Neck Pain Diagnosis

History and Physical Examination

The goal of diagnosis is to identify the anatomic pain generator(s). For the majority of neck pain patients, a diagnosis or at least a categorization of symptoms can be reached through a careful history that focuses on the mechanism of injury and the aforementioned symptoms.

Various specialists and primary care physicians frequently diagnose neck pain. Physiatrists are physicians trained to diagnose the specific types of neck pain and the various pain generators.

The patient history and examination are critical in distinguishing potential causes and identifying red flags. Each case should be approached with a very good history of how the symptoms started. Screens for red flags such as progressive neurological compromise should be performed and practitioners should make sure the bony structures are stable. Clinicians should take note of any prior neck trauma or symptoms, carefully question prior treatment successes and failures and be on alert for the warning signals that indicate potentially serious conditions. Such red flags include:

	Morning stiffness—gradual improvement over the course of a day may be indicative of rheumatic cases
	Fever, weight loss or night sweats—indicative of infection or neoplasm
	Unremitting night pain—may be secondary to a bone tumor, especially in the context of a prior history of malignancy
	Gait disturbance, balance/coordination problems or sphincter dysfunction—suggest myelopathy

There are some symptoms that when combined with neck pain, and in the absence of trauma, become worrisome. For example, a young patient with a stiff neck, headache and fever should not be discounted. These are key indicators of meningitis. Neck pain with neurologic signs like paresthesias or coordination issues can indicate spinal cord pressure, as can spasticity and bilateral hand symptoms. In this scenario, clinicians would want to rule out a large central herniated disk, tumor multiple sclerosis or Chiari malformation, among other things.

A thorough physical examination can be key to making such determinations. Posture, ease of movement and visible deformities should be the primary focus. Palpatation of soft tissue, bony and other cervical structures such as thyroid, lymph nodes and salivary glands should then be performed. Clinicians should take note of the cervical range of motion in flexion, extension, lateral bending and rotation, as well as shoulder range of motion. Also, of vital importance is a neurologic examination of sensory function, motor function, reflexes coordination and balance.

Staging for Imaging

Diagnostic imaging for neck pain can be misleading and should only be ordered as necessary. This is due to the high incidence of asymptomatic radiographic abnormalities, which may not be contributory to current symptoms. Radiographs are recommended, however, for WAD cases that present neck complaints plus neurologic signs, those that are suspected to include fracture or dislocation, and in patients with a history of trauma. Plain radiographs should also be considered in those cases of axial neck pain for which six to eight weeks of conservative treatment has been ineffective.

If myelopathy, infection or neoplasm is suspected, Magnetic Resonance Imaging (MRI) is appropriate. Loss of bowel or bladder control are indicators of potentially serious problems, because the nerves that supply those areas travel through the neck region. In this situation, the patient needs to be imaged to determine if all bony and neuro structures are intact. MRI should also be considered for patients with radicular pain associated with motor or reflex deficits, and for those with radicular symptoms that have not resolved within six to eight weeks.

Neck Pain Treatment

Untreated pain can interfere with the healing and rehabilitation process by affecting the immune system, interfering with exercise and increasing the risk of psychological distress. Promoting functional ability is important. Prolonged rest and immobilization weaken muscles and promote deconditioning and more disability.

Frequently, patients seek consultation with a physiatrist, who is a physician specifically trained in the non-operative treatment of neck pain.

If there is a gradual onset of pain, or acute pain for less than a couple of weeks, and if there is no indication of trauma or neurological problems, anti-inflammatories and range of motion exercises, under the guidance of a physical therapist, should be safe.

Drug Therapy for Treatment of Neck Pain

The goal with any pain medication should include opening a window of opportunity for the patient to do the proper core exercises so that muscles can be strengthened and further injury can be prevented as injured tissues heal. There are many first line drug therapies available, the efficacy of which depends largely on patient history and the nature of the neck pain.

Acetaminophen (full-dose) is supported by strong evidence and several major sets of guidelines as a first-line therapy. Liver toxicity is a risk in certain patients, and acetaminophen toxicity increases substantially when taken with Cyclooxygenase-2 (COX-2) inhibitors or Non-Steroidal Anti-Inflammatory Drugs (NSAIDs).

Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) are recommended by most major sets of guidelines. There is strong evidence of their efficacy in acute pain and moderate evidence in chronic pain. NSAIDs are useful for analgesic and anti-inflammatory properties, but care should be taken with patients who have the potential for gastrointestinal ulceration and kidney problems. The new generation of NSAIDs, Cyclooxygenase-2 (COX-2) inhibitors, can be very effective in certain patient populations, but are not tolerated by everyone. Because they have been linked to certain side effects, the risks and benefits of COX-2 inhibitors must be weighed carefully for each patient.

Muscle relaxants may also help, but the evidence is mixed. A review of 14 moderate-quality randomized, controlled trials showed that cyclobenzaprine was more effective than placebo for managing neck and back pain, particularly in the first four days of therapy. The effect, however, was modest and came at the price of greater adverse effects. Muscle relaxants should only be considered in the short term because of the risk for tolerance and abuse, although baclofen and tizanidine may have less potential for addiction. Muscle relaxants in general are not recommended for acute phase WAD due to limited evidence of efficacy.

Narcotic pain medications, particularly opioids, may be appropriate for more severe pain when other strategies do not provide adequate relief. Dosing must be closely monitored. Physical dependence occurs after longer-term use, which is different than addiction. Again, dose monitored care by an experienced physician is critical for the effectiveness of this aspect of treatment.

Adjuvant anti-depressants and anticonvulsants are widely supported for general pain management, but their specific effect on neck pain has not been adequately explored in trials. Studies show that anti-depressants may improve sleep patterns and that anticonvulsants (anti-seizure medications) are effective for off-label use in nerve pain.

Oral steroids administered in short course and based on a one-week tapering schedule can be effective for patients with a herniated disk that may be causing nerve impingement.

Injection Therapy for Treatment of Neck Pain

Injections may be appropriate, both diagnostically and therapeutically, following four to six weeks of ineffective conservative care. Injection therapy enables practitioners to target the problem specifically. Or, if physical therapy hurts too much, injection therapy can provide relief so that patients can work to strengthen the problem area. There are several types of injections suitable for neck pain, including trigger point, epidural steroid and facet joint.

Trigger point injections can be performed in an office, but because the needle is injected close to the spine and lungs, it requires substantial expertise.

For cervical radiculopathy, an epidural steroid injection may be the best course. An anesthetic and a steroid are combined to treat the pain while decreasing inflammation of the nerve. The anesthetic wears off in a few hours, but the steroid component improves after a week or so and can last for more than a month. Using this opportunity to get the patient participating in physical therapy means they will have a better chance of restoring their functional mobility.

Patients suffering with arthritic facet joints or injury may be good candidates for facet joint injections. Those delivered in the middle to lower neck are relatively safe, but facet joint injections to the upper facet joints are high-risk injections, as vulnerable areas of the spinal cord are more exposed in that region. They can be very effective for whiplash and occipital headaches, but must be performed cautiously and by experienced practitioners.

Radiofrequency Rhizotomy for Treatment of Neck Pain

Following injection, radiofrequency rhizotomy (a.k.a. RF neurotomy) may be the next step. This therapeutic procedure is designed to decrease or eliminate pain symptoms within spinal facets, utilizing a needle and x-ray guidance to place a small electrode adjacent to the facet. Experienced physicians cauterize the nerve fibers that extend to the joints. Rather than relying on the chemical of an injection to numb the pain, radiofrequency rhizotomy uses heat to unplug it. The resultant pain relief can last considerably longer than that following local anesthetic and steroid blocks.

Physical Therapy for Treatment of Neck Pain

Because neck pain is structural in nature, a physical approach is usually necessary. WAD in particular can benefit from physical modalities, as confirmed by a recent report. This goes far beyond the application of passive modalities such as heat, cold, ultrasound or electrical stimulation. Spine expert therapists, experienced in multiple treatment techniques, are critical to the resolution of pain, and return to normal activities.

There is a reasonable quantity of high-quality scientific evidence in support of the following physical modalities:

	Early return to usual activities — WAD patients in particular should avoid prolonged resting periods
	Manipulation — a high-velocity thrust at one or more joints of the cervical spine, which can provide at least short-term benefits. This should probably be avoided in cases of tight cervical stenosis. Spinal stability needs to always be confirmed first in post-traumatic cases.
	Mobilization — manual therapies directed at cervical joint dysfunction that do not involve high-velocity thrusts are also likely to provide at least short-term benefits, and are recommended for WAD cases with musculoskeletal symptoms. Again, spinal stability should be confirmed in post-traumatic scenarios.
	Supervised exercise — flexibility and strengthening exercises can lead to positive effects on both acute traumatic neck injuries and chronic neck pain

Alternative Therapies for Treatment of Neck Pain

Some long-criticized alternative therapies are slowly convincing the wider medical community of their pain management applicability. Many physicians believe that alternative medicine has its place and can be very effective. Recent studies have reinforced acupuncture’s ability to help manage back and neck pain, and chiropractic care has also proved helpful, though not without risk. In the right patient, manipulation or mobilization techniques can provide significant benefit. Because there have been reports of potentially serious neurologic or orthopedic complications, proper patient selection is important.