Identifying the Musculoskeletal Causes of Neck Pain
Identifying the Musculoskeletal Causes of Neck Pain
ABSTRACT: Neck pain is a common problem. The diagnosis most often can be made with the history and physical examination. In the examination, the physician should note any masses or asymmetries. Several provocative maneuvers are useful in evaluating cervical radiculopathy. Identifying key “red flag” symptoms helps clinicians identify malignancy, infection, and other potentially serious diagnoses. Cervical spondylosis may cause axial neck pain, radiculopathy, and myelopathy. Physical findings for cervical radiculopathy include a combination of deficits in motor function, sensation, and reflexes. Conditions that may mimic cervical radiculopathy include Pancoast tumor and peripheral entrapment neuropathies. Patients with cervical myelopathy often have a history of chronic neck, shoulder, and arm pain. Conservative treatment is acceptable in the absence of red flag symptoms or myelopathy. (J Musculoskel Med. 2012;29:82-86)
Neck pain, or cervicalgia, is a common problem; about two-thirds of persons in the US population have neck pain at some point in their lives.1 The diagnosis of neck pain most often can be made with the history and physical examination. However, care must be taken to evaluate for “red flag” symptoms, including intractable pain, fever, gait disturbance, and exquisite tenderness over a vertebral body, as signs of serious conditions.1
Although the reasons for neck pain may be complex, most neck pain is caused by local mechanical problems.2 Mechanical neck pain results from damage to the joints, disks, or soft tissue. Degenerative disk disease and cervical facet arthropathy are common mechanical causes of neck pain; muscle- and ligament-related injuries resulting from trauma or strenuous activity are others. Provocative maneuvers are helpful in the evaluation of neck pain because they are used to aggravate or relieve symptoms with the neck in various positions.
In this article, I discuss diagnosis and management of the musculoskeletal causes of neck pain. I emphasize neurological impairment and the accompanying signs elicited by provocative maneuvers.
The time frame for evaluation is important because acute neck pain most often is caused by trauma, whereas degenerative changes lead to chronic neck pain.3 Acute neck pain has a time frame of less than 3 weeks, and chronic neck pain is defined by a duration of 12 or more weeks; subacute neck pain falls in between.4 Degenerative changes are slow to develop, but injuries (eg, herniated disks) are likely to cause acute neck pain.3
The physical examination begins with careful inspection of the neck. The examiner should take note of any masses or asymmetries. Palpation, performed with the fingertips, includes evaluation of the thyroid gland, lymph nodes, muscles, and soft tissues.
Passive range of motion is assessed in 3 planes—flexion-extension; left-right rotation; and left-right flexion, or lateral bending. Most mechanical neck problems are asymmetrical, and passive range of motion may be limited asymmetrically by pain.2
Along with testing of sensation, strength, and reflexes, several provocative maneuvers are useful in evaluating cervical radiculopathy. Neck pain may radiate into the extremities, and it may be worsened by these various provocative maneuvers. Provocative tests place the neck and arm in various positions to aggravate or relieve symptoms. Provocative maneuvers and their resulting signs include the Spurling, Lhermitte, shoulder abduction, Adson, and Hoffmann signs.
Red Flag Symptoms
Noting the presence of red flag symptoms, such as intractable pain, fever, night sweats, unexpected weight loss, and gait disturbance, helps clinicians identify malignancy, infection, and other potentially serious diagnoses. Exquisite tenderness over a vertebral body is concerning for malignancy or compression fracture. When point tenderness occurs in the setting of fever, infection is a strong possibility.
Cervical osteomyelitis is a potential diagnosis in a patient who has fever and neck pain.5 MRI evaluation along with blood cultures and an erythrocyte sedimentation rate help confirm this diagnosis.5
Other Testing and Imaging
Electromyography and nerve conduction velocity studies are useful in determining which nerve is affected and the location of the compression. These studies help differentiate a cervical radiculopathy from an entrapment neuropathy, such as ulnar or median neuropathy. An MRI scan of the spine is most useful in evaluating a patient with cervical radiculopathy to confirm the actual cause of the radicular pain. In addition, an MRI scan can be used to assess structural changes of the disk. Intra-articular anesthetic injections with fluoroscopic guidance also may help confirm other causes of neck pain, such as facet joint arthropathy.6
NECK PAIN DISORDERS
This condition, the result of degenerative changes as a natural consequence of aging, may cause axial neck pain, radiculopathy, myelopathy, or a combination of these problems.7 Degenerative changes result in osteophyte formation,1 and osteophytes can impinge on adjacent structures.
The diagnosis of cervical spondylosis usually is made by clinical evaluation alone.1 Presenting features include neck pain aggravated by movement, poorly localized tenderness, limited range of movement, and vague paresthesias of the upper extremity.1
Axial Neck Pain
This is the most common cause of neck pain. Lesions of the upper cervical nerve roots (C2-4) are uncommon and give rise to no motor deficits.3,8 Sensory involvement is as follows:
• C2—occipital area.
• C3—posterior aspect of neck.
• C4—trapezial area.
The C2-3 facet joints may be the source of occipital, or cervicogenic, headache.2,9 The C2-4 nerve roots are not associated with motor involvement. Axial neck pain may radiate to the shoulders and head.7 In the absence of radicular symptoms, determining the source of the neck pain can present a diagnostic challenge.7
Eight pairs of cervical nerve roots originate from the spinal cord (Figure). Each cervical nerve root exits above the corresponding vertebra, except for the eighth nerve root, which exits above the first thoracic vertebra.
The brachial plexus is composed of nerve roots from the first thoracic and the lower 4 cervical levels (C5-T1). The nerve roots of C5 and C6 join to form the upper trunk; those of C8-T1 join to form the lower trunk. The nerve root of C7 alone makes up the middle trunk.
Compression at the nerve root level (eg, herniated disk) produces specific dermatomal symptoms (Table 1). Thoracic outlet syndrome (TOS), peripheral entrapment neuropathies, and other conditions have overlapping dermatomes.
Disk herniations may occur suddenly; nerve root compression related to spondylosis may develop slowly.3 Herniation of an intervertebral disk may be caused by degenerative processes or trauma.3 Disk herniations may occur centrally or laterally. Central disk herniations may compress the cervical cord directly; lateral disk herniations result in compression of a cervical nerve root.3
Physical findings for cervical radiculopathy, a neurological condition characterized by pain in the neck and arm, include a combination of deficits in motor function, sensation, and reflexes.3,10 The disorder typically is caused by degenerative changes that result in foraminal encroachment. Radiculopathy resulting from nerve root compression usually occurs at the C5-7 level; the C7 nerve root is most frequently involved.1 Cervical radiculopathy typically manifests as pain radiating from the neck into the distribution of the affected nerve root.8 Sensory symptoms are more common than weakness.1
The diagnosis of cervical radiculopathy most often can be made with the history and physical examination. There are no clear guidelines on when imaging is warranted.10 Red flag symptoms would justify imaging, as would neurological deficits.10 Nerve conduction studies could help differentiate cervical radiculopathy from a compressive peripheral entrapment neuropathy (eg, carpal tunnel syndrome [CTS]).
The Spurling test may be used to evaluate patients for cervical radiculopathy (Table 2). The sign is elicited by extending, rotating, and laterally flexing the patient’s neck toward the symptomatic side. Then, the examiner applies axial pressure on the spine. Pressure applied on top of the head may intensify symptoms.
The Spurling test has a sensitivity of 30% to 60% and a specificity of 90% to 100%,10-13 quite similar to those of other provocative maneuvers (low sensitivity but high specificity). Therefore, this test is not useful as a screening tool, but it does help confirm the diagnosis of cervical radiculopathy.11
The Lhermitte sign is performed by having the patient flex his or her neck forward. An electric shock–like sensation radiating down the spine and into both arms is considered a positive test result.14 The sign also may provoke paresthesias in the lower extremities.2
The Lhermitte sign suggests a lesion of the dorsal columns of the cervical cord that can be caused by several conditions that affect the cervical spine. The sign most often is associated with multiple sclerosis (MS), being present in up to 41% of patients who have definite MS,15 but it may present in other conditions, such as radiation myelopathy, herpes zoster, and subacute combined degeneration resulting from vitamin B12 deficiency.14,16,17
Other signs and maneuvers to consider in the evaluation of possible cervical radiculopathy include the arm abduction sign and manual traction. The shoulder abduction sign is performed by resting the patient’s abducted arm on top of his forehead with the elbow flexed.18 Pain relief with the arm in this position is a positive finding.
Manual traction of the neck, or the neck distraction test, also may result in pain relief.12 To perform this maneuver, the examiner grasps the patient’s head under the chin and occiput and applies axial traction force.12
Mimics of cervical radiculopathy. Conditions that may mimic cervical radiculopathy include Pancoast tumor, peripheral entrapment neuropathies, TOS, and herpes zoster. The peripheral entrapment neuropathies include CTS at the wrist (median nerve); cubital tunnel syndrome at the elbow (ulnar nerve); and “Saturday night palsy,” which involves compression of the radial nerve at the humeral spiral groove in patients with sustained compression (eg, an intoxicated person falls asleep with his arm over a chair).19
The median nerve is derived from the C6-T1 nerve roots; the ulnar nerve is derived from the C8-T1 nerve roots, and the radial nerve is derived from the C5-T1 nerve roots. A detailed history and physical examination would help differentiate these causes of neck pain from cervical radiculopathy.
Thoracic Outlet Syndrome
There is no objective confirmatory test for this syndrome. Arm claudication, exercise-induced paresthesia, and hand cyanosis and pallor after exercise are strong clues to the diagnosis.20,21 TOS also may mimic Raynaud phenomenon. The paresthesias most often are distributed in the ulnar aspect of the hand and forearm (C8-T1 distribution).10,20
TOS occurs when there is compression of the brachial plexus, subclavian vein, and subclavian artery. This neurovascular bundle passes through the interscalene triangle, which is bordered anteriorly by the anterior scalene muscles, posteriorly by the middle scalene muscles, and inferiorly by the first rib.20 Neurogenic TOS, with involvement of the brachial plexus, is more common than vascular TOS, with involvement of the subclavian vein or artery.21
A cervical rib, an anomalous enlargement of the transverse process of the seventh cervical vertebra,22 is a predisposing factor for the development of TOS. Symptomatic cervical ribs usually produce symptoms of neurogenic TOS.
When the vasculature is compromised, a drop in blood pressure often is noted on the affected side.20 To help confirm arterial TOS, the Adson test is performed by having the patient elevate his chin and rotate his head to the affected side while inspiring deeply. Obliteration of the radial artery pulse as it becomes compressed at the interscalene triangle is a positive test result,23 and it may be a sign of TOS. The vascular response is more common than the neurological response in the typical population.23 Sex-related differences are noted; a response is more common in women than in men.23 False-positive test results may be found in about 12% of normal patients.22,24
The onset of myelopathy, a potential complication of cervical spondylosis that results from spinal cord compression, is gradual; patients with myelopathy often have a history of chronic neck, shoulder, and arm pain.2 Red flags for cervical myelopathy include gait disturbance, hand clumsiness, and combined neurological deficits (eg, upper motor neuron signs in the legs with lower motor neuron signs in the arms).
Cervical radiculopathy typically manifests as pain radiating from the neck into the distribution of the affected nerve root; patients with cervical spondylotic myelopathy typically present with hand clumsiness, difficulty with grasping and holding objects, and gait disturbance. Patients may have a spastic paraparesis of the lower limbs; cervical spondylotic myelopathy is the most common cause of acquired spastic paraparesis in adults.7 Bladder dysfunction is a late symptom.1 MRI, the study of choice for evaluation of cervical myelopathy, provides critical information about the extent of cord compression.
Physical findings associated with myelopathy include hyperreflexia; clonus; and the Babinski, Hoffmann, and Lhermitte signs. A positive Hoffmann sign reflects the presence of an upper motor neuron lesion resulting from spinal cord compression; the test is performed by firmly grasping the middle finger and quickly snapping or flipping the dorsal surface. The sign is positive if quick flexion of both the thumb and index finger results.2 The Babinski sign is an upturning reflex as evidenced by dorsiflexion of the big toe on stimulation of the sole of the foot with a blunt instrument.
NSAIDs have combined analgesic and anti-inflammatory properties. However, prolonged NSAID use is limited by GI, renal, and cardiovascular toxicity.25
Acetaminophen is the preferred agent for mild to moderate pain.25 Opioid analgesics should be used, with caution, for moderate to severe pain.25 Muscle relaxants are helpful in the presence of associated muscle spasms. Anticonvulsants, such as gabapentin and pregabalin, are useful adjunctive medications in the management of radiculopathy. Pregabalin has been shown to be effective in the management of cervical radiculopathy.26 Gabapentin has been used to manage chronic neuropathic pain syndromes. To my knowledge, however, there have been no studies of gabapentin for the treatment of patients who have cervical radiculopathy.
Nonoperative, nonpharmacological interventions include physical therapy, cervical traction, use of soft collars, manual therapy, thermal therapy, and acupuncture.25 A multimodal approach using physical therapy, medication, and injection therapy is best. Surgery may be considered for patients who have medically refractory pain or signs of myelopathy. Conservative treatment is acceptable in the absence of red flag symptoms or myelopathy.
The reasons for neck pain can be complex, although most neck pain is caused by local mechanical problems. The diagnosis most often can be made with the history and physical examination. Serious diagnoses, including malignancy and infection, should not be overlooked. Red flag symptoms should be noted and followed up with further imaging of the neck structures.
1. Binder AI. Cervical spondylosis and neck pain. BMJ. 2007;334:527-531.
2. Tsang I. Rheumatology, 12: pain in the neck. CMAJ. 2001;164:1182-1187.
3. Polston DW. Cervical radiculopathy. Neurol Clin. 2007;25:373-385.
4. Jensen I, Harms-Ringdahl K. Strategies for prevention and management of musculoskeletal conditions: neck pain. Best Pract Res Clin Rheumatol. 2007;21:93-108.
5. Saha AR, Blackburn AM. Neck pain with fever. J R Soc Med. 1999;92:304-306.
6. Hoppenfeld JD. Cervical facet arthropathy and occipital neuralgia: headache culprits. Curr Pain Headache Rep. 2010;14:418-423.
7. Rao R. Neck pain, cervical radiculopathy, and cervical myelopathy: pathophysiology, natural history, and clinical evaluation. J Bone Joint Surg. 2002;84A:1872-1881.
8. Rhee JM, Yoon T, Riew KD. Cervical radiculopathy. J Am Acad Orthop Surg. 2007;15:486-494.
9. Sjaastad O, Fredriksen TA, Pfaffenrath V; Cervicogenic Headache International Study Group. Cervicogenic headache: diagnostic criteria. Headache. 1998;38:442-445.
10. Carette S, Fehlings MG. Clinical practice: cervical radiculopathy. N Engl J Med. 2005;353:392-399.
11. Tong HC, Haig AJ, Yamakawa K. The Spurling test and cervical radiculopathy. Spine (Phila Pa 1976). 2002;27:156-159.
12. Malanga GA, Landes P, Nadler SF. Provocative tests in cervical spine examination: historical basis and scientific analyses. Pain Physician. 2003;6:199-205.
13. Rubinstein SM, Pool JJ, van Tulder MW, et al. A systematic review of the diagnostic accuracy of provocative tests of the neck for diagnosing cervical radiculopathy. Eur Spine J. 2007;16:307-319.
14. Lewanski CR, Sinclair JA, Stewart JS. Lhermitte’s sign following head and neck radiotherapy. Clin Oncol (R Coll Radiol). 2000;12:98-103.
15. Al-Araji AH, Oger J. Reappraisal of Lhermitte’s sign in multiple sclerosis. Mult Scler. 2005;11:398-402.
16. Vollmer TL, Brass LM, Waxman SG. Lhermitte’s sign in a patient with herpes zoster. J Neurol Sci. 1991;106:153-157.
17. Fritschi J, Sturzenegger M. Spinal MRI supporting myelopathic origin of early symptoms in unsuspected cobalamin deficiency. Eur Neurol. 2003;49:146-150.
18. Davidson RI, Dunn EJ, Metzmaker JN. The shoulder abduction test in the diagnosis of radicular pain in cervical extradural compressive monoradiculopathies. Spine (Phila Pa 1976). 1981;6:441-446.
19. Shapiro BE, Preston DC. Entrapment and compressive neuropathies. Med Clin North Am. 2003;87:663-696, viii.
20. Huang JH, Zager EL. Thoracic outlet syndrome. Neurosurgery. 2004;55:897-903.
21. Barkhordarian S. First rib resection in thoracic outlet syndrome. J Hand Surg. 2007;32A:565-570.
22. Tubbs RS, Tyler-Kabara EC, Salter EG, et al. Additional vascular compression of the brachial plexus in a cadaver with a cervical rib: case illustration. Surg Radiol Anat. 2006;28:112-113.
23. Rayan GM, Jensen C. Thoracic outlet syndrome: provocative examination maneuvers in a typical population. J Shoulder Elbow Surg. 1995;4:113-117.
24. Plewa MC, Delinger M. The false-positive rate of thoracic outlet syndrome shoulder maneuvers in healthy subjects. Acad Emerg Med. 1998;5:337-342.
25. Mazanec D, Reddy A. Medical management of cervical spondylosis. Neurosurgery. 2007;60(1 suppl 1):S43-S50.
26. Saldaña MT, Navarro A, Pérez C, et al. Patient-reported-outcomes in subjects with painful lumbar or cervical radiculopathy treated with pregabalin: evidence from medical practice in primary care settings. Rheumatol Int. 2010;30:1005-1015.