Neck Pain: Initial Evaluation and Management | AAFP

Neck pain is a common presenting symptom in primary care, with an incidence of 10.4% to 21.3% per year.1 It is the fourth leading cause of disability worldwide.1 The prevalence of neck pain is higher in older adults because of degenerative changes in facet joints and the collapse of intervertebral disks.2 It is estimated that only one in five people with neck pain seeks medical care.3 The differential diagnosis is broad and includes common conditions such as muscular strains and arthritis, as well as more dire conditions such as fractures, spinal cord and nerve injuries, neoplastic disorders, infections, and inflammatory conditions. Family physicians must be able to recognize when neck pain signals a potentially serious condition and should be able to generate an accurate diagnosis through findings from the patient's history, physical examination, and appropriate testing.

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When evaluating a patient with neck pain, the physician must be alert for red flags in the history and physical examination that may indicate the need for urgent testing and intervention. Similar to guidelines for the evaluation of lower back pain, a systematic approach that maintains vigilance for severe pathology in the neck is recommended.4 Table 1 summarizes some of the more serious diagnoses and their associated clinical findings, as well as recommended diagnostic tests. Figure 1 is a recommended approach to patients with neck pain. This article does not focus on acute traumatic injuries or vascular emergencies, but these elements warrant consideration based on the presentation.

Rapidly progressive neuropathic symptoms warrant more aggressive evaluation. Injury to the central spinal cord or nerve roots may be the result of degenerative changes, trauma, mass effect, infection, or other inflammatory or demyelinating conditions. Even without an acute presentation, physicians should be mindful of myelopathic signs and symptoms.4 Myelopathy refers to neurologic compromise resulting from a disturbance of spinal cord tracts within the spinal canal. Initial symptoms include deep, aching neck pain with possible radicular symptoms and muscle weakness; these can quickly progress to gait changes, ataxia, and bowel and bladder dysfunction.5 Physical examination findings associated with a myelopathic disease process include increased muscle tone, fasciculation, clonus, hyperreflexia, the Babinski reflex, and the Lhermitte and Hoffmann signs.

Certain comorbid disorders and patient factors increase the risk of cervical spine conditions (Table 2). Cervical spine pathology is present in more than one-half of patients with rheumatoid arthritis, and the long-term risk of severe pathology in these patients is higher than in unaffected people.6 Individuals with trisomy 21 are at risk of atlanto-occipital instability, which should prompt concern for complications of even mild trauma, as well as for advanced or premature degenerative changes.7 Ankylosing spondylitis can cause neck stiffness and pain. Patients with this condition also have an increased risk of complications from mild trauma.8 Numerous other processes and conditions can be considered in the differential of neck pain, including herpes zoster, angina, endocrine and compressive tumors, fibromyalgia, and psychogenic pain. Many of these conditions can overlap and be part of multifactorial presentations. One study estimated that 43% of neck pain cases are nonneuropathic, 7% are neuropathic, and 50% are mixed.9

The physical examination should target concerns revealed in the history and distinguish between mechanical and neuropathic symptoms. Localized bony tenderness or prominence is an indication for imaging, whereas soft tissue tenderness may represent myofascial pain, infection, or lymphadenopathy. Although range of motion measurements are widely referenced, their diagnostic relevance is limited and nonspecific.10,11 Range of motion can be more useful in identifying asymmetry or provocation of local or radiating symptoms (e.g., shooting pain down the spine with neck flexion or extension).

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The American College of Radiology recommends plain radiography as the initial imaging modality in patients with new or increasing nontraumatic neck pain who do not have red flag symptoms.17 Validated clinical tools such as the National Emergency X-Radiography Utilization Study criteria and the Canadian C-Spine Rule can help determine when radiography may be helpful.17,18 Immediate radiography does not improve patient-oriented outcomes in those who do not have recent trauma or red flag symptoms.18 In addition, imaging can detect abnormalities even in asymptomatic patients; for example, magnetic resonance imaging (MRI) detects degenerative cervical disks in 15% of asymptomatic patients in their 20s, increasing to more than 85% of asymptomatic patients older than 65.19

The time to diagnosis and intervention can be critical when serious conditions are suspected. MRI is recommended for patients with suspected infection, overt neurologic compromise, or progressive neurologic symptoms; it may be appropriate for patients with moderate to severe neck pain that lasts longer than six weeks and does not resolve with standard treatment.20 Computed tomography may be useful in trauma cases, when bony disruption is suspected, or when MRI is contraindicated.

In the absence of red flag findings that require urgent care, treatment can generally focus on the patient's level of pain and function. Many patients will improve over time, regardless of treatment or whether the cause is neuropathic or nonneuropathic. For example, most patients with cervical radiculopathy will improve with nonsurgical care: 80% to 90% have significantly improved pain and resolution of weakness or reflex deficits within four weeks.21,22

Conservative care for patients with neck pain often includes medications for pain relief. Although practice patterns may prompt the use of specific agents, there is little evidence to support the long-term use of these medications in most patients with neck pain. Nonsteroidal anti-inflammatory drugs and oral muscle relaxants are commonly recommended for patients with nonneuropathic pain. Data on the effectiveness of these medications for neck pain are limited; however, these agents are not effective for similar musculoskeletal conditions, such as low back pain.23 Although there is some evidence that oral corticosteroids provide short-term pain relief in patients with acute radiculopathy,24 there is little evidence that any medication affects recovery. Tramadol may have some benefit, but only in the short term.25 Narcotics can provide modest short-term pain relief, but there is no evidence of sustained benefit, and the risks of cognitive impairment and abuse limit their use.26 Inflammatory conditions may briefly respond to steroids or nonsteroidal anti-inflammatory drugs, but there is minimal evidence that these medications provide lasting benefit in degenerative conditions, despite their widespread use.4 Similarly, injections of anesthetics, corticosteroids, or botulinum toxin have shown little or no long-term benefit in acute or chronic neck pain.27,28 There is limited evidence for the short-term use (one to two months) of radiofrequency ablation in patients with persistent cervical pain.29

Given the broad range of potential neck pain etiologies and the variety of complementary and alternative treatment options, it is challenging to determine the value of these treatments for neck pain. They generally provide modest benefit compared with medication alone or no therapy.30 Acupuncture has modest benefit in patients with mechanical neck pain.31 Isolated manipulation and mobilization may provide temporary pain relief but not consistent long-term benefit.32 Treatments such as dry needling, low-level laser therapy, transcutaneous electrical nerve stimulation, and compression therapy have some potential for short-term pain relief, but no reliable long-term data exist to offer specific guidance for these options.33,34

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• • Posture problems: Slouching over your keyboard, hunching over your , or even sleeping in an awkward position can put undue strain on your neck muscles.

• Muscle strain or overuse: Repetitive motions, heavy lifting, or even vigorous exercise can lead to muscle tension and pain.
• Injuries: Sports injuries, whiplash from a car accident, or falls can all damage the delicate structures in your neck.
• Arthritis: Age-related wear and tear on the joints in your neck can cause inflammation and pain.
• Stress: When you're feeling tense and anxious, your muscles can tighten up, including those in your neck.

DIY Strategies for Taming the Tension

While seeking professional help is crucial for persistent or severe pain, there are some handy strategies you can try at home to soothe your achy neck:

• Posture patrol: Become the guardian of your spine! Practice good posture throughout the day, whether you're working, driving, or scrolling through social media. Imagine a string gently pulling the crown of your head towards the ceiling, and keep your chin tucked slightly inward.
• Stretching sensation away: Gentle neck stretches are your allies in the fight against pain. Try slow, deliberate rolls forward and back, side bends, and gentle chin tucks. Aim for pain-free movements and hold each stretch for 15-30 seconds.
• Heat or ice relief: Apply a warm compress for muscle tension or an ice pack wrapped in a towel for inflammation. Remember, avoid direct ice contact with your skin!
• Stress, the silent saboteur: Don't underestimate the power of relaxation techniques! Deep breathing, meditation, yoga, or even a hot bath can work wonders in melting away stress and easing muscle tension.

When DIY Isn't Enough: Seeking Professional Help

If your neck pain persists or worsens despite your best efforts, it's time to reach out to the compassionate team at Monadnock Community Hospital. We offer a comprehensive range of services, including:

• Personalized treatment plans: Our team believes in a customized approach to care. We collaborate with you to create a tailored treatment plan, addressing the unique aspects of your neck pain and ensuring it aligns with your lifestyle.
• Physical therapy: Explore the benefits of physical therapy tailored to your neck pain. Our experts guide you through targeted exercises and stretches to enhance flexibility, strengthen muscles, and promote overall neck health.
• Minimally invasive procedures: For certain cases, minimally invasive procedures may offer effective relief. Our office provides insights into these procedures, prioritizing your comfort and recovery.
• Pain management techniques: Learn about innovative pain management techniques designed to alleviate discomfort. Our experts guide you through options that promote relief while considering your overall well-being.

Remember, taking care of your neck is an investment in your overall wellbeing. By implementing these tips and seeking professional help when needed, you can reclaim your pain-free range of motion and get back to enjoying life to the fullest. Together, let's keep your neck happy and healthy. Stay well, ) [_page_sections_1_wysiwyg] => Array ( [0] => field_5a79c5dfc5cca ) [page_sections_1_width] => Array ( [0] => normal ) [_page_sections_1_width] => Array ( [0] => field_5af99fbbc9de1 ) [page_sections_2_section_title] => Array ( [0] => ) [_page_sections_2_section_title] => Array ( [0] => field_5adad ) [page_sections_2_wysiwyg] => Array ( [0] => Dr. Terence McNamara, DO, FAAPMR, FABPM ) [_page_sections_2_wysiwyg] => Array ( [0] => field_5a79c5dfc5cca ) [page_sections_2_width] => Array ( [0] => normal ) [_page_sections_2_width] => Array ( [0] => field_5af99fbbc9de1 ) [_yoast_indexnow_last_ping] => Array ( [0] => ) [_yoast_wpseo_focuskeywords] => Array ( [0] => [] ) [_yoast_wpseo_keywordsynonyms] => Array ( [0] => [""] ) [page_sections_4_section_title] => Array ( [0] => Why Choose Monadnock Orthopaedic Associates? ) [_page_sections_4_section_title] => Array ( [0] => field_5adad ) [page_sections_4_wysiwyg] => Array ( [0] => Our board-certified pain management specialists combine decades of experience with training from prestigious institutions like the Mayo Clinic. We offer comprehensive orthopedic care using advanced techniques and technology, all while providing personalized attention. At Monadnock Orthopaedic Associates, we're committed to getting you back to pain-free living as quickly as possible with expert, compassionate care tailored to your unique needs. Choose us for expert care that's close to home, where your well-being is our highest priority. ) [_page_sections_4_wysiwyg] => Array ( [0] => field_5a79c5dfc5cca ) [page_sections_4_width] => Array ( [0] => normal ) [_page_sections_4_width] => Array ( [0] => field_5af99fbbc9de1 ) [page_sections_5_section_title] => Array ( [0] => ) [_page_sections_5_section_title] => Array ( [0] => field_5adad ) [page_sections_5_wysiwyg] => Array ( [0] => Monadnock Community Hospital Bond Wellness Center Suite 200 458 Old Street Road Peterborough, NH : 603-924- Fax: 603-924- ) [_page_sections_5_wysiwyg] => Array ( [0] => field_5a79c5dfc5cca ) [page_sections_5_width] => Array ( [0] => normal ) [_page_sections_5_width] => Array ( [0] => field_5af99fbbc9de1 ) [page_sections_7_section_title] => Array ( [0] => ) [_page_sections_7_section_title] => Array ( [0] => field_5a79c51c87bb0 ) [page_sections_7_section_text] => Array ( [0] => ) [_page_sections_7_section_text] => Array ( [0] => field_5ad4c99e98b3b ) [page_sections_7_posts_selection] => Array ( [0] => auto_taxonomy_terms ) [_page_sections_7_posts_selection] => Array ( [0] => field_5e99c1d934e7f ) [page_sections_7_post_type] => Array ( [0] => post ) [_page_sections_7_post_type] => Array ( [0] => field_5e99c7a534e80 ) [page_sections_7_taxonomy] => Array ( [0] => tag ) [_page_sections_7_taxonomy] => Array ( [0] => field_5e99c7e134e82 ) [page_sections_7_terms] => Array ( [0] => mcnamara, neck, pain management ) [_page_sections_7_terms] => Array ( [0] => field_5e99ce83 ) [page_sections_7_posts_limit] => Array ( [0] => 12 ) [_page_sections_7_posts_limit] => Array ( [0] => field_5e99ce84 ) )