Neck pain is a common presenting symptom in primary care, with an incidence of 10.4% to 21.3% per year.1 It is the fourth leading cause of disability worldwide.1 The prevalence of neck pain is higher in older adults because of degenerative changes in facet joints and the collapse of intervertebral disks.2 It is estimated that only one in five people with neck pain seeks medical care.3 The differential diagnosis is broad and includes common conditions such as muscular strains and arthritis, as well as more dire conditions such as fractures, spinal cord and nerve injuries, neoplastic disorders, infections, and inflammatory conditions. Family physicians must be able to recognize when neck pain signals a potentially serious condition and should be able to generate an accurate diagnosis through findings from the patient's history, physical examination, and appropriate testing.
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When evaluating a patient with neck pain, the physician must be alert for red flags in the history and physical examination that may indicate the need for urgent testing and intervention. Similar to guidelines for the evaluation of lower back pain, a systematic approach that maintains vigilance for severe pathology in the neck is recommended.4 Table 1 summarizes some of the more serious diagnoses and their associated clinical findings, as well as recommended diagnostic tests. Figure 1 is a recommended approach to patients with neck pain. This article does not focus on acute traumatic injuries or vascular emergencies, but these elements warrant consideration based on the presentation.
Rapidly progressive neuropathic symptoms warrant more aggressive evaluation. Injury to the central spinal cord or nerve roots may be the result of degenerative changes, trauma, mass effect, infection, or other inflammatory or demyelinating conditions. Even without an acute presentation, physicians should be mindful of myelopathic signs and symptoms.4 Myelopathy refers to neurologic compromise resulting from a disturbance of spinal cord tracts within the spinal canal. Initial symptoms include deep, aching neck pain with possible radicular symptoms and muscle weakness; these can quickly progress to gait changes, ataxia, and bowel and bladder dysfunction.5 Physical examination findings associated with a myelopathic disease process include increased muscle tone, fasciculation, clonus, hyperreflexia, the Babinski reflex, and the Lhermitte and Hoffmann signs.
Certain comorbid disorders and patient factors increase the risk of cervical spine conditions (Table 2). Cervical spine pathology is present in more than one-half of patients with rheumatoid arthritis, and the long-term risk of severe pathology in these patients is higher than in unaffected people.6 Individuals with trisomy 21 are at risk of atlanto-occipital instability, which should prompt concern for complications of even mild trauma, as well as for advanced or premature degenerative changes.7 Ankylosing spondylitis can cause neck stiffness and pain. Patients with this condition also have an increased risk of complications from mild trauma.8 Numerous other processes and conditions can be considered in the differential of neck pain, including herpes zoster, angina, endocrine and compressive tumors, fibromyalgia, and psychogenic pain. Many of these conditions can overlap and be part of multifactorial presentations. One study estimated that 43% of neck pain cases are nonneuropathic, 7% are neuropathic, and 50% are mixed.9
The physical examination should target concerns revealed in the history and distinguish between mechanical and neuropathic symptoms. Localized bony tenderness or prominence is an indication for imaging, whereas soft tissue tenderness may represent myofascial pain, infection, or lymphadenopathy. Although range of motion measurements are widely referenced, their diagnostic relevance is limited and nonspecific.10,11 Range of motion can be more useful in identifying asymmetry or provocation of local or radiating symptoms (e.g., shooting pain down the spine with neck flexion or extension).
The American College of Radiology recommends plain radiography as the initial imaging modality in patients with new or increasing nontraumatic neck pain who do not have red flag symptoms.17 Validated clinical tools such as the National Emergency X-Radiography Utilization Study criteria and the Canadian C-Spine Rule can help determine when radiography may be helpful.17,18 Immediate radiography does not improve patient-oriented outcomes in those who do not have recent trauma or red flag symptoms.18 In addition, imaging can detect abnormalities even in asymptomatic patients; for example, magnetic resonance imaging (MRI) detects degenerative cervical disks in 15% of asymptomatic patients in their 20s, increasing to more than 85% of asymptomatic patients older than 65.19
The time to diagnosis and intervention can be critical when serious conditions are suspected. MRI is recommended for patients with suspected infection, overt neurologic compromise, or progressive neurologic symptoms; it may be appropriate for patients with moderate to severe neck pain that lasts longer than six weeks and does not resolve with standard treatment.20 Computed tomography may be useful in trauma cases, when bony disruption is suspected, or when MRI is contraindicated.
In the absence of red flag findings that require urgent care, treatment can generally focus on the patient's level of pain and function. Many patients will improve over time, regardless of treatment or whether the cause is neuropathic or nonneuropathic. For example, most patients with cervical radiculopathy will improve with nonsurgical care: 80% to 90% have significantly improved pain and resolution of weakness or reflex deficits within four weeks.21,22
Conservative care for patients with neck pain often includes medications for pain relief. Although practice patterns may prompt the use of specific agents, there is little evidence to support the long-term use of these medications in most patients with neck pain. Nonsteroidal anti-inflammatory drugs and oral muscle relaxants are commonly recommended for patients with nonneuropathic pain. Data on the effectiveness of these medications for neck pain are limited; however, these agents are not effective for similar musculoskeletal conditions, such as low back pain.23 Although there is some evidence that oral corticosteroids provide short-term pain relief in patients with acute radiculopathy,24 there is little evidence that any medication affects recovery. Tramadol may have some benefit, but only in the short term.25 Narcotics can provide modest short-term pain relief, but there is no evidence of sustained benefit, and the risks of cognitive impairment and abuse limit their use.26 Inflammatory conditions may briefly respond to steroids or nonsteroidal anti-inflammatory drugs, but there is minimal evidence that these medications provide lasting benefit in degenerative conditions, despite their widespread use.4 Similarly, injections of anesthetics, corticosteroids, or botulinum toxin have shown little or no long-term benefit in acute or chronic neck pain.27,28 There is limited evidence for the short-term use (one to two months) of radiofrequency ablation in patients with persistent cervical pain.29
Given the broad range of potential neck pain etiologies and the variety of complementary and alternative treatment options, it is challenging to determine the value of these treatments for neck pain. They generally provide modest benefit compared with medication alone or no therapy.30 Acupuncture has modest benefit in patients with mechanical neck pain.31 Isolated manipulation and mobilization may provide temporary pain relief but not consistent long-term benefit.32 Treatments such as dry needling, low-level laser therapy, transcutaneous electrical nerve stimulation, and compression therapy have some potential for short-term pain relief, but no reliable long-term data exist to offer specific guidance for these options.33,34
Most neck pain can be treated with nonsurgical methods, and there is a wide range of potential treatment options. Many people find effective pain relief through a combination of treatments.
Most treatment plans for persistent neck pain include some form of physical therapy to improve neck strength and flexibility. Multiple sessions per week with a trained physical therapist may be recommended to start. After learning the prescribed exercises, you will be instructed to continue the exercise program at home.
Watch 3 Easy Neck Exercises for Neck Pain Video
Over-the-counter (OTC) pain relief medications, such as nonsteroidal anti-inflammatory drugs (NSAIDs) or acetaminophen, are typically tried for neck pain.
For severe neck pain, a doctor may prescribe stronger medications for one or two weeks, such as muscle relaxants or opioids.
All medications carry significant potential risks and side effects, even over-the-counter medications such as ibuprofen and acetaminophen, so be sure to work with your doctor and pharmacist.
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A targeted massage kneads the neck and shoulder muscles with the goal of loosening overly tight muscles that pull on your cervical spine and nerves. A secondary benefit is that massage promotes blood flow to the area, and the blood brings with it healing nutrients. There is not much conclusive evidence that massage is effective for neck pain, but it is low risk and non-invasive and many people find it helps at least in the short term.
See Massage Therapy for Chronic Stiff Neck
A chiropractor, osteopath, or other health professional may use their hands to adjust the cervical spine for improved range of motion and reduced pain. Spinal manipulation may be done with a mobilization technique that is slow and gentle, or a a high-velocity manipulation. Manual manipulation is sometimes used to treat certain types of neck pain, depending on the patient’s individual condition and preferences.
advertisementA certified acupuncturist places thin needles into specific points on the skin based on the pain type and/or suspected cause. When treating neck pain, the needles may be placed in the neck and/or elsewhere on the body with the goal of unblocking stagnant energy (qi) to promote healing.
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Some people feel better if their neck is supported by a soft cervical collar or brace. For a trauma, such as whiplash, a hard brace or cervical collar may be prescribed. There is mixed evidence about the effectiveness of neck bracing and support, but it is noninvasive and for short periods many people and doctors find it helps reduce pain.
For severe pain that has not gotten better with the most common treatments, a cervical injection may be recommended, for example:
Injections tend to provide temporary relief because they reduce inflammation or block pain, rather than address the underlying cause.
Watch Cervical Epidural Steroid Injection Video
While the risk is relatively low, injections carry the risk for serious side effects. Injections are typically one of the last treatments to try before considering surgery.
advertisementIn addition to medical treatments, most patients engage in their recovery process through self-care techniques and lifestyle modifications, such as:
One or two days of rest can provide a good healing environment. To rest your neck, keep your neck and head in an aligned and supported position.
After a short period of a few hours or days, you will typically be encouraged to gently stretch and move to make sure your neck doesn’t become weaker and stiffer.
Simple and inexpensive ice and/or heat therapy is surprisingly effective in reducing neck pain and inflammation.
For ice or heat therapy, applications are limited to 15 or 20 minutes with at least a 2-hour break in between to give the skin time to recover. Some people find continuous application of low-level heat works best, such as a heat wrap that you put on and wear for 4 to 6 hours during the day.
Some forms of neck pain or muscle tightness are alleviated with gentle range-of-motion neck stretches. If a particular movement or stretch exacerbates pain, stop and try another movement instead.
Watch 3 Gentle Stretches to Prevent Neck Pain Video
Practicing mindfulness and meditation helps relax your body, reduce pain, and helps by giving a sense of more control over the pain. Various mindful coping methods for pain management are available, such as controlled breathing exercises and distraction techniques.
advertisementA pillow specifically designed to keep your cervical spine aligned while sleeping prevents awkward angles and stresses that worsen pain, stiffness or radiculopathy. Another good option is to use a relatively thin pillow, so your neck is not at an angle while you sleep.
There is some evidence that application of a topical cream or gel with pain relieving and / or anti-inflammatory properties can relieve local neck pain, particularly pain related to muscle strain.
Many gels and creams are available over-the-counter that anti-inflammatory agents (e.g. Voltaren for arthritis pain, or lidocaine for muscle strain) and/or natural pain-relieving ingredients, such as ginger, tiger balm, and arnica.
Some are designed to work by interrupting the transmission of pain signals, and other patches have pain relieving ointment on them, such as lidocaine, tiger balm, camphor or menthol that penetrates through the skin. Many find them a good choice because the patch sticks to your neck and you can stay active.
In addition, most actions that are good for your overall health will go a long way in helping reduce your neck pain, such as:
Dr. Scott Curtis is a sports medicine specialist at Princeton Spine and Joint Center, specializing in sports-related injuries and general musculoskeletal care. He is the Director of Sports Medicine at Princeton Spine and Joint and is affiliated with Penn Medicine Princeton Medical Center.
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