Neck pain

Background

• Two types:

1. Musculoskeletal
2. Radiculopathy/myelopathy

Clinical Features

Musculoskeletal

• Pain is deep, dull ache, episodic
• History of excessive or unaccustomed activity
• Pain is localized and asymmetric
• Referred pain: head (upper cervical segments), limb girdle (lower cervical segments)
• Symptoms aggravated by neck movement, relieved by rest

Radiculopathy

• Pain is sharp or burning
• Radiates to trapzezial and periscapular areas or down arm
• Numbness/weakness in myotomal distribution
• Headache may occur if upper cervical roots are involved
• Symptoms aggravated by neck hyperextension (esp when head is toward affected extremity)
• Gradual onset of shocklike sensations spreading down spine to extremities
• Most common at level of 5th cervical vertebra (shoulder abduction, external rotation)

Differential Diagnosis

Neck pain

• Musculoskeletal
• Torticollis
• Dystonic reaction
• Cervical spondylosis
• Cervical stenosis
• Cancer
• Epidural abscess
• Vertebral osteomyelitis
• Transverse myelitis
• Temporal arteritis
• Epidural hematoma (anticoagulation, hemophilia)
• Cervical disk herniation
• Blunt neck trauma
• Anterior horn disease
• Cervical fractures and dislocations
• Cervical radiculopathy

Neck Trauma

• Penetrating neck trauma
• Blunt neck trauma
  • Vertebral and carotid artery dissection
  • Strangulation
  • Whiplash injury
• Cervical injury
  • Cervical fractures and dislocations
  • Cervical injury (peds)
  • Cervical spine clearance
• Neurogenic shock
• Spinal cord injury

Evaluation

• Musculoskeletal pain
  • Pain occurs on side away from head movement
• Radiculopathy
  • Spurling test
    • Apply gentle pressure to patient's head during extension and lateral rotation
    • May reproduce patient's radicular pain with radiation into ipsilateral upper extremity
  • Abduction relief sign
    • Placing hand of affected extremity on top of head leads to relief
    • Indicates soft disk protrusion

Imaging

• Consider x-ray for:
  • Chronic neck pain (weeks-months)
  • History of malignancy
  • History of RA, ankylosing spondylitis, psoriatic spondyloarthropathy
• Consider MRI for:
  • Neurologic signs/symptoms
  • Plain films show bone or disk margin destruction
  • Cervical instability
  • Epidural abscess is suspected

Management

• NSAIDs or acetaminophen
  • 1st line therapy
• Trigger point injections may be useful for trapezius muscle spasm
• Opioids
  • Appropriate for moderate-severe pain but only for limited duration
• Muscle relaxants
  • Efficacy appears equal to NSAIDs
  • Diazepam 5-10mg PO q6-8hr OR methocarbamol 1000-1500mg PO QID

Disposition

• Discharge unless concerning etiology exists

See Also

• Neck Diagnoses