by Nicole Berardoni M.D, Tory McJunkin M.D, and Paul Lynch M.D
Understanding the neck’s anatomy is critical for properly diagnosing and treating the source of your pain.
The anatomy and physiological function of the neck is the key in evaluating a person with neck pain. The bony spine is positioned so that individual vertebrae (bones of the spine) provide a flexible support structure while also protecting the spinal cord.
Separating each individual vertebrae are discs that act as cushions to minimize the impact that the cervical spinal column receives. Since the discs are designed to be soft and provide support, they have a tendency to herniate posterior (collapse backwards) through ligaments and cause irritation to adjacent nerves or even the spinal cord. Disc disease is one of the most common causes of neck pain and one of the most common reasons for surgery. Disc disease may be acute, resulting from trauma, or more commonly, chronic pain caused by degeneration. Degenerative disc disease is a process that is due to a thinning and dehydration of the discs over time that can lead to compression of other nearby structures.
Spinal Ligaments and MusclesThere are ligaments that attach to each vertebra and provide strength and mobility to the cervical spine as well as many muscles that are responsible for movement. Spinal nerves are attached to the cervical spinal cord and exit the spine to innervate the skin, muscles, and surrounding structures of the neck and upper extremities. Muscles and ligaments have a tendency to become strained and irritated during strenuous lifting and excessive use and can cause local nerve irritation. Myofascial (muscle-related) and ligament injury accounts for the majority of neck pain.
Trigger point injections, acupuncture, and physical therapy for neck pain are extremely successful. Structurally, the cervical spine is composed of seven small vertebrae, as well as the associated muscles, ligaments, joints, and nerves. The cervical spine has many important functions, which include providing support and mobility to the head and neck as well as protection of the spinal cord emerging from the brain. The cervical spine provides generous amounts of movement of the head. It is considered the most flexible portion of the spine and is therefore readily strained.
The atlas and axis are the top two cervical vertebrae and are responsible for the majority of the head’s rotational movement. These vertebrae form joints as they support the head and connect to the spine. They are also involved in coordination and balance for the rest of the body. Because the cervical spine is considered the most flexible portion of the spinal cord, it is also the most vulnerable to injury. The first through the third cervical nerves that exit from the cervical vertebrae provide sensory information to the head and face.
When these nerves become compressed or inflamed, they will cause pain and other sensory deficits in particular regions of the head and face. When the greater and lesser occipital nerves are involved, this can cause significant radiating pain to the face and head. The other nerves located lower in the cervical spine combine to form a large plexus of nerves that provides motor and sensory support to the upper extremities. Involvement of these nerves can cause weakness, pain, loss of feeling, or other symptoms in the arms.
There are many causes of neck pain but the most common causes are due to:
- Muscle strains
- Trauma or injury (damage to the muscles, tendons, or ligaments)
- Herniated cervical disk
Overuse of the muscles and falling asleep in awkward positions for extended periods of time often produces muscle strains. The neck muscles located in the back of the neck become tense. When the neck muscles are continuously or frequently strained, a chronic pain syndrome can develop.A well-known cause of neck pain, referred to as whiplash, occurs after motor vehicle accidents, specifically in rear-end collisions. This hyperextension of the neck often results in stretching of the soft tissues of the neck, producing local inflammation, muscle tension, and ligament strain. When ligaments and tendons become inflamed or damaged, they can cause persistent pain that intensifies with particular movements. In addition to neck muscle strains, the neck facet joints are also commonly involved in painful neck conditions.
Cervical spondylosis (neck arthritis) is caused by degenerative changes of the cervical vertebrae and adjacent facet joints. The symptoms typically present around the age of 40, but can present earlier with trauma. The arthritis continues to progress, and pain typically worsens with extending the head backwards. Degenerative disc changes occur as a person ages, and the disc can decay or herniate, producing local nerve root irritation or compression of the spinal cord.
Another frequent cause of neck pain is spinal stenosis, which is a narrowing of the central spinal canal. This narrowing can compress the spinal cord and surrounding nerves roots. This compression can cause cramping pain, shooting pain, or numbness in the legs, back, neck, shoulders, or arms. The symptoms typically depend on the area of the spine that is affected. In cervical spinal stenosis, the upper extremities and shoulders are most commonly affected. Depression, anxiety, and stress tend to exacerbate chronic pain syndromes. Worsening neck pain is a common manifestation of these emotional stressors.
Dr. Rubin of the Mayo Clinic recently published a statement saying:
It is extremely important to not only treat the physical symptoms of neck pain, but also the emotional stressors as well. Massage, acupuncture, biofeedback, and behavioral therapy can all be extremely beneficial in patients suffering from chronic pain worsened by depression, anxiety, or stress.
“Low back and neck pain is a common problem and one of enormous social, psychological, and economic burden. It is estimated that 15% to 20% of adults have back pain during a single year and 50% to 80% experience at least one episode of back/neck pain during a lifetime. Low back pain afflicts all ages, from adolescents to the elderly, and is a major cause of disability in the adult working population. Risk factors for developing spine pain are multidimensional; physical attributes, socioeconomic status, general medical health and psychological state, and occupational environmental factors all contribute to the risk for experiencing pain.” (Rubin 2007)
Central sensitization is a common complication associated with chronic pain of all kinds. This is a development involving both the peripheral nervous system (PNS) and the central nervous system (CNS). Local tissue injury and inflammation activate the PNS, which sends signals through the spinal cord to the brain. Central sensitization occurs when there is an increase in the excitability of neurons within the CNS at the level of the spinal cord and higher. Eventually normal inputs from the PNS begin to produce abnormal responses. Low-threshold sensory fibers activated by a very light touch of the skin activate neurons in the spinal cord that normally only respond to painful stimuli.
As a result, an input that would normally produce a harmless sensation now produces significant pain. Less common causes of neck pain include vertebral compression fractures, spinal cord disorders, tumors, and infection. Metastatic tumors (cancer spread from another organ system) are the most common type of malignant lesions of the spine. Some 5-10% of patients with a primary cancer suffer spinal metastases. Breast, lung, prostate, and renal cell carcinomas are the most common tumors that metastasize to the spine, whereas myeloma, lymphoma, and gastrointestinal carcinoma can also invade the vertebral column (James 2003).
Oropharyngeal cancers of the oral cavities and neck may also present with neck pain. All of these causes require immediate professional neck pain treatment, and seeing a physician should not be delayed. Symptoms that indicate a possible emergency situation that should receive immediate medical attentions include neck pain with altered level of consciousness, sudden blindness, paralysis, weakness, bowel/bladder changes, vision/hearing/taste change, severe vomiting, recent weight changes, or fever.
DiagnosisDiagnosis of neck pain can be difficult, so the pain physicians at Arizona Pain Specialists have received extra training to examine and diagnose your painful condition. The physician may perform a physical exam testing tenderness over certain areas of the spine as well as assessing the various limitations in movement. The physician may also order radiological imaging such as X-ray, CT scan, MRI, or bone scan depending on her or his clinical suspicion and the history obtained.
Common complaints of people experiencing neck pain are:
- Neck pain
- Reduced range of motion in the neck
- Upper extremity pain, weakness, or sensory changes
- Coordination and balance difficulty
Neck Pain Treatment and Therapy OptionsManagement of neck pain depends on the etiology of the pain. Minimally-invasive procedures are numerous and can be the most helpful to control pain and improve daily functioning. In the past few years there has been an abundance of research surrounding non-surgical procedures and their effectiveness in treating neck pain.
Some of the current treatments are:
- Pharmacotherapy: NSAIDs (ibuprofen-like drugs), acetaminophen (such as Tylenol), muscle relaxants, and membrane-stabilizing medications are often effective in treating neck pain.
- Cervical epidural steroid injections: Epidurals are frequently used for pain syndromes due to common conditions such as degenerative disc disease. The method involves injecting a steroid into the epidural space of the spinal cord where the irritated nerve roots are located. The medicine then spreads to other levels and portions of the spine, reducing inflammation and irritation.
In another recent analysis, cervical epidural steroid injections (CESIs) in patients with spinal stenosis and associated neck pain were studied. These resulted in a 72% effectiveness in relieving neck pain. The study concluded that the use of CESIs is a “safe and effective” method in treating patients with cervical neck pain and cervical radiculopathy (Kwon 2007). CESI are an injection made up of a combination of a corticosteroid and local anesthetic (like lidocaine). The neck pain therapy is minimally-invasive and can provide great pain relief. The benefits of CESIs increases with multiple injections, and usually a series of three are initiated.
- Cervical medial branch blocks/denervation: This is a widely-used treatment for neck pain by pain specialists. Medial branch blocks (MBBs) are a minimally-invasive non-surgical treatment that is used for arthritis-related neck and back pain. The injections work by reducing the inflammation and irritation in the facet joints of the spine that is causing your pain.
In a double-blind, randomized, controlled trial performed in 2006, it was noted that significant pain relief (³ 50%) and functional status improvement was observed at three months, six months, and 12 months in patients treated with cervical medial branch nerve blocks. The study showed that the use of therapeutic cervical medial branch nerve blocks may provide effective management for chronic neck pain of facet joint origin (Manchikanti 2006). In addition to blocking the medial branch nerves, the nerves can also be destroyed for longer durations. The procedure is called radiofrequency ablation and uses similar techniques, but typically takes longer to perform.
- post-laminectomy syndrome, radiculopathy, and disc disease. Cervical lysis of adhesions: Also known as the “Racz procedure,” this procedure has been proven effective in removing excessive scar tissue in the epidural space when conservative neck pain treatment has failed. This procedure is used in vertebral body compression fractures,
- Infusion techniques: This 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 time periods. When the nerves are blocked continuously with an infusion, pain relief can be dramatic and long-lasting.
- Cervical spinal cord stimulation (SCS): This method involves tiny electrodes being placed within the epidural space close to the spinal cord. The electrodes release a small electrical current to the spinal cord that inhibits pain transmission. This inhibition of pain signals allows for pain relief. Cervical SCS is currently used for treating chronic pain syndromes such as complex regional pain syndrome, chronic neck pain, diabetic neuropathy, post herpetic neuralgia, peripheral ischemia, and other conditions that are resistant to more conservative treatments (Vallejo 2007). Patients reported significant (70-90%) reductions in neck and upper extremity pain when treated by cervical SCS. Several of the patients in this particular study also benefited from a decrease in associated headache and lower extremity pain.
- Occipital nerve blocks: This method involves an injection of local anesthetic and corticosteroid over the occipital nerves (back of head). The blocks can dramatically improve pain and increase the quality of your life.
- Occipital nerve stimulation: This method involves tiny electrodes being placed close to the occipital nerves (back of head). The electrodes release a small electrical current that inhibits pain transmission and causes pain relief.
- Transcutaneous electrical nerve stimulation (TENS): This is a technique that relieves pain by applying mild electric current to the skin at the site of the pain. The electric impulses interfere with normal pain sensations and alter perceptions that were previously painful.
- Trigger point injections: These can be an effective treatment for muscle spasms. The procedure involves injecting a local anesthetic and steroid into a “trigger point.”
- Botox: Used in treating neck pain, this is an exciting new treatment that is widely accepted among modern medical practitioners. In 2005, “Botulinum toxin Type A (BtA) became the first line therapy for the treatment for cervical dystonia.” Although a single injection of BtA is effective, multiple injection cycles seem to work better for patients (Costa 2005). Botox injections have also been found to be effective in patients with whiplash injuries. Along with reductions in pain, patients were found to have improved range of motion (Juan 2004).
- Biofeedback: This is a treatment for neck pain that teaches a patient to become aware of processes that are normally thought to be involuntary inside of the body (such as blood pressure, temperature, and heart rate control). This method enables you to gain some conscious control of these processes, which can influence and improve your level of pain. A better awareness of one’s body teaches one to effectively relax, and this can help to relieve pain.
- Physical therapy: In order to decrease or prevent functional limitations, physical therapy and occupational therapy are recommended as well as medical treatments. Physical therapy for neck pain aims to increase range of motion and muscular strength.
- Acupuncture: In this procedure, small needles are inserted into the skin. These needles cause your body to release hormones called endorphins that are your body’s natural pain relievers. Acupuncture can also help you relax, decreasing stress, tension, and muscular spasm. Acupuncture has been shown to be very helpful in those with chronic pain, helping to relieve their symptoms (Trinh 2007).
- Nutrition and exercise: Exercise improves neck pain by increasing flexibility and range of motion. Another benefit is the release of hormones called endorphins that are your body’s natural pain relievers. Nutrition and healthy eating may be powerful treatments to combat nutritional deficits.
- Massage: Gentle focal rubbing of tender areas may help relieve muscle spasms or contractions and improve the discomfort associated with it. Massage can also help you relax, decreasing stress and tension.
- Chiropractic manipulations: Targeted adjustments, especially combined with other modalities, may significantly reduce neck pain. Manipulations are undertaken in order to allow correct nerve transmission.
- Prolotherapy: This treatment is also known as regenerative injection therapy. It is a technique of injecting irritating substances into painful ligaments and tendons. The procedure is used to initiate the body’s healing of a damaged ligament or tendon.
Treatment options are available for chronic pain, headaches, reduced range of motion, and more.
- Cervical interlaminar epidural steroid injection for neck pain and cervical radiculopathy: effect and prognostic factors. Skeletal Radiol. 2007 May;36(5):431-6. Epub 2007 Mar 6 Kwon JW, Lee JW, Kim SH, Choi JY, Yeom JS, Kim HJ, Kwack KS, Moon SG, Jun WS, Kang HS. PMID: 17340166
- Epidemiology and risk factors for spine pain Neurol Clin. 2007 May;25(2):353-71 Rubin DI. PMID: 17445733
- Botulinum toxin type A therapy for cervical dystonia Cochrane Database Syst Rev. 2005 Jan 25;(1):CD003633. Costa J, Espírito-Santo C, Borges A, Ferreira JJ, Coelho M, Moore P, Sampaio C. PMID: 15674910
- Use of botulinum toxin-A for musculoskeletal pain in patients with whiplash associated disorders BMC Musculoskelet Disord. 2004 Feb 13;5:5. Juan FJ PMID: 15018625
- Therapeutic cervical medial branch blocks in managing chronic neck pain: a preliminary report of a randomized, double-blind, controlled trial: clinical trial NCT0033272. Pain Physician. 2006 Oct;9(4):333-46 Manchikanti L, Damron K, Cash K, Manchukonda R, Pampati V. PMID: 17066118
- Neuromodulation of the cervical spinal cord in the treatment of chronic intractable neck and upper extremity pain: a case series and review of the literature.Pain Physician. 2007 Mar;10(2):305-11 Vallejo R, Kramer J, Benyamin R. PMID: 17387353
- Acupuncture for neck disorders. Spine. 2007 Jan 15;32(2):236-43. Trinh K, Graham N, Gross A, Goldsmith C, Wang E, Cameron I, Kay T. PMID: 17224820
- Cervical Spinal Metastasis: Anterior Reconstruction and Stabilization Techniques After Tumor Resection James K. Liu, M.D.; Ronald I. Apfelbaum, M.D.; Bennie W. Chiles Iii, M.D.; Meic H. Schmidt, M.D. Neurosurg Focus 15(5), 2003. © 2003 American Association of Neurological Surgeons Posted 12/17/2003