An approach to neck pain in primary care

Opening Vignette

Sharon, a 57-year-old secretary, presented to your clinic with a 2-month history of atraumatic, progressively worsening neck pain with associated left arm pain and numbness. This was her first episode of such neck pain, and she denied any apparent triggers or constitutional symptoms. The daily occurrence of the neck pain during work was causing her significant distress, and she had difficulty focusing while at work because of the pain. During the examination, you noted numbness in the left C7 dermatomal distribution. The rest of the musculoskeletal and neurological examination was unremarkable. You ordered a cervical spine X-ray, which showed normal vertebral alignment and intervertebral disc spaces [Figure 1]. Your impression was that of cervical radiculopathy, and you advised for conservative management with simple analgesia, activity modification and physical therapy. You gave her a follow-up appointment for review 4 weeks later.

Figure 1.

Normal cervical spine X-ray.

WHAT IS NECK PAIN?

Pain is defined as “an unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage”.[1] Neck pain is pain in the anatomical region of the neck, usually perceived posteriorly, and can present with or without radiation to the head, trunk and upper limbs.[2]

HOW RELEVANT IS THIS TO MY PRACTICE?

Neck pain is common across populations and age groups, and most people experienced neck pain in their lifetime.[3] The Global Burden of Disease study found that neck pain has a global point prevalence of 4.9%,[4] with an estimated 1-year incidence ranging from 10.4% to 21.3%.[5] A recent population-based study showed that Singapore’s 6-month prevalence of neck pain was 23.0%.[6] The mean overall prevalence of neck pain tends to be higher in females than males, in higher-income countries and in urban areas as compared to rural areas.[5]

Neck pain is the fourth leading cause of disability worldwide[4] and is associated with several comorbidities, including headache, back pain, arthralgias and depression.[7] Although sinister causes of neck pain are rare, primary care physicians must be able to recognise when neck pain signals a potentially serious pathology, so that further evaluation or specialist referral can be initiated timely without undue consequence. While most episodes of acute neck pain resolve with or without treatment, nearly 50% of individuals will continue to experience some degree of pain or frequent occurrences.[8] Appropriate management of these individuals can help to reduce potentially disabling psychosocial problems and improve their activity levels.[3]

WHAT CAUSES NECK PAIN?

The causes of neck pain are broad and encompass a wide range of differential diagnoses from common muscular strains and arthritis to more serious conditions including nerve and spinal cord injuries, infections, inflammatory conditions, malignancies and fractures.[9]

Atraumatic musculoskeletal

Cervical strain presents with neck pain and/or stiffness. It can result from physical stressors including poor posture and sleeping habits, or from an injury to the paraspinal muscles. Occasionally, there may be no obvious precipitating cause. On examination, there may be tenderness over the paraspinal and trapezius muscles. Symptoms may last for up to 6 weeks, and alternative diagnoses should be considered if symptoms are atypical or longer lasting.[9]

Cervical spondylosis refers to progressive degenerative changes of the cervical spine. Depending on where these degenerative changes occur, patients may have associated myeloradiculopathy (see Neuropathic neck pain). Cervical spine imaging may reveal osteophyte formation along the vertebral bodies and changes in the facet joints and lamina. However, there is often poor correlation between the degree of disease on imaging and the severity of symptoms.[10]

Cervical discogenic pain is the pain resulting from disc degeneration, and typically presents with pain and/or stiffness on neck movement. It can be associated with headaches, unilateral or bilateral shoulder pain, nonradicular arm pain and anterior chest wall pain.[11] Symptoms may be exacerbated when the neck is held in a position for prolonged periods, or when coughing and lifting. Lying supine may relieve the pain.[11]

Cervical facet osteoarthritis generally presents with pain and/or stiffness on neck movement. There can also be referred somatic pain to the shoulders, scapular or upper limbs or head. Examination shows decreased neck range of movement with neck spasm, with no neurological deficits.[10] Diagnosis is made clinically and correlates with imaging findings of osteoarthritic changes.

Myofascial pain syndrome is a regional pain disorder that is associated with trigger points, taut bands and pressure sensitivity. The causes of myofascial pain are not well understood, but it can develop secondary to biochemical imbalances, trauma, emotional stress and even endocrine and hormonal abnormalities.[11] The pain is often described as a deep aching quality, occasionally accompanied by a sensation of burning or stinging. A hallmark of myofascial pain is the presence of palpable trigger points.[9]

Traumatic musculoskeletal

Whiplash refers to an acceleration–deceleration mechanism of energy transfer to the neck, causing sudden extension and flexion of the neck. Whiplash injury often occurs after rear-end or side impact motor vehicle collisions. Structures that may be involved include the discs, muscles and ligaments. Consequently, the pain associated with whiplash injury often radiates to the trapezius muscle, shoulder, mid-back and occasionally, the face.[11] Radiographs may yield limited diagnostic information.[11]

Neuropathic neck pain

Cervical radiculopathy refers to the constellation of symptoms caused by dysfunction of one or more of the cervical spinal nerve roots. In a majority of cases, this is caused by degenerative changes in the spine such as cervical foraminal stenosis and cervical herniated disc. Less-common causes include herpes zoster and diabetic polyradiculopathy. Cervical radiculopathy presents with pain, paraesthesia and/or weakness in an upper limb. Physical examination may show decreased light touch sensation in a dermatomal pattern, muscle weakness in a myotomal distribution and/or decreased reflexes.[9]

Cervical myelopathy refers to spinal cord dysfunction, most often from injury due to spondylosis and narrowing of the spinal canal. Pathophysiology may involve direct spinal cord compression or ischaemia from compression of arteries or venous supplies to the cord.[8] It is associated with inflammation and oedema of the spinal cord, which leads to slow and progressive deterioration of neurological function.[12] Patients may present with neurological deficits including lower extremity weakness, gait disturbances, coordination difficulties and bladder or bowel dysfunction. Physical examination may reveal upper motor neuron signs in the arms and/or legs, including clonus, hyperreflexia, Hoffmann’s sign and Babinski’s sign.[12] Lhermitte’s sign may be present. Diagnosis is suspected clinically and confirmed by magnetic resonance imaging (MRI). Distinguishing cervical myelopathy from other causes of neck pain is critical as neurological recovery depends on early surgical decompression.

Others

Other causes of neck pain to consider include infection (meningitis, epidural abscess or discitis), malignancy, rheumatological conditions (polymyalgia rheumatica, fibromyalgia) and vascular conditions (vertebral or carotid artery dissection). Thus, it is important to evaluate for other clinical manifestations.[13] The presence of ‘red flags’ or suggestion of sinister causes should prompt early referral to a spine surgeon.

WHAT CAN I DO IN MY PRACTICE?

Initial assessment of neck pain begins with the identification of any red flags [Table 1].[13] Patients with red flags require urgent evaluation.

Table 1.

Red flags in patients with neck pain.

Red flags	Potential conditions
Unexplained loss of weight, history of cancer, unremitting night pain, night sweats, pain worst at rest	Malignancy, rheumatological disease
Neurological signs and symptoms	Cervical cord compression, demyelinating process
Ripping or tearing sensation	Arterial dissection
Significant neck trauma, prolonged use of steroids	Bony or ligamentous disruption of the cervical spine
History of rheumatoid arthritis, trisomy 21	Atlanto-axial disruption
Fever or chills, immunosuppression	Infection

A comprehensive history can provide important clues regarding aetiology. To evaluate the various causes of neck pain and to aid management, it is important to note the following: (a) patient’s age; (b) occupation; (c) past medical history, such as the history of cancer, immune suppression (e.g., human immunodeficiency virus, steroids, organ transplant medication) and diabetes mellitus; (d) character (sharp, dull, throbbing, radiating), severity and radiation of pain; (e) time course of symptoms — onset (precipitating factors including significant neck trauma), duration and progression; (f) associated symptoms (e.g., neurological symptoms, gait disturbance, issues with hand dexterity, bladder/bowel dysfunction); (g) systemic symptoms (loss of weight, appetite, night sweats); and (h) psychosocial impact, such as daily activity limitation and assessment of consequent disability (performance at work, driving, housework or sleep).

PHYSICAL EXAMINATION

The physical examination encompasses a look (observation), feel (palpation), move (range of motion) approach, a complete neurological examination and relevant provocative tests.[11]

1. General observation should focus on posture and head alignment, symmetry, muscle bulk and ease of movement.

2. Palpation of soft tissue and bony structures should be performed to assess for tenderness.

3. Assessment of cervical range of movement in flexion, extension, lateral bending and rotation should be performed.

4. Neurological examination of sensory and motor function, as well as assessment of reflexes are vital. The neurological examination will help to differentiate between radiculopathy and myelopathy by establishing the presence of lower or upper motor neuron findings [Table 2].[9] The American Spinal Injury Association (ASIA) score is a useful tool to help assess power and sensation in the myotomal and dermatomal distribution [Figure 2].[14]

5. Provocative tests can be helpful in the evaluation of suspected neuropathic conditions. These include special manoeuvres like the following:

   • (a)
     Lhermitte’s sign: a shock-like paraesthesia radiating down the spine that occurs with neck flexion. A positive test suggests central cord compression, but it can also be positive in patients with cervical myelopathy, intramedullary pathology (multiple sclerosis) and intraspinal masses.
   • (b)
     Spurling’s manoeuvre: radicular pain that is reproduced when the examiner exerts downward pressure on the vertex while tilting head towards the symptomatic side. A positive result is pain radiating to the upper limb ipsilateral to the rotation position and is suggestive of cervical radiculopathy.
   • (c)
     Shoulder abduction test: a sitting patient with radicular symptoms lifts his/her hand above the head. A positive finding is the reduction or disappearance of radicular symptoms and is suggestive of cervical radiculopathy.

Table 2.

Radicular vs. myelopathic examination findings.

Variable	Radiculopathy (lower motor neuron findings)	Myelopathy (upper motor neuron findings)
Motor	Weakness usually unilateral, in one myotome group	Upper or lower extremity weakness Clumsiness with fine motor skills in the hands
Muscle bulk and tone	Atrophy and fasciculations may be present	May occur without atrophy or fasciculations Gait spasticity
Sensation	Sensory loss follows a dermatomal pattern, same distribution as weakness	Loss of sensation below the level of involvement will follow spinal cord patterns, that is, complete loss, Brown-Sequard pattern, central cord syndrome
Reflexes	Hyporeflexia	Hyperreflexia Pathologic reflexes: Hoffmann’s reflex, Babinski sign, ankle clonus

Figure 2.

Diagram shows the American Spinal Injury Association score worksheet.

INVESTIGATIONS

Laboratory tests are rarely useful in the evaluation of neck pain, except in the evaluation of a patient with red flag symptoms suggestive of malignancy or inflammatory causes. In patients with recent trauma, clinical decision rules, such as the National Emergency X-Radiography Utilisation Study (NEXUS) criteria and the Canadian C-Spine Rule, can be used to determine the need for cervical spine imaging.[13]

In patients with atraumatic, acute (<6 weeks’ duration) or increasing neck pain without red flags, radiographs have not been shown to change clinical management and are not recommended.[15] In patients with chronic neck pain without red flags, anteroposterior and lateral radiographs are recommended for initial evaluation.[12] In the primary care setting, plain radiographs can also be considered for initial evaluation if the history and examination have yielded red flags for serious disease, for instance, progressive neurological findings, constitutional symptoms, infectious risk, history of malignancy or persistent neck pain affecting sleep or function.[13]

Ultimately, a cervical MRI or in selected cases, computed tomography (CT)[15] would be the imaging test of choice if serious underlying disease is suspected. The urgency for advanced imaging depends on the clinical suspicion, and patients suspected of having infection, malignancy or spinal cord compression should have an urgent MRI[11] and expedited referral to a spine surgeon.

MANAGEMENT IN PRIMARY CARE

In the absence of severe myelopathic or radicular symptoms, first-line treatment of neck pain without red flags would be conservative.[13] Understanding the impact of neck pain on a patient’s daily activities can help to determine the urgency and appropriateness of intervention. Patients with cervical radiculopathy due to degenerative disorders can be reassured that pain is usually self-limited and will resolve spontaneously without specific treatment. In most cases, patients improve in 4–6 weeks, but a minority of patients may have persistent pain for 1–2 years before complete resolution.[16]

Nonpharmacological management

Physiotherapy in combination with home exercises has been shown to reduce neck pain,[12] and acupuncture has been shown to have modest benefit.[8] Moreover, patients should be advised to avoid exacerbating their symptoms with lifestyle modifications such as limiting carrying heavy loads. Educating patients about the benefits of being physically active and participating in their care improves outcomes.[17]

Pharmacological management

The use of simple analgesic drugs, such as acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs) and oral muscle relaxants, is recommended in the guidelines. Although NSAIDs are more efficacious than acetaminophen, acetaminophen is recommended as a first-line drug because of its more favourable adverse effect profile.[9] Topical NSAIDs can also be used for patients with predominantly mechanical neck pain.[8] With regards to patients with neuropathic pain, a trial of neuropathic agent, such as gabapentin or pregabalin, can be offered to those with neurological signs or symptoms lasting over a month.[18] However, data on the effectiveness of these medications for neck pain are limited.[13,17] Tramadol and narcotics may have some benefit, but only for a short term.[13]

WHEN SHOULD I REFER TO A SPECIALIST?

Although majority of primary neck pain patients can be managed in primary care, some red flags or concerns would warrant a specialist referral. A specialist referral is recommended for patients with the following: (a) red flag symptoms [Table 1]; (b) history or examination findings of cervical myelopathy; (c) progressive neurological deficit; (d) persistent radicular symptoms for >6 weeks despite conservative treatment; and (e) patients with nonradicular neck pain lasting >3 months despite conservative treatment.

If indicated, the following may be offered to patients in the specialist setting: (a) advanced imaging including cervical MRI and CT; (b) electrophysiological testing; (c) specialised physiotherapy; (d) nerve root block injection for management of pain; (e) chronic pain management team; and (f) surgery, with the goals of decompressing the nerve roots or spinal cord and stabilising the spine.[12]

PREVENTION

Neck pain is a prevalent condition associated with significant functional impairment. Family physician should encourage patients to stay physically active and to maintain a good posture, as well as educate patients on the prevention of neck injuries, which may help to prevent degenerative cervical spondylosis. Additionally, as obesity and smoking have been found to be associated with spondylosis, managing these risk factors may confer benefits.[12]

In conclusion, neck pain is one of the leading causes of disability in the world and has a broad list of differential diagnoses. Hence, having a structured approach in the evaluation of neck pain is essential. The history and examination provide important clues and red flags, which are critical in identifying patients who would benefit from further diagnostic workup.

TAKE-HOME MESSAGES

1. Neck pain is a common presenting complaint in the primary care setting and can cause significant disability.

2. Primary care physicians must be able to recognise when neck pain indicates a potentially serious pathology, so that early treatment can be initiated.

3. An accurate diagnosis can be generated through a thorough history, physical examination and appropriate investigations.

4. Patients with red flags should be referred to a specialist for evaluation.

5. In the absence of red flags, treatment can focus on pain relief and the optimisation of function.

Closing Vignette

Four weeks later, Sharon returned with persistence of her symptoms despite simple analgesia and physiotherapy. In view of the persistence of her symptoms despite conservative management, you referred her to a spine surgeon. She was subsequently reviewed at a specialist outpatient clinic, and underwent MRI of her cervical spine. The MR image showed multi-level spondylotic changes, worst at the level of C6/C7. She was reassured, and simple analgesia and physiotherapy were recommended again, which led to resolution of her symptoms and improvement in her work performance at her review 3 months later.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

SMC CATEGORY 3B CME PROGRAMME

Online Quiz: https://www.sma.org.sg/cme-programme

Deadline for submission: 6 pm, 03 July 2024

Question: Answer True or False
1. Neck pain is more prevalent in higher-income countries.
2. Neck pain is associated with significant disability.
3. Most episodes of acute neck pain do not resolve.
4. The presence of red flags in the history and examination should prompt urgent evaluation.
5. A history of a ripping sensation associated with neck pain is a red flag and may suggest arterial dissection.
6. A comprehensive history in the assessment of neck pain should include the patient’s occupation.
7. Cervical strain can result from poor posture and sleeping habits.
8. Myofascial pain syndrome is not associated with trigger points or pressure sensitivity.
9. The ASIA score is a useful tool for assessing power and sensation.
10. Lhermitte’s sign is only positive in central cord compression.
11. A positive shoulder abduction test is suggestive of cervical radiculopathy.
12. Cervical radiculopathy is associated with lower motor neuron examination findings.
13. Clumsiness with fine motor skills in the hands is suggestive of radiculopathy rather than myelopathy.
14. Laboratory tests are usually useful in the evaluation of neck pain.
15. The degree of cervical spondylosis on imaging correlates well with the severity of symptoms.
16. The National Emergency X-Radiography Utilisation Study criteria can be used to determine the need for cervical spine imaging.
17. Patients with a suspected spinal cord compression should undergo urgent magnetic resonance imaging.
18. Physiotherapy has not been shown to reduce neck pain.
19. Acetaminophen is the recommended first-line analgesic because of its more favourable adverse effect profile.
20. The data on the effectiveness of neuropathic agents for the treatment of neck pain are limited.