Orthopaedic Surgery - Neck Pain

Basics

Neck pain is a common musculoskeletal complaint in adults.

In adults, it is most often related to:

Degenerative disc disease

Cervical spondylosis

Facet arthritis

In children and adolescents, persistent neck pain is less common and should prompt consideration of more serious causes such as:

Infection

Neoplasm

Inflammatory disease

Congenital or structural abnormalities

Neck pain is also common after trauma, particularly following motor vehicle collisions.

Prevention

No specific method reliably prevents all causes of neck pain.

General preventive measures include:

Seat-belt use

Appropriate head restraints

Protective equipment during sports

Avoidance of high-risk trauma when possible

Attention to posture, ergonomics, and conditioning may reduce some episodes of mechanical neck pain.

Epidemiology

Neck pain is common in the general population.

Older epidemiologic studies suggested that approximately 10% of people may experience neck pain at any given time.

One survey reported that nearly 35% of adults experienced neck pain during the preceding year.

Chronic neck pain has historically been reported in approximately:

9.5% of men

and

13.5% of women

in some populations.

Risk Factors

Potential risk factors include:

Congenital cervical fusion, such as Klippel–Feil syndrome

Positive family history

Degenerative cervical disease

Previous trauma

Occupational or postural stress

Etiology

The causes of neck pain can broadly be divided into:

Atraumatic

and

Traumatic causes.

Atraumatic Neck Pain

Common causes include:

Degenerative disc disease

Facet arthritis

Inflammatory arthritis

Disc herniation

Infection

Neoplasm

Muscle strain and nonspecific mechanical pain are also frequent causes.

Traumatic Neck Pain

Traumatic causes include:

Ligament sprain

Muscle strain

Fracture

Subluxation

Dislocation

Disc herniation

Some of these abnormalities, particularly degenerative changes and disc disease, may also occur without trauma in older adults.

Diagnosis

Signs and Symptoms

Common symptoms include:

Localized neck pain

Stiffness

Loss of cervical motion

Paraspinal muscle spasm

Cervical radicular pain

Cervical Radiculopathy

Cervical nerve-root compression may produce:

Pain radiating into the shoulder or arm

Numbness or paresthesia

Weakness

Diminished reflexes

The specific pattern depends on the involved nerve root.

History

Important historical features include:

Onset and duration of pain

Traumatic versus atraumatic mechanism

Radiation into the arm

Weakness or numbness

Difficulty walking

Bowel or bladder symptoms

Fever

Weight loss

History of malignancy

Immunosuppression

Previous cervical surgery

In trauma, the mechanism and energy of injury should be clearly established.

Physical Examination

The examination differs between routine neck pain and acute cervical trauma.

Routine Cervical Examination

Evaluation should focus on:

Range of motion

Areas of tenderness

Muscle spasm

Neurologic function

Range of Motion

Assess:

Flexion

Extension

Rotation

Lateral bending

Painful restriction or asymmetry should be documented.

Palpation

Palpate the:

Midline posterior cervical structures

Paraspinal muscles

Trapezius

Assess for:

Midline tenderness

Muscle spasm

Focal bony tenderness

Neurologic Examination

A complete neurologic examination should include:

Motor strength

Sensation

Deep tendon reflexes

Gait

Upper motor neuron signs

Upper Motor Neuron Findings

Findings suggesting cervical spinal cord involvement include:

Hyperreflexia

Clonus

Hoffmann sign

Babinski sign

Hand clumsiness

Gait disturbance

These findings warrant evaluation for cervical myelopathy or spinal cord compression.

Trauma Examination

In a patient with suspected cervical spine trauma, the neck should be protected until clinically significant instability has been excluded.

Evaluation should include:

Immobilization when indicated

Complete neurologic examination

Appropriate cervical spine imaging

Movement of the neck should not be forced when fracture or instability is suspected.

Spurling Test

The Spurling maneuver is used to evaluate for cervical radiculopathy.

The test generally involves:

Cervical extension and rotation toward the symptomatic side with gentle axial loading.

Reproduction of the patient’s characteristic arm pain or paresthesia supports nerve-root irritation.

The maneuver should be avoided in patients with suspected cervical instability or acute major trauma.

Laboratory Tests

Laboratory studies are not routinely required for uncomplicated mechanical neck pain.

When infection is suspected, useful tests include:

Complete blood count

ESR

CRP

Further testing is guided by the suspected cause.

Imaging

Plain Radiographs

Plain radiographs may be useful in selected patients with:

Persistent symptoms

Suspected degenerative disease

Possible deformity

Certain low-risk trauma patterns

Standard views may include:

AP and lateral cervical spine radiographs.

In modern significant cervical trauma, CT is generally preferred because of its greater sensitivity for fracture.

Oblique Views

Oblique radiographs can demonstrate:

Neural foramina

and may help identify:

Foraminal narrowing or osteophytic encroachment.

They are used selectively because CT and MRI often provide more useful information.

Open-Mouth Odontoid View

The open-mouth view is designed to visualize:

C1 lateral masses

C2 odontoid process

It can be useful in selected settings, although CT has largely replaced it in significant trauma.

Flexion–Extension Views

Dynamic flexion and extension radiographs may be used selectively to evaluate:

Segmental instability

They should not be performed acutely when an unstable fracture or significant ligament injury has not been excluded.

CT

CT is excellent for evaluating:

Cervical fractures

Facet dislocations

Bony canal narrowing

Congenital osseous abnormalities

Small cortical lesions such as osteoid osteoma

It is rapid and highly sensitive for osseous injury.

MRI

MRI is the preferred study for evaluating:

Spinal cord compression

Nerve-root compression

Disc herniation

Ligamentous injury

Bone marrow disease

Tumor

Infection

Foraminal stenosis

MRI is particularly important when neurologic abnormalities are present despite normal or equivocal radiographs or CT.

Differential Diagnosis

Adults: Atraumatic Causes

Important causes include:

Degenerative disc disease

Cervical spondylosis

Rheumatoid arthritis

Ankylosing spondylitis

Discitis

Vertebral osteomyelitis

Meningitis

Disc herniation

Neoplasm

Adults: Traumatic Causes

Consider:

Ligament sprain

Fracture

Subluxation

Dislocation

Traumatic disc herniation

Children: Atraumatic Causes

Important diagnoses include:

Atlantoaxial rotatory subluxation

Retropharyngeal or other deep-neck abscess

Osteomyelitis

Discitis

Neoplasm

Children: Traumatic Causes

Consider:

Ligamentous injury

Fracture

Dislocation

Spinal cord injury without obvious radiographic abnormality

SCIWORA

Spinal cord injury without radiographic abnormality, historically termed SCIWORA, is particularly relevant in children because their flexible spine may sustain cord injury without an obvious fracture on initial plain imaging.

Neurologic deficits after trauma may occasionally be delayed.

Therefore, transient symptoms such as:

Arm or leg weakness

Numbness

Paresthesias

following cervical trauma should be taken seriously.

MRI is important when spinal cord injury is suspected.

Treatment

General Principles

Treatment depends on the underlying cause.

Most uncomplicated mechanical neck pain is initially managed nonoperatively.

Rest and Activity

A short period of relative rest may be useful during the most painful stage.

Prolonged inactivity should be avoided because it may contribute to:

Muscle deconditioning and stiffness.

Activity should be resumed gradually as symptoms improve.

NSAIDs and Analgesia

NSAIDs may help reduce:

Pain and inflammation

when not contraindicated.

Acetaminophen may also be used for pain relief.

Cervical Collar

A soft cervical collar may provide temporary comfort in selected patients.

However, prolonged use should be avoided because it can cause:

Paraspinal muscle deconditioning and increased stiffness.

Posture and Ergonomics

Modification of:

Sitting posture

Workstation ergonomics

Pillow or sleep position

may be beneficial in mechanical neck pain.

Exercise

Appropriate exercise helps maintain:

Cervical range of motion

Postural control

Muscular endurance

Shoulder-girdle strength

Physical Therapy

Physical therapy may be useful for:

Restoring motion

Strengthening cervical and scapular stabilizers

Improving posture

Reducing muscle spasm

Managing chronic mechanical pain

Traction

Gentle cervical traction may reduce symptoms in selected patients with:

Cervical radiculopathy or nerve-root irritation.

It should not be used when instability, fracture, infection, or tumor is suspected.

Medication

NSAIDs are commonly used for a limited period, often several weeks, depending on symptom severity.

Medication should be discontinued or reduced when symptoms resolve.

Long-term medication use should be individualized according to risks and benefits.

Surgery

Surgery is rarely indicated for isolated axial neck pain alone.

Outcomes are generally less predictable when surgery is performed solely for nonspecific neck pain.

Surgical Indications

Operative treatment is more commonly considered when there is:

Progressive neurologic deficit

Spinal cord compression

Persistent nerve-root compression

Instability

Fracture or dislocation

Tumor

Infection requiring surgical management

Degenerative Disease

Surgery for degenerative disease typically aims to:

Decompress the nerve roots or spinal cord

and, when necessary,

Stabilize or fuse the affected segment.

Follow-Up

Patients with uncomplicated neck pain can generally be reviewed at approximately 4–6-week intervals until symptoms improve.

Earlier reassessment is necessary if neurologic symptoms appear or worsen.

Prognosis

The prognosis depends on the underlying cause.

Most patients with uncomplicated mechanical or inflammatory neck pain improve with:

Activity modification

Analgesia

Physical therapy

Postural correction

Persistent Axial Pain

Recovery from isolated axial neck pain can be unpredictable because many cases are:

Degenerative, multifactorial, or nonspecific.

Serious Causes

Prognosis is less favorable when neck pain results from:

Malignancy

Severe infection

Progressive myelopathy

Major trauma

Complications

The most important complication is progressive neurologic dysfunction from:

Nerve-root or spinal cord compression.

Warning Signs of Neural Compression

Concerning symptoms include:

Weakness of the arms or hands

Persistent sensory loss

Loss of hand dexterity

Difficulty walking

Balance problems

Bowel or bladder dysfunction

These findings warrant urgent evaluation.

Patient Monitoring

Follow-up should assess:

Pain severity

Range of motion

Motor strength

Sensation

Reflexes

Gait

Development of upper motor neuron signs

Patients with progressive neurologic findings, persistent constitutional symptoms, or worsening pain require further investigation.

Key Principle

Most uncomplicated adult neck pain is related to mechanical or degenerative disease and responds to nonoperative care.

The critical task is to identify patients with red flags for:

Trauma, infection, tumor, nerve-root compression, or cervical spinal cord involvement, because these conditions require more urgent imaging and specialist evaluation.