What is Neck Pain?
Neck Pain Explained by Las Vegas, Summerlin, and Henderson Nevada’s Top Pain Doctors
Neck pain is relatively common, with the greater number of those suffering from neck pain being female. In fact, estimates have suggested that up to 15% of males and 25% of female adults (ages ranging from 20 to 56 years of age) will experience some form of neck and shoulder pain over the course of their lifetime.
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Neck pain can also frequently occur as a persistent condition. Some evidence has suggested that around half of individuals suffering from neck pain continue to exhibit symptoms of pain after six months. Further, neck pain is recurrent, such that individuals are more at risk for developing future symptoms of neck pain following the initial incident than those with no history of difficulty with neck pain. Thus, previous difficulty with neck pain is a risk factor for developing neck pain later in life.
Epidemiology and Impact of Neck Pain
Neck pain can result in a significant loss of movement and normal function. As a result, neck pain has been linked with significant individual disability that may have a detrimental impact on an individual’s functioning both at home and at work. In fact, up to approximately 10% of individuals with persistent neck pain are unable to continue to work.
It is not surprising then that neck pain is also associated with a negative economic impact. Neck pain can be held to blame for decreased productivity at work and increases in the utilization of health care services. Indeed, studies have shown that between 25-50% of neck pain sufferers seek help for managing their symptoms of pain and discomfort.
For this reason, neck pain has begun to receive increased theoretical and empirical attention. Over the course of the last decade, there has been a significant increase in studies exploring prognostic indicators of neck pain, as well as randomized controlled trials testing the effectiveness of different treatment options available for reducing and relieving symptoms of neck pain.
Pathophysiology of Neck Pain
The cervical spine, which is the part of the spine that is located closest to the head, is thought to be the primary source of neck pain. Damage to the muscles, ligaments, and other tissues within the neck, however, may also be factors.
Within the spine, the spinal cord is surrounded by the cerebrospinal fluid (CSF), which acts as protective padding for the nerve bundle of the spinal cord. The spinal cord and the CSF are held in place within the spinal canal by a durable membrane. The spinal cord acts as the primary information pathway to and from the brain to various parts of the body. Cervical facet joints are located near the neck and are shaped somewhat differently from other facet joints in the body in order to allow for a more broad range of motion.
Injury or damage to these joints can present as inflammation, soreness, stiffness, or even pain that can be felt in the neck, shoulders, and upper back.
Diagnosis of Neck Pain
In many cases, the precise cause of the neck pain is not identified. In these instances, the physician will ensure that certain diagnoses are ruled out. Specifically, in terms of neck pain, the physician will be sure to rule out any specific spinal pathology and nerve root pain. Your physician will also generally assess for your degree of risk for persistent difficulties with neck pain by asking about risk factors. These factors, also known as “yellow flags,” will provide the physician with the information necessary to determine the most appropriate treatment and follow-up plan. While a patient exhibiting one of these signs does not necessarily guarantee the presence of an underlying condition, it is suggestive of an increased risk.
It is recommended that a patient receive further evaluation should they present more than one risk factor. Of primary concern to physicians is if the patient with neck pain also reports limited activity, impairments in bodily functioning, or if the patient’s account of the symptoms is not consistent with any of the typical descriptions of neck pain.
Causes of Neck Pain
Neck pain can arise from a number of sources, based on the anatomy of the neck. Many cases of neck pain originate because of a degenerative process or pathology. Damage to muscles, joints, or ligaments that comprise the neck region can also be the main sources of both acute and chronic neck pain. Despite this, there are a number of cases of neck pain where physicians are unable to locate the precise source of the pain.
The cervical area of the spine is located at the top, near the head, and is thought to be where most neck pain conditions occur. Damage to the muscles, ligaments, and other tissues within the neck, however, may also be factors. Joints in the neck are those between the seven vertebrae, or spinal bones, within the neck. These can be damaged, irritated, or subject to inflammation. Minor fractures or dislocation of the vertebrae can also cause chronic pain unless repaired.
Stenosis is another possible cause for neck pain. It is a condition in which the spinal cord is compressed by the abnormal tightening of the vertebrae or tissues around it. This condition has a number of causes, but the main factor is scar tissue forming around the spinal cord.
Another cause of chronic pain is bulging disc syndrome. This condition involves the protrusion outward of the protective discs between vertebrae, which compress or irritate spinal nerves, causing pain.
Whiplash, a common cause of neck pain, is caused by sudden back-and-forth jolting movements in the neck, usually experienced in motor vehicle accidents or rollercoaster rides. While not fatal, whiplash can result in chronic pain. This is due to damage caused to the muscles, main ligaments, and cervical vertebrae as a result of the unnatural whipping forward and subsequent jerking backward of the head.
There are a number of factors that can place an individual at increased risk for developing persistent difficulties with neck pain. These factors include gender (i.e., higher risk for females), being over the age of 40, history of neck pain, biking regularly, loss of strength in the hands, history of stress and uncontrollable worry, and poor quality of life.
Treatment for Neck Pain
Given the diversity in the underlying causes of neck pain, it is advisable to discuss your individual cluster of symptoms with your physician so as to determine the best available pain management treatment plan. Neck pain has received some increased attention within the literature and, as a result, many of the currently available interventions for managing neck pain have undergone rigorous investigation before ultimately receiving empirical support.
Indeed, the pain and disability associated with neck pain does not solely emerge by way of a somatic pathology. It is widely accepted that many factors are involved in accounting for a patient’s degree of pain severity and disability. For instance, attitudes that patients have regarding pain and beliefs that they possess about disability has been shown to have a significant impact on the severity of their pain and degree of impairment. Furthermore, psychological distress and responses to the onset of the condition also have been found to be influential.
For patients who are overly concerned or worried about their future with regard to neck pain (for instance, whether or not they will suffer in pain for the rest of their lives), it is recommended that the patient discuss these worries and concerns with their physician. The physician will be able to answer the patient’s questions about their neck pain and the treatment options available. In addition, the physician will likely provide the patient with lots of information and educational resources about the condition. For patients whose neck pain is not severe and is not causing the individual any significant impairment, it is likely that their physician will encourage them to make a gradual return to non-strenuous levels of activity maintained prior to the onset of neck pain.
Previous work in the field of neck pain has suggested that a large portion of all cervical pain patients will see significant improvements in their symptoms of pain by engaging in conservative treatments, such as physical therapy. These sorts of interventions focus on training patients to do stretching or various targeted exercises in order to regain lost mobility and to increase elasticity in the muscles.
Further, in addition to providing patients with relief from the distressing symptoms of pain, some pain-relieving interventions are also focused on reducing the level of impairment neck pain has on the patient’s life, as well as any accompanying disability. For instance, for patients who have had to take a leave of absence from their job due to debilitating cervical pain, it is likely that a goal of treatment will be to have the patient return to work. Reaching the status of disability can be an exacerbating factor in terms of neck pain and, thus, act like a feedback loop preventing the patient from setting goals and maintaining current routines. If an individual, debilitated by severe and chronic neck pain does not make efforts to maintain some mobility, their future health is at significant risk and they are at increased risk for ongoing symptoms of pain.
Pharmacotherapy is one of the more common treatments prescribed for cervical spine pain. Non-steroidal anti-inflammatory drugs (NSAIDs), including ibuprofen and naproxen, are widely utilized owing to their ability to reduce inflammation and thereby any associated symptoms of pain. While NSAIDs are widely available over-the-counter, they are associated with some side effects, including gastrointestinal irritation, ulcers, and bleeding. It is generally recommended that NSAIDs be taken for the temporary relief of neck pain and are not recommended in cases of chronic pain, due to the risk of side effects.
Anti-depressants have commonly been used in the treatment of neck pain and have received some empirical attention as well. The most frequently studied class of anti-depressants are the tricyclics, such as doxepin, clomipramine, or amitriptyline. Though the complete picture as to why anti-depressants have analgesic properties is not well understood, these drugs are believed to provide relief from neck pain by blocking the reuptake of the neurotransmitters norepinephrine and serotonin within the neuronal synapse.
Two new classes of anti-depressants that are prescribed for the treatment of neck pain are selective serotonin reuptake inhibitors (SSRIs), such as citalopram, fluvoxamine, and fluoxetine; and serotonin and norepinephrine reuptake inhibitors (SNRIs), such as duloxetine, venlafaxine, and desvenlafaxine. These drugs are sometimes preferred by physicians because of the fact that they have fewer side effects than that of the tricyclics; however, their actual mechanisms of action are not understood. SSRIs and SNRIs have received some attention for their particular effect in reducing pain in patients with chronic cervical pain. It is not clear, though, whether these pain-relieving benefits are associated with the anti-depressant effects of the medication. It is likely that patients who have suffered for significant portions of time with persistent cervical pain also develop accompanying feelings of hopelessness, withdrawal, and depression all of which are relieved along with the symptoms of pain when prescribing SSRIs or SNRIs.
Another medication commonly prescribed for the management of neck pain is muscle relaxants. These medications can be divided up further into two classes: antispasmodic and antispasticity. Antispasmodic medications, which include benzodiazepines and non-benzodiazepines, act to reduce muscle spasms that frequently occur in neck conditions. Antispasticity medications, which include dantrolene and baclofen, act to reduce the spasticity of the muscle. These medications have received some empirical support for the temporary relief of neck pain. Some anticonvulsants, such as gabapentin, are also often used in alleviating neck pain, particularly pain that is neuropathic in nature. Though the mechanisms of action are generally unclear, it is believed that these medications increase the ratio of gamma-aminobutyric acid (GABA) to glutamate. Further, it may be that their effects on the ion-channel or the enhancement of nonsynaptic GABA also accounts for this drug’s pain-relieving qualities.
Capsaicin skin patches are believed to provide some relief for neck pain, particularly pain that is neuropathic in nature. Derived from chile peppers, capsaicin binds itself to the nociceptors in the skin, which excites the neurons. Initially, this causes a period of increased sensory sensitivity to itching, pricking, or burning, which is followed by a refractory period of reduced sensory sensitivity. Following repeated applications, the patient can achieve persistent desensitization in the affected area. Evidence has provided strong support for the effectiveness of capsicum over placebo in control trials.
Individuals who are experiencing neck pain that is severe, debilitating, and has not responded to the other conservative remedies may wish to speak to their doctor about a trial of opioid medications, such as tramadol, codeine, morphine, or oxycodone, to help manage the pain. These medications are preferred for the treatment of cervical pain that is more chronic and treatment resistant in nature. Their pain-relieving effects arise by binding to the opioid receptors within the brain.
Studies have provided ample support for the use of opioids in the short-term relief of sudden onset, severe pain in the neck and shoulder region. Side effects of these medications after prolonged use include constipation, dizziness, sweating, and sexual impotence; however, these symptoms tended to fade over time. Concerns regarding the possibility of misuse and abuse of this medication suggest that long-term use of opioids to manage neck pain is contraindicated.
Other Treatment and Management Strategies for Neck Pain
Some patients suffer from neck pain that emerges as the result of back surgery. The back itself is comprised of a complex network of bones, muscles, and other tissue that span from the neck to the pelvic bone. The spinal column is a bony structure that acts as the body’s support and protects the delicate spinal cord and associated nerve roots. The spinal column is positioned such that the individual bones of the spine, or the vertebrae, link together, creating a flexible support. Inside of this column the spinal cord descends down from the brain. In cases of neck pain that emerges as a result of a failed back surgery, it is believed that the patient’s pain is caused by scar tissue that develops around the spinal nerves following surgery. For these patients, lysis of adhesions is recommended to provide relief from neck pain. During a lysis of adhesion procedure, the physician uses a catheter to inject a chemical compound, such as hyaluronidase, in the area. This chemical compound breaks up the scar tissue at a molecular level. A recent clinical trial evaluating the procedure indicated that it provides beneficial results.
In terms of pain in the cervical region that originates due to a damaged or bulging disc, a percutaneous discectomy may be warranted. This procedure is minimally invasive and is designed to remove the tissue and material from around the damaged disc that is believed to be the source of inflammation and pain. To achieve this, the physician will use a fluoroscope to guide the needle to the herniated disc. Once the needle is in the proper position, heat waves or radio waves are utilized to destroy and dissolve the damaged tissue. Recovery from this procedure typically takes about one to two days. Once the disc material has been removed, pressure on the surrounding spinal nerves is relieved, which in turn provides the patient with much needed pain relief.
Neck pain that affects the spinal nerves, such as stenosis or inflammation, can also be treated by epidural steroid injections. These are administered through the skin to the appropriate location (i.e., epidural spaces) in the vertebrae to reduce pain. To achieve this, the physician will use a fluoroscope to guide the needle that contains pain-relieving steroid medication. These steroids provide pain relief as they act on the nerve root, which is located within the epidural space.
Cervical steroid injections are another effective treatment for neck pain. They are non-surgical, easy to administer and are generally painless. They can be administered within an outpatient setting. Most patients treated with steroid injections are expected to feel an immediate reduction or elimination of their pain following the treatment. According to a study examining the use of multiple injections, there is support for the benefit of administering multiple injections over the course of a year for patients whose pain only moderately responds to the initial steroid injection. Side effects of steroids include weight gain, mood swings, arthritis, and gastric ulcers.
Other types of epidural injections include local anaesthetics, such as lidocaine, along with steroids, that are directed at specific nerves in the neck, such as the occipital nerve or the medial branch nerves (which serve the vertebral joints). These injections, also known as nerve blocks, are effective in achieving medium- to long-term pain relief, though they do carry risks. Side effects include numbness in the injected area, nausea, and chest discomfort. There is also a minimal chance that a blood vessel could be inadvertently injected, which can cause serious consequences.
Botox injections are another form of alternative treatment for managing the musculoskeletal symptoms associated with pain in the upper back, neck, and shoulders. Botox, or purified botulinum neurotoxins, are toxic enzymes produced by the Clostridium botulinum bacteria that have paralytic effects on musculature. Botox is believed to alleviate shoulder pain by blocking overactive nerve impulses and inhibiting the release of the neurotransmitters that are involved in sensing pain. Several randomized control trials have been conducted on the effectiveness of Botox injections. Findings suggest that pain reduction was achieved at three weeks and, at eight weeks, ongoing improvements in neck pain were reported and patients demonstrated overall improved function when compared to placebo controls.
For patients with chronic cervical pain as a result of a fractured vertebra, treatment to repair the fracture is required. A procedure known as vertebroplasty may be particularly beneficial in providing pain relief. This procedure is minimally invasive and can be conducted in an outpatient setting. It involves injecting medical grade acrylic cement to the site of the fractured vertebra. This cement dries quickly and provides pain relief to the patient by creating a support structure within the vertebra, eliminating compression caused by the fracture. While this procedure is relatively new, it has been shown to be highly effective in relieving cervical pain, though there is a risk of infection, bleeding, headaches, and in serious cases, paralysis due to inadvertent nerve damage. The cement can also “leak” out of the vertebrae, which is believed to cause painful inflammation.
Another minimally invasive procedure is radiofrequency ablation, which involves the insertion of electro-thermal probes near spinal nerves. These probes use a high frequency current to disrupt nerve function, thereby interfering with the nerve’s ability to transmit information regarding sensations of pain to the spinal cord. The risks associated with radiofrequency ablation are infection, bleeding, and accidental motor nerve damage.
Though rare, some cases of neck pain do not respond to either oral pain medications or even direct injections into the spinal nerve. In these instances, alternative methods for pain management are warranted. One of these methods, spinal cord stimulation, may provide relief for patients with treatment resistant neck pain as the result of conditions such as neuropathy or failed back surgery. This intervention involves implanting a medical device near the spine, which is designed to deliver electrical impulses that block pain. Typically, these devices include a hand-held controller that can be used to send out pain-blocking impulses as needed.
Operating in a similar fashion, intrathecal pump implants are also considered in cases of severe, chronic, and treatment-resistant neck pain. This treatment technique involves implanting a device that, rather than delivering pain-blocking electrical impulses, delivers pain medication directly to the spinal cord. Intrathecal pump implants are particularly effective in relieving neck pain as they deliver medication that reduces pain directly to the intrathecal or subarachnoid space. The risks involved in these procedures are similar to those of radiofrequency ablation and vertebroplasty. There is also a small risk that the implants may move out of the desired location, and thus fail to give pain relief as needed.
Neck pain has received some empirical attention within the literature, and many of the currently available interventions for managing neck pain have undergone rigorous investigation before ultimately receiving empirical support. Patients with this pain condition have hope in gaining control over their symptoms of pain and regaining their lives. Given the diversity in the underlying causes of neck pain, it is best to discuss your condition with your physician so as to determine the best available pain management treatment plan.
Complimentary Treatments for Neck Pain
For cases of neck pain that are characterized by a limited amount of impairment and accompanying disability, it is generally recommended that patients attempt non-invasive, conservative interventions first.
For instance, chiropractic treatment provides many patients significant relief from pain located in the cervical spine and has even been implicated in improvements in overall health. This treatment intervention involves manipulating the spine by way of a high velocity thrust to a joint beyond its restricted range of motion or low velocity movements that occur within or at the range of motion of the joint. In general, chiropractic treatment for cervical spine pain involves adjusting the neck by applying pressure to the cervical joints. There are a number of risks and side effects involved in this procedure, including complications related to cervical and lumbar manipulation, localized discomfort, headache, fatigue, and even discomfort felt in other areas of the body that were not targets of treatment. Studies report that these side effects tended to emerge the same day of the procedure and were no longer reported by the patient after 24 to 48 hours.
Modification to the patient’s physiological response system may also be warranted. It is well known that tension and stress can have a detrimental effect on the body’s overall health and ability to cope with daily disruptions. In fact, muscle tension is a common complaint and is linked with pain in the neck and shoulders. Individuals who work primarily on a computer all day are exponentially more at risk for neck pain.
Biofeedback training has received some support for assisting individuals in managing their symptoms of neck pain, along with the tension and stress that typically accompanies pain conditions. Further, biofeedback has received some support within the literature regarding its effectiveness in improving, but not eliminating, both muscle tension and pain. This non-invasive, non-pharmacological technique assists patients with recognizing symptoms in order to help them learn skills to control them.
To do this, the patient is provided real-time information about their physiological processes using psycho-physiological recordings. The biofeedback device is designed to detect very slight changes in the patient’s physiological responses and displays this information to the patient on a computer screen. This intervention includes a number of stress reducing exercises that teaches them how to effect change onto their physiological response system and gain more control over stress. This control also allows them to intervene on the degree of negative effects stress has on their pain condition.
The typical physiological systems recorded during biofeedback sessions include:
- Electromyogram (EMG) – measures muscle tension
- Electroencephalography (EEG) – measures brain wave activity
- Electrocardiogram (ECG) – measures heart rate and heart rate variability
- Galvanic skin response (GSR) – measures the amount of moisture on the surface of the skin
- Thermal feedback – measures skin temperature
During this training, the patient practices altering their internal processes by using the visual representation along with techniques taught to them by trained biofeedback technicians. In terms of treating neck pain specifically, the modules most recommended for biofeedback training are EMG, ECG, and respiration. Additionally, individuals are taught relaxation and coping skills, thereby allowing the patient to gain some control over reducing their own symptoms of neck pain.
Patients with neck pain that is not the result of a blunt trauma or who do not have any active inflammation may gain some relief from their pain and discomfort through a soft tissue therapeutic methods known as active release techniques. Using the thumb or fingers, deep pressure is applied to the soft tissue in the affected area. While this pressure is applied, the patient is instructed to engage in various repetitive movements. This causes the muscles to repeatedly elongate and contract and, over time, is believed to restore the underlying affected soft tissue to a normal texture. In doing so, active release techniques can help reduce the stiffness, inflammation, and pain associated with neck pain. These techniques are also believed to reduce the incidence of tissue scarring, tearing, and abnormal fusion.
There are a number of alternative treatment methods available for managing neck pain. For instance, acupuncture may help relieve neck pain by placing very tiny needles (1 cm to no more than 10 cm) in various regions of the body. Specific needle placement, or acupuncture points, are determined in terms of where the pain is located as well as other regions of the body that are thought to be contributing to the pain. This form of therapy was developed from ancient Chinese medicine practices and is regarded today as a low-risk alternative treatment for managing neck pain. In general, side effects are limited to soreness and minor bruising or bleeding in the area of needle placement. Further, if electroacupuncture is used, the patient may experience some minor skin irritation within the area of needle placement. Some evidence has suggested that acupuncture can improve the circulation of blood and other fluids within the affected tissue, provide reductions in pain, increase muscle strength, and reduce the patient’s recovery time. In fact, the World Health Organization recognized acupuncture as an effective therapy option for treating various pain conditions.
Neck pain is a common and potentially disabling condition affecting various components of the spinal column and shoulders. The vast majority of individuals will experience neck pain at least once in their lives. Neck pain can result in a significant loss of movement and normal function. As a result, neck pain has been linked with significant individual disability that can have a detrimental impact on the individual’s functioning both at home and at work.
Neck pain can be acute or chronic in nature. While the pain associated with the cervical spine generally arises due to damaged tissue or a degenerative condition, the exact cause of neck pain is not always known. In fact, research is still emerging in terms of pain conditions associated with the cervical spine that may help delineate a better understanding of the sources of many chronic neck pain conditions.
Despite this, it is well known that the severity of pain and perception of pain are two important factors in the prediction of long-term outcomes. While this knowledge is beneficial in terms of identifying individuals who are likely at risk for ongoing difficulties, these findings can be used to formulate resiliency-based interventions. For example, physicians could identify individuals who are at risk for chronic issues with neck pain and provide them with an individualized intervention. This plan likely will draw from the empirical data to strengthen that individual’s resiliency resources. Indeed, findings from previous work have suggested that an individual’s perceptions of their pain are in fact malleable. Additional studies are warranted, however, to more clearly delineate the relationship between the patient’s pain perception and severity of the pain in predicting individual outcomes.
Accurate assessment of cervical pain is essential. This will likely include a brief history, along with a physical examination. If you are exhibiting any symptoms of a more serious underlying condition, it may be recommended that you receive a more thorough evaluation to rule out other conditions, such as a tumor or spinal infection.
There are a number of treatment options available for managing neck pain. The treatment options range from conservative treatments, such as oral pain medications (i.e. NSAIDSs) or biofeedback, to interventional treatments, such as cervical joint injections or spinal cord stimulation. Patients with chronic neck pain are encouraged to speak with their physician about the possibility of corticosteroid injections to help relieve their symptoms of pain. For patients whose neck pain is unresponsive to the traditional interventions, more aggressive forms of pain management are available and have been shown to be highly effective in managing chronic cervical pain. It is recommended that you speak with your physician to determine which treatment option is right for you.
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