Neck pain

Mr Purnajyoti Banerjee FRCS (orth)

 Introduction
• 30%-60% of adults experience significant neck
or radicular pain during lifetime
• Point prevalence 5-10%
• History of previous trauma to cervical spine
increases risk of developing significant axial
neck pain or radiculopathy
 Epidemiology
• 30% + of population has significant neck pain
in lifetime
• ~15% of population with chronic neck pain of
> 6 months
• ~5% of population has disabling symptoms
 Pathophysiology
• Afferent nociceptors in facet joint synovium and
degenerative intervertebral discs likely responsible for most
neck pain

• Loss of disc height, facet arthrosis, osteophyte formation,

and listhesis can all contribute to pathological loading of
facet joints and intervertebral disc

• Fibromyalgia may be perceived as neck pain, often localizes

to trapezium, associated with decreased blood flow, high
resting muscle tension and intramuscular metabolic
derangement

• Although controversial because of the potential for

secondary gain, cervical injury including whiplash as a risk
factor for axial neck pain
 Axial neck pain
• Cervical injury may precede onset of neck pain
-Significant neck pain after trauma common even in
patients who have already settled resulting litigation
presumably decreasing secondary gain

• Axial neck pain should not be painful to palpation, and is

likely to be worse in extension and/or rotation

• Suboccipital pain suggests involvement of the occiput-C1 or

C1-C2 level

• Trigger points associated with fibromyalgia in the region of

the cervical spine are located in the: occiput, lateral aspect
of low cervical spine, trapezius and medial origin of the
supraspinatus
 Physical examination
• Range of motion of cervical spine – often limited by
spondylosis

• Palpation of trigger points to evaluate for fibromyalgia

• Also: lateral condyle, medial knee joint line, greater

trochanter, medial 2nd rib and upper, outer quadrant of
buttocks

• Complete sensory, strength, gait and reflex evaluation

• Although a patient’s pain may be predominantly in the

neck, this does not preclude myelopathy or an
unrecognised motor deficit
 Investigation
• Anteroposterior, lateral, and lateral flexion
and extension radiographs establish baseline
evaluations and may show dynamic instability

• MRI is gold standard for evaluation of disc

pathology such as annular injury, disc
dessication and facet arthritis

• Caution needed because of high prevalence of

findings in asymptomatic population
 Natural History
• At 15 year follow-up with nonoperative care, 79% of patients had
symptom improvement in comparison to pain level at presentation

• 43% were pain-free, 32% had moderate/severe pain

• Factors associated with persistent pain:

- severe pain on presentation
-history of related injury

• Axial neck pain rarely progresses to myelopathy

• ~20% of patients presenting with severe pain will still be

significantly disabled at 5 years
 Conservative treatment
• May include: steroids, NSAIDs, narcotics,
muscle-relaxants
• Physiotherapy
• Traction has not been shown to offer any
benefit
• Ill defined but can be beneficial with
favourable natural history
 Surgical treatment
• Axial neck pain is a contraindication to cervical
disc replacement
• Anterior cervical discectomy and fusion is the
procedure of choice for carefully selected
patients who fail nonoperative treatment
• Retrospective studies report good/excellent
results in 60-80% with poor results in 5-20%
 Cervical Radiculopathy
• Mechanical compression of nerve roots can result from several
causes:
- Loss of disc height, facet arthritis, uncovertebral joint osteophytes,
ligamentum flavum hypertrophy and disc herniation

• Chemical irritation of nerve roots occurs with exposure to

herniated nucleus pulposus mediated by TNF-alpha contained
within degenerative disc

• Foraminal stenosis and associated instability can cause symptom

worsening with extension or rotation to the ipsilateral side as the
neural foramen cross-sectional area decreases in these positions

• Conversely, arm abduction causes relative lengthening of cervical

roots and may result in pain relief
 Presentation
• Patients typically present with pain in a
dermatomal distribution in upper extremity
• Pain may be burning, sharp or electric, can be
accompanied by motor weakness or sensory
changes
• Positional changes in foraminal area may lead
patients to turn their head to the opposite side or
abduct their arm overhead (shoulder abduction
sign)
• Neck pain also present in 80%
 Physical examination
• Important to identify dermatomes/myotomes affected
through history and physical examination to treat only
symptomatic levels
• Spurling’s test – exacerbation of pain with extension
and rotation of head toward painful side
• Complete sensory, strength, gait and reflex evaluation
• Patients may present with concomitant myelopathy
• Pain, motor and sensory dysfunction can also result
from peripheral nerve entrapment and thoracic outlet
syndrome which must be ruled out
 Investigations
• MRI is gold standard for evaluation of nerve
compression, pathology must correlate with
dermatomal complaints when indicating
surgery
• EMG useful to differentiate cervical from
peripheral nerve compression
 Conservative treatment
• Natural History
• 70-90% of patients have good outcome with
nonoperative care
• Pain typically resolves within 6-12 weeks
• Conservative treatment
• Early treatment – brief course of opioiates if
necessary, brief immobilization with soft collar,
short steroid course may be helpful
• Later treatment may include: NSAIDs, muscle-
relaxants, physical therapy and stretching
 Surgical management
• Anterior Approach – Fusion
- Indicated for soft disc herniation, bilateral
symptoms, significant neck pain, kyphotic cervical
alignment
- Usually not performed when addressing more
than 3 levels as nonunion rates rise unless posterior
instrumentation used
• Anterior Approach – Cervical Disc Replacement-
-Theoretical benefit of reducing adjacent level
disease
-Elimination of increased load seen by motion
segment adjacent to fusion, not yet proven
clinically
 Posterior Approach

• Indicated for soft posterolateral HNP

– lateral recess or foraminal stenosis
– facet arthropathy with posterior compression
– > 3 level surgery

• Must have cervical lordosis for

decompression to be effective (> 10°)
 Cervical Myelopathy
• Myelopathy likely with cord narrowing >40% or
banana-shaped cord on axial MRI images
• While degenerative changes often cause
myelopathy in older population (most common at
C5-6 and C6-7), younger patients may become
myelopathic due to untreated HNP
• Congenital stenosis (canal diameter <13mm
predisposes patients to myelopathy
• Gait and bladder disturbances likely secondary to
spinothalamic and cortico spinal tract
compression
 Presentation
• May present with isolated myelopathy or with
radicular pain plus signs of cord compression
• Typical history often includes: difficulty
writing, trouble with buttons or zippers,
dropping objects, gait disturbances or
clumsiness, and falls
 Physical examination
• Evaluation of gait and balance
• Repetitive tasks such as rapid tapping of thumb and index
finger pads or slapping thigh alternating between palm and
dorsum of hand will be difficult and slow in patients with
myelopathy
• Complete sensory, strength, and reflex evaluation
• May see clonus or hyperactive reflexes
• Radicular and myelopathic symptoms often coexist so can
find sensory or motor deficiencies on examination
• Special signs
- Lhermitte’s sign – electric pain in back of neck on flexion
- Babinski’s sign – great toe dorsiflexion on plantar stroke
- Hoffman’s reflex – thumb IP flexion with flicking of 3rd or
4th fingernail
 Investigations
• Anteroposterior, lateral, and lateral flexion and
extension radiographs
• Pavlov ratio to screen for congenital stenosis
• AP diameter canal/AP diameter body <0.8 is
pathologic
• MRI is gold standard for evaluation of neural
impingement and may demonstrate cord signal
changes with severe compression
• Prognostic value of cord signal changes unclear,
however
 Natural history
• Insidious onset of symptoms with long periods of
stability without deterioration
• These stable periods are punctuated by episodic
worsening of symptoms after which a new
functional baseline is established and function
rarely regained
• ~5% have rapid onset of symptoms with no
further progression
• Delay of 1 year in mild cases does not affect
surgical outcome
 Conservative treatment
• Possible for elderly patients with minimal
symptoms and in patients with severe medical
co-morbidities
• May include: NSAIDs, physical therapy
• Patients with myelopathy should avoid
activities that will put them at risk for spinal
cord injury given the reduced tolerance for
trauma
 Anterior approach
• Patients with mild symptoms may not benefit from
surgery,
• especially in the elderly
• Indications based around level of disability, degree of
pain
• Milder symptoms may be indication in younger
patients, those with evidence of congenital canal
stenosis on imaging
• Anterior surgical indications (ACDF or corpectomy):
-One to three affected levels
- Any number of levels with loss of cervical lordosis
-Should not be used for congenital stenosis or posterior
based cord compression
• Significant axial neck pain
 Posterior surgery
• Laminectomy or laminoplasty:
- More than 3 affected levels with preserved
lordosis
- Cervical kyphosis with concomitant anterior
procedure
• Need wide decompression so
laminoforaminotomy not indicated
• Technique and surgical considerations same as for
radiculopathy
• Recovery of function depends on severity of
preoperative myelopathy
Thank you

Questions