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Neck Pain (cervicalgia, or cervicogenic pain) is a common and costly problem in Western society. In fact, 30-50% of people suffer from an aching neck each year in the United States, and at any one time about 5% of adults have neck pain severe enough to cause disability (Alexander, 2011). Although neck pain can be caused by sudden injury, more frequently it results from gradual stresses, such sitting, standing, work postures, lifting patterns, or sleeping positions (J Orthop Sports Phys Ther, 2011).
The neck provides a connection between the head and thorax. The posterior (back of the) neck is higher than the anterior (front of the) neck. In the neck are four major compartments enclosed by a collar of muscle and tough fascia. The first of these compartments houses vertebrae and associated muscles used chiefly in maintaining posture. The second compartment contains endocrine glands as well as respiratory and digestive structures such as the trachea and esophagus. And the other two compartments contain major blood vessels such as the carotid arteries and jugular veins.
Seven cervical vertebrae, cushioned by intervertebral discs, provide the bony framework for the neck. These vertebrae, labeled C1-C7, are the smallest of the vertebrae. Pairs of spinous and transverse processes, or spiny projections of bone that jut out from the vertebral body, articulate at delicate facet joints. The two upper vertebrae, C1 and C2, also called Atlas and Axis, permit gliding movement of the head.
Major muscle groups of the neck include muscles of the pharynx, larynx, and muscles that move the neck, including the strap muscles, muscles of the cervical collar, and postural muscles. These muscles extend both deeply and superficially from the base of the skull to the back, and serve to flex and extend the head, participate somewhat in breathing, and act in unison with the eye muscles, permitting the head to turn in sync with the eyes.
Four cranial nerves pass from the head through the neck, including the glossopharyngeal nerve, hypoglossal nerve, spinal accessory nerve, and the substantial vagus nerve. Additionally, there are eight cervical nerves of the neck that emerge from the vertebral canal above their respective vertebrae. The front portions of the first four of these nerves form the cervical plexus, which innervates many muscles and areas of outer skin of the neck, while the rear portions of the subsequent four form the brachial plexus, which innervates the upper limbs.
Neck pain is classified as acute or chronic in nature. Acute pain presents suddenly and lasts for fewer than three months, whereas pain that persists for more than three months is considered chronic. Some causes of acute neck pain are facet syndrome, acute muscle strain, or traumatic injury such as whiplash. Chronic pain can arise from multiple sources, but is frequently attributable to breakdown or irritation of intervertebral discs, nerves, facet joints, ligaments, and muscles within the neck.
Most neck pain is believed to result from unspecified mechanical causes. For example, neck pain can arise from gradual degeneration of the intervertebral discs between the cervical vertebrae (degenerative disc disease), which typically occurs due to normal aging, heredity, and possibly environmental factors such as work activities (Williams & Sambrook, 2011). The facet (zygapophysial) joints between the spinous processes, which guide and limit movement of the spine, are also prone to painful wear and tear from osteoarthritis of the spine and other causes. Such degeneration of the discs and vertebral joints can put pressure on spinal nerve roots, causing pain that often radiates (radiculitis).
Another potential cause of mechanical neck pain is tension in muscles and connective tissues of the neck (e.g., ligaments). The neck is particularly prone to tension as it supports the heavy head, and remains in constant use. Although desk jobs in particular are associated with strained tissues that lead to neck pain, any role in which the neck is held in place for prolonged periods can produce neck pain. For example, a study reported military helicopter aircrew personnel frequently complained of neck pain (Salmon et al, 2011). The researchers attributed this to prolonged or repeated exposure to loading factors such as posture adopted during flight, use of night vision goggles, and vibration, and noted previous research in military and civilian populations indicates exercise therapy has produced improved endurance capacity in the neck musculature and reduced self-reported neck pain.
Motor vehicle accidents represent an acute cause of mechanical neck pain. According to estimates, more than 2.3 million adult drivers and passengers were treated in emergency departments as the result of being injured in motor vehicle crashes in 2009 (CDC, 2011). Anatomical sites within the neck that are potentially injured during these collisions include facet joints, spinal ligaments, intervertebral discs, vertebral arteries, dorsal root ganglia, and neck muscles (Siegmund et al, 2009).
A common painful neck disorder arising from motor vehicle accidents is chronic whiplash-associated disorder (WAD). Most cases of whiplash occur as the result of rear-end vehicle collisions at speeds of less than 14 mph (Bannister et al, 2009). Patients present with neck pain and stiffness, occipital headache, thoracolumbar back pain and upper-limb pain and paraesthesia (a sensation of tingling, burning, “pins and needles,” or numbness). Patients can also have an associated post-traumatic stress disorder.
Over 66% of whiplash patients make a full recovery within a few weeks of the initial injury
Over 66% of whiplash patients make a full recovery (Bannister et al, 2009) within a few weeks of the initial injury. However, the remainder continues to have pain three months following the accident, and about 18% of people will continue to have pain after two years. Unfortunately, 2% of whiplash patients become permanently disabled (Bannister et al, 2009).
Fortunately, head restraints in vehicles have changed considerably over the last 40 years due to development of regulatory literature, consumer information programs, and efforts by vehicle manufacturers to address whiplash injuries, vehicle designs and, in particular, the designs of seats (Zuby & Lund, 2010). With varying degrees, these changes seem to be reducing the likelihood that occupants in rear struck vehicles will suffer neck injuries in such crashes (Zuby & Lund, 2010).
Less frequently, neck pain can arise from non-mechanical causes such as systemic illness. A few examples of these reported in the literature rheumatoid arthritis, ankylosing spondylitis, spondylolisthesis, diffuse idiopathic skeletal hyperostosis, myositis, fibromyalgia and cardiovascular disorders (Jiang et al, 2011; Oberstein et al, 2011; Nolet et al, 2012). Also, according to various reports, other rarer causes of neck pain unrelated to mechanical causes include local infection and tumor (Lyle et al, 2011; Mateo et al, 2011).
The specific etiology of neck pain can be extremely difficult to diagnose (Basho et al, 2011). However, identification of the structural source of the pain can be valuable in directing treatment. Patient history, including the nature, onset and location of the pain, is an important tool in diagnosing neck pain, and the physical examination, guided by the history, serves primarily to confirm suspicions (Alexander, 2011). By synthesizing data garnered from the patient history, physical examination, and imaging studies such as x-ray, CT scan, MRI, or bone scan if necessary, a healthcare provider formulates a differential diagnosis and treatment plan for each patient with neck pain (Basho et al, 2011).
Since diagnosis of neck pain can be difficult, consultation with a pain specialist can be invaluable. Pain specialists have received extra training in examination and diagnostics of neck pain and other painful conditions.
In general, physicians aim to develop conservative, minimally invasive treatment plans tailored to their patients’ individual beliefs and desires. More invasive treatments carry a higher risk of complications and are therefore reserved for intractable cases.
Treatment plans may begin with pharmacological therapy and rest. Drugs often prescribed for neck pain include NSAIDs (nonsteroidal anti-inflammatory drugs) such as Ibuprofen, Acetaminophen (Tylenol), muscle relaxants, adjuvants, and topical analgesics (Pangarkar & Lee, 2011). Due to their potentially severe side effects, opioids are typically avoided if possible.
Injections are another, slightly more invasive, line of therapy for troublesome neck pain. Prolotherapy, also known as regenerative injection therapy, is a technique of injecting irritating substances into painful ligaments and tendons. The procedure is used to promote and accelerate healing of damaged connective tissue in the neck. A systematic review of 200 studies determined that results from clinical studies published to date indicate prolotherapy has been effective at reducing spinal pain (Dagenais et al, 2005).
Trigger point injections can be an effective treatment for painful muscle spasms in the neck. The procedure involves injecting a local anesthetic and steroid into trigger points, or irritable, painful spots in skeletal muscle associated with hard knots felt in taut bands of muscle fibers. Research from the Cleveland Clinic Neurological Institute found trigger point injections lowered neck pain in over half of 147 patients with cervicogenic headache (Baron et al, 2011).
Epidural Steroid Injections (ESIs) into the neck are commonly used for neck pain arising from conditions such as degenerative disc disease. The treatment involves injection of a corticosteroid and local anesthetic (e.g., lidocaine) into the epidural space of the spinal cord, where the medication travels throughout the spine, soothing irritated nerve roots and lowering inflammation. A randomized, double-blind, active control trial in 120 patients with chronic function-limiting neck pain who received ESIs with local anesthetic with or without steroids were effective in 67% of patients overall, 87% of patients who received anesthetic only, and 72% of patients who received both anesthetic and steroid (Manchikanti et al, 2012).
Pain relief was reported by 80% of 120 patients, or 85% of patients who received injections of anesthetic only, and 93% of patients who received injections of both anesthetic and steroid
Nerve blocks are another type of injection technique used to combat neck pain. Most pain physicians agree that nerve blocks can dramatically improve pain increase quality of life. Nerve blocks involve the injection of local anesthetic and corticosteroid into target nerves around the neck and head. Occipital nerve blocks are delivered into the skin at back of head, around the occipital nerves, which are often implicated in neck pain. Cervical medial branch blocks target painful, irritated nerves that extend from the facet joints in the spine, temporarily interrupting the perception of neck pain. A retrospective and observational study in patients with persistent postsurgical neck pain who were treated with medial branch blocks containing local anesthetic and steroid found 52.9% were treated successfully (Klessinger, 2010). A successful treatment response was defined as at least 80% reduction of pain or if the patient was sufficiently satisfied with the relief. And a randomized, double-blind, controlled trial found therapeutic cervical medial branch blocks of local anesthetic with or without steroid, repeated approximately six times over a period of two years, provided patients with significant improvement over a period of two years (Manchikanti, 2010). Pain relief was reported by 80% of 120 patients, or 85% of patients who received injections of anesthetic only, and 93% of patients who received injections of both anesthetic and steroid. There was an improvement in numeric pain scores, Neck Disability Index (NDI), opioid intake, and work status evaluated at baseline, six, 12, 18, and 24 months.
A newer injection therapy used in treating neck pain is Botulinum toxin A (BtA), also known as Botox. A meta-analysis of high-quality eligible studies found a single injection cycle of BtA is effective and safe for treating cervical dystonia, and enriched trials using patients previously treated with BtA suggest further injection cycles continue to work for most patients (Costa et al, 2005). In addition, Botox injection has been studied in small trials on whiplash associated disorder patients and has generally been found to relieve pain and improve range of motion (Juan, 2004).
Sometimes an injection can be delivered as a long-term infusion of medication. The procedure involves inserting a small catheter through a needle into the epidural space or directly next to affected nerves. Local anesthetic and other medicines are often given through the catheter for extended periods. When the nerves are blocked continuously with an infusion, pain relief can be significant and enduring.
Percutaneous implantation techniques are another viable solution to persistent neck pain. For example, cervical Spinal Cord Stimulation (SCS) involves tiny electrodes being placed within the epidural space close to the spinal cord. The electrodes release a mild electrical current that inhibits pain transmission. In a case series of five consecutive patients outlining the use of spinal cord stimulation to treat upper extremity pain, spinal cord stimulators were placed in the cervical epidural space through a thoracic needle placement, and stimulation parameters were adjusted to capture as much of the painful area(s) as possible. In all cases, patients reported significant (70-90%) reductions in pain, including axial neck pain and upper extremity pain, and interestingly, two patients also obtained relief with associated headache and lower extremity pain (Vallejo et al, 2007). The patients continued to report excellent pain relief up to nine months following implantation. Another type of implantation technique for pain relief is percutaneous stimulation of the occipital nerve, which is sometimes implicated in neck pain. This treatment modality involves implantation of small electrodes close to the occipital nerves at the back of head. As with spinal cord stimulation, the electrodes produce a mild electrical current that modulates transmission of pain signals.
An additional stimulation technique is transcutaneous electrical nerve stimulation (TENS), which relieves pain by applying mild electric current to the skin at the site of the pain. This technique is slightly less invasive than percutaneous implantation as the unit is applied topically to the painful region without surgical implantation.
Destruction of chronically and intractably painful tissues that produce neck pain, or denervation, is a treatment commonly used by pain specialists to treat resistant neck pain. For example, patients who receive significant and repeated relief from medial branch blocks may become candidates for radiofrequency ablation, or heat-activated destruction of persistently painful nerves causing neck pain. Destruction of these problematic nerves can bring permanent relief to individuals with stubborn neck pain.
Manual therapies, or therapies involving gentle physical manipulation, have provided minimally invasive pain relief solutions to patients with cervicalgia. For instance, physical therapy is recommended in order to decrease or prevent functional limitations, and increase range of motion and muscular strength. A systematic review with meta-analysis of randomized controlled trials of adults with nonspecific neck pain found one of the interventions with significant short-term effects on pain was manual therapy (Leaver et al, 2010). The meta-analysis also found manual therapy had a significant short-term effect on disability. Massage, or gentle focal rubbing of painful areas, is another physical treatment modality that has brought relief to patients with painful necks. Also, researchers have recently tested the benefits of a thrust manipulation of the upper back to treat neck pain. A systematic review of studies to determine the effects of thoracic spine thrust manipulation on pain, range of motion, and self-reported function in patients with mechanical neck pain, found the treatment may provide short-term improvement in patients with acute or subacute mechanical neck pain (Cross et al, 2011).
A well-known manual therapy used for neck pain is chiropractic manipulation, which involves targeted “adjustments” undertaken in order to allow correct nerve transmission. A prospective, multicenter, cohort study of symptomatic reactions, clinical outcomes and patient satisfaction associated with upper cervical chiropractic care found outcome assessments were significantly improved for neck pain and disability, headache, mid-back pain, as well as lower back pain and disability with a high level of patient satisfaction (Eriksen et al, 2011). In addition, the 83 chiropractors who administered more than 5 million upper cervical adjustments reported no incidences of serious adverse events. Also, a systematic review found a baseline of evidence that suggests chiropractic care improves cervical range of motion and pain in the management of Whiplash-Associated Disorders (WAD) (Shaw et al, 2010).
Self-management techniques such as exercise, cognitive behavioral therapy, and biofeedback are another approach to the treatment of neck pain. These techniques are the safest available and highly effective.
Exercise improves neck pain by increasing flexibility and range of motion. Another benefit of exercise is the release of natural agents called endorphins, which are endogenous pain relievers. A systematic review of studies published between 1980 and April 2010 found strong evidence for the effectiveness of muscle strengthening and endurance exercises in treating neck pain (Sihawong et al, 2011). Moderate evidence supported the use of muscle endurance exercise in reducing disability attributed to neck pain. The researchers concluded either muscle strengthening or endurance exercise is recommended for treatment of neck pain, whereas for reduction of pain-related disability, muscle endurance exercise is suggested.
Cognitive behavioral therapy (CBR) seeks to help patients redefine perceptions and opinions about illness, and teaches symptom reduction skills, which may help alter behavioral response to pain. While CBR has been successful when applied directly to the management of neck pain, a study found that use of CBR to treat post-traumatic stress disorder arising from whiplash also reduced neck disability (Dunne et al, 2011).
Biofeedback is a treatment method that teaches a patient to become aware and gain some degree of conscious control of processes normally thought to be involuntary inside of the body (e.g., blood pressure, temperature, heart rate). The goal of biofeedback is to influence and improve level of pain.
Alternative therapies such as acupuncture, yoga, Tai Chi and meditation have also been used successfully in the treatment of painful conditions such as cervicalgia. Ideally, such treatment modalities are engaging, available, financially feasible, potentially efficacious, and low risk for the patient (Plastaras, 2011).
Neck pain is common, and its determinants and prognosis are multifactorial (Haldeman et al, 2010). Since diagnosis of neck pain can be difficult, consultation with a pain specialist can be invaluable. Pain specialists have received extra training in examination and diagnostics of neck pain and other painful conditions.
- Neck Pain – PainDoctor.com
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