Patient information: Neck pain (Beyond the Basics)

NECK PAIN OVERVIEW

Neck pain can be caused by a number of factors, including muscle strain, ligament sprains, arthritis, or a "pinched" nerve. Approximately 10 percent of adults have neck pain at any one time. The majority of patients, regardless of the cause of pain, recover with conservative therapy.

This topic review discusses the causes, evaluation, and available treatments for the most common types of neck pain.

NECK ANATOMY

The neck, or cervical spine, is formed by seven square-shaped bones (cervical vertebrae), which are stacked one on top of another. The vertebrae are named for their position in the neck, beginning at the top with C1, C2, C3, down to C7. Together with the supporting ligaments and the overlying long neck muscles, the cervical vertebrae form a strong spinal canal that surrounds and protects the spinal cord (figure 1).

Between the neck bones are discs, which function as shock absorbers, cushioning one bone from another. Applying excessive pressure to the disc causes the inner gelatin-like material to protrude through its outer capsule; this is called a herniated disc (see 'Cervical radiculopathy' below). Other variations of disc injury include "bulging," "protruding," or "rupture."

Directly over the bones and the discs is a dense layer of taut ligaments. These thick tissues are attached directly to the bones and function to limit the movement of one cervical vertebra against the other. Car accidents and injuries to the head or body can cause injury to these ligaments. This whiplash movement of the neck can range in severity from minor bruising to complete tear and separation of ligament from the bone.

After the small muscles between the vertebrae, the major muscles of the neck form the next protective layer (figure 2). These muscles are responsible for holding the head up, maintaining normal posture, and supporting and moving the neck. Overuse and irritation of these muscles is called neck strain or neck tension.

NECK PAIN CAUSES

There are several possible causes of neck pain, although it is often difficult to know with certainty what is causing pain. This is because the examination, and even imaging tests, are not able to easily differentiate among the various causes.

Cervical strain — Cervical muscle strain can occur when there is an injury to the muscles of the neck, causing spasm of the cervical and upper back muscles. Cervical strain may result from the physical stresses of everyday life, including poor posture, muscle tension from psychologic stress, or poor sleeping habits. The mechanism of injury in sports concussions can also result in cervical strain. Typically, cervical strain symptoms include pain, stiffness, and tightness in the upper back or shoulder, which may last for up to six weeks.

Cervical spondylosis — Cervical spondylosis is a condition caused by abnormal wear and tear (called degenerative changes) of the cervical spine. Wear-and-tear causes gradual narrowing of the disc space, a loss of the normal square-shaped bone, and growth of the edges of the bone (bone spurs). These spurs can increase pressure on the surrounding tissues. Up to 90 percent of pinched nerves in the neck are caused by bone spurs. Some degree of wear and tear is normal with aging, although severe degenerative changes are not normal.

Symptoms of cervical spondylosis can include neck pain or weakness, numbness or abnormal sensations of the arms or shoulders, headaches, or limited ability to move the neck.

Cervical discogenic pain — Cervical discogenic pain may be the most common cause of neck pain. It is caused by changes in the structure of one or more of the cervical intervertebral discs. Common symptoms of discogenic pain include pain in the neck when turning or tilting the head. Pain may be worsened when the neck is held in one position for prolonged periods, such as occurs with driving, reading, or working at a computer. There is often associated muscle tightness and spasms. Discogenic pain can also refer pain or odd sensations into the arm or shoulder.

Cervical facet syndrome — The facet joint, which is located on the left and right side of the vertebrae, is the most commonly affected area in whiplash-related neck pain and headaches. Another potential cause of cervical facet syndrome includes a job that requires a person to repeatedly extend the neck (tilt the head backwards). Symptoms of cervical facet syndrome include pain in the middle or side of the neck; some people also notice pain in the shoulders, around the shoulder blades, at the base of the head, or in one arm.

Whiplash injury — The cervical whiplash syndrome is caused by a traumatic event that causes an abrupt forward/backward movement of the cervical spine. The most common cause of whiplash is a motor vehicle accident. Symptoms of whiplash include severe pain, spasm, and loss of range of motion in the neck.

Cervical myofascial pain — Myofascial pain causes tight and tender areas of muscle that are sensitive to pressure. Myofascial pain in the neck can develop after trauma or with other medical conditions, such as psychologic stress, depression, or insomnia.

Diffuse skeletal hyperostosis — Diffuse skeletal hyperostosis (DISH) is a syndrome in which there are abnormal calcifications in the ligaments and tendons along the cervical spine, causing these tissues to become hardened. Many people with DISH have no symptoms while others develop stiffness, loss of mobility, and pain. This condition can also involve the thoracic (middle) and lumbar (lower) spine.

Cervical spondylotic myelopathy — Cervical spondylotic myelopathy occurs when there are degenerative changes that narrow the central (middle) spinal canal. This narrowing can injure the cervical spinal cord or cause it to function improperly. In addition to pain and loss of motion, signs of cervical spondylotic myelopathy may include a variety of neurological complaints. Weakness, difficulty walking or coordinating movement, inability to empty or control the bowels or bladder, and sexual dysfunction (eg, erectile dysfunction) may occur as a result of irritation of the spinal cord.

Cervical radiculopathy — Cervical radiculopathy occurs when a nerve root is irritated by a protruding disc, arthritis of the spine, or a mass that compresses a nerve (eg, a synovial cyst). Signs of radiculopathy can include pain, weakness, or changes in sensation (eg, numbness, pins and needles) in the arms. The most common causes of cervical radiculopathy include the following:

Degenerative changes related to aging or injury

Herniation of a cervical disc

NECK PAIN TESTS

It is helpful to determine the cause of a person’s neck pain. An evaluation with a healthcare provider is recommended for anyone with a severe head or neck injury, inability to control the bowels or bladder, severe pain, numbness or changes in sensation in the arms or legs, or if pain does not begin to improve after one week with treatment at home.

The evaluation of neck pain usually begins by observing the person's ability to move the head to the left and right, forward and backward, and side to side. The healthcare provider will observe the posture and movement of the neck and shoulders. He or she will feel the muscles in the neck, head, upper back, and shoulders to detect areas of pain, weakness, or tension. If weakness or sensory complaints are present, strength and sensation in the extremities will also be examined.

In some cases, further testing, such as an x-ray, computed tomography scan (CT), magnetic resonance imaging (MRI), or electrodiagnostic testing (EMG or electromyography) will be recommended. The need for these tests depends upon the person's age, symptoms, medical history, and examination.

NECK PAIN TREATMENTS

In most cases, neck pain can be treated conservatively with over-the-counter pain medications, ice, heat and massage, and strengthening and/or stretching exercises at home. If pain does not improve after a few weeks of conservative treatment, further evaluation is usually recommended.

Pain relief — Acetaminophen (eg, Tylenol and others) or a nonsteroidal antiinflammatory medication (eg, ibuprofen, naproxen) may be helpful to relieve mild to moderate neck pain. (See "Patient information: Nonsteroidal antiinflammatory drugs (NSAIDs) (Beyond the Basics)".)

For people with severe muscle spasm, a muscle relaxant may be recommended. For people with severe neck pain, a tricyclic antidepressant may also be recommended. Both tricyclic antidepressants and muscle relaxants can cause a person to feel sleepy.

Ice — For some people, ice can reduce the severity of neck pain. It can be applied directly to the sore area of the neck. Ice can be frozen in a paper cup, and then the upper edge of the cup can be torn away. The ice should be moved continuously in strokes on the neck muscles for five to seven minutes.

To control sudden onset muscle tightness, place a bag of ice, bag of frozen peas, or a frozen towel wrapped in a dry towel, on the painful area. The ice should be left in place for 15 to 20 minutes to deeply penetrate the tissues; this can be repeated every two to four hours until symptoms improve.

The skin can become injured with excessive use of ice, especially in those with poor skin sensation. The skin should be inspected with each ice application for changes in pigmentation (eg, lighter or darker colored skin) and any changes should be reported to a healthcare provider.

Heat — Heat can help to reduce pain in the neck muscles. Moist heat can be applied for 10 to 15 minutes in a shower, hot bath, or with a moist towel warmed in a microwave. However, acute injuries should utilize ice as the initial treatment. Heat may be used initially for patients who have cold intolerance to ice.

It is important to avoid overheating the towel and potentially injuring the skin, especially in people with poor skin sensation. The skin can become pigmented (discolored) in a blotchy pattern in people who use heat frequently.

Massage — Massage can be helpful for relieving muscle spasm and can be performed after heating or icing the neck. Massage can be done with the hands by applying pressure to both sides of the neck and the upper back muscles, or with an electric hand-held vibrator. The neck muscles should be relaxed during massage by supporting the head or lying down.

Stretching exercises — The range of motion of the neck must be restored and preserved after an injury; this is done with exercises that stretch and strengthen the neck muscles. Range of motion exercises and stretching may help decrease pain from muscle injury.

Exercises can be performed in the morning to relieve stiffness and again at night before going to bed. Expect mild, achy muscle pain; sharp or electric pain in the shoulder or arm is not normal and should be reported to a healthcare provider.

Do not attempt to perform these exercises if you have a pinched nerve in the neck, especially if there is pain or numbness into the arm and hand, unless recommended by a healthcare provider. While these exercises can dramatically improve symptoms of a pinched nerve, they can actually make the problem worse if performed improperly.

The most useful stretching exercises for the neck include the following:

Neck bending — Tilt the head forward and try to touch your chin to your neck. Hold for a few seconds, breathe in gradually, and exhale slowly with each exercise. Exhaling with the movement helps relax the muscles. Repeat 10 to 15 times. Relax the neck and back muscles with each neck bend.

Shoulder rolls — In the sitting or standing position, hold the arms at the side with the elbows bent. Try to pinch the shoulder blades together. Roll the shoulders backwards 10 to 15 times, moving in a rhythmic, rowing motion. Rest. Roll the shoulders forwards 10 to 15 times.

Other exercise may include neck rotation, neck tilting, vertical shoulder stretches, upper back stretches, and back bending.

Neck rotation — Slowly look to the right. Hold for a few seconds. Look to the center. Rest for a few seconds between movements. Repeat 10 to 15 times. Perform on the left side.

Neck tilting — Look straight forward, then tilt the top of the head to the right, trying to touch your right ear to the right shoulder (without moving the shoulder). Hold in place for a few seconds. Return the head to the center. Repeat 10 to 15 times. Repeat on the left side.

Vertical shoulder stretches — In the sitting or standing position, use the right hand to hold the left wrist and pull the arm (and shoulder) up and over the head, towards the right. Hold for five seconds. Keep the left shoulder and back muscles relaxed. Rest and repeat 10 to 15 times. Repeat using left hand to hold right wrist.

Upper back stretches — In the standing position, lean forward from the hips and rest both hands on a low counter with the elbows straight. Exhale, relax the neck and shoulders, and allow the head to fall forward as you round the upper back. This requires the shoulder blades to spread apart and mimics the motion of a cat stretching its back. Exhaling with the motion helps to relax the muscles. Return to the standing position with hands on a counter. Repeat slowly 10 times.

Upper back side bends — Stand or sit up straight in a chair. Bend the trunk to the right while holding the hands together slightly behind the neck for support. Hold for five seconds, and then return to center. Repeat to the left. Repeat 10 to 15 times. Keep the lower back straight or supported against a chair.

Reduce stress — Emotional stress can increase neck tension and interfere with or delay the recovery process. Reducing stress may help to prevent a recurrence of neck pain. Relaxation techniques can relieve musculoskeletal tension. An example of a relaxation exercise is to take a deep breath in, hold it for a few seconds, and then exhale completely. Breathe normally for a few seconds, and then repeat.

Other activities that may help to reduce stress include meditation, progressive muscle relaxation, prayer, self-hypnosis, or biofeedback.

Posture — Activities and body positions that prevent or reduce neck pain include those that emphasize a neutral neck position and minimize tension across the supporting muscles and ligaments of the neck. Extremes of range of motion, activities, and body positions that cause constant tension should be minimized or avoided:

Avoid sitting in the same position for prolonged periods of time. Take periodic five minute breaks from the desk, work station, etc. Avoid looking up or down at a computer monitor; adjust it to eye level.

Avoid placing pressure over the upper back with backpacks, over-the-shoulder purses, or children riding on your shoulders. Alternatives may include wheeled backpacks or cases, handbags, and having a child walk or ride in a stroller.

Do not perform overhead work for prolonged periods at a time.

Maintain good posture by holding your head up and keeping your shoulders back and down.

Use the car or chair arm rests to keep the arms supported.

Sleep with your neck in a neutral position by sleeping with a small pillow under the nape of your neck (sleeping on your back) or sleeping with enough pillows to keep your neck straight in line with your body (sleeping on your side). If you sleep on your back, putting a pillow under the knees can help to flatten the spine and relax the neck muscles. Avoid sleeping on the stomach with the head turned.

Carry heavy objects close to your body rather than with outstretched arms.

OTHER NECK PAIN TREATMENTS

Acupuncture and biofeedback — Acupuncture involves inserting hair-thin, metal needles into the skin at specific points on the body. It causes little to no pain. Biofeedback involves learning to control certain bodily functions, such as muscle tension, which can help to decrease pain.

Acupuncture and biofeedback have been used in patients with persistent neck pain with cervical muscle strain. The quality of many of these studies is insufficient to draw firm conclusions regarding their efficacy. One review found that acupuncture may help to relieve chronic neck pain [1].

Cervical collar — A soft cervical collar is a piece of foam covered with fabric that is worn around the neck to support the head. Routine use of a cervical collar is not recommended because it may delay recovery or allow the neck muscles to weaken. In addition, collars can make neck pain worse in some people due to the fit of the collar.

At night, a rolled towel under the neck or a neck pillow can provide comfort and keep the neck in a neutral position. The ear should be aligned with the middle of the shoulder when lying on the back. When lying on the side, the nose should be aligned with the middle of the chest bone. Using one or two regular pillows is not recommended because it can cause too much forward or side-bending of the neck.

Injections — Trigger point injections are injections of a local anesthetic medication (eg, lidocaine) into an area of the muscle that is tightened and tender (a trigger point).

Trigger point injections may be recommended if other treatments (eg, stretching exercises, massage) do not significantly improve pain. However, there is no good evidence that trigger point injections help to reduce pain or speed healing in the long term. Steroid injections into the neck muscles are not recommended due to the risk of injury to the muscles.

Electrical stimulation — Transcutaneous electrical nerve stimulation (TENS) is a treatment that uses a mild electric current, which is applied to the skin, to decrease pain and increase mobility and strength. Studies of TENS are poorly designed and it is not clear if the treatment is effective [2]. However, a trial of TENS is reasonable if other forms of treatment are not successful. A healthcare provider can teach the patient how to perform TENS at home.

Chiropractic or physical therapy — Treatment of neck pain by physically handling the muscles, soft tissue, and joints can be performed by several qualified healthcare professionals, including physicians, physical therapists, and chiropractors. This type of treatment may include massage, heat, ultrasound, or electrical stimulation.

Some studies have found that treatments that include quick “thrusting” of the neck are associated with serious injury [3]. Aggressive manipulation or adjustments to the cervical spine should be discouraged in elderly patients and those with cervical stenosis. Other treatments that include gentle movement or massage may be safe and helpful for many people, especially when it is combined with stretching and strengthening exercises.

Cervical traction — Cervical traction involves the use of weights to realign or pull the spinal column into alignment.  Clinical studies have shown that there is no benefit to traction in the treatment of neck pain.

Surgery — Surgery is not useful for treating most types of neck pain. However, surgery does have a role in relieving symptoms related to a pinched nerve caused by a herniated disc (cervical radiculopathy or cervical spondylotic myelopathy) after a trial of conservative therapy (eg, stretching exercises, physical therapy). People with chronic neck pain who do not improve with the above treatments may benefit from referral to a Spine or Pain Specialty clinic.

WHERE TO GET MORE INFORMATION

Your healthcare provider is the best source of information for questions and concerns related to your medical problem.

This article will be updated as needed on our web site (www.uptodate.com/patients). Related topics for patients, as well as selected articles written for healthcare professionals, are also available. Some of the most relevant are listed below.

Patient level information — UpToDate offers two types of patient education materials.

The Basics — The Basics patient education pieces answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials.

Patient information: Neck pain (The Basics)

Patient information: Neck fracture (The Basics)
Patient information: Whiplash (The Basics)
Patient information: Torticollis in children (The Basics)
Patient information: Muscle strain (The Basics)
Patient information: Central spinal cord syndrome (The Basics)
Patient information: Radiculopathy (The Basics)
Patient information: Diffuse idiopathic skeletal hyperostosis (The Basics)

Beyond the Basics — Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are best for patients who want in-depth information and are comfortable with some medical jargon.

Patient information: Nonsteroidal antiinflammatory drugs (NSAIDs) (Beyond the Basics)

Professional level information — Professional level articles are designed to keep doctors and other health professionals up-to-date on the latest medical findings. These articles are thorough, long, and complex, and they contain multiple references to the research on which they are based. Professional level articles are best for people who are comfortable with a lot of medical terminology and who want to read the same materials their doctors are reading.

Cervicogenic headache
Clinical features and diagnosis of cervical radiculopathy
Evaluation of the patient with neck pain and cervical spine disorders
Treatment of cervical radiculopathy
Treatment of neck pain

The following organizations also provide reliable health information.

National Library of Medicine

     (www.nlm.nih.gov/medlineplus/healthtopics.html)

American Academy of Orthopaedic Surgeons

     (http://orthoinfo.aaos.org/)

American Academy of Physical Medicine and Rehabilitation

     (www.aapmr.org)

National Institute of Arthritis and Musculoskeletal and Skin Disease

     (www.niams.nih.gov)

American Physical Therapy Association

     (www.apta.org)

Arthritis Foundation

     (www.arthritis.org)

[1-4]

Literature review current through: Oct 2014. | This topic last updated: Jan 9, 2014.
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