinguish cervical radicular pain from peripheral causes of extremity dysesthesia

Management

  • Cervical strain, Cervical radiculopathy: PT

    • 5 d course of oral prednisone 60-80 mg, followed by 7-14 day taper

    • Anti-spasmodic prn: Flexeril or Robaxin

    • If not improving or progressive symptoms refer to Ortho Spine + PM&R

  • Cervical myelopathy requires urgent surgical evaluation