Neck pain

Editor-In-Chief: Robert G. Schwartz, M.D. [mailto:RGSHEAL@aol.com], Piedmont Physical Medicine and Rehabilitation, P.A.

Overview
Neck pain (or cervicalgia) is a common problem, with two-thirds of the population having neck pain at some point in their lives. It is increasing in both intensity, frequency and severity of episodes. As people are increasingly sedentary, live fast-paced and hectic lives, they place more stress and strain on the upper back and neck regions of their spines.

Neck pain, although felt in the neck, can be caused by numerous other spinal issues. Neck pain may arise due to muscular tightness in both the neck and upper back. Joint disruption in the neck creates pain, as does joint disruption in the upper back. Neck pain is a frequent cause of headache or migraine.

The head is supported by the lower neck and upper back, and it is these areas that commonly cause neck pain. The top three joints in the neck allow for most movement of your neck and head. The lower joints in the neck and those of the upper back create a supportive structure for your head to sit on. If this support system is affected adversly, then the muscles in the area will tighten, leading to neck pain.

Neck pain may also arise from many other physical and emotional health issues.

Neck Pain Causes
Reasons for neck pain can be complex. Major and severe causes of neck pain include:


 * Spondylosis - degenerative arthritis and osteophytes
 * Spinal stenosis – a narrowing of the spinal canal
 * Spinal disc herniation – protruding or bulging discs, or if severe prolapse.
 * Severe degeneration – usually as a result of past injuries or whiplash accidents.

The more common and lesser neck pain causes include:


 * Stress – physical and emotional stresses
 * Prolonged postures – many people fall asleep on sofas and chairs and wake with sore necks
 * Minor injuries and falls – car accidents, sporting events and day to day minor injuries
 * Referred pain – mostly from upper back problems
 * Over-use – muscular strain or ligamentous sprain are two the most common causes

Although the causes are numerous, most are easily rectified by either professional help or using self help advice and techniques.

History and Physical Examination
A thorough medical history and physical exam can usually identify any dangerous conditions or family history that may be associated with pain. The patient describes the onset, site, and severity of the pain; duration of symptoms and any limitations in movement; and history of previous episodes or any health conditions that might be related to the pain. The physician will examine the back and conduct neurologic tests to determine the cause of pain and appropriate treatment. Blood tests may also be ordered. Imaging tests may be necessary to diagnose tumors or other possible sources of the pain.

A variety of diagnostic methods are available to confirm the cause of neck pain:

X-ray imaging includes conventional and enhanced methods that can help diagnose the cause and site of back pain. A conventional x-ray, often the first imaging technique used, looks for broken bones or an injured vertebra. A technician passes a concentrated beam of low-dose ionized radiation through the neck and takes pictures that, within minutes, clearly show the bony structure and any vertebral misalignment or fractures. Tissue masses such as injured muscles and ligaments or painful conditions such as a bulging disc are not visible on conventional x-rays. This fast, noninvasive, painless procedure is usually performed in a doctor’s office or at a clinic.

Computerized tomography (CT) is a quick and painless process used when disc rupture, spinal stenosis, or damage to vertebrae is suspected as a cause of neck pain. X-rays are passed through the body at various angles and are detected by a computerized scanner to produce two-dimensional slices (1 mm each) of internal structures of the neck. This diagnostic exam is generally conducted at an imaging center or hospital.

Magnetic resonance imaging (MRI) is used to evaluate the lumbar region for bone degeneration or injury or disease in tissues and nerves, muscles, ligaments, and blood vessels. MRI scanning equipment creates a magnetic field around the body strong enough to temporarily realign water molecules in the tissues. Radio waves are then passed through the body to detect the “relaxation” of the molecules back to a random alignment and trigger a resonance signal at different angles within the body. A computer processes this resonance into either a three-dimensional picture or a two-dimensional “slice” of the tissue being scanned, and differentiates between bone, soft tissues and fluid-filled spaces by their water content and structural properties. This noninvasive procedure is often used to identify a condition requiring prompt surgical treatment.

Electrodiagnostic procedures include electromyography (EMG), nerve conduction studies, and evoked potential (EP) studies. EMG assesses the electrical activity in a nerve and can detect if muscle weakness results from injury or a problem with the nerves that control the muscles. Very fine needles are inserted in muscles to measure electrical activity transmitted from the brain or spinal cord to a particular area of the body. With nerve conduction studies the doctor uses two sets of electrodes (similar to those used during an electrocardiogram) that are placed on the skin over the muscles. The first set gives the patient a mild shock to stimulate the nerve that runs to a particular muscle. The second set of electrodes is used to make a recording of the nerve’s electrical signals, and from this information the doctor can determine if there is nerve damage. EP tests also involve two sets of electrodes — one set to stimulate a sensory nerve and the other set on the scalp to record the speed of nerve signal transmissions to the brain.

Bone scan is used to diagnose and monitor infection, fracture, or disorders in the bone. A small amount of radioactive material is injected into the bloodstream and will collect in the bones, particularly in areas with some abnormality. Scanner-generated images are sent to a computer to identify specific areas of irregular bone metabolism or abnormal blood flow, as well as to measure levels of joint disease.

Thermography involves the use of infrared sensing devices to measure small temperature changes between the two sides of the body or the temperature of a specific organ. Thermography may be used to detect the presence or absence of nerve root compression, especially when the sympathetic nerves are involved.

Diagnostic musculoskeletal ultrasound imaging, also called ultrasound scanning or sonography, uses high-frequency sound waves to obtain images inside the body. The sound wave echoes are recorded and displayed as a real-time visual image. Ultrasound imaging can show tears in ligaments, muscles, tendons, and other soft tissue masses in the back.

Treatment
Medications, such as muscle relaxants,[14] narcotics, non-steroidal anti-inflammatory drugs (NSAIDs/NSAIAs)[15] or paracetamol (acetaminophen).

Neck pain is treated by numerous physical therapies. They range in complexity depending on the severity and underlying causes of the pain. Treatment is administered by chiropractic, osteopathic and physical therapy. All of these specialties treat neck pain issues. The benefit of mobilisation and manipulation is not clear. Neck pain can also be eased via many self help techniques such as stretching, strength building exercises. Non-traditional methods such as Acupressure, Reflexology and therapeutic massage are commonly used as well.

Interventional therapy can ease pain by blocking nerve conduction between specific areas of the body and the brain. Approaches range from injections of local anesthetics, steroids, proliferative agents (Prolotherapy) into affected soft tissues, joints, or nerve roots to more complex nerve blocks. When extreme pain is involved, low doses of drugs may be administered by catheter directly into the spinal cord. Chronic use of steroid injections may lead to increased functional impairment.

Indications of Surgery

 * Severe Degenerative disc disease
 * Spinal stenosis
 * Spondylolisthesis
 * Scoliosis
 * Compression fracture
 * Spinal instability
 * Spinal trauma
 * Spinal malignancy (cancer)
 * Spinal hematoma

Surgical Treatment Options

 * Discectomy is one of the more common ways to remove pressure on a nerve root from a bulging disc or bone spur. During the procedure the surgeon takes out a small piece of the lamina (the arched bony roof of the spinal canal) to remove the obstruction below.
 * Foraminotomy is an operation that “cleans out” or enlarges the bony hole (foramen) where a nerve root exits the spinal canal. Bulging discs or joints thickened with age can cause narrowing of the space through which the spinal nerve exits and can press on the nerve, resulting in pain, numbness, and weakness in an arm or leg. Small pieces of bone over the nerve are removed through a small slit, allowing the surgeon to cut away the blockage and relieve the pressure on the nerve.
 * IntraDiscal Electrothermal Therapy (IDET) uses thermal energy to treat pain resulting from a cracked or bulging spinal disc. A special needle is inserted via a catheter into the disc and heated to a high temperature for up to 20 minutes. The heat thickens and seals the disc wall and reduces inner disc bulge and irritation of the spinal nerve.
 * Radiofrequency lesioning is a procedure using electrical impulses to interrupt nerve conduction (including the conduction of pain signals) for 6 to12 months. Using x-ray guidance, a special needle is inserted into nerve tissue in the affected area. Tissue surrounding the needle tip is heated for 90-120 seconds, resulting in localized destruction of the nerves.
 * Spinal fusion is used to strengthen the spine and prevent painful movements. The spinal disc(s) between two or more vertebrae is removed and the adjacent vertebrae are “fused” by bone grafts and/or metal devices secured by screws. Spinal fusion may result in some loss of flexibility in the spine and requires a long recovery period to allow the bone grafts to grow and fuse the vertebrae together.
 * Spinal laminectomy (also known as spinal decompression) involves the removal of the lamina (usually both sides) to increase the size of the spinal canal and relieve pressure on the spinal cord and nerve roots.

Other surgical procedures to relieve severe chronic pain include rhizotomy, in which the nerve root close to where it enters the spinal cord is cut to block nerve transmission and all senses from the area of the body experiencing pain; cordotomy, where bundles of nerve fibers on one or both sides of the spinal cord are intentionally severed to stop the transmission of pain signals to the brain; and dorsal root entry zone operation, or DREZ, in which spinal neurons transmitting the patient’s pain are destroyed surgically.

The course of treatment for neck pain will usually be dictated by the clinical diagnosis of the underlying cause of the pain.

Prognosis
About one-half of episodes resolve within one year. About 10% of cases become chronic.