Neck pain is a common problem in our society and, at any given time, affects about 10% of the general population. The actual cause of the problem is frequently difficult to determine.
Our neck is an extremely flexible part of our body. Seven cervical vertebrae allow more motion than any other part of the spine; however, because it is less protected than the rest of the spine, the neck is more vulnerable to injury. In many patients it is a temporary condition and disappears with time, whereas others may need medical attention.
Relevant Anatomy and common causes of neck pain
Figure 1 shows the relevant anatomy of the neck.
Involvement of the cervical nerve roots (N) usually results in pain and neurologic findings in the distribution of the nerve. In this figure one can appreciate the proximity of the disc (D) to the nerve root; even a very small herniation of the disc can thus irritate the nerve root. Similarly the uncinate process (U), a bony part of the vertebra forms one of the walls of the canal through which the nerve root exits. During the aging process we all develop degenerative or arthritic changes in these processes which in effect narrow the space for the nerve and thus irritate the nerve. This diagram also shows the location of vertebral artery in a canal, degenerative changes lead to narrowing of this canal leading to giddiness and vertigo in elderly patients
Cervical nerves are both sensory and motor so that damage, in addition to pain, may cause numbness, tingling, muscle weakness, and reflex deficits in a specific location. Signs and symptoms along the distribution of a cervical nerve root are called cervical radiculopathy.
The cervical nerve roots C5, C6, and C7 are the most commonly involved and result in characteristic signs and symptoms in the upper extremities. Because the distal-most innervation of C4 is to the top of the shoulder, compression of the C4 nerve root does not produce symptoms below the level of the shoulder, and usually there is no demonstrable muscle weakness or any reflex abnormalities. Damage or irritation of C1, C2, and C3 does not result in reflex or motor deficits but can result in pain in the back of the neck extending along the back of the head. Pain from neck sources other than cervical nerve roots does not result in sensory, motor, or reflex deficits and the pain patterns are not as well defined.
Aside from patients with disc herniations demonstrated on imaging studies (MRI/CT scan) and pain in a specific nerve root distribution, the relationship with degenerative changes is not always clear. This is because degenerative conditions are common with aging and many times are incidental findings in asymptomatic people. Specific conditions that have been studied but also are not well understood are post-traumatic neck pain syndrome, commonly known as whiplash injuries, and pain following repetitive activities in an occupational setting. Although causes of neck pain are not well understood, outcome studies have shown that it frequently is not a self-limiting condition and can be a long-term problem.
The human neck is a complex structure that contains the extension of a number of vital visceral structures, including the trachea, esophagus, and the carotid and vertebral arteries, and a musculoskeletal system that provides for support and motion of the head. (See fig.2). The cervical spine itself is a series of seven separate bone elements, all with intricate articulations and an elaborate system of ligaments and associated muscles.
Referred neck pain
Referred neck pain is generated by disease in an anatomic structure other than the neck. Examples of this are visceral diseases such as angina, apical lung tumors, and subdiaphragmatic irritation as in a subdiaphragmatic abscess. The most common conditions that may be confused with neck problems are intrinsic shoulder diseases such as impingement, rotator cuff tears, and adhesive capsulitis (frozen shoulder). Peripheral nerve entrapment occurring in thoracic outlet syndrome, ulnar cubital tunnel syndrome, and carpal tunnel syndrome can simulate cervical nerve root compression. Systemic diseases such as rheumatoid arthritis, spondyloarthropathies, fibromyalgia, and herpes zoster may also cause neck pain. However, in these conditions it is unusual for the only symptom to be in the neck.
In addition to neck pain being more common in women it has also been observed that older patients, those involved in both mentally and physically stressful jobs, and chronic smokers were more likely to have neck pain.
Another common complaint in the elderly age group is of giddiness and vertigo. This is due to vertebral artery compression during the movements of the neck. These attacks occasionally are associated with retro-ocular pain (pain felt behind the eyeball), blurring of vision, tinnitus etc.
A routine AP and lateral radiographs are a must. Flexion and extension views are ordered in case one suspects instabilty e.g. post-traumatic neck pain. Occasionally a MRI or a CT scan is required e.g. if one suspects a nerve root compression.
When a nerve entrapment is suspected, EMG/ Nerve conduction studies may be ordered.
X-Ray Showing Early Degenerative Changes
MRI showing a posterior disc protrusion
The primary aim of the cervical spine and associated musculature is to support the head while providing a conduit for the nervous system. The forces acting on the cervical spine are therefore smaller in comparison to the forces acting on the lower lumber spine.
It is important to remember that cervical spine is vulnerable to muscular tension forces excessive motion and postural fatigue and therefore all conservative modalities focus to reduce these causative factors.
The commonest regimen is rest, ice, massage and non-steroidal anti-inflammatory drugs.
The position of the neck for comfort is essential for the relief of pain. For example patients with hyperextension injuries will feel comfortable with a flexion attitude.
Postural aspects of neck pain can be treated easily after discussing the details of work environment, personal habits etc. A computer operator will get neck pain if the monitor in front of him is at such a height that he has to keep his neck extended all the time. Many tailors and weavers are prone to neck pain because they work with their neck flexed all the time. Sleeping prone can cause neck sprains easily because one has to keep the head and neck tilted so that the nose is not obstructed.
Cervical traction is helpful in certain patients. Traction has to be applied in the position of maximum comfort and should never be continued if it increases pain. The weights should not exceed 10 pounds.
A collar is most useful in a patient who is very active. Collars help because they limit excessive motion. They should be tailored to the most comfortable neck position.
Counseling for reducing stress
Neck pain is very commonly seen in patients who are involved in stressful jobs and an effort should be made to reduce the stress by suggesting various relaxation techniques.
Neck and Shoulder exercises
Exercises are most beneficial when started after the acute pain has subsided. Isometric exercises are helpful in acute phase.
I have shown some simple exercises for the shoulder and the neck. All these exercise can be done even at your place of work and they do not need any special equipment.
I recommend 2 sets of twenty minutes any time during the day.
This is a useful modality especially for chronic pain. A TENS machine is supplies electrical shocks of low intensity via electrodes applied to the affected area. Patient experiences these shocks as a tingling sensation. A TENS machine is portable and is similar to a pager in size. This works on what is known as a �gait control theory� at the brain level. In simple terms by supplying continuous tingling sensation the pain fibers at the brain level are blocked so much so that patient no longer feels the pain. TENS obviously does not treat the underlying pathology.
Role of surgery
Very few patients require surgery to relieve neck pain. For the vast majority of patients, a combination of rest, medication, and physical therapy will relieve neck pain. Surgery may be necessary to reduce pressure on the spinal cord or a nerve root when pain is caused by a herniated disk or bony narrowing of the spinal canal. Surgery may also be required
Following an injury, to stabilize the neck and minimize the possibility of paralysis such as when a fracture results in instability of the neck.
Tips To avoid a sore Neck
1. Good Posture
2. Avoid Sleeping On Your Tummy
3. Do Not Read in Bed
4. Routine Neck Exercises
5. Read/Watch TV/ Use Computer at Eye Level
6. Do Not Use A Very Thick Pillow
Dr. Shreedhar Archik is a consultant Orthopaedic surgeon attached to Lilavati Hospital, Bandra.
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