The Centers for Advanced Orthopaedics is redefining the way musculoskeletal care is delivered across the region with locations throughout Maryland, DC, Virginia and Pennsylvania.
Chronic neck pain is a very common condition in adult population. The pain may be mild, moderate or severe and recurring. Symptoms may resolve spontaneously or become chronic and disabling, impacting the quality of life and activities of daily living. Injuries may or may not precede the onset symptoms. Pain and clinical findings are variable, fluctuant and may be non specific. Diagnostic studies may or may not identify the exact source of pain in every patient. However, in vast majority of cases, careful history, pain pattern, clinical examination and diagnostic studies do identify the source of pain generation and provide guidelines for relevant management.
Several medical disorders that are not directly located in the neck refer symptoms to the neck and the upper extremities. These include, but are not limited to cardiac, pulmonary, shoulder, neurological, hematological and connective tissue disorders. Disorders of the Temporomandibular joint can also refer pain to the cervical area.
Loss of weight, anemia, fever, chills, nocturnal symptoms and rest pain include some of the warning sings for systemic problems that produce neck pain.
The cervical spine is comprised of seven vertebrae. Each possesses five articulations. In addition to the vertebrae and the joints, discs, nerves and ligamentous structures can become potential source of pain. The upper two vertebral segments are especially prone to get inflammatory disease while the lower segments are frequently involved in the degenerative processes.
Traumatic neck pain is produced by injury to several structures. The pain can be limited to the neck (axial) or extend to upper extremities (radicular). Axial pain is usually produced by the discs or facet joints while radicular pain is a manifestation of nerve root involvement. The nerve root may be chemically irritated by the pain producing chemicals or directly compressed by displaced disc material or a bone spur. A typical radicular pain follows the path of the nerve and is clinically discernible during physical examination. On occasion extremity pain is not due to nerve involvement is referred to the arm as deep aching pain with poor localization. Thoracic outlet syndrome is a relatively rare condition that mimics nerve root involvement.
During the examination the physician will usually examine the neck and the upper extremities for mobility, reflexes, sensations and strength evaluation.
The diagnostic studies include X- rays or CT scan in acute trauma setting. For chronic neck and extremity pain Magnetic Resonance Imaging has become study of choice.
30-40% asymptomatic and normal adult population shows disc protrusions and extrusions on MRI scans; therefore clinical correlation is critical to make a diagnosis. At times physiological tests such as Electromyography or Discograms are necessary to arrive at a precise diagnosis.
Most patients with non malignant or non- systemic conditions respond to conservative management. Patient education is important for protective postures, avoidance of prolonged flexion and extension and prolonged single positions.
Anti-inflammation medications, mild muscle relaxants, analgesics help in reducing symptoms and inflammation. Strong muscle relaxants produce fatigue and addiction, therefore should be avoided or used for a limited period. Cervical collar should be limited to the acute phase of the problem. Chronic utilization of collar produces muscle atrophy and sets back recovery.
Physical therapy is helpful in improving range of motion, upper extremity strength, pain tolerance and postural improvement. Physical therapy as a single intervention lacks long term benefits. Patients should be graduated to a self supervised home based exercise program for long term results.
Cervical traction is beneficial in radicular type of pain where disc or bone spur is contributing to the symptoms. Manipulation treatments are beyond the scope of this article. These treatments are usually as effective as neck exercises and physical therapy.
For recalcitrant and refractory pain further specialized care may be needed that includes regional pain blocks or operative intervention.
Center for Advanced Orthopedics