Pain in the Neck: More than a Metaphor

The cervical spine is a slender stack of fragile bones that balances the 15-17 lb. skull atop the body. Each bone has a round thick body and an arch of thinner bone projecting from its backside. The knobs of bone you feel in your own spine are just the tips of each bony arch, called the spinous processes. A wide array of ligaments, tendons and muscles hold the vertebrae together, and thirty-seven separate joints allow the head to move through a wide range of finely calibrated movements.  Arthritic changes accumulate in most necks over the years, particularly in the lower regions where most movement takes place.   In scans of people over 50, almost all will show some degree of wear and tear change in the lower vertebrae.

Aging changes in bones neck bones and ligaments

Wear and tear takes form of thickening of bony edges of the vertebrae and degeneration of the discs between them.  These changes may put pressure on the nerves that exit from the spinal cord through bony canals between the stacked vertebrae, and occasionally on the spinal cord itself, which travels through a canal formed by the centers of the stacked arches.  The ligaments that line this canal also thicken with age and create ridges inside the canal that press on the spinal cord. Degenerative changes contribute to episodic neck pain, and sometimes to more severe symptoms that require medical attention.

Why the neck hurts

The neck is second only to the low back pain as a common source of pain. Most neck pain is benign and episodic, coming from muscles, tendons, ligaments and joints. Painful episodes usually occur after some unaccustomed activity, such as painting a ceiling or suddenly twisting or bending the neck, or after sustaining a neck position for an unusual amount of time – for example, over a long drive.  Even an unaccustomed head position occasioned by wearing new bifocals can trigger a bout of stiff neck.

Other symptoms

Neck pain requires medical attention when it persists or is associated with neurological symptoms in the arms or legs.  Sensory symptoms like numbness or tingling in fingers and arms are quite common when underlying degenerative changes are present in the neck. While they may indicate pressure on nerve roots, sensory symptoms also occur when neck pain is simply a reflection of tight muscles and ligaments. The same nerve fibers that carry pain sensations also carry sensory messages and pain seems to have a kind of spillover effect into other sensory pathways.  That same spillover effect also can also cause a wide variety of sensory and pain symptoms in the head.  Headaches, pain in the back of the head, and even eye pain can be attributed to some neck problems.

Red flag symtoms: weakness and bladder control problems

Neurological symptoms indicating trouble in the motor nerves or in the spinal cord, in the setting of neck pain and degenerative changes, often indicate a more serious degree of trouble. Weakness in arm or hand muscles may mean that motor nerve roots are being squeezed as they exit the spinal column.  Weakness, fatigue and stiffness in the legs, and new trouble with bladder control are symptoms of pressure on the spinal cord. Sensory problems usually recover when the painful cause is successfully treated, but motor nerves and the spinal cord are more fragile and less reliably improve even after surgical decompression.  When motor problems are part of the picture, medical attention should be sought sooner rather than later.

Diagnosis

Careful history and physical examination are crucial to the proper diagnosis.  Diagnosis of a painful, stiff neck begins with taking a history. Most people do this before they ever see a doctor. What did I do yesterday? Did I sleep sitting up on a plane? In a strange bed? What movement makes this worse? What makes it better? Do I have any other funny symptoms? Most people also do the right thing by avoiding maneuvers that cause pain, applying either heat or ice, and even trying a soft cervical collar, which does not really immobilize the neck, but gives the head a temporary place to rest. Most often the neck improves and no medical attention is required.

Medical attention, when sought, should begin with a very detailed history, not only of the current episode, but of past problems, and other medical problems which might cause or complicate neck problems.  Important facts include history of trauma, rheumatoid arthritis, cancer, vascular disease, infections and past radiation treatment. Evaluation then moves to a physical examination, not only of the neck, but a general physical exam and a neurological exam. Imaging studies, electrical evaluation of nerves and muscles, and blood work follow under some circumstances. These include symptoms persisting more than 6 weeks, severe symptoms involving a single joint, presence of fever and weight loss, suspected fracture or dislocation, associated neurological symptoms or findings, and failure of simple treatments over a course of 4-6 weeks.

Treatment

Conservative measures are effective for treating common types of neck pain, especially if carried out conscientiously. Massage, hot or cold applications, topical pain relieving and muscle relaxing creams and intermittent use of aspirin or non-steroidal anti-inflammatory agents are all helpful but they are play a  only a supporting role. The major goal is to correct posture, not only of the neck, but of the whole spine, by strengthening and stretching of the muscles that support the spine and those that suspend and move the shoulders.   An effective exercise program, under supervision of a qualified physical therapist, involves the entire spine, as well as legs and arms.  In addition, supporting the neck’s normal curve in sleep with a good cervical pillow is crucial.

When conservative measures fail, more invasive means of treatment such as injections of anti-inflammatory and analgesic drugs are often added. Surgical treatment of neck pain problems is reserved for situations in which a nerve root or the spinal cord must be decompressed, or ones in which pain is so severe and unremitting that fusing the bones to decrease movement of the neck is considered the only option. In comparison to the number of people with neck pain at some point in their lives, surgically treated neck complaints are actually few and far between.  Considering how much the neck moves, how much wear and tear it sustains and how little protection it has, this is a remarkable measure of its resilience.

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