 |
 |
Keywords
Bulging/Protruded/Herniated/Ruptured Lumbar Disc «» Degenerative Disc Disease «» Fibromyalgia «» Cervical/Spinal Stenosis «» Pinched Nerve «» Radiculopathy/Radicular Pain «» Spondylitis «» Whiplash
What is the anatomy of the cervical (neck) spine?
What is neck pain?
What causes neck pain?
Who is at risk?
What conditions are associated with neck pain?
How is neck pain diagnosed?
How is neck pain treated?
What is the anatomy of the cervical (neck) spine?
The cervical (neck) spine is an intricate structure, made up of bones, muscles, blood vessels, and other tissues, which not only supports the weight of the head but also houses and protects the spinal cord -- the delicate nervous system structure that carries signals that control the body’s movements and convey its sensations. Stacked on top of one another are 7 bones (vertebrae) that form the cervical spinal column -- the bottom-most vertebra in the neck is attached to the first thoracic (chest) vertebra. Each of these bones contains a round hole that, when stacked in register with all the others, creates a channel that surrounds the spinal cord. The spinal cord descends from the base of the brain and extends in the adult to just below the rib cage.
Small nerves enter and emerge from the spinal cord through spaces between the sides of the vertebrae. The vertebrae are separated by round, spongy pads of cartilage called intervertebral discs that allow for flexibility in the neck and act much like shock absorbers throughout the spinal column to cushion the bones as the body moves. Bands of tissue known as ligaments and tendons hold the vertebrae in place and attach the muscles to the spinal column.
Simply stated, neck pain is any type of pain, stiffness, spasm, or discomfort that is experienced in the to neck -- usually caused by chronic wear and tear, trauma, or strain on the components that make up the cervical spine. Nearly every person, at some point in their life, will experience neck pain that interferes with work, routine daily activities, or recreation. It is one of the most common causes of job-related disability and a leading contributor to missed work.
Acute, or short-term, neck pain generally lasts from a few days to a few weeks. Most acute neck pain is mechanical in nature -- the result of bad posture during work or sleep, trauma/whiplash, or a disorder such as arthritis. Pain from trauma may be caused by a sports injury, work around the house or in the garden, or a sudden jolt such as a car accident or other stress on spinal bones and tissues. Symptoms may range from muscle ache to shooting or stabbing pain, or limited flexibility and/or range of motion. Some acute pain syndromes can become more serious if left untreated.
Chronic neck pain is measured by duration -- pain that persists for more than 3 months is considered chronic. It is often progressive and the cause can be difficult to determine.
As people age, bone strength and muscle elasticity and tone tend to decrease; and the discs begin to lose fluid and flexibility, which decreases their ability to cushion the vertebrae. Pain can occur with over-exertion, causing a sprain, strain, or spasm in one of the muscles or ligaments in the neck, or rupture of a disc. This rupture may put pressure on one of the nerves that emerge from or enter the spinal cord. When these nerve roots in the cervical spine become compressed or irritated, neck pain results.
Neck pain may reflect nerve or muscle irritation or bone lesions. Pain may also be caused by degenerative conditions such as arthritis or disc disease, osteoporosis or other bone diseases, viral infections, irritation to joints and discs, or congenital abnormalities in the spine. Smoking, Stress, poor physical condition, posture inappropriate for the activity being performed, and poor sleeping position also may contribute to neck pain. Additionally, scar tissue created when the injured neck heals itself does not have the strength or flexibility of normal tissue. Buildup of scar tissue from repeated injuries eventually weakens the neck and can lead to more serious injury.
Occasionally, neck pain may indicate a more serious medical problem. Pain accompanied by fever or loss of bowel or bladder control, pain when coughing, and progressive weakness in the arms and/or legs may indicate an infection, spine tumor, pinched nerve or other serious conditions. People with diabetes can have chronic nerve damage which may manifest itself as severe neck pain or pain radiating down the arms. These are issues that require more immediate attention by a physician.
Nearly everyone has neck pain at some point in their lifetime. It occurs most often between ages 30 and 60, due in part to the aging process and more sedentary life styles; and it affects men and women equally. The risk of experiencing neck pain from disc disease or spinal degeneration increases with age.
What conditions are associated with neck pain?
Conditions that may cause neck pain and require treatment by a physician or other health specialist include:
Bulging, Protruded, Herniated, or Ruptured Disc (also known as Degenerative Disc Disease): The intervertebral discs are under constant pressure. As discs degenerate and weaken over time, cartilage can bulge or be pushed into the space containing the spinal cord or a nerve root, causing pain -- a phenomenon commonly known as a pinched nerve, radicular pain, or radiculopathy. Studies have shown that most herniated discs occur in the lumbar (lower back) portion of the spinal column, but they can also occur in the neck. The symptoms usually include shock-like or burning pain in the neck combined with pain through the shoulders and down one or both arms to the elbows, wrists, or hands. In the most extreme cases, when the nerve is pinched between the disc and an adjacent bone, the symptoms involve not pain but numbness and some loss of motor control over the arm due to interruption of nerve signaling. The condition may also be caused by a tumor, cyst, or degeneration of the nerve root.
Spinal Stenosis: Spinal degeneration from disc wear and tear can lead to a narrowing of the spinal canal, called stenosis. A person with this disorder may experience pain and stiffness in the neck as well as loss of fine motor movement in the upper extremity leading to difficulty with writing, buttoning buttons, and similar tasks. This condition can also lead to weakness in the arms and stiffness in the legs making it difficult to walk.
Osteoporosis: This is a metabolic bone disease marked by progressive decrease in bone density and strength. Fracture of brittle, porous bones in the spine results when the body fails to produce new bone and/or absorbs too much existing bone. Women are four times more likely than men to develop osteoporosis, and caucasian women of northern European heritage are at the highest risk. While this condition is more prevalent in the thoracic (chest) and lumbar (low back) spine, it may also lead to neck pain in severe cases.
Fibromyalgia: This is a chronic disorder characterized by widespread musculoskeletal pain, fatigue, and multiple tender points, particularly in the neck, shoulders, and hips. Additional symptoms may include sleep disturbances, morning stiffness, and anxiety.
Spondylitis: This refers to chronic neck pain and stiffness caused by a severe infection or inflammation of the spinal joints. Another painful inflammatory/infectious syndrome in the neck is called osteomyelitis (infection in the bones of the spine) which requires prompt medical attention.
A thorough medical history and physical exam can usually identify any dangerous conditions or family history that may be associated with back pain. The physician will examine the back and conduct neurologic tests to determine the cause of pain and appropriate treatment. Blood tests may also be ordered, and imaging tests may be necessary to diagnose tumors or other possible sources of the pain. A variety of diagnostic methods are available to confirm the cause of low back pain, including x-rays, computed tomography (CT), magnetic resonance imaging (MRI), discography, myelography, and electrodiagnostic procedures.
X-ray: This imaging modality includes conventional and enhanced methods that can help diagnose the cause and site of back pain. A conventional x-ray, often the first imaging technique used, looks for broken bones or injured vertebrae. Tissue masses such as injured muscles and ligaments or painful conditions such as a bulging disc are not visible on conventional x-rays. This fast, noninvasive, and painless procedure is usually performed in a doctor’s office or at a clinic.
Computed Tomography (CT): This is a quick and painless exam that is used when damage or trauma to the bony vertebrae is suspected as a cause of back pain. x-rays are passed through the body at various angles and are detected by a computerized scanner to produce two-dimensional images of internal structures of the back. This diagnostic exam is generally conducted at an imaging center or hospital.
Magnetic Resonance Imaging (MRI): This imaging modality is used to evaluate the lumbar region for bone degeneration, injury or disease in tissues and nerves, muscles, ligaments, and blood vessels, or to detect herniated discs. MRI scanning equipment uses a strong magnetic field (not x-rays) and radio waves to generate signals from tissue that are then interpreted by a computer which creates pictures of the tissue being scanned, and differentiates between bone, soft tissues and fluid-filled spaces by their structural properties. This noninvasive procedure is often used to identify a condition requiring prompt surgical treatment.
Discography: This technique involves the injection of a special contrast dye into a spinal disc thought to be causing low back pain. The dye outlines the damaged areas on x-rays taken following the injection and can provide information with regard to the integrity of the disc. Furthermore, the injection of the dye into the disc will usually reproduce the patient's pain; and, when compared to discography results for normal discs (which should be pain-free), can more definitively rule in the diseased disc as the source of the pain. This procedure is often suggested for patients who are considering lumbar surgery or whose pain has not responded to conventional treatments.
Myelography: In this procedure, the contrast dye is injected into the spinal canal, followed by a CT or x-ray imaging of the spine. This allows for detection of spinal cord and nerve compression caused by herniated discs or masses within the spinal canal.
Electrodiagnostic Procedures: These include electromyography (EMG), nerve conduction studies (NCS), and evoked potential (EP) studies. EMG assesses the electrical activity in a nerve and can detect if muscle weakness results from injury or a problem with the nerves that control the muscles. Very fine needles are inserted in muscles to measure electrical activity transmitted from the brain or spinal cord to a particular area of the body.
With nerve conduction studies the physician uses two sets of electrodes that are placed on the skin over the muscles. The first set gives the patient a mild shock to stimulate the nerve that runs to a particular muscle, and the second set of electrodes is used to make a recording of the nerve’s electrical signals in response to the shock. From this information the doctor can determine if there is nerve damage.
EP tests also involve two sets of electrodes -- one set to stimulate a sensory nerve and the other set on the scalp to record the speed of nerve signal transmissions to the brain. Changes in the speed of transmission of the signal to the brain can help to diagnose certain nerve or spinal cord diseases.
Most neck pain can be treated without surgery. Treatment involves using analgesics, reducing inflammation, restoring proper function and strength to the neck, and preventing recurrence of the injury. Most patients with neck pain recover without residual functional loss, but patients should contact a doctor if there is not a noticeable reduction in pain and inflammation after 72 hours of self-care, or immediately if there is any numbness, weakness, bowel or bladder problems, or any other neurologic deficits.
Although the use of cold and hot compresses have never been scientifically proven to quickly resolve neck injury, compresses may help reduce pain and inflammation and allow greater mobility for some individuals. As soon as possible following trauma, patients should apply a cold compress (such as a bag of ice or bag of frozen vegetables wrapped in a towel) to the tender spot several times a day for up to 20 minutes. After 2 to 3 days of cold treatment, they should then apply heat (such as a heating pad) for brief periods to relax muscles and increase blood flow -- warm baths may also help relax muscles. Patients should avoid sleeping on a heating pad, which can cause burns and lead to additional tissue damage.
Bed rest is only recommended for a maximum of 1 to 2 days. Studies have shown that persons who continued their activities without bed rest following onset of neck pain appeared to have better neck flexibility than those who rested in bed for a week. In addition, bed rest alone may make neck pain worse and can lead to secondary complications such as depression, decreased muscle tone, and life-threatening blood clots in the legs. Therefore, patients should resume activities as soon as possible.
Exercise may be the most effective way to speed recovery from neck pain and help strengthen neck muscles. Maintaining and building muscle strength is particularly important for persons with skeletal irregularities. Doctors and physical therapists can provide a list of gentle exercises that help keep muscles moving and speed the recovery process. A routine of neck-healthy activities may include stretching exercises, swimming, and movement therapy to improve coordination and develop proper posture and muscle balance. Any mild discomfort felt at the start of these exercises should disappear as muscles become stronger. But if pain is more than mild and lasts more than 15 minutes during exercise, patients should stop exercising and contact a doctor.
Medications are often used to treat acute and chronic neck pain. Effective pain relief may involve a combination of prescription drugs and over-the-counter remedies. Patients should always check with a doctor before taking drugs for pain relief since certain medicines, even those sold over the counter, are unsafe during pregnancy, may conflict with other medications, may cause side effects including drowsiness, or may lead to liver damage. Over-the-counter analgesics, including nonsteroidal anti-inflammatory drugs (aspirin, naproxen, and ibuprofen), are taken orally to reduce stiffness, swelling, and inflammation and to ease mild to moderate neck pain. Counter-irritants applied topically to the skin as a cream or spray stimulate the nerve endings in the skin to provide feelings of warmth or cold and dull the sense of pain. Topical analgesics can also reduce inflammation and stimulate blood flow. Many of these compounds contain salicylates, the same ingredient found in oral pain medications containing aspirin.
Opioids, such as codeine, oxycodone, hydrocodone, and morphine, are often prescribed to manage severe acute and chronic neck pain but should be used only for a short period of time and under a physician’s supervision. Side effects can include drowsiness, decreased reaction time, impaired judgment, and potential for addiction. Many specialists are convinced that chronic use of these drugs is detrimental to the neck pain patient, adding to depression and even increasing pain.
Interventional therapy can ease chronic pain by blocking nerve conduction between specific areas of the body and the brain. Approaches range from injections of local anesthetics, steroids, or narcotics into affected soft tissues, joints, or nerve roots to more complex nerve blocks and spinal cord stimulation. Chronic use of steroid injections may lead to increased functional impairment.
Anticonvulsants (drugs primarily used to treat seizures) may also be useful in treating certain types of nerve pain and may also be prescribed with analgesics. In addition, some antidepressants, particularly tricyclic antidepressants (amitriptyline and desipramine) have been shown to relieve pain and assist with sleep.
Antidepressants alter levels of brain chemicals to elevate mood and dull pain signals. Many of the new antidepressants, such as the selective serotonin reuptake inhibitors, are being studied for their effectiveness in pain relief.
Acupuncture has also been shown to relieve neck pain, and it involves the insertion of needles the width of a human hair along precise points throughout the body. Practitioners believe this process triggers the release of naturally occurring painkilling molecules which help to relieve the symptoms of neck pain.
Biofeedback is used to treat many acute pain problems, most notably neck/back pain and headache. Using a special electronic machine, the patient is trained to become aware of, to follow, and to gain control over certain bodily functions, including muscle tension, heart rate, and skin temperature by controlling local blood flow patterns. The patient can then learn to change his or her response to pain, for example, by using relaxation techniques. Biofeedback is often used in combination with other treatment methods, generally without side effects.
Traction involves the use of weights to apply constant or intermittent force to gradually pull the skeletal structures into better alignment. Traction is not recommended for certain conditions and consultation with a qualified healthcare professional should be made before this treatment is initiated.
Transcutaneous electrical nerve stimulation (TENS) is administered by a battery-powered device that sends mild electric pulses along nerve fibers to block pain signals to the brain. Small electrodes placed on the skin at or near the site of pain generate nerve impulses that block incoming pain signals from the peripheral nerves. TENS may also help stimulate the brain’s production of endorphins, which are chemicals that have pain-relieving properties.
Ultrasound is a noninvasive therapy that sends sound waves (undetectable by human ears) into the injured muscles and other soft tissues and warms the body’s internal tissues, which causes muscles to relax.
In the most serious cases, when the condition does not respond to other therapies, surgery may relieve pain caused by neck problems or serious musculoskeletal injuries. It may be months following surgery before the patient is fully healed, and he or she may suffer permanent loss of flexibility, depending on the type of surgery. Since invasive neck surgery is not always successful, it should be performed only in patients with progressive neurologic disease or damage to the peripheral nerves. Some of the surgical procedures commonly performed to relieve neck pain are listed below.
Discectomy and fusion is one of the more common ways to remove pressure on a nerve root and/or spinal cord from a bulging disc or bone spur. During the procedure the surgeon reaches the spine though an incision in the front of the neck, and takes out the disc that is compressing the spinal cord and/or the nerve root. A bone graft is then placed between the two vertebrae (from in-between which the disc was removed), and small metal plates and screws are placed over the site to keep the graft in place and facilitate fusion of the two vertebrae together over time.
Foraminotomy is an operation that enlarges the bony hole (foramen) through which a nerve root exits the spinal canal. Bulging discs or joints thickened with age can cause narrowing of the space through which the spinal nerve exits and can press on the nerve, resulting in pain, numbness, and weakness in an arm or leg. Small pieces of bone over the nerve are removed through a small incision, allowing relief of pressure on the nerve.
Spinal laminectomy (also known as spinal decompression) involves the removal of the lamina (usually both sides) to increase the size of the spinal canal and relieve pressure on the spinal cord and nerve roots.
Posterior spinal fusion is used to strengthen the spine and prevent painful movements. This is done through an incision in the back of the neck where adjacent vertebrae are “fused” by bone grafts and metal devices secured by screws. Spinal fusion may result in some loss of flexibility in the spine and requires a long recovery period to allow the bone grafts to grow and fuse the vertebrae together.
Radiofrequency lesioning is a procedure using electrical impulses to interrupt nerve conduction (including the conduction of pain signals) for 6 to12 months. Using x-ray guidance, a special needle is inserted into nerve tissue in the affected area. Tissue surrounding the needle tip is heated for 90-120 seconds, resulting in localized destruction of the nerves.
