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neck pain; cervicalgia

Etiology: 1) neck muscle strain or sprain (cervical sprain) 2) trauma 3) torticollis 4) cervical spondylosis 5) radiculopathy 6) cervical myelopathy 7) chronic pain syndrome 8) rheumatoid arthritis 9) spondyloarthropathy - ankylosing spondylitis 10) giant cell arteritis 11) polymyalgia rheumatica 12) Paget's disease 13) fibromyalgia 14) neoplasm 15) vertebral osteomyelitis 16) meningitis 17) Lemierre syndrome (septic thrombosis of the jugular vein) - tenderness anterior to the sternocleidomastoid, overlying erythema 16) referred pain: a) temporomandibular joint b) bursitis, tendonitis or arthritis of the shoulder c) reflex sympathetic dystrophy d) thoracic outlet syndrome e) bronchogenic carcinoma f) coronary artery disease g) aortic dissection h) peptic ulcer disease i) pancreatitis j) cholecystitis k) salivary gland disease 18) psychological Epidemiology: - very common problem in adults Clinical manifestations: 1) pain, tenderness, stiffness, loss of motion of neck & shoulder 2) neck pain without neck tenderness, loss of neck motion or pain with neck movement suggests referred pain 3) nuchal rigidity suggest meningitis 4) polyradiculopathy suggests neoplasm, infection or widespread spondylosis - neck pain with radiating arm pain, dermatomal paresthesias - diminished deep tendon reflexes, loss of strength in affected arm [7] 5) bowel or bladder dysfunction or lower extremity numbness, weakness, hyperreflexia or hypotonicity or ataxia suggests myelopathy 6) red flags [7] a) recent trauma b) lower extremity weakness c) ataxia d) bowel or bladder dysfunction e) fever/chills f) injection drug use g) immunosuppression (including chronic glucocorticoid use) h) cancer i) weight loss j) refractory headache Caution: Never force a neck when evaluating range of motion Special laboratory: 1) electromyography (EMG) 2) nerve conduction studies Radiology: 1) atraumatic mechanical neck pain rarely requires imaging regardless of age [7] 2) radiograph of neck with odontoid view in cases of trauma or suspected rheumatoid arthritis 3) may be considered for neck sprain not responsive to 6-8 weeks of conservative therapy [7] 4) cervical radiographs (AP & lateral) may demonstrate evidence of neoplasm, osteomyelitis, fracture or traumatic subluxation 5) bone scan may demonstrate osteomyelitis or neoplasm 6) magnetic resonance imaging (MRI) is better than CT for soft tissue imaging; used for preoperative imaging 7) computed tomography (CT) is used for preoperative imaging Management: 1) prognosis - most cases are self limited with 70% resolving within 1 month 2) relative rest a) cervical pillow [4] b) soft cervical collar - may delay improvement; regular or prolonged use discouraged [7] c) cervical traction (not uniformly accepted) 3) pharmacologic agents a) analgesics 1] acetaminophen 2] non-steroidal anti-inflammatory agents 3] aspirin 4] lidocaine patch ineffective [14] 5] narcotic analgesics no better than placebo at 6 weeks [13] b) muscle relaxants effective for acute neck pain with muscle spasm [7] 1] cyclobenzaprine (Flexeril) 2] benzodiazepines 3] methocarbamol (Robaxin) c) increased spending on pharmaceuticals has not resulted in corresonding improvement in functional status [5] d) no benefit in adding muscle relaxant to NSAID [6] 4) physical modalities: ice, heat, ultrasound 5) physical therapy with improvement in pain [3] - home exercise more effective than medication [9] - Alexander technique of benefit [10] 6) spinal manipulation [9], manual manipulation [2] a) muscular & articular mobilization techiques & coordination or stabilization techniques b) performed by chiropractors, osteopaths, physical therapists c) more effective than medication [9] 7) trigger point & epidural injections 8) acupuncture may be of benefit [10] - benefits of acupuncture for chronic neck pain not clinically meaningful [15] 9) surgery a) myelopathy b) instability with neurologic abnormalities or severe pain c) severe radicular pain with definable lesion not responding to 6-12 weeks of conservative therapy

Related

neck

Specific

cervicobrachial syndrome spine pain

General

pain [odyn-]

References

  1. Saunders Manual of Medical Practice, Rakel (ed), WB Saunders, Philadelphia, 1996, pg 735-36
  2. Journal Watch 22(12):94, 2002 Hoving JL et al Manual therapy, physical therapy, or continued care by a general practitioner for patients with neck pain. A randomized, controlled trial. Ann Intern Med 136:713, 2002 PMID: 12020139 - Posner J et al Neck pain. Ann Intern Med 136:758, 2002 PMID: 12020144
  3. Journal Watch 25(4):35, 2005 Klaber Moffett JA, Jackson DA, Richmond S, Hahn S, Coulton S, Farrin A, Manca A, Torgerson DJ. Randomised trial of a brief physiotherapy intervention compared with usual physiotherapy for neck pain patients: outcomes and patients' preference. BMJ. 2005 Jan 8;330(7482):75. Epub 2004 Dec 07. PMID: 15585539
  4. Helewa A et al, Effect of therapeutic exercise and sleeping neck support on patients with chronic neck pain: A randomized clinical trial. J Rheumatol 2007, 34:151 PMID: 17216683
  5. Martin BI et al, Expenditures and health status among adults with back and neck problems. JAMA 2008, 299:656 PMID: 18270354
  6. Khwaja SM et al Comparison of ibuprofen, cyclobenzaprine or both in patients with acute cervical strain: A randomized controlled trial. CJEM 2010 Jan; 12:39 PMID: 20078917
  7. Medical Knowledge Self Assessment Program (MKSAP) 15, 16, 17, 18, 19. American College of Physicians, Philadelphia 2009, 2012, 2015, 2018, 2021. - Medical Knowledge Self Assessment Program (MKSAP) 19 Board Basics. An Enhancement to MKSAP19. American College of Physicians, Philadelphia 2022
  8. Garra G et al. Heat or cold packs for neck and back strain: A randomized controlled trial of efficacy. Acad Emerg Med 2010 May; 17:484. PMID: 20536800
  9. Bronfort G et al Spinal Manipulation, Medication, or Home Exercise With Advice for Acute and Subacute Neck Pain: A Randomized Trial Annals of Internal Medicine 2012, 156(1):1-10 PMID: 22213489 http://www.annals.org/content/156/1_Part_1/1.abstract - Walker BF and French SD Pain in the Neck: Many (Marginally Different) Treatment Choices Annals of Internal Medicine 2012, 156(1):52-53 PMID: 22213495 http://www.annals.org/content/156/1_Part_1/52.extract
  10. MacPherson H et al Alexander Technique Lessons or Acupuncture Sessions for Persons With Chronic Neck Pain: A Randomized Trial. Ann Intern Med. 2015;163(9):653-662 PMID: 26524571 http://annals.org/article.aspx?articleid=2467961
  11. Gross A, Kay TM, Paquin JP Exercises for mechanical neck disorders. Review. Cochrane Database Syst Rev. 2015 Jan 28;1:CD004250. Review. PMID: 25629215 - Kay TM, Gross A, Goldsmith CH et al Exercises for mechanical neck disorders. Cochrane Database Syst Rev. 2012 Aug 15;8:CD004250. Review. Update in: Cochrane Database Syst Rev. 2015;1:CD004250. PMID: 22895940
  12. Cohen SP. Epidemiology, diagnosis, and treatment of neck pain. Mayo Clin Proc. 2015 Feb;90(2):284-99. Review. PMID: 25659245
  13. Jones CMP, Day RO, Koes BW et al Opioid analgesia for acute low back pain and neck pain (the OPAL trial): a randomised placebo-controlled trial. Lancet 2023. Jue 28. PMID: 37392748 https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(23)00404-X/fulltext
  14. Cohen SP et al. Multicenter, randomized, placebo-controlled crossover trial evaluating topical lidocaine for mechanical cervical pain. Anesthesiology 2024 Mar; 140:513. PMID: 38079112 Free article https://pubs.asahq.org/anesthesiology/article/140/3/513/139530/Multicenter-Randomized-Placebo-controlled
  15. Zhao L, Sun M, Yn Z et al Long-Term Effects of Individualized Acupuncture for Chronic Neck Pain: A Randomized Controlled Trial. Ann Intern Med. 2024 Sep 3 PMID: 39222507 https://www.acpjournals.org/doi/10.7326/M23-2425