Management Of Neck Pain
Tai Q. Nguyen, M.D.
Introduction
Neck pain is a ubiquitous and recurring symptom that is
usually of short duration and does not require medical
attention. When neck pain is persistent enough to prompt a
visit to the doctor, it deserves a systematic physical exami-
nation to determine the presence of structural damage and/
or neural involvement.
History And Physical Examination
A history of trauma is important to determine at the initial
visit, including its relation to the onset of neck pain, for
diagnostic as well as for medico-legal purposes. The exact
location of the pain, whether it is associated with shoulder
and/or arm pain and paresthesia, and whether there is
limitation of the range of motion of the neck or the shoul-
ders are factors that will help in the differential diagnosis.
When the pain involves both neck and shoulder, it is
important to determine whether the pain comes primarily
from the neck, the shoulder or both. Severe pain with
muscle spasm may limit the range of motion of the neck or
the shoulders, but this limitation can be overcome, with
encouragement, by the patient. Real limitation of the range
of motion of the neck or the shoulders indicates the presence
of structural damages within the corresponding joints. A
neurological examination will determine the presence or
absence of myelopathy and nerve root dysfunction. Signs
that suggest the presence of a radiculopathy: a focal muscle
weakness or decreased sensation in the distribution of a
cervical nerve root; a paresthesia affecting one or two digits
of one hand; a decrease or absence of a deep tendon reflex.
Myelopathy is denoted by hyperreflexia, the presence of
clonus or a Babinski sign, spasticity of the lower extremi-
ties, sensory loss and disturbance in bladder function. The
emotional condition of the patient should also be assessed
as part of the initial examination to determine psychologi-
cal factors that might contribute to the experience of pain. 1
Differential Diagnosis
Neck pain may arise from affections of the cervical
musculature or the cervical vertebral column and its sur-
rounding neurovascular structures or from diseases of other
organs with pain irradiation to the neck. A number of
diseases presenting with neck pain require immediate inter-
vention: myocardial infarction and aortic dissection where
the pain is more typically located in the anterior neck, throat
or tongue and the range of motion of the neck is not
compromised; meningeal irritation from infection or sub-
arachnoid hemorrhage, causing neck stiffness; severe arte-
rial hypertension, where the pain is usually suboccipital. 2
Degenerative changes in cervical spines are visible radio-
graphically in 40% of the adult population and its frequency
can reach 90% by the age of 603. Degenerative changes are
most frequently observed in the C5-6 and C6-7 discs. The
disc narrows as nuclear material desiccates, and osteophytes
develop at the outer margins of the bony end-plate. These
bony spurs can encroach on the cervical spinal canal and the
neural foramen, causing compression of the spinal cord and
the nerve roots, and more rarely the vertebral arteries.
Degeneration of the facet joints often accompanies disc
degeneration. The joint of Luschka are similarly involved.
Fracture of vertebrae, disruption of ligaments, disloca-
tion of joints and ruptures of intervertebral discs may be
seen after falls or traffic accidents. These injuries may or
may not cause neural injuries, and may not even cause
enough pain at the initial visit to the emergency room so that
they may be missed by a cursory examination. When the
nature of the accident is such that a severe injury to the
cervical spine is suspected, a careful radiographic investi-
gation must be conducted, with review by an experienced
radiologist of the complete series of plain radiographs of the
spine, supplemented if necessary by CT scan of the sus-
pected region. Tumoral and infectious processes may have
an insidious or an acute onset. Although rare, the possibility
of tumor must be considered in the differential diagnosis of
persistent neck pain, with or without neurological symp-
toms.
Diagnostic Studies
Imaging studies
Plain radiography of the cervical spine is indicated when
there is suspicion of traumatic injuries (fracture, disloca-
tion), or a tumoral or infectious process. Dynamic studies
(lateral views with flexion and extension of the cervical
spine) may be performed in patients without neurological
deficits to demonstrate spinal instability when a spinal
injury is suspected and routine cervical-spine series is
negative. CT scan of the spine will show linear fractures of
the vertebrae where plain radiographs may not be able to
detect. It also allows the assessment of the spinal canal
(spinal canal stenosis) and the neural foramen (neural
foramen narrowing). For the diagnosis of intervertebral
disc rupture and herniation, or intraspinal soft tissue pro-
cesses (such as epidural and intradural abscesses and he-
matomas, intraspinal tumors), MRI scanning is an excellent
tool because it gives a better definition of soft tissues.
Myelogram and CT scan with intrathecal contract are still
useful in the surgical planning because they allow the best
Tai Q. Nguyen, M.D. is Associate Professor of
Neurosurgery at the University of Florida Health
Science Center / Jacksonville.
June, 1999/ Jacksonville Medicine 235
 visualization of the relationship between the bony struc-
tures and the neural tissues. When all other imaging studies
fail to produce an anatomical explanation for the patients
symptoms, provocative discography has been advocated to
produce the precipitation or exacerbation of the very symp-
toms that cause the patient to seek medical attention. Dis-
cography has also been shown to demonstrate disc annular
tears when MRI scanning was negative.4 Even in experi-
enced hands, the incidence of complication is still signifi-
cant,5 and with the questionable value of its efficacy in
identifying the site of the cervical symptomatology,6 dis-
cography is not a routine diagnostic procedure.
Nerve blocks
Nerve blocks for the diagnosis of cervical joint pain have
been used with some success,7 and should be done carefully
in a double-blind manner.
Electrodiagnostic studies
Electromyography and nerve conduction velocity tests
are helpful in confirming cervical radiculopathies when the
presence of a peripheral neuropathy compounds the symp-
toms. The absence of abnormal electrodiagnostic findings
does not however rule out a radiculopathy.
Etiologies
Identifiable etiologies of neck pain include: Chronic
inflammatory processes, such as rheumatoid arthritis; tu-
mors of the spine (primary or metastatic), or tumors of the
neural structures (spinal cord tumors: astrocytomas or
ependymomas) or of their coverings (meningiomas, also
metastatic tumors); infectious processes such as osteomy-
elitis, epidural or subdural abscesses; intervertebral disc
herniation or prominent spondylotic spurs causing spinal
cord and/or nerve root compression.
Unless the symptoms are typical of a radiculopathy or
radiographic investigations reveal an acute traumatic, tu-
moral or infectious process, it is often times difficult to
ascribe neck pain to a particular anatomical abnormality.
Ligamental tenderness and muscle spasm may be the result
of direct injuries but may also be secondary to referred pain.
Degenerative changes in the cervical spine are so prevalent
that the presence of such abnormalities cannot be taken as
prima facie evidence of their causality. In a study of
individuals between 20 and 65 years of age, disc degenera-
tion was associated with neck pain in men but not in women.
Osteoarthritis was not related to neck pain, either in the men
or in the women. The presence of degenerative changes on
the cervical spine radiographs therefore does not indicate
the etiology of the neck pain. Neuroticism was found to be
a more powerful determinant of neck pain than radiological
signs of disc degeneration or osteoarthritis in the general
population.8 Recurrent neck pain with intermittent symp-
toms of cervical nerve root irritation however has been
attributed to recurrent inflammation of the facet joints or the
236 Jacksonville Medicine / June, 1999
uncovertebral joints, causing transient irritation of the nerve
roots.
Management Of Neck Pain
The management of neck pain without an obvious iden-
tifiable cause is therefore best treated conservatively. Nar-
cotic analgesics may be used but only for a short period of
time. Nonsteroidal anti-inflammatory agents often offer
significant relief.
The effectiveness of physical therapy in reducing neck
pain has been and still is a subject of debate. At best,
physical therapy provides a degree of short-term pain relief,
and encourages the patient to resume the normal motion of
the neck. In acute neck pain after road traffic accidents, a
home exercise program has been shown to be as effective in
reducing pain and improve cervical movements as outpa-
tient physiotherapy.9 Moist heat and gentle massage done at
home with help from a family member, may be palliative
and therefore advised. Cervical traction has been used as a
form of physical therapy for neck pain. It may reduce pain
during its application and for a short period thereafter. Its
efficacy in affecting the likelihood and the rate of improve-
ment is still under question. Soft collars often provided
some comfort to the patient with neck pain and are therefore
often prescribed, although their benefit has not been statisti-
cally proven.10 Manipulation of the spine may give short-
term benefits for some patients with neck pain. Although
the rate of complications of cervical manipulation has been
shown to be small, 11 the potential of permanent impairment
or death makes its risks outweigh its possible benefits.
Acupuncture as an alternative modality of treatment of
neck pain has not yet been studied on a large scale to assess
its effectiveness in shortening the period of recovery or the
rate of permanent pain relief.
Neck pain is a frequent complaint after motor vehicle
accidents, especially after rear-end collisions. The pain
may not be experienced immediately, but sometime later
when neck motion precipitates muscle spasm. Sixty-two
percents of patients attending hospital following road traf-
fic accidents state that they have suffered pain in the neck
at some time following their accident, compared with 31%
who were noted to have neck pain when examined soon
after the accident.12 The majority of neck pain after traffic
accidents subsides however, and in one study of over 200
individuals where medico-legal implications are not rel-
evant, the prevalence of chronic symptoms are not higher
than in the general population. Expectation of disability, a
family history and attribution of pre-existing symptoms to
the trauma are important determinants for the chronicity of
the neck pain.13 The outcome of acute neck pain after traffic
accidents is better for patients who are encouraged to
continue to engage in their normal activities as usual than
for patients who are given sick leave and immobilized in a
soft collar during the first 14 days after the accident. 14
 Surgical Treatment
Neck pain will benefit from surgical treatments when it is
due either to neural compression and/or spinal instability.
Radicular pain will be relieved by decompression of the
nerve root(s) involved. Instability is corrected by reduction
and fusion of the involved vertebrae. Decompression of the
nerve root may be accomplished via a posterior lamino-
tomy and foraminotomy, or an anterior discectomy with or
without fusion of the vertebral bodies. Oftentimes, a fusion
is necessary to re-establish the spinal stability or to prevent
a future deformity due to the weakening of the supportive
structure after the decompression. Controversy still sur-
rounds the indications for operating on degenerated discs
without demonstrated neural compression. A recent study
showed that surgical fusion of cervical discs may bring
relief of neck pain to a certain number of selected cases.
Only in cases in which radiographic changes correlate with
the results of diagnostic nerve blocks should surgical fusion
be considered as a last therapeutic means to resolve the
painful condition.
A Case Presentation
The patient was a 35-year old woman who presented with
complaints of posterior neck pain, right shoulder and arm
pain, and occasional paresthesia in the right arm and in the
first two digits of the right hand. The patient dated the onset
of her symptoms to a motor vehicle accident occurring one
year before, when her car, which was stationary, was hit
head-on by another car. There was however no pending
litigation. The pain had gotten more intense and more
frequent over the previous few months, with an intensity of
7 over 10 on a 0 to 10 scale. It affected the patients sleep
and required acetaminophen with codeine for pain control.
Past medical history was remarkable for hypothyroidism.
Review of systems was otherwise negative. The patient
smoked a pack of cigarettes a day for the previous 20 years
and consumed alcohol moderately. The patient had under-
gone physical therapy three times a week for 6 weeks with
transient pain relief. She had continued to work as a com-
puter operator. She was single and had 3 children. Physical
examination was remarkable for an increase in pain in the
posterior aspect of the neck going down the spine on neck
flexion. Shoulder movements were not limited and did not
elicit any discomfort. Motor examination revealed a weak-
ness of the right elbow flexion of 4 over 5 on a 0 to 5 scale.
Sensory examination showed a decreased sensation to
touch and pinprick over the C6 dermatome distribution.
Deep tendon reflexes were symmetrical. There were no
pathological reflexes. The rest of the neurological examina-
tion was negative. Plain radiographs of the cervical spine
showed degenerative disc disease at the C5-6 level with a 2-
mm retrolisthesis of C5 vertebra on C6 (Figure 1). MRI
scan subsequently revealed an intervertebral disc hernia-
tion at C5-6 on the right side, compressing the right C6
nerve root (Figure 2). Because the patient had persistent and
severe pain, a surgical decompression by anterior discectomy
and interbody fusion with allograft was recommended to
relieve the pressure off the C6 nerve root and to prevent
compression of the spinal cord. The patient was asked to
stop smoking.15 She underwent the operation without com-
plications. Post-operative radiographs of the cervical spine
showed good fusion at the graft site (Figure 3). The neck
and arm pain subsided completely. Muscle strength re-
turned to normal. The patient resumed her occupation
without any problem.

Figure 1 (Left). Pre-operative lateral plane radio-

graph of the cervical spine, showing degenerative
disc disease at C5-6 level, with posterior bony spurs
and a 2-mm retrolisthesis of C5 vertebra on C6.
Figure 2 (Center). MRI scan with axial view at the
level of C5-6 disc, showing right paracentral disc
protrusion, with large asymmetric right dorsal osteo-
phytic spurring inducing encroachment on the right
C5-6 neural foramen and stretching of the right C6
nerve root. Figure 3 (Right). Post-operative lat-
eral plane radiograph of the cervical spine showing
fusion at the graft site.

June, 1999/ Jacksonville Medicine 237

 Conclusion
Neck pain without evidence of acute structural damage
and without neural compression is best treated with reassur-
ance, non-narcotic analgesics and nonsteroidal anti-inflam-
matory medication. The patients (including those with
post-traumatic neck pain) should be also encouraged to
maintain or resume normal neck motion with a home
program of exercises and physical therapy. A soft cervical
collar should be used only for a short period of time to allow
the patient to initiate the above recommended measures.
When acute structural damages to the spine or an infection
are suspected, imaging studies are warranted. Degenerative
changes will be seen on most plain radiographs of patients
of over 30 years of age and are of limited value in the
differential diagnosis. In patients with acute structural dam-
age caused by trauma or an infectious / inflammatory or
tumoral process, and those with compressive myelopathy
and/or radiculopathy confirmed by diagnostic studies, sur-
gical intervention is warranted. Therefore, the initial inves-
tigation should be aimed at distinguishing these two groups.
Early assessment of the emotional make-up of the patient
will help to avoid unnecessary diagnostic and surgical
procedures.
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