A Patient's Guide to Neck Pain
Introduction
Neck pain is a common reason people visit their doctor.
Neck pain typically doesn't start from a single injury.
Instead, the problem usually develops over time from the
stress and strain of daily activities. Eventually, the parts
of the spine begin to degenerate. The degeneration can
become a source of neck pain.
Knowing how your neck normally works and why you feel
pain are important in helping you care for your neck
problem. Patients are often less anxious and more satisfied
with their care when they have the information they need to
make the best decisions about their condition.
This document will give you a general overview of neck
pain. It should help you understand
- what parts make up the spine and neck
- what causes neck pain
- what tests your doctor may run
- how to decrease your pain and increase your mobility
Anatomy
What parts make up the cervical spine, and how do they
work?
The human spine is made up of 24 spinal bones, called
vertebrae. Vertebrae are stacked on top of one
another to form the spinal column. The spinal column
is the body's main upright support.
The cervical spine is formed by the first seven
vertebrae. Doctors often refer to these vertebrae as C1 to
C7. The cervical spine starts where the top vertebra (C1)
connects to the bottom edge of the skull. The cervical spine curves slightly inward and ends where C7 joins
the top of the thoracic spine. This is where the
chest begins.
Each vertebra is formed by a round block of bone, called
a vertebral body. A bony ring attaches to the back of the vertebral body.
When the vertebrae are stacked on top of each other, the
rings form a hollow tube. This bony tube surrounds the
spinal cord as it passes through the spine. Just as the
skull protects the brain, the bones of the spinal column
protect the spinal cord.
As the spinal cord travels from the brain down through
the spine, it sends out nerve branches between each
vertebrae called nerve roots. These nerve roots join
together to form the nerves that travel throughout the body
and form the body's electrical system. The nerve roots that
come out of the cervical spine form the nerves that go to
the arms and hands. The thoracic spine nerves go to the
abdomen and chest. The nerves coming out of the
lumbar (lower) spine go to the organs of the pelvis,
the legs, and the feet.
One way to understand the anatomy of the cervical spine
to look at a spinal segment. Each spinal segment includes
two vertebrae separated by an intervertebral disc,
the nerves that leave the spinal cord at that level, and the
small facet joints (described later) that link each
level of the spinal column.
An intervertebral disc is made of connective
tissue. Connective tissue is the material that holds the
living cells of the body together. Most connective tissue is
made of fibers of a material called collagen. In some
cases, the collagen fibers join together to form a structure
like a rope. In other cases, the fibers are arranged like a
piece of cloth, or knitted materials such as you find in a
sweater. The disc is a specialized connective tissue
structure that separates the two vertebral bodies of the
spinal segment. The disc normally works like a shock
absorber. It protects the spine against the daily pull of
gravity. It also protects the spine during activities that
put strong force on the spine, such as jumping, running, and
lifting.
An intervertebral disc is made up of two parts. The center, called the nucleus, is
spongy. It provides most of the ability to absorb shock. The
nucleus is held in place by the annulus, a series of
strong ligament rings surrounding it. Ligaments are
strong connective tissues that attach bones to other
bones.
There are two facet joints between each pair of
vertebrae, one on each side of the spine. A facet joint is made up of small, bony knobs that line
up along the back of the spine. Where these knobs meet, they
form a joint that connects the two vertebrae. The alignment
of the facet joints of the cervical spine allows freedom of
movement as you bend and turn your neck.
The surfaces of the facet joints are covered by
articular cartilage. Articular cartilage is a smooth,
rubbery material that covers the ends of most joints. It
allows the bone ends to move against each other smoothly,
without pain.
Two spinal nerves exit the sides of each spinal segment,
one on the left and one on the right. As the nerves leave
the spinal cord, they pass through a small bony tunnel on
each side of the vertebra, called a neural foramen. (The term used to describe more
than one opening is neural foramina.)
Causes
Why do I have neck pain?
There are many causes of neck pain. Doctors are not
always able to pinpoint the source of a patient's pain. Your
doctor will make every effort to ensure that your symptoms
are not from a serious medical cause, such as cancer or a
spinal infection. Below is a brief overview of some of the
most common causes of neck pain. Spondylosis
Most neck problems happen after years of wear and tear on
the parts of the cervical spine. At first, these small
injuries are not painful. But over time they can add up.
Eventually they begin to cause neck pain.
Doctors sometimes call these degenerative changes in the
spine spondylosis. Spondylosis can affect the bones
and soft tissues of the spine. However, it is important to
know that most problems with spondylosis are a normal part
of aging. Degenerative Disc Disease
The normal aging process involves changes within the
intervertebral discs. Repeated stresses and strains weaken
the connective tissues that make up a disc. Over time, the
nucleus in the center of the disc dries out. When this
happens, it loses some of its ability to absorb shock. The
annulus also weakens and develops small cracks and
tears.
Often these changes are not painful. But larger tears
that reach to the outer edge of the annulus can cause neck
pain. The body tries to heal the cracks with scar tissue.
But scar tissue is not as strong as the tissue it replaces.
At some point the disc may finally lose its ability to
absorb shock for the spine. Then forces from gravity and
daily activities can take even more of a toll on the disc
and other structures of the spine.
As the disc continues to degenerate, the space between the
vertebrae becomes smaller. This compresses the facet joints
along the back of the spinal column. As these joints are
forced together, extra pressure builds on the articular
cartilage on the surface of the facet joints. This extra
pressure can damage the facet joints. Over time, this may
lead to arthritis in the facet joints.
These degenerative changes in the disc, facet
joints, and ligaments cause the spinal segment to become
loose and unstable. The extra movement causes even more wear
and tear on the spine. As a result, more and larger tears
occur in the annulus.
The nucleus may push through the weakened and torn
annulus and into the spinal canal. This is called a
herniated or ruptured disc. The disc material
that squeezes out can press against the spinal nerves. The
disc also emits enzymes and chemicals that produce
inflammation. The combination of pressure on the nerves and
inflammation caused by the chemicals released from the disc
cause pain.
As the degeneration continues, bone spurs develop
around the facet joints and around the disc. No one knows
exactly why these bone spurs develop. Most doctors think
that bone spurs are the body's attempt to stop the extra
motion between the spinal segment. These bone spurs can
cause problems by pressing on the nerves of the spine where
they pass through the neural foramina. This pressure around
the irritated nerve roots can cause pain, numbness, and
weakness in the neck, arms, and hands.
 Muscle Strain
People with minor neck pain or stiffness are often told
they have a muscle strain. However, unless there was a
severe injury to the neck, the muscles probably haven't been
pulled or injured. Instead, the problem may be coming from
irritation or injury in other spine tissues, such as the
disc or ligaments. When this happens, the neck muscles may
go into spasm to help support and protect the sore
area. Mechanical Neck Pain
Mechanical neck pain is caused by wear and tear
on the parts of the neck. It is similar in nature to a
machine that begins to wear out. Mechanical pain usually
starts from degenerative changes in the disc. As the disc
starts to collapse, the space between the vertebrae narrows,
and the facet joints may become inflamed. The pain is
usually chronic. (Chronic pain builds over time and
is long-lasting.) The pain is typically felt in the neck,
but it may spread from the neck into the upper back or to
the outside of the shoulder. Mechanical neck pain usually
doesn't cause weakness or numbness in the arm or hand,
because the problem is not from pressure on the spinal
nerves. Radiculopathy (Pinched Nerve)
Pressure or irritation in the nerves of the cervical
spine can affect the nerves' electrical signals. The
pressure or irritation can be felt as numbness on the skin,
weakness in the muscles, or pain along the path of the
nerve. Most people think of these symptoms as indications of
a pinched nerve. Health care providers call this condition
cervical radiculopathy.
Several conditions can cause radiculopathy. The most
common are degeneration, disc herniation, and spinal
instability.
Related Document: A
Patient's Guide to Cervical Radiculopathy
- Degeneration: As the spine ages, several changes occur
in the bones and soft tissues. The disc loses its water
content and begins to collapse, causing the space between
the vertebrae to narrow. The added pressure may irritate
and inflame the facet joints, causing them to become
enlarged. When this happens, the enlarged joints can press
against the nerves going to the arm as they squeeze
through the neural foramina. Degeneration can also cause
bone spurs to develop. Bone spurs may put pressure on
nerves and produce symptoms of cervical
radiculopathy.
- Herniated Disc: Heavy, repetitive bending, twisting,
and lifting can place extra pressure on the
shock-absorbing nucleus of the disc. If great enough, this
increased pressure can injure the annulus (the
tough, outer ring of the disc). If the annulus ruptures or
tears, the material in the nucleus can squeeze out of the
disc. This is called a herniation. Although daily
activities may cause the nucleus to press against the
annulus, the body is normally able to withstand these
pressures. However, as the annulus ages, it tends to crack
and tear. It is repaired with scar tissue. Over time, the
annulus becomes weakened, and the disc can more easily
herniate through the damaged annulus.
If the herniated disc material presses against a nerve
root it can cause pain, numbness, and weakness in the area
the nerve supplies. This condition is called cervical
radiculopathy (mentioned earlier). And any time the
herniated nucleus contacts tissues outside the damaged
annulus, it releases chemicals that cause inflammation and
pain. If the nucleus herniates completely through the
annulus, it may squeeze against the spinal cord. This
causes a condition that is even more serious because it
affects all the nerves of the spinal cord. This condition
is called cervical myelopathy.
- Spinal Instability: Spinal instability means
there is extra movement among the bones of the spine.
Instability in the cervical spine can develop if the
supporting ligaments have been stretched or torn from a
severe injury to the head or neck. People with diseases
that loosen their connective tissue may also have spinal
instability. Spinal instability also includes conditions
in which a vertebral body slips over the one just below
it. When the vertebral body slips too far forward, the
condition is called spondylolisthesis. Whatever the
cause, extra movement in the bones of the spine can
irritate or put pressure on the nerves of the neck,
causing symptoms.
Spinal Stenosis (Cervical
Myelopathy)
Stenosis means closed in. Spinal stenosis refers to a condition in which
the spinal cord is closed in, or compressed, inside the tube
of the spinal canal. Spinal stenosis may be caused by
degenerative changes, such as bone spurs pushing against the
spinal cord within the spinal canal.
However, stenosis can also develop when a person of any
age has a disc herniation that pushes against the spinal
canal. When the spinal cord is squeezed in the neck, doctors
call the condition cervical myelopathy. This is an alarming
condition that demands medical attention. Cervical
myelopathy can cause problems with the bowels and bladder,
change the way you walk, and affect your ability to use your
fingers and hand.
Symptoms
What are some of the symptoms of neck problems?
Symptoms from neck problems vary. They depend on your
condition and which neck structures are affected. Some of
the more common symptoms of neck problems are
- neck pain
- headaches
- pain spreading into the upper back or down the arm
- neck stiffness and reduced range of motion
- muscle weakness in the shoulder, arm, or hand
- sensory changes (numbness, prickling, or tingling) in
the forearm, hand, or fingers
Diagnosis
How will my doctor find out what is causing my
problem?
The diagnosis of neck problems begins with a thorough
history of your condition. You might be asked to fill out a
questionnaire describing your neck problems. Then your
doctor will ask you questions to find out when you first
started having problems, what makes your symptoms worse or
better, and how the symptoms affect your daily activity.
Your answers will help guide the physical examination.
Your doctor will then physically examine the muscles and
joints of your neck. It is important that your doctor see
how your neck is aligned, how it moves, and exactly where it
hurts.
Your doctor may do some simple tests to check the
function of the nerves. These tests measure your arm and
hand strength, check your reflexes, and help determine
whether you have numbness in your arms, hands, or
fingers.
The information from your medical history and physical
examination will help your doctor decide which tests to run.
The tests give different types of information.
Radiological Imaging
Radiological imaging tests help your doctor see the
anatomy of your spine. There are several kinds of imaging
tests. X-rays
X-rays show problems with bones, such as infection, bone
tumors, or fractures. X-rays of the spine also can give your
doctor information about how much degeneration has occurred
in the spine, by showing the amount of space in the neural
foramina and between the discs. X-rays are usually the first
test ordered before any of the more specialized tests.
Special X-rays called flexion and extension
X-rays may help to determine if there is instability
between vertebrae. These X-rays are taken from the side as
you lean as far forward and then as far backward as you can.
Comparing the two X-rays allows the doctor to see how much
motion occurs between each spinal segment. MRI
The magnetic resonance imaging (MRI) scan uses
magnetic waves to create pictures of the cervical spine in
slices. The MRI scan shows the cervical spine bones, as well
as the soft tissue structures such as the discs, joints, and
nerves.
MRI scans are painless and don't require needles or dye.
The MRI scan has become the most common test to look at the
cervical spine after X-rays have been taken. CT
scan
The computed tomography (CT) scan is a special
type of X-ray that lets doctors see slices of bone
tissue. The machine uses a computer and X-rays to create
these slices. It is used primarily when problems are
suspected in the bones. Myelogram
The myelogram is a special kind of X-ray test
where a special dye is injected into the spinal sac. The dye
shows up on an X-ray. It helps a doctor see if there is a
herniated disc, pressure on the spinal cord or spinal
nerves, or a spinal tumor. Before the CT scan and the MRI
scan were developed, the myelogram was the only test that
doctors had to look for a herniated disc. The myelogram is
still used today but not nearly as often. The myelogram is
usually combined with CT scan to give more
detail. Bone Scan
A bone scan is a special test where radioactive
tracers are injected into your blood stream. The
tracers then show up on special X-rays of your neck. The
tracers build up in areas where bone is undergoing a rapid
repair process, such as a healing fracture or the area
surrounding an infection or tumor. Usually the bone scan is
used to locate the problem, and other tests such as the CT
scan or MRI scan are then used to look at the area in
detail.
Other Tests
Your doctor may also ask you to have other tests
done. Electromyogram
An electromyogram (EMG) is a special test used to
determine if there are problems with any of the nerves going
to the upper limbs. EMGs are usually done to determine
whether the nerve roots have been pinched by a herniated
disc. During the test, small needles are placed into certain
muscles that are supplied by each nerve root. If there has
been a change in the function of the nerve, the muscle will
send off different types of electrical signals. The EMG test
reads these signals and can help determine which nerve root
is involved. Laboratory Tests
Not all causes of neck pain are from degenerative
conditions. Doctors use blood tests to identify other
conditions, such as arthritis or infection. Other tests may
be needed to rule out problems that do not involve the
spine.
Treatment
What can be done to relieve my symptoms?
Nonsurgical Treatment
Whenever possible, doctors prefer to use treatments other
than surgery. The first goal of these nonsurgical treatments
is to ease your pain and other symptoms.
Your health care providers will work with you to improve
your neck movement and strength. They will also encourage
healthy body alignment and posture. These steps are designed
to slow the degeneration process and enable you to get back
to your normal activities. Medications
Many different types of medications are typically
prescribed to help gain control of the symptoms of neck
pain. There is no medication that will cure neck pain. Your
doctor may prescribe medications to ease pain, fight
inflammation, and to help you get a better night's
sleep. Soft Neck Collar
If your pain is severe, your doctor may recommend a soft
neck collar to keep your neck still for short periods of
time. Resting the muscles and joints can help calm pain,
inflammation, and muscle spasm. Ice and Heat
Applications
You might also be advised to place a cold pack on your
neck for 10 to 15 minutes at a time, or you may be shown how
to do a contrast treatment. Contrast treatments involve
switching between a cold pack and a hot pack. Physical
Therapy
Some doctors ask their patients to work with a physical
therapist. Therapy treatments focus on relieving pain,
improving neck movement, and fostering healthy posture. A
therapist can design a rehabilitation program to address
your particular condition and to help you prevent future
problems. Injections
Spinal injections are used for both treatment and
diagnostic purposes. There are several different types of
spinal injections that your doctor may suggest. These
injections usually use a mixture of an anesthetic and
some type of cortisone preparation. The anesthetic is
a medication that numbs the area where it is injected. If
the injection takes away your pain immediately, this gives
your doctor important information suggesting that the
injected area is indeed the source of your pain. The
cortisone decreases inflammation and can reduce the pain
from an inflammed nerve or joint for a prolonged period of
time.
Some injections are more difficult to perform and require
the use of a fluoroscope. A fluoroscope is a special
type of X-ray that allows the doctor to see an X-ray picture
continuously on a TV screen. The fluoroscope is used to
guide the needle into the correct place before the injection
is given.
- Epidural Steroid Injection: Neck pain or pain that
spreads down the arm may require treatment with an epidural steroid injection (ESI). In an ESI,
the medication mixture is injected into the epidural space
around the nerve roots. Generally, an ESI is given only
when other nonoperative treatments aren't working. ESIs
are not always successful in relieving pain. If they do
work, they may only provide temporary relief.
- Selective Nerve Root Injection: Another type of
injection to place steroid medication around a specific
inflamed nerve root is called a selective nerve root
injection. The fluoroscope is used to guide a needle
directly to the painful spinal nerve. The nerve root is
then bathed with the medication. Some doctors believe this
procedure gets more medication to the painful spot. In
difficult cases, the selective nerve root injection can
also help surgeons decide which nerve root is causing the
problem before surgery is planned.
- Facet Joint Injection: When the problem is thought to
be in the facet joints, an injection into one or more
facet joints can help determine which joints are causing
the problem and ease the pain as well. The fluoroscope is
used to guide a needle directly into the facet joint. The
facet joint is then filled with medication mixture. If the
injection immediately eases the pain, it helps confirm
that the facet joint is a source of pain. The steroid
medication will reduce the inflammation in the joint over
a period of days and may reduce or eliminate your neck
pain.
- Trigger Point Injections: Injections of anesthetic
medications mixed with a cortisone medication are
sometimes given in the muscles, ligaments, or other soft
tissues near the spine. These injections are called
trigger point injections. These injections can help
relieve neck pain and ease muscle spasm and tender points
in the neck muscles.
Surgery
Only rarely is cervical spine surgery scheduled
immediately. Your doctor may suggest immediate surgery if
there are signs of pressure developing on the spinal cord or
if your muscles are becoming weaker very rapidly.
For other conditions, doctors prefer to try
nonsurgical treatments for a minimum of three months before
considering surgical options. Most people with neck pain
tend to get better, not worse. Even people who have
degenerative spine changes tend to gradually improve with
time.
Surgery may be suggested when severe pain is not
improving.
There are many different operations for neck pain. The
goal of nearly all spine operations is to remove pressure
from the nerves of the spine, to stop excessive motion
between two or more vertebrae, or both.
The type of surgery that is best depends on the patient's
conditions and symptoms. Foraminotomy
A foraminotomy is done to open up the neural
foramen and relieve pressure on a spinal nerve root. A
foraminotomy may be done because of bone spurs or
inflammation.
Related Document: A
Patient's Guide to Cervical
Foraminotomy Laminectomy
The lamina is the covering layer of the bony ring
of the spinal canal. It forms a roof-like structure over the
back of the spinal cord. When the nerves in the spinal canal
are being squeezed by a herniated disc or from bone spurs
pushing into the canal, a laminectomy removes part or all of the lamina
to release pressure on the spinal cord.
Related Document: A
Patient's Guide to Laminectomy Discectomy
In a discectomy, the surgeon removes a problem disc.
Surgeons usually do this surgery from the front of the neck.
This procedure is called anterior cervical
discectomy. In most patients, discectomy is done
together with a procedure called cervical fusion
(described next).
Related Document: A
Patient's Guide to Cervical Discectomy Cervical
Fusion
A fusion surgery joins two or more bones into one
solid bone. The purpose for doing spinal fusion is to
increase the space between the vertebrae and to keep the
sore joint from moving. This is usually done by placing a
small block of bone graft in the space where a disc was
removed. Opening up more space enlarges the neural foramen,
takes pressure off the nerve roots, and eases tension on the
facet joints. Cervical fusion is used to treat neck problems
such as cervical radiculopathy, disc herniations, fractures,
and spinal instability. There are two main types of fusion
for neck problems.
The bone graft needs time to heal in order for the fusion
to succeed. This requires the neck to be held still. After
cervical fusion surgery, patients usually have to wear a
special neck brace for several months. These neck braces are
often bulky and restrictive. Recently, surgeons have begun
using metal plates and screws (often referred to as
instrumentation) to lock the bones in place. The instrumentation is
fastened to the vertebrae, where it holds the bones still
while the graft heals. Corpectomy and Strut Graft
A corpectomy relieves pressure over a large part
of the spinal cord. In this procedure, the surgeon takes off
the front part of the spinal column and removes several
vertebral bodies. The spaces are then filled with bone graft
material. Metal plates and screws are generally used to hold
the spine in place while it heals. A corpectomy is used in
cases of severe spinal stenosis and myelopathy.
Related Document: A
Patient's Guide to Cervical Corpectomy and Strut
Graft
Rehabilitation
What should I expect after treatment?
Nonsurgical Rehabilitation
Nonsurgical treatments can maximize the health of your
neck and prolong the time before some type of surgery is
needed. Physical therapy treatment is often prescribed for
two to four weeks for patients with neck pain. Treatments
are designed to help ease pain and to improve mobility,
strength, posture, and function. Therapy treatments will
teach you how to control your symptoms and protect your neck
in the years ahead. You may be given exercises to do on a
regular basis.
After Surgery
Rehabilitation after surgery is much more complex. Some
patients leave the hospital shortly after surgery, but some
surgeries require patients to stay in the hospital for a few
days. Patients who stay in the hospital may visit with a
physical therapist in the hospital room soon after surgery.
The treatment sessions help patients learn to move and do
routine activities without putting extra strain on the
neck.
Many surgical patients need physical therapy outside of
the hospital as well. They often see a therapist for one to
three months, depending on the type of surgery. Therapy
treatments are designed to calm pain and muscle spasm, teach
patients to move safely, and help patients develop strength
and mobility.
As the therapy sessions come to an end, the therapist may
help the patient get back to work. The therapist can do a
work assessment to ensure the patient can do his or her job
safely. Some patients may need to modify their work or other
activities to avoid future problems. | 
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