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Revised by Dr Noran Ramli

Neck Pain

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Outlines

  • Case Scenario
  • Introduction and Definition
  • Neck Anatomy
  • Causes
  • Symptoms and Red Flags
  • Physical Examination
  • Investigation
  • Prevention
  • Treatment

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Case Scenario

  • Mrs TYL, a 50-year-old lady presented with neck pain for 4 months
  • Described as insidious onset episodic pain at back of her neck
  • Worsened with time intense in last 2 weeks
  • Relieved temporarily with PCM and resting
  • Not radiated to shoulder or back
  • Felt restriction and stiffness of the neck
  • No traumatic event

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Case Scenario (cont’d)

  • She had already been to a GP, prescribed with NSAIDs and had transient improvement of symptoms
  • She experienced difficulty to carry on her work due to pain and concerned about long term deformity

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What is your further questioning?

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Case Scenario (cont’d)

  • PMHx – HPT & Hyperlipidemia on medication
  • No past surgical history
  • No drug allergy
  • No family hx of malignancy or other medical illness
  • Social hx – married and blessed with 3 children

worked as clerk in a law firm

non smoker /alcoholic

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What is your next step?

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Case Scenario (cont’d)

  • General Examination

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    • Medium built, afebrile, no pallor
    • BP 130/80, PR 98, P/S 4/10
    • Normal gait
    • No lymphadenopathy
    • No tenderness, swelling of small joints
    • No rashes

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Case Scenario (cont’d)

  • Neck

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    • Look – No deformities/visible lumps/scars/swellings/muscle wasting in the neck or upper limbs
    • Feel – No tenderness over the spine
    • Move – decreased range of all the neck movements

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  • Neurology

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    • No weakness or altered sensation in upper or lower limb

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What are your differential diagnoses?

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Case Scenario (cont’d)

  • Differential Diagnoses:

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    • Cervical Spondylosis
    • Mechanical Pain (Posture, Trauma, Whiplash)
    • Cervical Disk Herniation (Nerve Root Entrapment)
    • Cervical Spinal Malignancy
    • Rheumatoid Arthritis

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What is your next approach?

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Case Scenario (cont’d)

  • Investigation

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    • X-ray of the cervical spine normal

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We already Recognised and Assessed, so what is your next plan?

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Case Scenario (cont’d)

  • Treatment

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    • Non-pharmacological
      • Physiotherapy
      • Cervical collar use only for unstable spine !!

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    • Pharmacological - Based on WHO Pain Ladder

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  • Health Education and Prevention

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  • Follow up – reassess pain, functional level, exercise compliance

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Introduction

  • Neck pain is a highly prevalent condition that leads to considerable pain, disability, and economic cost.

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  • In 2017, the global age-standardised prevalence and incidence rate of neck pain were 3551.1 and 806.6 per 100,000, respectively.

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  • The point prevalence of neck pain was higher in females across all age groups and the highest burdens being in the 45–49 and 50–54 age groups for men and women, respectively.

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  1. Henschke N, Kamper SJ, Maher CG. The epidemiology and economic consequences of pain. Mayo Clin Proc2015;90:139-47. doi:10.1016/j.mayocp.2014.09.010 pmid:25572198
  2. Safiri S, Kolahi A-A, Hoy D, Buchbinder R, Mansournia MA, Bettampadi D, et al. Global, regional, and national burden of neck pain in the general population, 1990–2017: systematic analysis of the Global Burden of Disease Study 2017. BMJ. 2020;368.

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Definition

  • Global Burden of Disease Study defined neck pain as pain in the cervical spine region (with or without pain referred to the arms) that lasts for at least 24 hours.

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  • The International Association for the Study of Pain (IASP) in its classification of Chronic Pain defines cervical spinal pain as "pain perceived anywhere in the posterior region of the cervical spine, from the superior nuchal line to the first thoracic spinous process".

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Neck Anatomy

The neck region of the spinal column, the cervical spine, consists of seven bones (C1-C7 vertebrae), which are separated from one another by intervertebral discs.

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Neck Anatomy

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Neck Anatomy

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Causes of Neck Pain

  • Musculoskeletal (most common)
  • Myofascial pain syndrome
  • Joint dysfunction – Facet joint pain
  • Strains/sprains/injuries

Whiplash injury

Myofascial pain

Muscle strains

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Strain/Sprain

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Facet Joint Pain

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Inflammation

  • OA
  • RA
  • AS

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Infective

  • Meningitis
  • Osteomyelitis
  • TB
  • Herpes zoster

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Degenerative

  • Spondylosis

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Neoplasia

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Fibromyalgia

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Psychogenic

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Referred pain

  • Cardiac
  • Oesophagus
  • Lung
  • Cranial

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Symptoms

  • Neck pain which worsened on prolonged head holding in one position.
  • Neck muscle spasm
  • Limited neck movement
  • Headache

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Red Flags

  • Severe and persistent neck pain more than 12 weeks
  • Has history of neck injury
  • Has upper limb(s) muscle weakness and wasting
  • Unexplained weight loss with loss of appetite
  • Neck spasm with passive range of movement

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Physical Examination

Inspection

    • Posture
    • Loss of cervical curvature
    • Torticollis
    • Scar
    • Swelling
    • Bony deformity
    • Skin changes
    • Shoulder imbalance

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Physical Examination

Range of Movement

  • Limited active and passive movement

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Muscle Power

  • Reduced

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Neurological examination

  • Loss of sensation within affected dermatome
  • Reflexes

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Investigation

Blood

  • FBC- leucocytosis in infection and inflammation
  • ESR/CRP – inflammation

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XRay Cervical Spine (AP/ Lateral/ Oblique View to see foramen)

  • Loss of cervical lordosis
  • Degenerative changes
  • Reduced intervertebral disc height
  • Reduced size of foramen
  • Signs of osteoporosis

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MRI

  • Degenerative changes
  • Disc prolapse
  • Cord and nerve compression
  • Cord (myelopathic) changes indicating chronic cord compression

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Non-Pharmacological Treatment

Physiotherapy Aspects:

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  • Electrotherapy
      • Transcutaneous Electrical Nerve Stimulation (TENS)
      • Ultrasound

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  • Thermal Therapy
      • Hot modalities – Short Wave Diathermy, Hot Pack, Infrared (for chronic pain)
      • Cold modalities – Ice pack, Cryo Compression Therapy (for acute pain)

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Non-Pharmacological Treatment

Physiotherapy Aspects:

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  • Manual Therapy
      • Soft tissue manipulation
      • Joint mobilization
      • Myofascial Release
      • Muscle Energizing Technique
      • Dry Needling

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  • Therapeutic Exercise Therapy
      • Stretching exercises
      • Coordination, strengthening and endurance exercises
      • Neurodynamic exercises

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  • Cognitive Behavioural Therapy

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Non-Pharmacological Treatment

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Traditional & Complementary Medicine Aspect:

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  • Acupuncture
  • Massage

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Pharmacological Treatment

  • Topical/Oral/Injection Analgesics
  • NSAIDs
  • Cox2-Inhibitors
  • Anti-neuropathic medication
  • Steroid/local anaesthetic injection (orthopaedic/pain clinic)

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Prevention

Health Education on Ergonomic Posture

    • Use good posture
    • Take frequent breaks to stretch neck and shoulder
    • Adjust chair, desk and computer to be at eye level
    • Avoid tucking phone between ear and shoulder when talking
    • Avoid carrying heavy bags with straps on the shoulder
    • Avoid sleeping in a prone position and use pillow of suitable size

 

Behavioural Modification and Adaptation

    • Stop smoking
    • Pacing (break up your activity into smaller, more manageable tasks with rest breaks with guidance of physiotherapist)
    • Encourage exercise to improve flexibility, strength and endurance of upper limbs muscle, shoulder and neck

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Every 30-60 minutes, take a brief (2-5 minute) break to stretch and/or walk around.

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