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What to do when neck pain is more than just a simple pain in the neck

Early identification of the cause of a patient’s neck pain is important, but equally important is choosing the treatment that will provide the most optimal results.

Heather S. Miller, BS, PA-C, FAAPA

Heather Miller is a summa cum laude graduate of the Medical College of Georgia and currently specializes in pain management at the Augusta Pain Center, Augusta, Georgia. She has indicated no relationships to disclose relating to the content of this article.

Neck pain can manifest as an acute sprain, strain, or inflammation.¹ A sprain is a sudden twisting or displacement of the joint leading to stretched ligaments and is often accompanied by the tearing of blood vessels, bruising, instability, and pain. Strain occurs with excessive tension or overstretching of the muscles or tendons and can result in pain or weakness. Inflammation is a local response to injury and can occur in most body tissues and joints; it can be acute as well as chronic. The onset of neck pain may also be insidious, secondary to chronic arthritis, inflammation, or progressive instability. Symptoms often resolve spontaneously.² To better treat the condition, PAs must be aware of common presenting complaints and causes, as well as of the most efficient diagnostic tests and treatments.

In the general population, up to 22% of persons experience neck pain and, if it becomes chronic, 44% will consult their primary care provider for relief.³ In addition, one-third of patients with neck pain will also report associated radicular symptoms or arm pain.² Chronic pain can be defined as pain that has been present for at least 3 months; it may also be defined as continuous or intermittent pain persisting beyond a reasonable time of healing.⁴ Second only to low back pain, neck pain is a frequent cause of absence from work.¹ Although the condition occurs in both men and women, one collective study reported that neck pain is more prevalent in women.⁵ In that study, 60% of the women complained of neck pain, compared to 38% of the men.⁵

ANATOMY AND PHYSIOLOGY

The cervical spine is comprised of the first seven vertebrae. These vertebrae provide stability to the head and connect to the thoracic spine (see Figure 1). The vertebrae have many potential pain generators. Within a vertebra, articulating facet joints are innervated by the medial branches of the dorsal rami.⁴ In addition to the bony structures, vertebrae are supported by a network of ligaments including the transverse ligament, the anterior longitudinal ligament, the posterior longitudinal ligament, the supraspinous ligament, the interspinous ligament, and the ligamentum flavum^6,7 (see Figure 2). Ligament functions include cervical motility, intervertebral joint support, and stabilization of the vertebral arch. The musculature of the neck and upper back provide additional support. Neck pain can arise from neural tissue disorders, spinal ligament strains,⁸ or natural degeneration of the facet joints;² it may also be secondary to injury or muscle fatigue.

The intervertebral disks are also potential pain generators. The disks act as shock absorbers, stabilize the vertebra, allow cervical motion, and distribute weight.⁹ A cervical disk is composed of two major parts: the gelatinous nucleus pulposus, or center of the disk, and the surrounding annulus fibrosus, or capsule. In a normal intervertebral disk, nerve endings capable of transmitting nociceptive information are concentrated mostly in the outer third of the annulus.^4,7 Discogenic pain is produced by disk degeneration or herniation; this results in referred neck pain, shoulder pain, or upper extremity pain.^10,11 The center of the disk herniating through the capsule or the capsule protruding into the canal can irritate a nearby nerve root, resulting in radicular pain. Cervical radicular pain may also be secondary to foraminal encroachment or narrowing caused by degenerative changes.²

CLINICAL PRESENTATION

Collecting information to reach an accurate diagnosis can be challenging. PAs must consider the patient’s history—previous surgeries, recent diagnoses, recent trauma, mechanism of injury, and the presence of neurologic symptoms.¹² These factors may influence the questions a PA needs to ask to obtain a thorough history of the patient’s neck pain. A good starting point is to follow the mnemonic “OLD CARTS” (see Table 1).

A quantified pain score is an important part of the history. Scales for obtaining a pain score include the visual analog scale, the graphic rating scale, and the numerical rating scale. The patient can also quantify his or her pain using a pain drawing or a verbal rating scale.¹³ Pain scales can be used to assess the effectiveness of treatment as well as to assess pain intensity. The common intensity scale of 0 to 10 is often easily understood by patients.

Differential diagnosis The symptoms of underlying cervical spine disorders must be differentiated from serious disease, chronic conditions, and referred pain (see Table 2). For example, rapid weight loss, severe night pain, night sweats, progressive myelopathy, and low-grade fever indicate a possible neoplasm, whereas morning stiffness suggests arthritis.² Contributing factors such as the patient’s occupation, activity level, and environment are also important.

One study on the prevalence and risk factors for neck pain found that 68% of the subjects who experienced neck pain also admitted to having a poor psychosocial working environment.⁵ Neck pain may be a somatic complaint in a patient with depression. A common manifestation of depression is other somatic complaints in addition to neck pain.¹⁴ The severity of the somatic symptoms may also be increased in patients with underlying depression.¹⁵ A US study identified by a literature review found that 69% of patients with depression presented to primary care complaining of mild to severe aches and pains.¹⁴

Objective findings An initial evaluation should include a systems-appropriate physical examination, including a complete musculoskeletal and neurologic examination. Significant underlying abnormalities that may require immediate treatment must be ruled out. The clinician must keep specific pain generators and their common clinical features in mind. For example, facet-mediated pain often manifests as paraspinal tenderness to palpation over the facet joints.¹⁶ The facet joint capsule is one of the major stabilizing structures during spinal extension,⁸ and the patient may report increased pain with cervical extension. Facet-mediated pain may also be secondary to disk degeneration, injury, or increased physical stress. A common cause of facet-mediated pain secondary to injury is whiplash or whiplash-associated disorder.² Cervical fusion may increase the stress on the facet joints. The joints above or below the fused vertebrae induce pain, leading to facet joint dysfunction and postlaminectomy syndrome.⁴

A patient with discogenic pain commonly presents with cervical pain aggravated by cervical flexion, Valsalva maneuvers, and axial compression.⁹ Disk pain may manifest as nonfocal pain in a general distribution,¹⁷ whereas radicular pain is diagnosed by mapping out a pain pattern consistent with a dermatome pattern and the patient’s history.² The foraminal compression test, also known as Spurling maneuver, can be used to exacerbate radicular symptoms. This maneuver is performed by applying cervical compression with an axial load on the patient’s head, while the patient extends the neck and laterally rotates toward each side. Radiating pain into the arm signifies a positive result and possible nerve impingement. In a clinical study, a positive compression test correlated with the patient’s history in up to 68% of cases.¹⁶

Motor or sensory changes may also be appreciated. Decreased sensation to pain, touch, or vibration may be noted in a specific dermatome pattern.^2,9 Conversely, the patient may experience hypersensitivity rather than decreased sensation. Muscle strength or deep tendon reflexes may vary if a spinal root is compromised.^2,17 Although the physical examination often provides vital information, many of the evaluation tools utilized during the examination can stress multiple pain generators simultaneously and fail to identify a single pain producer.⁴ Additional diagnostic studies should therefore be considered.

DIAGNOSTIC STUDIES

Radiography plays an important role in the evaluation of neck pain. Plain films are often preferred as the initial study in trauma cases.¹⁸ A plain film provides a comprehensive anatomical overview at a relatively low cost.^18,19 In addition, plain films are specifically indicated for instability, which can be seen in lateral views of flexion and extension positions. Although diagnostic imaging studies help differentiate an unstable injury from a routine sprain or strain,¹² they can be misleading. Underlying abnormalities may be identified that are not related to the current complaint or the current symptoms.²

CT or MRI may be required to evaluate soft tissue, diagnose a disk abnormality, or assess the spinal anatomy in greater detail. CT is commonly used if MRI is not available or cannot be used; CT may also provide a better image of an abnormality in the bony structures, such as a hairline fracture, degenerative changes, or facet joint orientation or asymmetry.⁸ CT myelography produces high resolution images of the bony structures, the spinal canal, and the neural foramina and aids in evaluating canal stenosis before surgery.²⁰ MRI is contraindicated in patients with cardiac pacemakers, surgical hardware, surgical clips, or cerebral aneurysm clips unless the surgeon can confirm that the device is MRI-compatible.¹⁹ Degenerative changes in the nucleus pulposus and annulus fibrosus are easily identified on MRI, making it the most accurate method for assessing intervertebral disk disease.⁷ PAs should remember, however, that the abnormalities identified by MRI may not be significant or relevant to the patient’s symptoms. In one study, MRI analysis of 30 asymptomatic volunteers identified annular tears in 37% of the volunteers and bulging disks in 73%; mild disk degeneration was found in 75% of the volunteers aged 31 to 45 years.¹⁰ All the volunteers were asymptomatic and had no history of neck or arm pain.

A bone scan is sensitive but not specific. Bone scans easily identify osteoblastic activity, including inflammation, degeneration, infection, fracture, and tumors.¹⁹ However, each of these pathologic processes can appear similarly on the bone scan. Plain films, CT, or MRI may be needed following an abnormal bone scan to make a definitive diagnosis.

TREATMENT OPTIONS

Pharmacologic Initial treatment of neck pain should be conservative and may include medication, physical therapy, and nonsurgical interventional techniques. Many medications are indicated for their analgesic potential, such as acetaminophen, NSAIDs, muscle relaxants, anticonvulsants, and some antidepressants.^21,22 These pharmaceutical agents have the ability to diminish pain and improve function.²² Chronic pain is best managed by following a therapeutic regimen rather than taking medication as needed for pain control. The goal of medication management is a favorable balance between analgesia and adverse effects through a gradual dose titration until stabilization is attained.^11,23

The least invasive route of administration at the lowest effective dosage of medication is the preferred approach. Oral drugs are the least invasive route and are preferred over transdermal, intramuscular, or intrathecal medications. Acetaminophen is the first-line treatment for moderate pain.²³ NSAIDs reduce inflammatory mediators of central and peripheral pain by inhibiting cyclooxygenase (COX) and reducing prostaglandin synthesis.²³ NSAIDs are available as COX-1 (indomethacin, piroxicam, tolmetin) and COX-2 inhibitors (celecoxib, meloxicam); these drugs directly interfere with both COX isoforms. Side effects associated with NSAIDs include GI problems (ulcers, gastritis), renal failure, and cardiovascular toxicity (stroke, heart attack); however, COX-2 selective inhibitors have a reduced risk for GI effects compared to COX-1 inhibitors.²³

Pregabalin and gabapentin, common anticonvulsants, are effective for treating chronic nerve pain and are considered the first-line medication for neuropathic pain.²³ In addition, pregabalin was recently approved for fibromyalgia, and studies show its efficacy against pain and fatigue.²⁴ Tricyclic antidepressants (TCAs) have analgesic effects, but venlafaxine and duloxetine, also indicated for neuropathic pain and somatic complaints, are often better tolerated than TCAs.²³ TCAs must be used with caution because of problematic side effects such as urinary retention, dry mouth, and tachycardia, especially in the elderly.²⁵ Using the lowest, most effective dose is especially important with anticonvulsants and antidepressants to minimize potential side effects, most commonly dizziness, somnolence, nausea, and headache.²³ For example, the patient takes the lowest dose daily at bedtime at the beginning of therapy. If the patient tolerates the medication, the dosage can be increased every few days. This method achieves an acceptable level of comfort with minimal medication.

Narcotic medications have a high potential for addiction, tolerance, opioid-induced hyperalgesia, and abuse. Therefore, drugs such as oxycodone, morphine, fentanyl transdermal, methadone, and propoxyphene should be prescribed with caution and used only after other medications fail to provide adequate pain control.^11,23 Random urine drug screens and written agreements can ensure that narcotic medications are taken only as directed. Before initiating long-term opioid therapy, consider the commitment of the patient to adhere to regular follow-up, opioid monitoring, proper documentation, and plans for weaning off or discontinuing opioids if treatment goals are not met.¹¹

Physical therapy Exercise therapy, physical therapy, and limited rest are recommended to maximize function and restore flexibility.²² In fact, resolution of pain is more responsive to early mobilization than to rest.²¹ A study that followed whiplash injuries confirmed that patients told to “act as usual” had a better outcome compared with patients instructed to rest or who were granted leave from work.²⁶ Myofascial pain, such as trigger points, is often relieved through stretching, physical therapy, and transcutaneous electrical stimulation.²⁷ Rehabilitation exercises are recommended for chronic pain problems; cryotherapy, ultrasound application, and massage are more beneficial for acute pain problems.¹ Physical therapy is also beneficial for acute and chronic pain.

Injections If no significant improvement is seen with medication or physical therapy, therapeutic injections, facet joint blocks, and epidural corticosteroid injections may be considered. Trigger point injections with local anesthetics and corticosteroids or simply dry needling can treat myofascial pain secondary to taut bands of skeletal muscle.²⁷ Typically, the trigger point is painful on palpation and may refer pain from the initial site. Caution must be taken when injecting trigger points in the cervical or thoracic region. A pneumothorax can occur if the needle penetrates too deeply.²⁷

Interventional techniques such as facet joint injections, medial branch nerve blocks, epidural corticosteroid injections, and radiofrequency neurotomy are proven to be therapeutic.^4,26 Facet joint injections can provide short-term relief, thus increasing function and flexibly. Following an injection, patients often can perform movements that they were unable to do previously without discomfort.⁴ This effect is valuable when injections are given in conjunction with physical therapy. Epidural corticosteroid injections are indicated for radicular arm pain and can provide pain relief for more than 6 weeks.⁴ The pain-free intervals often allow patients to postpone surgery to complete a task or reduce pain medication use. Radiofrequency neurotomy is a procedure that denervates a painful joint.⁴ When applied to the cervical facet joints, the procedure can provide long-lasting pain relief.^4,28 In a study on the effectiveness of percutaneous radiofrequency neurotomy, the average number of days before pain returned to 50% of preprocedural levels was 263 days in the treatment group compared to 8 days in the control group.²⁹

Surgery If conservative treatment fails to resolve pain after 4 to 6 weeks, then surgery should be considered. An immediate referral to surgery is essential if the patient complains of progressive myelopathy, progressive neurologic defects, or severe pain refractory to conservative treatments. Surgical fusion often relieves discogenic and facet pain secondary to severe degeneration, misalignment, or instability.³⁰ Surgical decompression is often indicated for severe stenosis to relieve radiating pain, and surgical diskectomy is considered a reasonable treatment for radicular pain.³⁰

CONCLUSION

In summary, many persons suffer from neck pain. However, effective pain management can be attained. The first step to successful resolution is to determine the cause of the patient’s pain. A complete history with physical and neurologic examination and diagnostic imaging studies help determine if the source of the patient’s pain is an acute injury or a chronic condition. Conservative treatment with analgesics and physical therapy should be attempted before a more invasive procedure, such as injection or surgery, is considered. A base knowledge of anatomy, physiology, and pathologic conditions paired with a thorough clinical evaluation are the framework for effective pain management. JAAPA

DRUGS MENTIONED

Acetaminophen
Celecoxib (Celebrex)
Duloxetine (Cymbalta)
Fentanyl transdermal (Duragesic)
Gabapentin (Gabarone, Neurontin)
Indomethacin (Indocin)
Meloxicam (Mobic)
Methadone
Morphine
Oxycodone
Piroxicam (Feldene)
Pregabalin (Lyrica)
Propoxyphene
Tolmetin (Tolectin)
Venlafaxine (Effexor)

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