What is Neck Pain?
Neck pain explained by Denver, Golden, Aurora, Boulder, Broomfield, Jefferson, and Littleton Colorado’s top pain doctors
Pain in the cervical region, or neck, is a widespread condition, particularly prevalent in women. Estimates indicate that approximately 15% of men and 25% of women (between 20 and 56 years of age) will be subject to some form of neck (and shoulder) pain at some points in their lives.
Neck pain can be acute or chronic. Some evidence has suggested that around 50% of neck pain patients experience the condition for six months or more. Neck pain can also be episodic, and cumulative, in that patients with a history of neck pain are associated with a higher risk of developing a subsequent new or recurrent form of pain in this region, compared with normal healthy controls. In other words, current neck pain is a prevalent risk factor for neck pain in the future.
Neck pain can cause significant deficits in functional status and independent motion. This may have a profound effect on the personal and professional life of an affected individual. An approximate tenth of chronic neck pain patients are unable to sustain a working life. The condition is associated with economic effects, due in part to this. Neck pain may also be associated with deficits in productivity and an increase in healthcare burden. Some reports indicate that up to 50% of neck pain sufferers ask for physician consultations and other medical assistance due to the condition. Neck pain has been the subject of an increasing body of research and assessment over the last few years. These include randomized controlled trials into novel treatments and therapies for the condition, and studies to identify diagnostic markers and risk factors for neck pain.
The cervical spine, or the spinal region located within the neck, is regarded as strongly associated with neck pain. Damage to the tissues surrounding it, e.g. the ligaments and muscles that make up the rest of the neck, may also contribute to neck pain. The spinal cord is located inside a canal created by the cervical vertebrae (bones of the spine). It is surrounded by cerebrospinal fluid (CSF), which functions as a protective and stabilizing layer around the nerve-rich cord. The CSF is held in place by a tough membrane. The spinal cord is the central information highway, sending signals or impulses about external stimuli (the information in question) from all parts of the body to the brain, and processed and reactionary impulses from it back to the body. Cervical facet joints are the points at which cervical vertebrae meet, shaped somewhat differently to the other facet joints lower in the spine, in a way that facilitates a wider range of motion. Injury or damage to these joints can result in discomfort, stiffness, and inflammation. Facet joint pain can also be a source of neck, upper back, or shoulder pain.
Neck pain diagnosis may start with an assessment of patient history or self-report by a pain specialist or physician. Medical professionals will often try to identify the precise cause of neck pain, although this may not always be possible. They may begin by eliminating some of the more obvious causes or risk factors. This involves ruling out a history of certain types of spinal and nerve root damage. Your physician will also attempt to eliminate the possibility of risk factors by interviewing the patient for evidence of these. Risk factors (or “yellow flags”) may direct accurate diagnosis and appropriate treatment plan structure. The presence of a yellow flag does not automatically prove the presence of a disorder or injury associated with neck pain. It is indicative of an increased probability of this, however. Two or more yellow flags may necessitate further assessment of the patient for an underlying condition. Neck pain of an unusual nature or accompanied with motor or autonomic impairments may indicate a serious condition. This may result in recommendations for more immediate medical treatment.
Causes of Neck Pain
Neck pain can be associated with a range of factors, depending on the location within the region. The condition may be the result of a progressive degenerative disorder (or a condition associated with tissue loss). Both acute (sudden-onset pain that may be temporary) or chronic (consistent or episodic, often present over a greater time-frame) pain is associated with damage to the joints, muscles, or ligaments of the neck. Some cases of neck pain are idiopathic (i.e. occurring for no detectable or associated cause or risk factor at all). The top part of the neck (nearest the skull) may be associated with the majority of pain cases. Another main cause of neck pain is damage or inflammation in the facet joints of the cervical spine, as mentioned above. Fractures in the cervical vertebrae are also another factor associated with the condition.
Spinal stenosis is another condition associated with pain in the cervical region. Stenosis is compression or impingement of the spinal cord by the tissues or vertebrae around it. This condition is associated with scar tissue forming within vertebrae and pressing on the spinal cord. Another cause is abnormal bone growth on the inner surfaces of vertebrae. Stenosis can cause motor problems in addition to chronic pain. Bulging (or herniated) intervertebral discs are also associated with chronic neck pain. Intervertebral discs are present between each pair of vertebrae, for the purposes of spinal protection, shock absorption, and stability. When discs are damaged, they can “bulge” outwards, irritating or compressing spinal nerves, which can be a source of pain.
Whiplash is another condition often associated with neck pain. This is caused by sudden, unnatural over-flexion and extension of the neck, typically occurring in motor vehicle accidents, or other events where acceleration is followed by abrupt deceleration. Whiplash is rarely fatal, but can be a source of persistent pain that remains long after normal recovery. This is linked to damage sustained by main ligaments, muscles, and cervical vertebrae as a result of the excessive extension and flexing of the area.
Risk factors for neck pain are varied and many. There are characteristics that may increase the susceptibility of an individual to neck pain. They include age, a prior history of neck pain, regular cycling, gender (as outlined above), being over the age of 40, weakness in the muscles of the hands, poor quality of life, and a history of stress and anxiety.
Treatments For Neck Pain
The risk factors, injury, or condition identified as the cause of neck pain can influence the type of treatment that will most effectively treat each individual patient. Neck pain treatments have been the subject of considerable research and development over the last ten years. Therefore, there are many well-regarded, evidence-based, reliable methods of therapy for this condition currently available.
The pain and possible debility associated with neck pain rarely has one contributory factor. The consensus among a number of researchers is that many variables interact to form a certain level of pain and disability. For instance, it has been claimed that subjective and psychological values of the patients in relation to their own pain and functional status influences pain severity and disability to a degree. Psychological distress and patient reactions to the onset of a disorder or condition are particularly associated with this perception. For patients with negative psychological factors in relation to potential life changes caused by neck pain (for instance, that they believe they are facing a future significantly affected by pain), discussion of this with their physician may be beneficial. The absence of uncertainty about the next steps or consequences relating to their neck pain may have a positive effect on the patient’s mentality. In addition, the provision of either many options or a detailed treatment plan and probabilities of improvement may have a psychological impact. For example, a patient with moderate neck pain may benefit from being reassured that a gradual resumption of normal activity is possible, in addition to appropriate treatment.
The first line of treatment for mild to moderate neck pain is often rehabilitative therapy. This is associated with effective retention of normal function and movement in the neck, and may also contribute to pain reduction. These therapies usually take the form of training or guiding patients in a program of stretches and specialized exercise, to ease tension and help repair damage in muscles, and to reduce stiffness in the neck (which may be related to ligament damage). In cases of whiplash, chiropractic therapy applied may address the effects of excessive flexion and over-extension of the neck, and contribute to the correction of damage to muscles and ligaments.
Based on this, neck pain therapy ideally focuses on restoring a full range of motion and function in the area, as well as treating the associated negative stimuli. Patients who have had to leave or reduce working life due to pain and immobility may have the goal of fully returning to this. Complete rehabilitative and pain-reducing therapy may be more in line with achieving this aim. The psychological effects of significant debility associated with neck pain can be a contributing factor to further deficits in function and in treatment uptake. As such, this may result in a vicious cycle of progressive disablement and increased pain. Poor treatment acceptance and compliance may be associated with increases in neck pain severity and functional detriment over time.
Pharmacotherapy is a first-line treatment often recommended for neck pain. As many cases of neck pain are linked to inflammation in damaged tissues, non-steroidal anti-inflammatory drugs (NSAIDs) are often prescribed for this type of pain. Many NSAIDs are over-the-counter products, such as aspirin, naproxen, and ibuprofen. They are associated with some risks, including side-effects such as gastrointestinal bleeding, ulcers, and irritation. As the probability of these risks occurring increase with high doses or regular dosing over time, NSAIDs are often recommended for short-term management of neck pain.
Antidepressants are associated with reductions in pain perception and are often prescribed for cases of neck pain. Tricyclic antidepressants (TCAs) are an older class of antidepressants that are increasingly applied to pain management instead. These include clomipramine, or doxepin. The pain-relieving properties of TCAs have not been fully defined. However they may act by preventing the reuptake of the neurotransmitters serotonin and norepinephrine between nerve cells, thus providing more of these molecules to elicit their effects. These are often associated with improvements in mood, and with the regulation of pain processing and perception. These have been largely replaced as depressive disorder treatments by selective serotonin reuptake inhibitors (SSRIs), including fluvoxamine, citalopram, and fluoxetine; and serotonin and norepinephrine reuptake inhibitors (SNRIs, e.g. desvenlafaxine, venlafaxine, and duloxetine). These have the same essential functions (i.e. retaining availability of neurotransmitters) as TCAs, but have a different chemical structure and range of risks and side effects. SSRIs and SNRIs are also associated with significant effects on chronic neck pain. It is not understood if these are linked to their mood-enhancing properties or not, however. It is possible that they have positive effects on the detrimental psychological effects of severe pain (which is reported to contribute to a depressive disorder) thus reducing pain perception.
Muscle relaxantsare another drug class often recommended for neck pain management. These fall under two broad classifications: anti-spastic and spasmolytic. Spasmolytic muscle relaxants, which include benzodiazepine-based and non-benzodiazepine-based molecules, act to treat muscular spasm that is often associated with neck conditions. The anti-spastic class, including drugs such as baclofen and dantrolene, reduce tightness and rigidity in affected muscles. Both type of muscle relaxants have been reported as effective in treating neck pain. Anticonvulsants, such as gabapentin, are also often prescribed for neck pain, particularly for pain associated with nerve damage. These drugs are associated with increased release of the neurotransmitter gamma-amino butyric acid (GABA) that may play a role in pain processing in the brain. They may also have other effects on the availability of GABA, which may be an interesting target of future analgesic research.
Capsaicin skin patches are another application increasingly linked to pain relief, including that caused by nerve damage in the neck. Capsaicin is the active compound found in chili peppers that has activity in the pain receptors of the skin. This causes initial reactions including sensations of burning and irritation, but is followed by a longer-lasting desensitization of the affected tissue. Repeated application of capsaicin can elicit prolonged sensory reduction in the target area. Some placebo-controlled trials have indicated that capsaicin may have a considerable effect on pain perception on test areas.
Physicians treating patients with severe, intractable chronic neck pain that does not respond appreciably to other options may consider a course of opioid medications as the next step. These drugs are effective in treating severe chronic neck pain. They act by mimicking natural molecules such as endorphins, which bind receptors in the body to inhibit a pain response. Some research shows that opioids are also associated with the treatment of acute shoulder and neck pain also. This requires a less long-term dose-regimen than those for chronic cases. Opioids are associated with negative side effects such as dizziness, constipation, skin itching, and dry mouth. Opioids are associated with high indices of tolerance (the decreased response to a constant dose over time) and addiction, however.
Interventional Treatments For Neck Pain
“Failed back surgery syndrome” is pain inadvertently caused in the course of major procedures on the spine in the back or neck. The spine, as mentioned above, is an intricate structure of bones and other tissues around the spinal cord, to which tissues such as muscles are connected. The bones are a specifically oriented stack of vertebrae that provides the body with basic upright support and the spinal cord (and spinal nerves) with protection. The vertebrae interlock to a degree that allows for a certain range of motion (depending on the region of the spine). Within the canal formed by these, the spinal cord runs from the brain to the pelvic region.
Cases of painful failed back surgery in the cervical spine are thought to be most often linked to scar tissue that accumulates around spinal nerves as a result of surgery. Adhesiolysis is often indicated as a treatment to remove this scar tissue. This procedure (also known as lysis of adhesion; adhesions are scar tissue that attach to or significantly affect internal organs or tissues) requires that a catheter is injected into the target area (under local anesthetic) to deliver medical-grade substances such as hyaluronidase. These lyse or disrupt the scar tissue to remove adhesions. A clinical trial investigating adhesiolysis as a treatment for failed back surgery produced positive results associated with the procedure.
Bulging or herniated intervertebral discs in the neck may be treated by discogram, also known as percutaneous discectomy. Similar to adhesiolysis, this is minimally invasive. A percutaneous discectomy removes the damaged areas of the disc, which is associated with pain, and the release of inflammation in the spine. A physician or pain specialist will visualize the bulging disc using techniques such as fluoroscopy beforehand. This will enable the location of needle placement (again under sedation or analgesia) and extension toward the disc in question. When this needle is in the accurate location, thermal or radio impulses are emitted to disrupt and remove the damaged disc material. Percutaneous discectomy is associated with a recovery period of one or two days. This procedure can result in significant relief from pain associated with spinal nerve damage or impingement by invading disc tissue.
Neck pain that otherwise involves spinal nerves, such as inflammation or stenosis, may be addressed with epidural steroid injection procedures. These are other types of percutaneous injection, this time into the epidural spaces (the location of spinal nerves within the bone) of relevant vertebrae. They are injected into this space, rather than directly into the nerve, as mechanical contact may seriously damage the nerve and the effect of drugs will work equally well when introduced into the immediate vicinity of neural tissue. Again, the specialist will use imaging equipment to inform accurate needle placement, although in this instance the needle is a hollow, IV-like type for drug delivery. The compounds in this case are steroids that inhibit nerve inflammation and reduce pain.
Cervical steroid injections are associated with significant neck pain relief. Their advantages include convenience, short procedure times, and little medical invasion. Steroid injection procedures may be available in outpatient or pain clinics. Immediate pain decrease or absence is associated with steroid injections in many cases. They are associated with medium- to long-term relief from pain. However, in some cases multiple injections over several months or a year may be required for maximal effect. Steroid injections are associated with risks, which are mainly side effects of the drugs used. These include mood fluctuations, gastric ulcers, weight gain, and an increased tendency to develop arthritis later in life.
There are alternative variations on the epidural injection, such as nerve blocks. These are injections of local anesthetics, such as lidocaine, with or without steroids that target specific nerves of the cervical region. These include the occipital nerve or the medial branch nerves (which are associated with facet joints). These are associated with medium- to long-term pain reduction, although they carry risks similar to steroid injections. Again, these are mainly related to drug side-effects. Negative anesthetic effects include loss of sensation in the affected area, chest discomfort, and transient neurological events. More serious side-effects of epidural injections are that a needle may be inaccurately placed, which may result in severe discomfort or paralysis of the relevant region.
Botox injections are another option when managing pain associated with damaged or otherwise affected muscle tissue. Botox is a neurotoxin that can occur in concentrations sufficient to inhibit the movement of major autonomic muscle groups, including those controlling the lungs and throat. This can result in asphyxia and respiratory depression. In clinical (i.e. much more dilute) doses, it can inhibit movement and nervous input to superficial muscles, i.e. those of the face (which is associated with wrinkle prevention). Botox may treat musculoskeletal pain in the shoulder region by inhibiting the abnormal nerve activity that causes extensive muscle tension. It may also block the release of neurotransmitters associated with conducting pain signals. Several clinical trials have been carried out on the application of Botox injection to pain conditions. Some of these indicate that Botox achieves neck pain reduction at three weeks into a trial, and continued effect at eight weeks. Botox was also reported to have positive effects on functional impairments in these trials.
Vertebral fractures may be managed by pharmacotherapy in mild cases, but in many others a surgical procedure is necessary to correct them, as untreated fractures may lead to serious spinal damage. These techniques are known as vertebroplasty, and are associated with the restoration of spinal bone integrity and pain relief. This procedure is minimally invasive and can be performed in an outpatient setting. The area around fractured vertebrae is anesthetized beforehand. A needle is then inserted, in conjunction with imaging. When it reaches the vertebra, it injects medical-grade acrylic cement into the fractures. Medical cement is quick-drying and eases spinal compression or irritation associated with the vertebral damage.
A newer variation of vertebroplasty is known as kyphoplasty. In this procedure, a small medical balloon is inserted prior to the cement and inflated to support or stabilize the fractures while cement is injected. The main risks of either procedure are related to the possibility that cement may “leak” out of the bone into the surrounding spinal areas. This may be associated with discomfort, inflammation, and nerve irritation. There may also be a risk of bleeding and infection at the needle insertion site, headaches, and numbness or paralysis due to inadvertent spinal nerve damage in serious cases.
Radiofrequency ablation (RFA) is another option when treating severe, intransigent neck pain. This is another minimally invasive, percutaneous procedure. In the case of radiofrequency ablation, electrothermal (or radiofrequency) waves are introduced to a spinal nerve that sends high levels of pain signals to the brain. These waves (or impulses) are delivered via thin probes inserted through the skin under local anesthetic. This creates a lesion, or selective damage targeting the regions of nervous tissue responsible for transmitting painful signals, on the spinal nerve in question. This disruption may not be permanent, but is associated with several months of significant pain relief in many cases. Radiofrequency ablation is associated with the risks of other percutaneous procedures, which (as before) are skin damage, bleeding, and infection in the area of skin through which the probes are inserted. In isolated cases, RFA may be associated with loss of motor control due to inaccurate probe placement. Again, this is reduced by the integration of imaging techniques into radiofrequency ablation procedures.
Some singular cases of neck pain may not respond appreciably to any of these treatments. These require yet more variations on pain management. One of these is a recently developed technique known as spinal cord stimulation (SCS). This is associated with effective relief from severe, intractable neck pain caused by failed back surgery and nerve damage. SCS employs thin, flexible implants in a soft, medical-grade material. These are surgically placed near spinal nerves associated with a serious pain condition. The implants emit electrical impulses that can override or “drown out” painful signals. The implants are attached to leads that travel out of the body into a hand-held control device. The patient may operate this independently, to activate the implants in response to pain. The risks of spinal cord stimulationare infection in the skin through which implants were inserted, bleeding, and spinal cord stimulationfailure. This occurs (albeit with a low incidence) when the device’s impulses do not affect pain signaling or make it paradoxically worse. Another rare adverse event is migration of the implants, i.e. that they move away from their desired location, which may cause pain.
Intrathecal pump implants are based on a similar innovation to spinal cord stimulation. In this case, a catheter connected to a pump device is inserted into the relevant area of the spine. The pump contains a supply of analgesic medication that can be delivered to the spine in response to activation by an attached controller. Intrathecal pump implants are associated with significant improvements in neck pain and functional status. They are also associated with risks such as infection, bleeding, and migration.
Alternative Treatment Options For Neck Pain
Physiological responses to physical or physiological stressors may also contribute to a painful condition. Many scientists and medical researchers have concluded that stress and tension may be associated with detriments to overall health and abilities to cope with negative environmental factors. Muscular tension is a widespread patient complaint that may be linked to both shoulder and neck pain. This is commonly associated with occupational posture defects, such as those associated with office work. These are also factors that may contribute to cases of neck pain.
In these cases, biofeedback training may be associated with effective reductions of stress, tension, and even pain. This may be due to positive effects on pain perception and muscle relaxation. Biofeedback is a non-pharmacological, non-invasive option that focuses on educating patients on the physiological impacts of their pain or tension, and training them in techniques that may reduce this. The patient is made familiar with measurements of important physiological parameters, such as brain activity (measured by electroencephalogram (EEG)), heart rate (cardiograms (ECG)), and skin responses (galvanic measurements) among others. The patient is then shown how pain or tension affects these metrics, often in real time (i.e. the patient is connected to diagnostic equipment during a pain episode). The rationale is that patients may then employ conscious control techniques in order to return these readings to a baseline. These often take the form of stress reduction or relaxation techniques. These interventions may be associated with a decrease in muscle tension and pain.
Biofeedback is often applied and taught at a clinic or other professional setting by trained and competent technicians, and can then be used independently by the patient in their own environment. The relaxation techniques may be applied in response to relevant changes in vital sign measurements or to the onset of a pain/tension episode. Biofeedback for neck pain typically uses EEG, ECG, and galvanic readings. Biofeedback may be recommended singly or in combination with further relaxation training to elicit the expected effect.
Neck pain cases accompanied by mild functional or motor impairments may be initially addressed by non-invasive conventional treatments. These include chiropractic manipulation, which may be associated with significant effects on neck pain with or without debility, and with improvements in general health and mood. Chiropractic manipulation of the spine is a range of applications of pressure to vertebrae and vertebral joints that may cause subtle movements of the bones (i.e. contributing to a return to the correct confirmations, particularly in conditions causing spinal abnormalities) with the hands or fingers (of licensed practitioners). Chiropractic manipulation of the cervical spine pain typically focuses on adjustment of the vertebral joints. This treatment option is associated with some side effects and risks however, including further loss of motor ability, discomfort in the area following manipulation, fatigue, headache, and discomfort in other, unrelated areas of the body. Studies report that these side effects are most often felt in the first 24 hours after treatment and abate the next day after this in most cases.
Active release techniques (ART) may be recommended for patients whose neck pain is a result of blunt force trauma, but without the presence of inflammation. ART is the application of specific pressure to affected soft tissue (e.g. skin or muscle) using the thumb or fingers. At the same time, the patient is asked to perform some repetitive motions, within the area pressed or others in the vicinity. This results in repeated contraction and relaxing muscles, which is thought to correct damage and return muscle fibers to their proper conformation. This may contribute to a return of muscle inflexibility, reduce the risk of inflammation, and reduce pain. There is some evidence that active release techniques may also reduce the probability of muscle disorders commonly associated with damage, including fusion, scarring, and tearing.
Acupuncture is another example associated with positive results in trials for neck pains. This is a technique derived from traditional Chinese therapy that involves the placement of thin, sterilized needles through the skin into specific body areas. These locations (or acupuncture points), depend on where the pain is felt, in addition to certain other regions in which acupuncture is thought to influence the former. This is currently in use (in more modern forms) as a treatment for neck pain for those who do not wish to undergo drug therapy or other treatments. The risks of this technique are relatively mild, including discomfort and minor bleeding and skin damage in the acupuncture points targeted. Electroacupuncture is a modern variation of this therapy, in which mild electrical impulses, or weakly electrified needles, are applied to the relevant points. In this case, the side effects may be skin damage and also mild irritation. Some evidence indicates that the positive effects of acupuncture may lie in causing improved blood and lymph circulation in and around the damaged tissue, improving muscle function, decreasing pain, and thus decreasing recovery time. The World Health Organization has acknowledged acupuncture as a viable treatment in many pain cases.
Treatments and medical applications for neck pain have received considerable scientific interest, research, and development. The options discussed are associated with thorough clinical trial processes, and with positive reports and results in several studies. Therefore, many patients have a high probability of effectively controlling their pain, and of alleviating functional disablement or motor difficulties that may accompany it. Neck pain has a wide range of causative and contributory factors, adequate detection of which are associated with the most appropriate and effective treatment for each individual case.
Neck pain is a relatively widespread form of pain that is associated with potential detriments in functional status and normal movements. Many people are likely to suffer from one type of neck pain or another in their lives. Neck pain may be associated with significant effects on professional and personal life. Therefore, it may be regarded as a considerable socio-economic issue. Neck pain has been found to have negative effects on national productivity and healthcare resources. The pain may have a sudden onset and restricted duration, or be persistent over a number of months or even years. This condition is commonly associated with damage in or around the cervical spine that may be linked to degenerative disorders.
There is no one definitive etiology of neck pain. Research to further understand this condition, or to investigate cervical spine damage in more detail, is still ongoing. It is accepted by many in the field that pain perception and pain severity are prominent variables in outcome projections for chronic cases. There is an additional range of risk factors associated with neck pain. Adequate detection of this, mainly through analysis of patient reports and history, play important roles in the creation of appropriate, efficient treatments. This will be influenced by factors such as genetic predilection, prior history of neck pain, occupational hazards, and gender. There is some evidence that psychological perception and reactions to pain influence the probability of treatment compliance and recovery. Patient education on neck pain, risk factors, and treatment options may have a positive psychological impact, which is thought by some researchers to reduce pain perception.
An adequate diagnosis of neck pain, and its most probable causes, involves a physical examination and patient interviews. If unusual types or levels of neck pain are reported, this may warrant a referral to another specialist to rule out a serious condition. Neck pain can be addressed with a variety of treatments. These may begin with typical first-line treatments, such as over-the-counter medications or physical therapy. More invasive options include spinal cord stimulation and radiofrequency ablation. Corticosteroid injections are also associated with medium- to long-term chronic neck pain alleviation. Very severe pain that is resistant to these methods of treatment may be addressed by intrathecal pump implant. This choice of treatments indicates that the probability of relief and return of function in a case of neck pain is far from impossible.
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