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Answers for Neck Pain

By Terrence Crowder, M.D.

artificial_disk3A natural consequence of aging is degeneration. When this degeneration occurs in the spine, it is called spondylosis (or degenerative arthritis of the spinal vertebra) . Although degeneration can affect any part of the spine and is common in adults, development of pain and disability from spondylosis is far less common. More than 60% of all adults will experience neck pain in their lifetime but only 5% will be disabled by it. Seventy percent of those seeking medical treatment for their neck pain will experience complete or significant relief of their symptoms. 

Your neck carries the weight of a bowling ball so as you can imagine, hunching your shoulders or slumping at your desk makes its job more difficult. Good posture can make a huge difference over the years and reduce the work of your neck. Contrary, poor posture can make your neck vulnerable to aging and injury. 

Spinal Anatomy and Disease Process

The neck, or cervical spine, is comprised of bones, discs, joints, tendons, muscles, ligaments and nerves, any of which can be a source of pain. If nerves are involved, symptoms of numbness, tingling or weakness in an arm or legs can occur. Sometimes pain is due to adjacent parts such as the head and shoulders or jaw. It can be confusing but neck problems can be accurately diagnosed so treatment options can be instituted.

In the cervical spine, there are seven stacked bones called vertebrae. These vertebrae serve to support the head, allow motion, and connect the head to the rest of the body.

In between each vertebral level of the cervical spine, a spinal disc and two facet joints located behind each disc take on the weight and strain of the neck supported by ligaments and muscles. As we grow older, the discs between the vertebrae lose their water content, resulting in disc height loss and bulging into the spinal canal. Spondylosis (arthritis) causes the development of bone spurs and ligamentous involvement which can push into the spinal canal as well.  

Causes of Neck Pain

Disorders of the cervical spine can be broken down into three categories: 1) cervicalgia, or neck pain, 2) radiculopathy, or pain that radiates into a shoulder or arm, and 3) myelopathy, compression of spinal cord or, a combination.

Most causes of neck pain are not serious and can be resolved by simple means. Pain caused by improper ergonomics, posture, stress or chronic muscle fatigue usually is easily solved. However, sometimes neck pain can signify something more serious. If postural and ergonomic changes don't solve the problem, it deserves an investigation to determine the cause (diagnosis) and appropriate treatments. Some symptoms of various neck disorders include dull aching, pain increased by movement of the neck, numbness, tingling, tenderness, sharp shooting pain, or dizziness. Experiencing weakness in an arm or leg, or a shuffling gait is reason to seek prompt medical evaluation. 

Diagnosing Neck Pain

A thorough review of symptoms includes location, intensity, duration and pattern of radiating pain and noting any injury. Positions that aggravate or relieve the pain should be noted too. A neck examination should be done at rest and in motion. During the exam, the nervous system is evaluated to determine nerve involvement.

Diagnostic imaging testing begins with plain x-rays which help identify degenerative and rheumatoid arthritis, cancer, trauma, and infection. Magnetic resonance imaging (MRI) has become the test of choice when evaluating the patient with neck pain. Computer tomography (CT) is also helpful in assessing the cervical spine. CT scans give a more detailed view of the joints, bones, and alignment of the vertebrae. If dye is added to the spinal canal to better delineate soft tissue before a CT is performed, it is called a CT myelogram. Other tests that can be helpful include electromyography (EMG) and nerve conduction studies (NCS). Because multiple clinical studies have shown that a significant number of people with no symptoms exhibit degenerative changes on imaging films, the physical exam and history, along with any imaging studies, must be used to delineate and correlate the true reason for one's pain. 

Treatment for Neck Pathology

An accurate diagnosis is the first step to instituting treatments, which can include physical therapy to strengthen muscles around the neck, anti-inflammatory medication, heat/ice applications, soft collar, traction and activity modification. Other options considered are spinal injections, topical anesthetic creams, topical pain patches, muscle relaxants, analgesics or surgical intervention. Chiropractic cervical manipulation is controversial. Studies show that rehabilitative neck exercises are superior to manipulation. There are risks associated with neck manipulation that are significantly more serious than those seen with lower back.

Radiculopathy (Arm or Shoulder Pain)

Radiculopathy refers to symptoms resulting from nerve compression of specific nerve root(s). One who experiences possible nerve compression in the neck can complain of sharp or aching pain, tingling, numbness, and/or a burning sensation in the upper extremity. Weakness of the muscles supplied by that nerve may also occur. Neck pain can accompany these complaints. Possible reasons for radicular pain include disc herniation, spinal stenosis (narrowing of the spinal canal due to degeneration), tumor or infection.

Conservative treatment is always tried first. The majority of patients with radiculopathy particularly those diagnosed with a disc herniation improve without any treatment. Persistent symptoms can benefit from the same conservative treatment as neck pain without radicular symptoms.  

Myelopathy

The origin of myelopathy differs from radiculopathy. While radiculopathy refers to nerve roots which exit the spine, myelopathy refers to injury to the spinal cord itself. Cervical spinal stenosis (narrowing of the spinal canal from enlarged arthritic bones and soft tissues) can cause compression of the spinal cord. Patients complain about difficulty with handwriting, small finger tasks or even opening a door. Lower extremity symptoms include weakness, loss of balance, difficulty walking and decreased bowel or bladder control. Severity of myelopathy varies from mild to rapid progression. Those patients who are stable can go as is while those whose symptoms and compression progress, surgery is recommended to stop or stabilize the progression. 

Non-Operative Treatment

A number of non surgical treatment options exist for the treatment of cervicalgia, radiculopathy, or myelopathy. Classic conservative treatment involves using nonsteroidal medications to reduce inflammation and physical therapy to strengthen the supporting muscles around the cervical spine which resolve complaints in a significant percentage of patients. Rest, patient education, and acupuncture have shown some benefit in a few studies. Occasional immobilization in a cervical collar can be beneficial when neck pain is severe. Manual or automated traction have also been shown to provide relief. Epidural and selective nerve steroid injections have shown good short term benefit but do not decrease the rate of eventual surgery. One can also consider spinal injections of the arthritic facet joints or by burning away the nerves supplying the joint with some success. 

Considering Surgery

If nonoperative treatment fails and symptoms persist or progress, surgical intervention may become necessary. Multiple factors are considered when deciding the approach to surgical intervention. Surgery of the neck is either performed from the front, back, or a combination of the two. Surgery can be as simple as a one-level discectomy through a minimally invasive approach to more complicated procedures for multiple decompressions or tumor removal. For selected cases that have disc pathology, artificial disc replacement, which preserves motion, is now an option. Since cervical procedures can be technically demanding, they should be performed by spine surgeons.

Fortunately, there are a range of options when deciding the approach and type of surgery that is best for the problem. Most importantly, the surgery should be selected to produce the best outcome for the patient in the long term, not because it is new or is popular in marketing circles.  

A Final Word

A thorough medical history and examination are essential along with appropriate imaging studies so symptoms and findings can be correlated. While nonoperative treatments will benefit the majority of patients, if these methods fail, surgical interventions offer excellent resolution of certain cervical spine disorders. Although no one ever wants to resort to having surgery, it can be a viable solution to return you to improved comfort and a more active lifestyle.

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