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Epidemiology, Diagnosis, and Treatment of Neck Pain

  • Steven P. Cohen
    Correspondence
    Correspondence: Address to Steven P. Cohen, MD, 550 N Broadway, Ste 301, Baltimore, MD 21029.
    Affiliations
    Department of Anesthesiology and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, MD
    Department of Physical Medicine and Rehabilitation, Johns Hopkins School of Medicine, Baltimore, MD
    Department of Anesthesiology, Uniformed Services University of the Health Sciences, Bethesda, MD
    Department of Physical Medicine and Rehabilitation, Uniformed Services University of the Health Sciences, Bethesda, MD
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      Abstract

      Neck pain is the fourth leading cause of disability, with an annual prevalence rate exceeding 30%. Most episodes of acute neck pain will resolve with or without treatment, but nearly 50% of individuals will continue to experience some degree of pain or frequent occurrences. History and physical examination can provide important clues as to whether the pain is neuropathic or mechanical and can also be used to identify “red flags” that may signify serious pathology, such as myelopathy, atlantoaxial subluxation, and metastases. Magnetic resonance imaging is characterized by a high prevalence of abnormal findings in asymptomatic individuals but should be considered for cases involving focal neurologic symptoms, pain refractory to conventional treatment, and when referring a patient for interventional treatment. Few clinical trials have evaluated treatments for neck pain. Exercise treatment appears to be beneficial in patients with neck pain. There is some evidence to support muscle relaxants in acute neck pain associated with muscle spasm, conflicting evidence for epidural corticosteroid injections for radiculopathy, and weak positive evidence for cervical facet joint radiofrequency denervation. In patients with radiculopathy or myelopathy, surgery appears to be more effective than nonsurgical therapy in the short term but not in the long term for most people.

      Abbreviations and Acronyms:

      MRI (magnetic resonance imaging), NSAID (nonsteroidal anti-inflammatory drug), SNRB (selective nerve root block)
      CME Activity
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      Learning Objectives: On completion of this article, you should (1) be able to distinguish the different types (eg, neuropathic or nociceptive) of neck pain, (2) be able to identify “red flags” that may warrant advanced work-up, (3) be familiar with the risk factors for development of neck pain and its natural course, (4) know when and in whom advanced diagnostic testing may be helpful, and (5) be able to identify which patients to refer for specialty care (eg, injections or surgery).
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      In their editorial and administrative roles, William L. Lanier, Jr, MD, Terry L. Jopke, Kimberly D. Sankey, and Nicki M. Smith, MPA, have control of the content of this program but have no relevant financial relationship(s) with industry.
      Dr Cohen serves as a consultant for Regenesis Biomedical and Semnur Pharmaceuticals, Inc, and is on the advisory board of Kimberly Clark Health Care. This work was funded in part by a Congressional grant from the Center for Rehabilitation Sciences Research. The role of the funding source was only to pay for salary support for the author.
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      In the past few years, several reviews have been written on neck pain, although far fewer than on back pain, which often, but not always, involves similar mechanisms. Most of these reviews have targeted a specific specialty audience and have focused on one particular aspect of neck pain, rather than encompassing a broad overview aimed toward a general medical audience. The purpose of this review is to provide such an article, to include epidemiological aspects, classification, the natural course of neck pain, and an evidence-based, comprehensive guide to work-up, diagnosis, and treatment.

      Methods

      Databases on Medline via PubMed and Ovid, Embase, and the Cochrane Database of Systematic Reviews were searched using the key words neck pain, cervical pain, cervical radiculopathy, and cervical myelopathy, with no date restrictions. For individual sections, key words relating to specific topics (eg, physical exam, history, radiological, surgery, epidural steroid injection, antidepressant, spinal manipulation, acupuncture, complementary and alternative medicine) were identified and cross-referenced with the initial search terms using the aforementioned databases. Prime references and additional articles were obtained by cross-referencing all search terms with review article and manually searching through reference lists.

      Overview and Epidemiology

      The physical, psychological, and socioeconomic impact of neck pain is underappreciated. According to the Global Burden of Disease 2010 Study, neck pain is the fourth leading cause of years lost to disability, ranking behind back pain, depression, and arthralgias.
      US Burden of Disease Collaborators
      The state of US health, 1990-2010: burden of diseases, injuries, and risk factors.
      Approximately half of all individuals will experience a clinically important neck pain episode over the course of their lifetime.
      • Fejer R.
      • Kyvik K.O.
      • Hartvigsen J.
      The prevalence of neck pain in the world population: a systematic critical review of the literature.
      There is substantial heterogeneity in the reported prevalence rates of neck pain; however, most epidemiological studies report an annual prevalence ranging between 15% and 50%,
      • Fejer R.
      • Kyvik K.O.
      • Hartvigsen J.
      The prevalence of neck pain in the world population: a systematic critical review of the literature.
      • Hogg-Johnson S.
      • van der Velde G.
      • Carroll L.J.
      • et al.
      Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders
      The burden and determinants of neck pain in the general population: results of the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders.
      • Binder A.I.
      Neck pain.
      • Fernández-de-las-Peñas C.
      • Hernández-Barrera V.
      • Alonso-Blanco C.
      • et al.
      Prevalence of neck and low back pain in community-dwelling adults in Spain: a population-based national study.
      with one systematic review reporting a mean rate of 37.2%.
      • Fejer R.
      • Kyvik K.O.
      • Hartvigsen J.
      The prevalence of neck pain in the world population: a systematic critical review of the literature.
      The prevalence of neck pain is higher in females and peaks in middle age.
      • Fejer R.
      • Kyvik K.O.
      • Hartvigsen J.
      The prevalence of neck pain in the world population: a systematic critical review of the literature.
      • Hogg-Johnson S.
      • van der Velde G.
      • Carroll L.J.
      • et al.
      Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders
      The burden and determinants of neck pain in the general population: results of the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders.
      • Binder A.I.
      Neck pain.
      • Fernández-de-las-Peñas C.
      • Hernández-Barrera V.
      • Alonso-Blanco C.
      • et al.
      Prevalence of neck and low back pain in community-dwelling adults in Spain: a population-based national study.
      Neck pain is associated with several comorbidities including headache, back pain, arthralgias, and depression.
      • Hogg-Johnson S.
      • van der Velde G.
      • Carroll L.J.
      • et al.
      Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders
      The burden and determinants of neck pain in the general population: results of the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders.
      • Fernández-de-las-Peñas C.
      • Hernández-Barrera V.
      • Alonso-Blanco C.
      • et al.
      Prevalence of neck and low back pain in community-dwelling adults in Spain: a population-based national study.

      Who Gets Neck Pain?

      The factors associated with the development and persistence of neck pain overlap considerably with those of other musculoskeletal conditions. The prevalence of neck pain is higher in females than in males, and the literature is mixed as to whether it peaks or plateaus in middle age.
      • Fejer R.
      • Kyvik K.O.
      • Hartvigsen J.
      The prevalence of neck pain in the world population: a systematic critical review of the literature.
      • Hogg-Johnson S.
      • van der Velde G.
      • Carroll L.J.
      • et al.
      Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders
      The burden and determinants of neck pain in the general population: results of the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders.
      • Binder A.I.
      Neck pain.
      • Fernández-de-las-Peñas C.
      • Hernández-Barrera V.
      • Alonso-Blanco C.
      • et al.
      Prevalence of neck and low back pain in community-dwelling adults in Spain: a population-based national study.
      • Strine T.W.
      • Hootman J.M.
      US national prevalence and correlates of low back and neck pain among adults.
      Variables associated with neck pain that overlap with other rheumatologic conditions include genetics, psychopathology (eg, depression, anxiety, poor coping skills, somatization), sleep disorders, smoking, and sedentary lifestyle. For obesity, the results of epidemiological studies have usually but not always found a positive association between neck and shoulder pain and body mass index.
      • Hogg-Johnson S.
      • van der Velde G.
      • Carroll L.J.
      • et al.
      Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders
      The burden and determinants of neck pain in the general population: results of the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders.
      • Strine T.W.
      • Hootman J.M.
      US national prevalence and correlates of low back and neck pain among adults.
      • Son K.M.
      • Cho N.H.
      • Lim S.H.
      • Kim H.A.
      Prevalence and risk factor of neck pain in elderly Korean community residents.
      • Nilsen T.I.
      • Holtermann A.
      • Mork P.J.
      Physical exercise, body mass index, and risk of chronic pain in the low back and neck/shoulders: longitudinal data from the Nord-Trøndelag Health Study.
      • Kääriä S.
      • Laaksonen M.
      • Rahkonen O.
      • Lahelma E.
      • Leino-Arjas P.
      Risk factors of chronic neck pain: a prospective study among middle-aged employees.
      Some of the reasons why obese individuals may be predisposed to neck pain include elevated systemic inflammation, deleterious structural changes, increased mechanical stress and ground reaction force, diminished muscle strength, more psychosocial issues, and greater disability related to kinesiophobia compared with nonoverweight people.
      • Vincent H.K.
      • Adams M.C.
      • Vincent K.R.
      • Hurley R.W.
      Musculoskeletal pain, fear avoidance behaviors, and functional decline in obesity: potential interventions to manage pain and maintain function.
      Unique risk factors for neck pain include trauma (eg, traumatic brain and whiplash injuries) and certain sports injuries (eg, wrestling, ice hockey, football). Although certain occupations such as office and computer workers, manual laborers, and health care workers, have been found in some studies to have a higher incidence of neck pain, the major workplace factors associated with the condition are low job satisfaction and perceived poor workplace environment.
      • Côté P.
      • van der Velde G.
      • Cassidy J.D.
      • et al.
      The burden and determinants of neck pain in workers: results of the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders.

      Classification of Neck Pain

      There are many ways to categorize neck pain including duration (acute, <6 weeks; subacute, ≤3 months; chronic, >3 months), severity, etiology/structure, and type (ie, mechanical vs neuropathic). Among the various systems of categorization, duration is perhaps the best predictor of outcome. For a variety of different treatments, shorter duration has been found to be associated with a better prognosis than long-standing pain.
      • May S.
      • Gardiner E.
      • Young S.
      • Klaber-Moffett J.
      Predictor variables for a positive long-term functional outcome in patients with acute and chronic neck and back pain treated with a McKenzie approach: a secondary analysis.
      • Royuela A.
      • Kovacs F.M.
      • Campillo C.
      • Casamitjana M.
      • Muriel A.
      • Abraira V.
      Predicting outcomes of neuroreflexotherapy in patients with subacute or chronic neck or low back pain.
      • Peterson C.
      • Bolton J.
      • Humphreys B.K.
      Predictors of outcome in neck pain patients undergoing chiropractic care: comparison of acute and chronic patients.
      The association between longer duration of pain and poorer prognosis is consistent with the findings in cohort studies that greater disease burden in general (eg, higher baseline pain scores and disability) predicts poorer outcomes for spinal pain.
      • Enthoven P.
      • Skargren E.
      • Carstensen J.
      • Oberg B.
      Predictive factors for 1-year and 5-year outcome for disability in a working population of patients with low back pain treated in primary care.
      • Wilkens P.
      • Scheel I.B.
      • Grundnes O.
      • Hellum C.
      • Storheim K.
      Prognostic factors of prolonged disability in patients with chronic low back pain and lumbar degeneration in primary care: a cohort study.
      • Kleinstueck F.S.
      • Fekete T.
      • Jeszenszky D.
      • et al.
      The outcome of decompression surgery for lumbar herniated disc is influenced by the level of concomitant preoperative low back pain.
      Neck pain can also be categorized by mechanisms as mechanical, neuropathic, or secondary to another cause (eg, referred pain from the heart or vascular pathology). Mechanical pain refers to pain originating in the spine or its supporting structures, such as ligaments and muscles. Common examples of mechanical pain include pain arising from the facet joints (eg, arthritis), diskogenic pain, and myofascial pain. Neuropathic pain refers to pain resulting primarily from injury or disease involving the peripheral nervous system, which generally involves mechanical or chemical irritation of nerve roots. The most common examples of peripheral neuropathic pain are radicular symptoms from a herniated disk or osteophyte and spinal stenosis. Myelopathy, or symptoms arising from spinal cord pathology, is a form of central neuropathic pain. Mixed neuropathic-nociceptive pain states include postlaminectomy (failed neck surgery) syndrome and degenerated disks that result in a combination of mechanical pain from annular disruption and radicular symptoms from herniated nucleus pulposus (Figure 1, Figure 2, Figure 3).
      Figure thumbnail gr1
      Figure 1T2-weighted sagittal magnetic resonance image acquired slightly lateral to midline in a patient with unilateral radicular pain demonstrates a disk-osteophyte complex at C5-6 (arrow), which contributes to neural foraminal narrowing.
      Figure thumbnail gr2
      Figure 2T2-weighted sagittal magnetic resonance image demonstrating multilevel disk bulging spanning levels C3-4 to C7-T1 causing central spinal stenosis in a patient with neuropathic pain extending into both arms. Ligamentum flavum hypertrophy at C5-6 (arrow A) and low-grade retrolisthesis of C4 on C5 (arrow B) contribute to central spinal stenosis. Note the absence of spinal cord signal hyperintensity, suggesting that there is no active cord edema.
      Figure thumbnail gr3
      Figure 3T2-weighted sagittal magnetic resonance image in a patient with signs of myelopathy demonstrating a large central disk extrusion at C5-6. The signal hyperintensity within the spinal cord (arrow) indicates edema.
      Differentiating neuropathic from mechanical pain is probably the most important clinical distinction to make, as it affects treatment decisions at every level (eg, which medications, injections, or surgical procedure). There are several instruments available that have been found to distinguish neuropathic from nociceptive or mechanical pain, with 2 of the most common being the painDETECT questionnaire and the S-LANSS (Self-report Leeds Assessment of Neuropathic Symptoms and Signs) pain scale.
      • Freynhagen R.
      • Baron R.
      • Gockel U.
      • Tölle T.R.
      painDETECT: a new screening questionnaire to identify neuropathic components in patients with back pain.
      • Bennett M.
      The LANSS Pain Scale: the Leeds Assessment of Neuropathic Symptoms and Signs.
      For chronic low back pain, multiple studies have indicated a prevalence range of between 17% and 55% for predominantly neuropathic pain in a variety of cohorts, with a median of 41%.
      • Cohen S.P.
      • Bicket M.C.
      • Jamison D.
      • Wilkinson I.
      • Rathmell J.P.
      Epidural steroids: a comprehensive, evidence-based review.
      No studies have examined the prevalence of neuropathic pain in a general neck pain population, but one study that aimed to validate S-LANSS and painDETECT in 152 individuals with cervical pain and a suspected nerve lesion found that 72% had definite or probable neuropathic pain, while another 18% had possible neuropathic pain according to the International Association for the Study of Pain Neuropathic Pain Special Interest Group grading system.
      • Tampin B.
      • Briffa N.K.
      • Goucke R.
      • Slater H.
      Identification of neuropathic pain in patients with neck/upper limb pain: application of a grading system and screening tools.
      Among 6 patients with whiplash, one-third had probable neuropathic pain and two-thirds possible neuropathic pain. Of note, the authors found that both instruments suffered from low sensitivities in this population.

      Natural Course of Neck Pain

      Similar to back pain, most cases of acute (<6 weeks’ duration) neck pain will resolve to a large extent within 2 months, but close to 50% of patients will continue to have some pain or frequent recurrences 1 year after occurrence.
      • Vasseljen O.
      • Woodhouse A.
      • Bjørngaard J.H.
      • Leivseth L.
      Natural course of acute neck and low back pain in the general population: the HUNT study.
      • Vos C.J.
      • Verhagen A.P.
      • Passchier J.
      • Koes B.W.
      Clinical course and prognostic factors in acute neck pain: an inception cohort study in general practice.
      For acute pain, treatment appears to have little effect on persistence.
      • Vos C.J.
      • Verhagen A.P.
      • Passchier J.
      • Koes B.W.
      Clinical course and prognostic factors in acute neck pain: an inception cohort study in general practice.
      Factors that may be associated with poorer prognosis include female sex, older age, coexisting psychosocial pathology, and radicular symptoms (Table 1).
      • Vasseljen O.
      • Woodhouse A.
      • Bjørngaard J.H.
      • Leivseth L.
      Natural course of acute neck and low back pain in the general population: the HUNT study.
      • Vos C.J.
      • Verhagen A.P.
      • Passchier J.
      • Koes B.W.
      Clinical course and prognostic factors in acute neck pain: an inception cohort study in general practice.
      • Pernold G.
      • Mortimer M.
      • Wiktorin C.
      • Tornqvist E.W.
      • Vingård E.
      Musculoskeletal Intervention Center-Norrtälje Study Group
      Neck/shoulder disorders in a general population: natural course and influence of physical exercise; a 5-year follow-up.
      • Christensen J.O.
      • Knardahl S.
      Time-course of occupational psychological and social factors as predictors of new-onset and persistent neck pain: a three-wave prospective study over 4 years.
      • Carstensen T.B.
      The influence of psychosocial factors on recovery following acute whiplash trauma.
      Table 1Factors Associated With the Development or Persistence of Neck Pain
      Psychopathology
      Low work satisfaction
      Occupation/poor physical work environment
      Female sex
      Genetics
      Concomitant back pain/other rheumatologic conditions
      Poor coping skills
      Catastrophization
      Trauma/previous neck injury
      Poor self-assessed health status
      Sedentary lifestyle
      Secondary gain
      Smoking
      Headache
      A study by Gore et al
      • Gore D.R.
      • Sepic S.B.
      • Gardner G.M.
      • Murray M.P.
      Neck pain: a long-term follow-up of 205 patients.
      performed in patients with long-standing or recurrent neck pain found that individuals with more severe pain following an injury and those with symptoms or signs of cervical radiculopathy had a greater likelihood of persistent pain, although a formal statistical analysis was not performed for evaluation of radiculopathy. No association was found between the degree of radiographic degeneration and satisfaction with treatment results. A large retrospective, epidemiological study conducted in patients with radicular pain evaluated at Mayo Clinic found that although recurrence was frequent (31.7%), at the mean follow-up of 5.9 years, 90.5% of patients experienced either no or only mild pain.
      • Radhakrishnan K.
      • Litchy W.J.
      • O’Fallon W.M.
      • Kurland L.T.
      Epidemiology of cervical radiculopathy: a population-based study from Rochester, Minnesota, 1976 through 1990.
      The finding that higher pain scores and radicular symptoms are associated with chronicity and poor outcome for neck pain is similar to what occurs with low back pain
      • Hsu E.
      • Atanelov L.
      • Plunkett A.R.
      • Chai N.
      • Chen Y.
      • Cohen S.P.
      Epidural lysis of adhesions for failed back surgery and spinal stenosis: factors associated with treatment outcome.
      • Costa Lda C.
      • Maher C.G.
      • McAuley J.H.
      • et al.
      Prognosis for patients with chronic low back pain: inception cohort study.
      • Cherkin D.C.
      • Deyo R.A.
      • Street J.H.
      • Barlow W.
      Predicting poor outcomes for back pain seen in primary care using patients' own criteria.
      • Thomas E.
      • Silman A.J.
      • Croft P.R.
      • Papageorgiou A.C.
      • Jayson M.I.
      • Macfarlane G.J.
      Predicting who develops chronic low back pain in primary care: a prospective study.
      and suggests that both subjective and objective factors play a role in prognosis.
      The observation that most patients with cervical radiculopathy experience alleviation of symptoms with or without treatment is consistent with the results of small studies that revealed significant resorption in between 40% and 76% of cervical disk herniations.
      • Maigne J.Y.
      • Deligne L.
      Computed tomographic follow-up study of 21 cases of nonoperatively treated cervical intervertebral soft disc herniation.
      • Mochida K.
      • Komori H.
      • Okawa A.
      • Muneta T.
      • Haro H.
      • Shinomiya K.
      Regression of cervical disc herniation observed on magnetic resonance images.
      These statistics are similar to those noted for lumbar disk herniations.
      • Saal J.A.
      Natural history and nonoperative treatment of lumbar disc herniation.
      Although acute neuropathic symptoms in spinal stenosis will stabilize or improve in over half of individuals, the anatomic derangements do not generally improve without treatment.
      • Minamide A.
      • Yoshida M.
      • Maio K.
      The natural clinical course of lumbar spinal stenosis: a longitudinal cohort study over a minimum of 10 years.
      • Micankova Adamova B.
      • Vohanka S.
      • Dusek L.
      • Jarkovsky J.
      • Bednarik J.
      Prediction of long-term clinical outcome in patients with lumbar spinal stenosis.
      Cervical myelopathy involves pathology of the cervical spinal cord due to either trauma (spinal cord injury) or inflammation (myelitis), resulting in upper motor neuron signs. The natural course of nonsurgically treated myelopathy is highly variable. In a 1960s study that evaluated long-term follow-up in 28 patients treated nonoperatively, Lees and Turner
      • Lees F.
      • Turner J.W.
      Natural history and prognosis of cervical spondylosis.
      reported improvement in 17 patients, stable symptoms in 7, and progression in 4. Kadanka et al
      • Kadanka Z.
      • Mareš M.
      • Bednarík J.
      • et al.
      Approaches to spondylotic cervical myelopathy: conservative versus surgical results in a 3-year follow-up study.
      conducted a randomized, 3-year study comparing surgical with nonsurgical treatment for mild to moderate spondylotic myelopathy. No differences were noted between treatment groups, with 80% of patients in both groups exhibiting improvement or no clinical deterioration. Shimomura et al
      • Shimomura T.
      • Sumi M.
      • Nishida K.
      • et al.
      Prognostic factors for deterioration of patients with cervical spondylotic myelopathy after nonsurgical treatment.
      also reported a 20% deterioration rate at a mean follow-up of 3 years. A prospective study by Sampath et al
      • Sampath P.
      • Bendebba M.
      • Davis J.D.
      • Ducker T.B.
      Outcome of patients treated for cervical myelopathy: a prospective, multicenter study with independent clinical review.
      in 62 patients with cervical myelopathy found that equal proportions of medically and surgically treated patients (70%-75%) reported satisfaction with treatment, although the nonsurgically treated patients experienced worsened neurologic symptoms and a decreased ability to perform activities of daily living. Some investigators have reported more dire outcomes for spondylotic myelopathy. Matsumoto et al
      • Matsumoto M.
      • Chiba K.
      • Ishikawa M.
      • Maruiwa H.
      • Fujimura Y.
      • Toyama Y.
      Relationships between outcomes of conservative treatment and magnetic resonance imaging findings in patients with mild cervical myelopathy caused by soft disc herniations.
      reported that 10 of 27 patients treated conservatively over 6 months underwent surgery because of either neurologic deterioration or persistent disability. In another study by Sadasivan et al,
      • Sadasivan K.K.
      • Reddy R.P.
      • Albright J.A.
      The natural history of cervical spondylotic myelopathy.
      the authors reported deterioration in all 22 patients with cervical myelopathy, with 21 requiring surgery. In a consensus statement on the nonoperative treatment of spondylotic myelopathy, the authors concluded that between 20% and 62% of patients will have deterioration between 3-year and 6-year follow-up, with no patient or disease-specific factor being able to reliably predict progression of symptoms.
      • Fehlings M.G.
      • Wilson J.R.
      • Yoon S.T.
      • Rhee J.M.
      • Shamji M.F.
      • Lawrence B.D.
      Symptomatic progression of cervical myelopathy and the role of nonsurgical management: a consensus statement.

      Evaluation of Neck Pain

      History

      A comprehensive history can provide important clues regarding etiology and help differentiate primary neck pain from shoulder pain, thoracic outlet syndrome, brachial plexopathy, upper extremity pain, vascular pathology, and referred pain from thoracic viscera (eg heart, lungs). Patients with neuropathic pain typically describe their symptoms as shooting, electrical-like, stabbing, and/or burning, whereas mechanical pain is more often described as throbbing or aching.
      • Freynhagen R.
      • Baron R.
      • Gockel U.
      • Tölle T.R.
      painDETECT: a new screening questionnaire to identify neuropathic components in patients with back pain.
      • Bennett M.
      The LANSS Pain Scale: the Leeds Assessment of Neuropathic Symptoms and Signs.
      Neuropathic pain (eg, stenosis or herniated disk) is nearly always characterized by radiation into one or both upper extremities, usually in a single dermatomal or multidermatomal (eg, stenosis or a large or multilevel herniation) distribution. Because C7 and C6 are the most commonly affected nerve roots, radicular symptoms usually radiate into the middle or first 2 digits (eg, thumb and index finger), respectively.
      • Radhakrishnan K.
      • Litchy W.J.
      • O’Fallon W.M.
      • Kurland L.T.
      Epidemiology of cervical radiculopathy: a population-based study from Rochester, Minnesota, 1976 through 1990.
      Nonneuropathic pain arising from midlevel facet joints, disks (eg, C5-6), or even muscles may also occasionally extend into the upper arm, but referral patterns tend to be nondermatomal and more variable.
      • Fukui S.
      • Ohseto K.
      • Shiotani M.
      • et al.
      Referred pain distribution of the cervical zygapophyseal joints and cervical dorsal rami.
      • Aprill C.
      • Dwyer A.
      • Bogduk N.
      Cervical zygapophyseal joint pain patterns, II: A clinical evaluation.
      • Simons D.G.
      • Travell J.G.
      • Simons L.S.
      In pain stemming from the atlantoaxial, atlantooccipital, or upper facet joints or disks, radiation often extends into the occiput.
      • Dreyfuss P.
      • Michaelsen M.
      • Fletcher D.
      Atlanto-occipital and lateral atlanto-axial joint pain patterns.
      Associated signs and symptoms can often distinguish neuropathic from nonneuropathic pain. Neuropathic pain is frequently accompanied by numbness, paresthesias, or dysesthesias. Sensory symptoms are unusual in patients with nonneuropathic neck pain, and when they occur, they tend to be nondermatomal. The presence of confirmed neurologic symptoms in a patient with normal imaging results warrants a search for other sources of neuropathic pain, such as brachial plexopathy, or carpal or cubital tunnel syndrome.
      Aggravating and alleviating factors can provide information relevant to the decision to pursue further work-up. Mechanical pain of any origin is classically associated with a low-level baseline pain that tends to worsen with activity, while neuropathic pain is associated with less predictable bouts of more intense exacerbations. Pain exacerbated when turning or bending the head ipsilateral to the source may indicate radicular or facetogenic pain, whereas pain worsened by contralateral turning of the head could suggest myofascial orgin. Because the major cause of facet joint pain is arthritis, patients frequently report morning stiffness. Owing to a reduced spinal canal area, arm pain aggravated by neck extension is consistent with spinal stenosis; in contrast, pain worsened with forward flexion often signifies a diskogenic origin.
      Cervical radiculopathy can often be distinguished from mechanical neck and shoulder pain by the abduction relief sign, in which abduction of the ipsilateral arm over the head alleviates symptoms.
      • Fast A.
      • Parikh S.
      • Marin E.L.
      The shoulder abduction relief sign in cervical radiculopathy.
      This maneuver can distinguish radicular from certain types of shoulder pain, which may be worsened by shoulder abduction. One condition that is often mistaken for cervical radicular pain is thoracic outlet syndrome, which may be neurogenic (which comprises about 95% cases), arterial, and/or venous in origin. Thoracic outlet syndrome is classically unilateral, affects women more frequently than men, and peaks in prevalence in the fourth decade of life. In about half the cases, it is preceded by either trauma or repetitive stress. Imaging and Doppler analysis are most helpful for diagnosing vascular thoracic outlet syndrome but have low sensitivity for the neurogenic type. Several tests have been advocated to identify thoracic outlet syndrome including the elevated arm stress test, Adson test, and tenderness to palpation at the scalene triangle or insertion of the pectoralis minor, although none have high specificity.
      • Freischlag J.
      • Orion K.
      Understanding thoracic outlet syndrome.
      Because neck pain is typically alleviated by rest and recumbency, severe unrelenting pain not affected by rest or position warrants consideration of “red flags” such as malignant neoplasms, primary neurologic conditions, and infection (Table 2, Figure 4).
      Table 2What Not to Miss: “Red Flags” Associated With Neck Pain
      Red flagPotential conditionsAssociated signs and symptoms
      Trauma (eg, fall, motor vehicle accident, whiplash injury)Vertebral fractures, spinal cord injury/syrinx, ligamentous disruptionLoss of or alternating consciousness, cognitive deficits, traumatic brain injury, headaches, neurologic symptoms
      Rheumatoid arthritis, Down syndrome, spondyloarthropathyAtlantoaxial subluxationEasy fatiguability, gait abnormalities, limited neck mobility, torticollis, clumsiness, spasticity, sensory deficits, upper motor neuron signs
      Constitutional symptomsMetastases, infectious process, systemic rheumatologic diseaseWeight loss, unexplained fevers, anorexia, family or personal history of malignant neoplasm, diffuse joint pain and stiffness, abnormal laboratory test results
      Infectious symptomsEpidural abscess, spondylodiskitis, meningitisFever, neck stiffness, photophobia, elevated white blood cell count
      Upper motor neuron lesionSpinal cord compression, demyelinating diseaseHoffmann sign, hyperreflexia, Babinski sign, spasticity, incontinence, sexual dysfunction
      Age <20 yCongenital abnormalities (cervical spina bifida, Scheuermann disease), conditions associated with substance abuse such as infectionCongenital anomalies: birthmarks, overlying skin tags, patches of hair, family history, systemic disease (eg, diabetes, epilepsy for spina bifida)

      Substance abuse: male sex, poor work or school performance, depression or other psychiatric morbidity
      Concurrent chest pain, diaphoresis, or shortness of breathMyocardial ischemia or infarctionNausea, extension of pain into the left arm (especially medial upper arm)
      Age >50 yMetastases, vertebral fracture, carotid or vertebral artery dissection/bleedingFamily or personal history of malignant neoplasm, previous trauma

      Arterial dissection: tearing sensation, headache, visual loss, or other neurologic sequelae
      Figure thumbnail gr4
      Figure 4T1-weighted sagittal magnetic resonance image in a patient with a known primary malignant neoplasm demonstrating hypointense lesions within the C3 (arrow A) and T3 (arrow B) vertebral bodies. At T3, there is an accompanying compression fracture with loss of vertebral body height. Breast, lung, prostate, renal cell, and gastrointestinal tract cancers, lymphoma, and melanoma are the primary malignant neoplasms most likely to metastasize to the vertebral bodies and should be considered in the differential diagnosis of a vertebral body infiltrative lesion in patients older than 40 years of age.
      Occasionally, the inciting event can facilitate identification of a pain generator. The most common precipitating event for neck pain is whiplash injury, which occurs when the neck and head continue to lurch forward after the trunk has ceased to move, resulting in shearing stress that involves the disks and facet joints that connect adjacent vertebrae. Although Bogduk and Yoganandan
      • Bogduk N.
      • Yoganandan Y.
      Biomechanics of the cervical spine Part 3: minor injuries.
      reported that videoradiographic studies performed with and without headrests in cadavers in the 1970s indicated that rear-end collisions were most frequently associated with injuries to the intervertebral disks (90%), anterior spinal ligaments (80%), and facet joints (40%), more recent
      • Matsumoto M.
      • Okada E.
      • Ichihara D.
      • et al.
      Prospective ten-year follow-up study comparing patients with whiplash-associated disorders and asymptomatic subjects using magnetic resonance imaging.
      and methodologically sound
      • Pettersson K.
      • Hildingsson C.
      • Toolanen G.
      • Fagerlund M.
      • Björnebrink J.
      MRI and neurology in acute whiplash trauma: no correlation in prospective examination of 39 cases.
      studies have found no consistent relationship between pain and imaging abnormalities following motor vehicle collisions. In clinical studies performed by the Bogduk group using response to “double-blocks” as the reference standard, between 30% and 60% of patients with whiplash injury have predominantly facet joint pain.
      • Barnsley L.
      • Lord S.
      • Bogduk N.
      Comparative local anaesthetic blocks in the diagnosis of cervical zygapophysial joint pain.
      • Lord S.M.
      • Barnsley L.
      • Wallis B.J.
      • Bogduk N.
      Chronic cervical zygapophysial joint pain after whiplash: a placebo-controlled prevalence study.
      • Barnsley L.
      • Lord S.M.
      • Wallis B.J.
      • Bogduk N.
      The prevalence of chronic cervical zygapophysial joint pain after whiplash.
      For nontraumatic facetogenic and discogenic pain, the onset tends to be insidious because of the progressive strain on these structures from repetitive, low-level stress. For cervical radicular pain, particularly in younger individuals with robust disks, patients will sometimes report a specific antecedent event.

      Physical Examination

      The physical examination is often used to confirm a historical finding, screen patients for serious or treatable pathology, and inform advanced imaging or further diagnostic work-up but is rarely pathognomonic. Gait abnormalities, which can herald spinal cord (eg, myelopathy or syrinx) or brain injury, and major traumatic or developmental abnormalities should be noted. For example, doughy lipomata may indicate spina bifida or spinal cord abnormalities, and a prominent, palpable vertebral body can signify spondylolisthesis.
      General appearance should be observed to identify facial expressions and behaviors indicative of pain. Patients who report severe pain in the absence of pain-related behaviors should be further evaluated for signs of nonorganic pathology. Abnormal lateral or forward flexion, or rotation, may indicate torticollis. Muscle atrophy, or winging or drooping of the shoulder, may be observed with radiculopathy, brachial plexopathy, or nerve entrapment.
      True neurologic weakness should be distinguished from pain-induced weakness. In individuals with nerve injury, muscle wasting or asymmetric reflexes may be present, although 10% of asymptomatic individuals may have absent or asymmetric reflexes. In patients with poor effort or suspected malingering, reflexes may be the most (or only) objective examination tool. Signs of upper motor neuron lesions must be vigorously investigated.
      Range of motion may be limited in all types of mechanical neck pain, but specific exacerbating movements may provide clues to the origin. For example, reproducible arm pain with neck flexion toward the affected side may indicate foraminal stenosis and/or radiculopathy. In one study conducted in whiplash patients, no difference in facet block responders and nonresponders was found for range of motion in any direction.
      • Smith A.D.
      • Jull G.
      • Schneider G.
      • Frizzell B.
      • Hooper R.A.
      • Sterling M.
      A comparison of physical and psychological features of responders and non-responders to cervical facet blocks in chronic whiplash.
      Provocative maneuvers may be more helpful in identifying potential sources of neuropathic pain. For cervical radiculopathy, the Spurling shoulder abduction and neck distraction tests have moderate sensitivity (approximately 50%) but high specificity (>80%).
      • Rubinstein S.M.
      • Pool J.J.
      • van Tulder M.W.
      • Riphagen I.I.
      • de Vet H.C.
      A systematic review of the diagnostic accuracy of provocative tests of the neck for diagnosing cervical radiculopathy.
      • Malanga G.A.
      • Landes P.
      • Nadler S.F.
      Provocative tests in cervical spine examination: historical basis and scientific analyses.
      For cervical myelopathy, the Hoffmann sign has been reported to have moderate sensitivity and specificity.
      • Malanga G.A.
      • Landes P.
      • Nadler S.F.
      Provocative tests in cervical spine examination: historical basis and scientific analyses.
      • Cook C.E.
      • Hegedus E.
      • Pietrobon R.
      • Goode A.
      A pragmatic neurological screen for patients with suspected cord compressive myelopathy.
      For facetogenic pain, one study found that paraspinal tenderness was weakly correlated with positive treatment response
      • Cohen S.P.
      • Bajwa Z.H.
      • Kraemer J.J.
      • et al.
      Factors predicting success and failure for cervical facet radiofrequency denervation: a multi-center analysis.
      (Tables 3 and 4).
      Table 3Accuracy of Physical Examination Tests for Neck Pain
      Data from Eur Spine J,
      • Rubinstein S.M.
      • Pool J.J.
      • van Tulder M.W.
      • Riphagen I.I.
      • de Vet H.C.
      A systematic review of the diagnostic accuracy of provocative tests of the neck for diagnosing cervical radiculopathy.
      Pain Physician,
      • Malanga G.A.
      • Landes P.
      • Nadler S.F.
      Provocative tests in cervical spine examination: historical basis and scientific analyses.
      and Phys Ther.
      • Cook C.E.
      • Hegedus E.
      • Pietrobon R.
      • Goode A.
      A pragmatic neurological screen for patients with suspected cord compressive myelopathy.
      TestDescriptionDiagnosisAccuracy
      Ranges of accuracy are given when multiple studies were available.
      SpurlingLateral flexion and rotation to the affected side with axial compression of the head reproduces radicular painCervical radiculopathy40%-60% Sensitivity,

      85%-95% specificity;

      moderate to substantial reliability
      Shoulder abductionRelief of ipsilateral cervical radicular symptoms with abduction of symptomatic arm (eg, placing it on head)Cervical radiculopathy40%-50% Sensitivity,

      80%-90% specificity;

      fair to moderate reliability
      Neck distractionRelief of radicular symptoms when examiner grasps patient’s head under occiput and chin and lifts, applying axial tractionCervical radiculopathy40%-50% Sensitivity,

      90% specificity;

      moderate reliability
      ValsalvaReproduction of radicular pain with forced expiratory effort with mouth and nose closedCervical radiculopathyLow sensitivity (22%),

      high specificity (94%)
      Upper limb tensionReproduction of radicular pain with scapular depression; shoulder abduction; forearm supination, wrist and finger extension; shoulder external rotation; elbow extension; contralateral followed by ipsilateral cervical lateral flexionCervical radiculopathy70%-90% Sensitivity,

      15%-30% specificity
      Lhermitte signElectrical-like sensations down spine or arms with passive flexion of neckCervical myelopathy<20% Sensitivity,

      >90% specificity
      Hoffmann signFlexion-adduction of thumb and index finger elicited with snapping flexion of middle or fourth finger distal phalanxCervical myelopathy50%-80% Sensitivity,

      78% specificity
      Babinski signStimulation of the sole of the foot elicits dorsiflexion of hallux and sometimes dorsiflexion and abduction of other toesCervical myelopathy10%-75% Sensitivity,

      >90% specificity
      HyperreflexiaOverreactive or overresponsive deep tendon reflexesCervical myelopathy above level of muscle reflex innervation>65% Sensitivity,

      high specificity
      Clonus>2 Repetitive beats during wrist or ankle dorsiflexion movementsCervical myelopathy<50% Sensitivity
      Jackson compressionDownward pressure on head with lateral flexion. Localized pain may indicate facet joint pain; arm pain may indicate radiculopathyCervical radiculopathy/myelopathy or facet joint painNot validated for facet joint pain. Low sensitivity, high specificity for myelopathy
      Paraspinal tendernessParaspinal > midline pain with palpationCervical facet joint painWeak evidence for predicting a positive response to treatment
      a Ranges of accuracy are given when multiple studies were available.
      Table 4Signs and Symptoms of Cervical Radiculopathy
      Affected nerve root (frequency)
      Percentage data in part from Brain.28
      Pain locationSensory deficitsMuscle weaknessReflex abnormalities
      C4 (<10%)Upper-mid neckCapelike distribution, shoulderNoneNone
      C5 (10%)Neck, shoulder, interscapular region, anterior armLateral aspect of shoulder and armShoulder abduction and external rotation, elbow flexionDeltoid, biceps, and brachioradialis
      C6 (20%-25%)Neck, shoulder, interscapular region, lateral forearm, first and second digitsLateral aspect of forearm and hand, first and second digitsElbow flexion, shoulder external rotation, abduction and protraction, forearm supination and pronation, wrist extensionBiceps, brachioradialis
      C7 (45%-60%)Lower neck, shoulder, interscapular region, extensor surface of forearm, chest, third digitThird digit, sometimes parts of first 4 digitsElbow and finger extension, forearm pronationTriceps
      C8 (10%)Lower neck, medial forearm and handDistal medial forearm to medial hand and fourth and fifth digitsWrist flexion, finger and thumb abduction, adduction, extension and flexionFinger flexors
      a Percentage data in part from Brain.
      • Radhakrishnan K.
      • Litchy W.J.
      • O’Fallon W.M.
      • Kurland L.T.
      Epidemiology of cervical radiculopathy: a population-based study from Rochester, Minnesota, 1976 through 1990.

      Diagnostic Work-up

      In patients with suspected structural abnormalities (eg, scoliosis, spondylolisthesis, fractures), plain radiographs are generally sufficient. Magnetic resonance imaging (MRI) is the most sensitive test for detecting soft-tissue (eg, disk) abnormalities but is characterized by a high rate of abnormalities in asymptomatic individuals. The rates of abnormalities in people without symptoms varies from around 60% in individuals in their 40s to more than 80% in individuals older than 60 years, with the most common abnormalities being decreased signal intensity and disk protrusions.
      • Matsumoto M.
      • Fujimura Y.
      • Suzuki N.
      • et al.
      MRI of cervical intervertebral discs in asymptomatic subjects.
      • Lehto I.J.
      • Tertti M.O.
      • Komu M.E.
      • Paajanen H.E.
      • Tuominen J.
      • Kormano M.J.
      Age-related MRI changes at 0.1 T in cervical discs in asymptomatic subjects.
      Therefore, MRI is recommended to rule out red flags, in patients with serious or progressive neurologic deficits, and when referring patients for procedural interventions (eg, surgery); for individuals with persistent pain that does not respond to conservative treatment, radiologic evaluations can be considered.
      Electrodiagnostic testing can be considered in patients with equivocal symptoms or imaging findings and to rule out peripheral neuropathy. The American Association of Electrodiagnostic Medicine reported 50% to 71% sensitivity in diagnosing cervical radiculopathy,
      American Association of Electrodiagnostic Medicine
      Practice parameter for needle electromyographic evaluation of patients with suspected cervical radiculopathy: summary statement.
      but a later study by Ashkan et al
      • Ashkan K.
      • Johnston P.
      • Moore A.J.
      A comparison of magnetic resonance imaging and neurophysiological studies in the assessment of cervical radiculopathy.
      found that compared with neurophysiologic studies, MRI was associated with a higher sensitivity (93% vs 42%) and negative predictive value (25% vs 7%) based on operative findings. Selective nerve root blocks have been used to identify painful nerve root(s) and have been reported to improve surgical outcomes, but randomized trials are lacking (see “Injections” section).
      • Anderberg L.
      • Annertz M.
      • Rydholm U.
      • Brandt L.
      • Säveland H.
      Selective diagnostic nerve root block for the evaluation of radicular pain in the multilevel degenerated cervical spine.
      • Sasso R.C.
      • Macadaeg K.
      • Nordmann D.
      • Smith M.
      Selective nerve root injections can predict surgical outcome for lumbar and cervical radiculopathy: comparison to magnetic resonance imaging.
      • Cohen S.P.
      • Hurley R.W.
      The ability of diagnostic spinal injections to predict surgical outcomes.

      Treatment

      Conservative Therapy

      Similar to back pain, cervical and scapular stretching and strengthening exercises have been found to provide intermediate-term relief for mechanical neck pain.
      • Kay T.M.
      • Gross A.
      • Goldsmith C.H.
      • et al.
      Exercises for mechanical neck disorders.
      • Sihawong R.
      • Janwantanakul P.
      • Sitthipornvorakul E.
      • Pensri P.
      Exercise therapy for office workers with nonspecific neck pain: a systematic review.
      • Bertozzi L.
      • Gardenghi I.
      • Turoni F.
      • et al.
      Effect of therapeutic exercise on pain and disability in the management of chronic nonspecific neck pain: systematic review and meta-analysis of randomized trials.
      In one large randomized study of 206 patients with acute cervical radiculopathy, both physical therapy accompanied by home exercises and the use of a hard cervical collar produced greater reductions in neck pain and disability over a 6-week period than a “wait and see” approach.
      • Kuijper B.
      • Tans J.T.
      • Beelen A.
      • Nollet F.
      • de Visser M.
      Cervical collar or physiotherapy versus wait and see policy for recent onset cervical radiculopathy: randomised trial.
      However, systematic reviews have concluded that cervical collars are no more effective than sham interventions for neck pain.
      • Thoomes E.J.
      • Scholten-Peeters W.
      • Koes B.
      • Falla D.
      • Verhagen A.P.
      The effectiveness of conservative treatment for patients with cervical radiculopathy: a systematic review.
      For complementary and alternative medical treatments, the strongest evidence supports a modest effect for spinal manipulation compared with no treatment or other noninterventional treatments. With regard to other complementary and alternative treatments, although they have generally been found to be superior to no treatment, the evidence that they are superior to sham treatments or other treatments is weak, negative, or conflicting (Table 5).
      Table 5Alternative and Complementary Medicine Treatments for Neck Pain
      Data from references
      • Kay T.M.
      • Gross A.
      • Goldsmith C.H.
      • et al.
      Exercises for mechanical neck disorders.
      ,
      • Sihawong R.
      • Janwantanakul P.
      • Sitthipornvorakul E.
      • Pensri P.
      Exercise therapy for office workers with nonspecific neck pain: a systematic review.
      ,
      • Bertozzi L.
      • Gardenghi I.
      • Turoni F.
      • et al.
      Effect of therapeutic exercise on pain and disability in the management of chronic nonspecific neck pain: systematic review and meta-analysis of randomized trials.
      ,
      • Kuijper B.
      • Tans J.T.
      • Beelen A.
      • Nollet F.
      • de Visser M.
      Cervical collar or physiotherapy versus wait and see policy for recent onset cervical radiculopathy: randomised trial.
      ,
      • Thoomes E.J.
      • Scholten-Peeters W.
      • Koes B.
      • Falla D.
      • Verhagen A.P.
      The effectiveness of conservative treatment for patients with cervical radiculopathy: a systematic review.
      ,
      • Furlan A.D.
      • Yazdi F.
      • Tsertsvadze A.
      • et al.
      A systematic review and meta-analysis of efficacy, cost-effectiveness, and safety of selected complementary and alternative medicine for neck and low-back pain.
      ,
      • Hurwitz E.L.
      • Carragee E.J.
      • van der Velde G.
      • et al.
      Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders
      Treatment of neck pain: noninvasive interventions; results of the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders.
      ,
      • Kong L.J.
      • Zhan H.S.
      • Cheng Y.W.
      • Yuan W.A.
      • Chen B.
      • Fang M.
      Massage therapy for neck and shoulder pain: a systematic review and meta-analysis.
      ,
      • Patel K.C.
      • Gross A.
      • Graham N.
      • et al.
      Massage for mechanical neck disorders.
      ,
      • Graham N.
      • Gross A.
      • Goldsmith C.H.
      • et al.
      Mechanical traction for neck pain with or without radiculopathy.
      ,
      • Kroeling P.
      • Gross A.
      • Goldsmith C.H.
      • et al.
      Electrotherapy for neck pain.
      ,
      • Cramer H.
      • Lauche R.
      • Hohmann C.
      • et al.
      Randomized-controlled trial comparing yoga and home-based exercise for chronic neck pain.
      ,
      • Bronfort G.
      • Evans R.
      • Anderson A.V.
      • Svendsen K.H.
      • Bracha Y.
      • Grimm R.H.
      Spinal manipulation, medication, or home exercise with advice for acute and subacute neck pain: a randomized trial.
      .
      TreatmentDescriptionEvidence
      Spinal manipulationManual therapy designed to maximize painless movement, reduce muscle tightness, improve joint mobility, and correct alignment problemsSuperior to no treatment or sham treatment in the short term. Weak evidence for intermediate-term benefit and for superiority over pharmacotherapy and other alternative therapies
      AcupunctureInserting needles into the skin at various anatomic locations to reduce pain or induce anesthesia. Needles may be manipulated manually or through electrical stimulationWeak evidence that acupuncture is superior to no treatment in the short term. Strong evidence that acupuncture is not better than sham acupuncture or other treatments
      Massage therapyThe manipulation of muscle and connective tissue to enhance function and promote relaxation and well-beingSuperior to no treatment or sham treatment but not more effective than other active treatments in the short and intermediate term. No evidence for improved function
      Exercise therapyActive or passive physical exercises designed to strengthen or stabilize the spine that may reduce pain, prevent injuries, and improve posture and body mechanicsStrong evidence for intermediate-term relief for nonspecific neck pain and whiplash-type injuries. Conflicting evidence for improvement of disability. No clear evidence supporting one technique over another or that exercise can prevent the development of neck pain
      TractionProcedures designed to relieve pressure on the spineThere is low-quality evidence that traction is not superior to placebo treatments for neck pain with or without radiculopathy
      Soft cervical collarOrthopedic device used to immobilize the neck and support the head and neck, often after injuryThere is low-quality evidence that a cervical collar is no more effective than physical therapy or other active therapies for cervical radiculopathy and whiplash
      ElectrotherapyThe use of electrical energy as a medical treatment to relieve pain, usually by interfering with nerve conductionThere is low-quality evidence that various forms of electrotherapy (eg, transcutaneous electrical nerve stimulation, pulsed electromagnetic field therapy) are better than placebo but not other treatments
      YogaA series of physical, mental, and spiritual exercises designed to achieve a peaceful state of mind, improve conditioning, and attain self-actualizationThere is weak evidence that yoga is more effective than home-based exercise treatment
      Few high-quality studies have evaluated pharmacotherapy for neck pain. Systemic nonsteroidal anti-inflammatory drugs (NSAIDs) have been found to be beneficial for spinal pain in general
      • White A.P.
      • Arnold P.M.
      • Norvell D.C.
      • Ecker E.
      • Fehlings M.G.
      Pharmacologic management of chronic low back pain: synthesis of the evidence.
      but have not been formally studied in neck pain. Although NSAIDs are more efficacious than acetaminophen, the American College of Rheumatologists recommends acetaminophen as a first-line treatment, even for arthritis, because of its more favorable adverse effect profile.
      • Flood J.
      The role of acetaminophen in the treatment of osteoarthritis.
      In patients who present with predominantly mechanical neck pain, topical NSAIDs have proven efficacy.
      • Hsieh L.F.
      • Hong C.Z.
      • Chern S.H.
      • Chen C.C.
      Efficacy and side effects of diclofenac patch in treatment of patients with myofascial pain syndrome of the upper trapezius.
      In one randomized trial that compared spinal manipulation, home exercise and advice, and pharmacotherapy with NSAIDs or acetaminophen in acute and subacute neck pain, the manipulation and exercise groups fared better than medicinal treatment through 12-month follow-up.
      • Bronfort G.
      • Evans R.
      • Anderson A.V.
      • Svendsen K.H.
      • Bracha Y.
      • Grimm R.H.
      Spinal manipulation, medication, or home exercise with advice for acute and subacute neck pain: a randomized trial.
      In 2 large (n=1405) randomized controlled trials evaluating the muscle relaxant cyclobenzaprine for acute neck (more than one-third of the patients) or low back pain associated with muscle spasm, the authors found both intermediate-dose (15 mg/d) and high-dose (30 mg/d) therapy to be more effective than placebo but no difference between low doses (7.5 mg/d) and placebo.
      • Borenstein D.G.
      • Korn S.
      Efficacy of a low-dose regimen of cyclobenzaprine hydrochloride in acute skeletal muscle spasm: results of two placebo-controlled trials.
      A double-blind crossover study comparing the stand-alone anti-inflammatory drug benorylate to benorylate plus the muscle relaxant chlormezanone found no benefit of add-on therapy for low back or joint pain but significantly better pain relief and sleep quality in patients with neck pain.
      • Berry H.
      • Liyanage S.P.
      • Durance R.A.
      • Goode J.D.
      • Swannell A.J.
      A double-blind study of benorylate and chlormezanone in musculoskeletal disease.
      Muscle relaxants tend to be more effective for acute than chronic pain.
      • Elenbaas J.K.
      Centrally acting oral skeletal muscle relaxants.
      In light of their abuse potential and lack of greater efficacy compared with other muscle relaxants, many experts believe benzodiazepines should be prescribed only when other muscle relaxants have proven ineffective and with clearly defined goals, time frames, and appropriate surveillance.
      • Cohen S.P.
      • Mullings R.
      • Abdi S.
      The pharmacologic treatment of muscle pain.

      Injections

      The evidence supporting trigger point injections to treat myofascial pain is mixed. Part of the difficulty in evaluating clinical trials for trigger point injections is that the injection of any substance (or even dry needling) into taut bands of muscle may relieve pain, which makes it difficult to perform true placebo-controlled trials. In a systematic review by Scott et al
      • Scott N.A.
      • Guo B.
      • Barton P.M.
      • Gerwin R.D.
      Trigger point injections for chronic non-malignant musculoskeletal pain: a systematic review.
      evaluating trigger point injections for chronic pain, the authors found no clear evidence for either benefit or ineffectiveness. With regard to the type of procedure, there is limited evidence that injections may be more effective and less painful than dry needling.
      • Scott N.A.
      • Guo B.
      • Barton P.M.
      • Gerwin R.D.
      Trigger point injections for chronic non-malignant musculoskeletal pain: a systematic review.
      • Kamanli A.
      • Kaya A.
      • Ardicoglu O.
      • Ozgocmen S.
      • Zengin F.O.
      • Bayik Y.
      Comparison of lidocaine injection, botulinum toxin injection, and dry needling to trigger points in myofascial pain syndrome.
      For botulinum toxin, there is mixed evidence for superiority over trigger point injections performed with saline or local anesthetic. A Cochrane review identified 4 studies that met inclusion criteria, 3 of which focused on myofascial pain in the neck and/or shoulder region.
      • Soares A.
      • Andriolo R.B.
      • Atallah A.N.
      • da Silva E.M.
      Botulinum toxin for myofascial pain syndromes in adults.
      Although all 3 studies favored botulinum toxin, in only 1 study did the results reach statistical significance.
      • Göbel H.
      • Heinze A.
      • Reichel G.
      • Hefter H.
      • Benecke R.
      Dysport Myofascial Pain Study Group
      Efficacy and safety of a single botulinum type A toxin complex treatment (Dysport) for the relief of upper back myofascial pain syndrome: results from a randomised double-blind placebo-controlled multicentre study.
      • Ojala T.
      • Arokoski J.P.
      • Partanen J.
      The effect of small doses of botulinum toxin A on neck-shoulder myofascial pain syndrome: a double-blind, randomized, and controlled crossover trial.
      • Qerama E.
      • Fuglsang-Frederiksen A.
      • Kasch H.
      • Bach F.W.
      • Jensen T.S.
      A double-blind, controlled study of botulinum toxin A in chronic myofascial pain.
      A more recent study of 114 previous responders that used an enriched protocol design found modest benefit in some but not most outcome measures for some variables that persisted through 26 weeks.
      • Nicol A.L.
      • Wu I.I.
      • Ferrante F.M.
      Botulinum toxin type A injections for cervical and shoulder girdle myofascial pain using an enriched protocol design.
      In 2 controlled studies performed in patients with low back pain, the results were mixed regarding the effectiveness of botulinum toxin.
      • De Andrés J.
      • Adsuara V.M.
      • Palmisani S.
      • Villanueva V.
      • López-Alarcón M.D.
      A double-blind, controlled, randomized trial to evaluate the efficacy of botulinum toxin for the treatment of lumbar myofascial pain in humans.
      • Jabbari B.
      Botulinum toxin A and chronic low back pain: a randomized, double-blind study.
      The authors found there was inconclusive evidence to support the use of botulinum toxin injections for myofascial pain syndrome. In a non-systematic review by Jabbari and Machado,
      • Jabbari B.
      • Machado D.
      Treatment of refractory pain with botulinum toxins—an evidence-based review.
      the authors concluded there was level A evidence for the use of botulinum toxin injections to treat cervical dystonia. One caveat that is important to heed when interpreting studies on trigger point injections is that they are widely acknowledged to be more effective when used in patients in whom discrete, taut bands of muscle can be palpated (ie, trigger points) than in individuals with more diffuse symptoms.
      • Simons D.G.
      • Travell J.G.
      • Simons L.S.
      In some primary studies, however, the methodology used to identify trigger points was unclear.
      For cervical radiculopathy, the results of clinical trials evaluating epidural corticosteroid injections have been mixed. A small (n=40) randomized study found no significant differences at 3-week follow-up between transforaminal corticosteroids plus local anesthetic and transforaminal local anesthetic.
      • Anderberg L.
      • Annertz M.
      • Persson L.
      • Brandt L.
      • Säveland H.
      Transforaminal steroid injections for the treatment of cervical radiculopathy: a prospective and randomised study.
      This is consistent with 3 randomized, double-blind studies by the same group that compared epidural corticosteroid plus local anesthetic to epidural local anesthetic alone in a variety of conditions (herniated disc, spinal stenosis, and failed neck surgery syndrome) and found no differences between treatment groups, with both groups experiencing improvement.
      • Manchikanti L.
      • Malla Y.
      • Cash K.A.
      • McManus C.D.
      • Pampati V.
      Fluoroscopic cervical interlaminar epidural injections in managing chronic pain of cervical postsurgery syndrome: preliminary results of a randomized, double-blind, active control trial.
      • Manchikanti L.
      • Malla Y.
      • Cash K.A.
      • McManus C.D.
      • Pampati V.
      Fluoroscopic epidural injections in cervical spinal stenosis: preliminary results of a randomized, double-blind, active control trial.
      • Manchikanti L.
      • Cash K.A.
      • Pampati V.
      • Wargo B.W.
      • Malla Y.
      A randomized, double-blind, active control trial of fluoroscopic cervical interlaminar epidural injections in chronic pain of cervical disc herniation: results of a 2-year follow-up.
      In a randomized, placebo-controlled, nonblinded study that compared a series of epidural corticosteroid and local anesthetic injections to intramuscular injections, Stav et al
      • Stav A.
      • Ovadia L.
      • Sternberg A.
      • Kaadan M.
      • Weksler N.
      Cervical epidural steroid injection for cervicobrachialgia.
      reported significant benefit lasting up to 1 year. In a large, multicenter comparative effectiveness study, Cohen et al
      • Cohen S.P.
      • Hayek S.
      • Semenov Y.
      • et al.
      Epidural steroid injections, conservative treatment or combination treatment for cervical radiculopathy: a multi-center, randomized, comparative-effectiveness study.
      found that combination treatment with a series of epidural corticosteroid injections plus conservative treatment with adjuvants and physical therapy was superior to either treatment alone. Of note, a systematic review and meta-analysis concluded that epidural local anesthetic and/or saline constituted an efficacious treatment intermediate in efficacy between epidural corticosteroids and a true intramuscular placebo injection.
      • Bicket M.C.
      • Gupta A.
      • Brown IV, C.H.
      • Cohen S.P.
      Epidural injections for spinal pain: a systematic review and meta-analysis evaluating the “control” injections in randomized controlled trials.
      Cervical facet joint pain is estimated to account for between 40% and 60% of nonneuropathic neck pain based on controlled blocks.
      • Lord S.M.
      • Barnsley L.
      • Wallis B.J.
      • Bogduk N.
      Chronic cervical zygapophysial joint pain after whiplash: a placebo-controlled prevalence study.
      • Manchikanti L.
      • Boswell M.V.
      • Singh V.
      • Pampati V.
      • Damron K.S.
      • Beyer C.D.
      Prevalence of facet joint pain in chronic spinal pain of cervical, thoracic, and lumbar regions.
      The evidence for medial branch (facet joint nerve) radiofrequency ablation of cervical facet joint pain is weakly positive. In one small, placebo-controlled study performed in 24 meticulously selected patients with whiplash injury, the treatment group fared better than the sham group for pain relief and functional improvement, with the mean duration of benefit lasting about 9 months.
      • Lord S.M.
      • Barnsley L.
      • Wallis B.J.
      • McDonald G.J.
      • Bogduk N.
      Percutaneous radio-frequency neurotomy for chronic cervical zygapophyseal-joint pain.
      In a smaller study in 12 patients with cervicogenic headache that performed empirical radiofrequency denervation without diagnostic injections, 4 of 6 persons in the treatment group experienced success at 3 months, which favorably compared with 2 of 6 in the treatment group.
      • Stovner L.J.
      • Kolstad F.
      • Helde G.
      Radiofrequency denervation of facet joints C2-C6 in cervicogenic headache: a randomized, double-blind, sham-controlled study.
      Although small uncontrolled studies have reported benefit with intra-articular corticosteroid injections,
      • Kim K.H.
      • Choi S.H.
      • Kim T.K.
      • Shin S.W.
      • Kim C.H.
      • Kim J.I.
      Cervical facet joint injections in the neck and shoulder pain.
      the only placebo-controlled study reported no differences between the corticosteroid and local anesthetic control injections at 6-month follow-up.
      • Barnsley L.
      • Lord S.M.
      • Wallis B.J.
      • Bogduk N.
      Lack of effect of intraarticular corticosteroids for chronic pain in the cervical zygapophyseal joints.
      Injections in the form of selective nerve root blocks (SNRBs) have also been advocated as a tool to identify symptomatic spinal levels and select patients for surgery.
      • Cohen S.P.
      • Hurley R.W.
      The ability of diagnostic spinal injections to predict surgical outcomes.
      There is a strong correlation between the results of SNRB and single-level MRI pathology,
      • Anderberg L.
      • Annertz M.
      • Brandt L.
      • Säveland H.
      Selective diagnostic cervical nerve root block—correlation with clinical symptoms and MRI-pathology.
      but the correlation between SNRBs, MRI findings, and neurologic examination results in individuals with multilevel pathology is much lower.
      • Anderberg L.
      • Annertz M.
      • Rydholm U.
      • Brandt L.
      • Säveland H.
      Selective diagnostic nerve root block for the evaluation of radicular pain in the multilevel degenerated cervical spine.
      Although uncontrolled studies have found good surgical outcomes in patients who experience pain relief after diagnostic injections,
      • Anderberg L.
      • Annertz M.
      • Rydholm U.
      • Brandt L.
      • Säveland H.
      Selective diagnostic nerve root block for the evaluation of radicular pain in the multilevel degenerated cervical spine.
      • Sasso R.C.
      • Macadaeg K.
      • Nordmann D.
      • Smith M.
      Selective nerve root injections can predict surgical outcome for lumbar and cervical radiculopathy: comparison to magnetic resonance imaging.
      • Anderberg L.
      • Annertz M.
      • Brandt L.
      • Säveland H.
      Selective diagnostic cervical nerve root block—correlation with clinical symptoms and MRI-pathology.
      there have been no randomized studies evaluating their ability to improve treatment results.
      • Cohen S.P.
      • Hurley R.W.
      The ability of diagnostic spinal injections to predict surgical outcomes.
      One recent review concluded that adding SNRB to diagnostic work-ups in patients with lumbar radiculopathy being considered for surgery was not cost-effective.
      • Beynon R.
      • Hawkins J.
      • Laing R.
      • et al.
      The diagnostic utility and cost-effectiveness of selective nerve root blocks in patients considered for lumbar decompression surgery: a systematic review and economic model.

      Surgery

      Few randomized studies have evaluated surgical treatment for neck pain, and none have done so for mechanical pain. In a randomized study comparing anterior decompression and fusion operations, physical therapy, and hard collar immobilization in 81 patients with cervical radiculopathy, Persson et al
      • Persson L.C.
      • Carlsson C.A.
      • Carlsson J.Y.
      Long-lasting cervical radicular pain managed with surgery, physiotherapy, or a cervical collar: a prospective, randomized study.
      • Persson L.C.
      • Moritz U.
      • Brandt L.
      • Carlsson C.A.
      Cervical radiculopathy: pain, muscle weakness and sensory loss in patients with cervical radiculopathy treated with surgery, physiotherapy or cervical collar: a prospective, controlled study.
      found greater reductions in pain (29% for surgery, 19% for physical therapy, and 4% for cervical collar) and improvements in muscle strength and sensory loss in the surgical group than in the other treatment groups. Yet at 1-year follow-up, the differences favoring surgery were for the most part no longer statistically significant. A more recent randomized study that compared surgery and physical therapy to physical therapy alone for cervical radiculopathy found that surgery was associated with superior outcomes at 1 year, but by 2 years, the differences between groups were no longer statistically significant.
      • Engquist M.
      • Löfgren H.
      • Öberg B.
      • et al.
      Surgery versus nonsurgical treatment of cervical radiculopathy: a prospective, randomized study comparing surgery plus physiotherapy with physiotherapy alone with a 2-year follow-up.
      In a clinical trial performed in 120 patients with neck and/or arm pain secondary to a single, small contained disk herniation, plasma disk decompression was found to be superior to conservative treatment for pain and function throughout the 1-year follow-up.
      • Cesaroni A.
      • Nardi P.V.
      Plasma disc decompression for contained cervical disc herniation: a randomized, controlled trial.
      Of note, conservative treatment had already failed in all patients.
      In the only randomized study evaluating surgery for cervical myelopathy, Kadanka et al
      • Kadanka Z.
      • Bednarík J.
      • Vohánka S.
      • et al.
      Conservative treatment versus surgery in spondylotic cervical myelopathy: a prospective randomised study.
      compared operative therapy to conservative care consisting of immobilization with a soft collar, NSAIDs, and intermittent bed rest. Sixty-eight patients were randomized by coin flip, with discrepancies noted for some baseline variables. Overall, through the 10-year follow-up period, no significant differences were found for major outcome variables between treatment groups.
      • Kadanka Z.
      • Bednarík J.
      • Vohánka S.
      • et al.
      Conservative treatment versus surgery in spondylotic cervical myelopathy: a prospective randomised study.
      • Kadaňka Z.
      • Bednařík J.
      • Novotný O.
      • Urbánek I.
      • Dušek L.
      Cervical spondylotic myelopathy: conservative versus surgical treatment after 10 years.
      A subgroup analysis found that patients who were younger and had greater baseline disease burden and small spinal canal areas tended to fare better with surgery than those who were older and had greater function and transverse spinal canal diameter.
      • Kadanka Z.
      • Mares M.
      • Bednarík J.
      • et al.
      Predictive factors for spondylotic cervical myelopathy treated conservatively or surgically.
      There are no randomized controlled trials comparing surgical to nonsurgical therapies for mechanical neck pain associated with common degenerative changes, but extrapolated studies in the lumbar spine suggest that less than one-third of patients will experience clinically meaningful pain relief or functional improvement, with the results diminishing over time.
      • Jacobs W.
      • Van der Gaag N.A.
      • Tuschel A.
      • et al.
      Total disc replacement for chronic back pain in the presence of disc degeneration.
      • Brox J.I.
      • Nygaard Ø.P.
      • Holm I.
      • Keller A.
      • Ingebrigtsen T.
      • Reikerås O.
      Four-year follow-up of surgical versus non-surgical therapy for chronic low back pain.
      The results of systematic reviews comparing cervical disk replacement to anterior decompression and fusion operations are conflicting as to whether the former is associated with better outcomes for single-level spondylosis.
      • Fallah A.
      • Akl E.A.
      • Ebrahim S.
      • et al.
      Anterior cervical discectomy with arthroplasty versus arthrodesis for single-level cervical spondylosis: a systematic review and meta-analysis.
      • Yu L.
      • Song Y.
      • Yang X.
      • Lv C.
      Systematic review and meta-analysis of randomized controlled trials: comparison of total disk replacement with anterior cervical decompression and fusion.
      One study evaluating outcome predictors for anterior cervical decompression and fusion found that good functional capacity, male sex, and nonsmoking status were associated with successful long-term treatment results.
      • Peolsson A.
      • Peolsson M.
      Predictive factors for long-term outcome of anterior cervical decompression and fusion: a multivariate data analysis.

      Future Directions

      Compared with other leading causes of pain and disability, relatively few randomized controlled trials exist to guide treatment of neck pain, and the guidelines for neck pain are often extrapolated from those for other conditions. Clinical trials designed to determine efficacy and comparative effectiveness are needed for all types of treatments but particularly adjuvants for neuropathic pain and surgery for mechanical pain.
      The use of biological therapies, including stem cell therapy, and nerve growth factor and cytokine inhibitors have been or are currently being studied for other chronic pain conditions such as low back pain but have yet to be critically evaluated for neck pain. Future research should be expanded to determine their efficacy for spinal pain in general or neck pain in particular.
      The persistence of neck pain after whiplash and other types of injuries poses substantial physical, psychological, and economic consequences for patients and society. There is currently a very poor relationship between symptoms and imaging abnormalities in injured patients who continue to experience neck pain.
      • Matsumoto M.
      • Okada E.
      • Ichihara D.
      • et al.
      Prospective ten-year follow-up study comparing patients with whiplash-associated disorders and asymptomatic subjects using magnetic resonance imaging.
      Finding ways to identify those individuals at increased risk for development of persistent pain, and preventing it, represents an important challenge to the medical community.

      Conclusion

      Neck pain is one of the leading causes of disability in the world, yet the amount of research devoted to treatment is relatively low in comparison to the other leading causes. For acute neck pain, most cases will resolve spontaneously over a period of weeks to months, but a substantial proportion of individuals will be left with residual or recurrent symptoms. Treatment appears to have little effect on the course of acute neck pain. History and physical examination may provide important clues as to whether the pain is neuropathic or mechanical and are critical in determining who might benefit from advanced imaging or further diagnostic work-up. In patients with whiplash injuries, there is a poor correlation between pain and imaging results. Clinical trials have found that exercise may be beneficial, and for acute pain, muscle relaxants are effective. In individuals with chronic pain, there is conflicting evidence supporting epidural corticosteroid injections in patients with radiculopathy and spinal stenosis and weak evidence in favor of facet joint radiofrequency denervation for spinal arthritis.

      Acknowledgments

      The opinions or assertions contained herein are the private views of the author and are not to be construed as official or as reflecting the views of the Department of the Army or the Department of Defense.

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