How to banish neck pain
by Nathan Wei, MD, FACP, FACR
Nathan Wei is a nationally known board-certified rheumatologist and author of the Second Opinion Arthritis Treatment Kit. It's available exclusively at this website... not available in stores.
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Neck pain is one of the more common problems and affects almost half the population at some point in their lives.
The neck consists of seven vertebrae, stacked on top of each other and separated from each other by discs and joints. This structure is supported by muscles, ligaments and tendons.
The neck is designed to bend forward and back (flexion and extension) as well as to turn to either side (rotate). Bending to either side is restricted by both the shape of the vertebrae as well as by the ligaments that connect the vertebrae.
Because of this unique structure, pain can originate from many different locations. Pain in the neck can also be referred to many different areas including the back and top of the head, face, shoulders, arms, chest, and upper back.
Causes of neck pain include trauma, muscle spasm, degenerative arthritis, inflammatory arthritis (rheumatoid arthritis, ankylosing spondylitis), metabolic bone disease (osteoporosis with fracture), thyroiditis, disorders of the esophagus, and more rarely, tumors and infection.
The most common cause of acute neck pain is probably strain. This occurs with overuse which occurs as a result of repetitive motion or holding the head in one position for an extended period of time (e.g. sitting at the computer).
Patients will avoid moving their head and report tightness in the neck. Examination shows restricted range of motion due to muscle spasm. Neurological evaluation is otherwise normal. Acute pain can also arise from other causes such as infection or fracture.
Acute neck pain can also be more serious when there is a sprain (soft tissue injury with actual tearing of muscle, ligaments, etc.) One of the more common causes is the sudden deceleration injury (whiplash). The head is whipped backward, then forward, then back with injury to the supporting structures in the neck.
Chronic neck pain usually comes from degenerative arthritis or related disorders. As with the acute situation, muscle spasm causes much of the pain.
Patients with neurological abnormalities tend to have a worse prognosis than those who do not. Neurological problems occur as a result of compression of nerve roots (radiculopathy), spinal cord (myelopathy), or spinal cord injury.
Patients with rheumatoid arthritis can develop compression of the spinal cord when the vertebrae “slip” as a result of erosion or ligament damage. Severe osteoarthritis can cause spinal stenosis, where the central bony canal that holds the spinal cord narrows and causes pressure on the cord. Osteoarthritis can also be a common cause of radiculopathy.
Physical examination should evaluate range of motion, muscle strength, reflexes, and the presence of muscle spasm. It is imperative that a careful examination be done to look for underlying conditions that might predispose to neck pain.
Laboratory testing is directed by the results of history and physical exam.
X-rays are generally not that helpful since most older patients will have osteoarthritis on x-ray. In patients with chronic or severe discomfort or where the neurological exam is abnormal, other imaging studies such as magnetic resonance imaging may be helpful.
Electrical testing (electromyography) is also useful for detecting the presence of radiculopathy.
Treatment of neck pain, as with other diseases, begins with determining the cause of the neck pain. Patients with benign neck pain due to strain will respond to conservative measures including anti inflammatory medication, muscle relaxants, rest using a soft cervical collar, and a neck support pillow. Some patients will require a course of physical therapy.
Occasionally gentle traction may be helpful.
Patients with more severe mechanical neck pain may require soft tissue injections with lidocaine and glucocorticoid. Epidural injections may also be warranted.
Prolotherapy is a procedure where an irritant solution such as dextrose or sodium morhuate is injectred using ultrasound guidance into damaged ligaments. This causes local inflammation with healing of the ligaments. This allows muscles that have been in spasm as a result of loose ligaments to untighten and often relieves neck pain of myofascial origin.
Recently, it has been demonstrated that some patients with severe neck spasm may respond to botulinum toxin injection.
Those patients with intractable pain or severe/progressive neurological deficit are candidates for surgery.
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