Neck Pain

Sitting at your desk at work, you struggle to ignore shooting neck pain and headaches as you check your e-mail – it’s a familiar scenario in the life of many Americans. In fact, neck pain, or cervicalgia, is one of the leading reasons people seek help from pain management doctors, with two-thirds of people experiencing neck pain at some point in their lives (Binder, 2007). Fortunately, the highly trained pain management doctors at Wake Spine & Pain Specialists have years of unparalleled experience in bringing lasting relief to patients with neck pain, and we look forward to developing an effective treatment regimen for you that will promote your recovery and restore quality of life.

Anatomy of the Neck

The neck, or cervical spine, is comprised of 7 small vertebrae in addition to muscles, ligaments, intervertebral discs and nerves. The neck is the smallest, most flexible area of the five regions that comprise the spine, which puts it at great risk for acute (sudden) or chronic (long-term) injury. The topmost vertebra, C1, or atlas, is named after the Atlas of Greek mythology, the primordial Titan who supported the heavens, because it supports the globe of the head. The vertebra directly beneath atlas is axis, or C2, which serves as the pivot upon which atlas swings, permitting head movement. Problems with these two uppermost vertebrae can cause muscles in the area to tighten, leading to neck pain.

Spinal Ligaments and Muscles

The most common cause of acute neck pain is myofascial injury in associated muscles and ligaments. Repetitive work, poor posture, sleeping in an awkward position, and heavy lifting are some of the pathways leading to painful tension in cervical connective tissues. Excessive strain can result in local nerve irritation, which may cause pain, numbness and tingling in the neck, shoulders, arms and hands. When nerve irritation affects nerves that exit from the cervical vertebrae, pain and sensory deficits may arise in specific regions of the head and face.

Sudden falls or vehicular accidents can result in strained or torn muscles and ligaments, which can cause severe pain. One variety of neck trauma is whiplash, an injury commonly associated with rear-end vehicular accidents and falls. In whiplash, sudden force from the rear propels the head forward, after which the head snaps back violently to its original position. Whiplash is associated with pain, stiffness, numbness, tingling and burning in the neck, shoulder and back; damage to muscles, ligaments, and facet joints; intervertebral disc problems; nerve root irritation; and even brain injury. Symptoms such as neck pain may present immediately following the injury or within several days of the event.

Spinal Bones

The vertebrae of the spine provide a mobile, supportive framework for the spinal cord and back. These bones interconnect, or articulate, smoothly with each other at special joints called facets. Each facet joint is comprised of articular and transverse processes. The articular processes of a vertebra include two superior (upwardly pointing) processes that are linked to two inferior (downwardly pointing) processes from the preceding vertebral body. These processes project outward and can be felt through the skin. The transverse processes are located on either side of each vertebra and serve as attachment points for muscles and ligaments.

Each vertebra contains a central opening to permit passage of the spinal cord, as well as apertures on either side to accommodate spinal nerves and vessels. Degeneration of the bone from aging and overuse can lead to painful friction between facet joints and compression of nerves that exit the vertebral column.

Sometimes cervical facet joint pain is arthritic in nature. In this condition, facet joint arthritis, painful, destructive friction between the processes of the facet joints results from breakdown of the cartilaginous tissues between each joint. In healthy joints, these tissues provide a smooth cartilage surface and a lubricating fluid that facilitate smooth movement. When these tissues degrade, the bony surfaces grind upon each other, inhibiting movement and causing pain and stiffness that are typically exacerbated upon extending the head backwards. Generally, symptoms of neck arthritis appear around the age of 40, although they can present earlier with trauma.

Vertebral Discs

Problems with intervertebral discs represent another cause of neck pain. Located between neighboring vertebrae are pliable intervertebral discs filled with a soft, gelatinous substance. These discs cushion and promote smooth, flexible movement of the vertebral column. When excess pressure is put on a disc, it may bulge out of place, producing local nerve irritation and compression of the spinal cord, and you may be diagnosed with a bulging disc. Sometimes a disc tear or softening in the outer fibrous layer of an intervertebral disc forces the pliable inner material through the weakened part of the disc. This phenomenon is known as a herniated disc. As in the case of a bulging disc, a herniated disc causes local nerve irritation and compresses the spinal cord, producing pain.

When spinal nerve roots in the cervical region are compressed from disc problems or other reasons, pain often radiates down the length of the nerve. Termed radiculitis, this pain is frequently described as “shooting” since it travels from the spine outward. For example, pain from a compressed cervical nerve may shoot down an arm.

When radiculitis goes untreated, complications such as muscle atrophy, reflex changes and sensory loss may occur over time. In addition, a patient may begin to favor their unaffected side, causing overdevelopment of unaffected muscles. This more severe nerve root condition is known as radiculopathy and underscores the importance of seeking help for your radiating nerve pain.

Other Causes of Neck Pain

Spinal stenosis is another chronic condition that can be responsible for neck pain. In spinal stenosis, pathological narrowing of the spinal canal puts painful pressure on the spinal cord. The condition may result from a variety of causes including arthritis of the spine, herniated discs, congenital defects (abnormalities present at birth) and Paget’s disease, a bone disorder involving abnormal breakdown and regrowth of bone tissue. If your doctor diagnoses you with central spinal stenosis, the narrowing is occurring around the central region of the spinal canal. If your spinal stenosis is “neural foraminal” or “neuroforaminal stenosis,” the narrowing is affecting spinal nerves where they exit through the foramen, which are openings on the sides of the vertebrae.

Another pain-producing ailment of the neck is osteoporosis, an age-related disorder where bones become weaker and more brittle due to loss of bone mass. This weakening heightens the risk for painful vertebral compression fractures of the vertebrae and irritated nerves. Osteoporosis can be diagnosed following a bone fracture using imaging and bone density tests. Treating osteoporosis early can prevent deformity, back pain, broken vertebrae and other fractures.

Chronic neck pain from any long-term condition like osteoporosis, facet arthritis, radiculopathy, and spinal stenosis may lead to central sensitization. In central sensitization, chronic injury and inflammation in peripheral tissues eventually prompt pain receptors in the central nervous system to overreact to normal physical sensations. Low-threshold sensory fibers activated by light touch of the skin trigger neurons in the spinal cord that normally respond only to painful stimuli. As a result, harmless stimuli eventually provoke feelings of pain. To avoid central sensitization, do not delay seeking help for your neck pain.

Rarer mechanisms of neck pain include cancer and infection. In the case of cancer, tumors or metastases to the spine weaken or expand bone in the vertebral column, often leading to fracture, nerve compression, or spinal instability. The most frequent spinal metastases (60%) are from breast, lung, or prostate cancer (Aebi, 2003). In addition, oropharyngeal cancers may sometimes cause neck pain. In the case of osteoporosis, weakened bones lead to painful compression fractures of the cervical vertebrae. And any source of infection (e.g., dental abscess, pneumonia) can seed to the spine; urinary tract infection is the most common (Siemienow et al, 2008).

Emergency Situations

Any of the following symptoms in conjunction with neck pain may constitute a medical emergency:

• mental confusion
• balance changes
• sudden blindness or visual changes
• slurred speech
• severe headaches
• paralysis or new weakness
• bowel or bladder changes
• hearing and taste changes
• severe vomiting
• fever

If your neck pain occurs with any of the above symptoms, you should seek immediate medical attention at an Emergency Room. These symptoms could be caused by potentially life-threatening conditions such as heart attack, stroke, aneurysm, severe spinal stenosis, and meningitis (inflammation of the membranes surrounding the brain and spinal cord).

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Diagnosing Neck Pain

Your doctor may order a variety of tests to help diagnose the cause and severity of your pain. Some of these tests include:

• Imaging studies – MRI, CT scan and X-ray are used to help our practitioners visualize structures that may be causing your pain.
• Medial Branch Blocks (MBBs) – Medial Branch Blocks are a minimally invasive non-surgical treatment used for arthritis-related neck pain. Diagnostically, MBBs are used to test whether your pain-producing medial branch nerves will respond to more permanent interruption by a radio-frequency procedure. They also reduce inflammation and irritation in the facet joints of the spine.
• Selective Nerve Blocks – These are used to help your doctor identify which nerves are causing your pain. By selectively numbing each nerve, pain-causing nerves can be identified and treated.
• Discography – Discography involves the use of contrast dyes to obtain a detailed image of intervertebral discs. It is used to evaluate patients whose neck pain has not improved with comprehensive conservative care regimens. It provides the doctor with detailed information on the pain potential of the affected area, and is commonly used for surgical planning prior to a cervical fusion.

Neck Pain Treatment Options

Treatment of neck pain depends upon the nature and severity of the pain. In general, minimally invasive procedures are tried before more aggressive procedures are used. An abundance of research supports the efficacy of non-surgical procedures in treating neck pain. Below is a basic overview of diagnostic procedures and pain relief options we offer:

• Pharmacotherapy – Non-steroidal anti-inflammatory drugs (NSAIDs, or Ibuprofen-like drugs), Acetaminophen (Tylenol), muscle relaxants, and membrane stabilizing medications are often effective in treating neck pain. Our doctors are highly trained in pain medication management.
• Epidural Steroid Injections – Epidural injections are often used for radicular pain, spinal stenosis, herniated disc, degenerative disc disease, and other pain syndromes. The doctor injects a steroid into the epidural space of the spinal canal, where the irritated nerve roots are located. The medicine then spreads to other levels and portions of the spine, reducing inflammation and irritation.
• Facet injections – These minimally invasive injections can temporarily relieve neck pain caused by inflamed facet joints.
• Spinal Cord Stimulation (SCS) – An implanted electrical device decreases the perception of pain by confusing the pain processing centers in the spinal cord and brain. Initially, a trial is conducted to determine whether this device will help the patient on a long-term basis.
• Lysis of Adhesions (Racz Procedure) – This procedure helps remove excessive scar tissue in the epidural space. It is used in post-laminectomy syndrome, radiculopathy, and disc disease.
• Peripheral Nerve Stimulation – This method involves placement of tiny electrodes near the affected nerves or painful area. The electrodes release a small electrical current that inhibits pain transmission and provides pain relief.
• Radiofrequency Ablation – Nerves branching away from the spinal cord (peripheral nerves) can be blocked with local anesthetic, after which nerve ablation or destruction can be initiated.
• Trigger Point Injections – These injections can extremely successful in alleviating musculoskeletal pain. A local anesthetic and steroid are injected into a “Trigger Point.”
• Transcutaneous Electrical Nerve Stimulation (TENS) – This is a pain relief technique performed by applying mild electric current to the skin at the site of the pain. The electric impulses interfere with normal pain sensations and alter perceptions that were previously painful.
• Biofeedback – This therapy teaches awareness of processes normally thought to be involuntary inside of the body such as blood pressure, temperature and heart rate, enabling some degree of conscious control of these processes. Biofeedback can influence and improve level of pain and promotes relaxation.
• Nutrition and Exercise – Exercise may help manage neck pain by increasing flexibility and range of motion. Another benefit of exercise is the release of pain-relieving hormones called endorphins. In conjunction with a reasonable exercise regimen, good nutrition helps combat nutritional deficits that may hamper the body’s functionality and healing processes.
• Massage – Gentle focal rubbing of tender areas may help relieve muscle spasms or contractions and improve the discomfort associated with these. Massage may also promote relaxation, decreasing stress and tension.
• Chiropractic Manipulations – Targeted physical “adjustments” may significantly reduce neck pain, especially when combined with other modalities. Specialized manipulations intended to correct nerve transmission are delivered by a knowledgeable, experienced practitioner.
• Prolotherapy – Also known as Regenerative Injection Therapy, this technique involves injection of irritating substances into painful ligaments and tendons. The procedure is used to initiate the body’s natural healing processes.
• Occipital Nerve Blocks – This method involves an injection of local anesthetic and corticosteroid over the occipital nerves located in the back of head. The blocks can dramatically improve pain, thereby increasing the quality of your life.
• Occipital Nerve Stimulation – this method involves tiny electrodes being placed close to the occipital nerves located in the back of head. The electrodes release a small electrical current that inhibits pain transmission, which brings pain relief.
• Botox – This is an exciting new treatment for neck pain that is widely accepted in modern medicine. In 2005 Botulinum toxin Type A (BtA) became the first line therapy for the treatment for cervical dystonia, according to a Cochrane Database Systematic Review (Costa, 2005). Botox injections have also been found to be effective in patients with whiplash injuries. Along with reductions in pain, whiplash patients treated with Botox have shown improved range of motion (Juan, 2004).

Most people with neck pain recover within 4 to 6 weeks. Although neck pain may resolve in a relatively short period of time, it often recurs, contributing to the large number of Americans who seek help from pain management doctors for a chronic neck pain condition. Current research suggests early intervention decreases the chance of developing chronic pain which can lead to sensitization, so it is important to consult with a pain specialist promptly to explore your treatment options.

When neck pain threatens to diminish your quality of life, consult with the knowledgeable practitioners at Wake Spine & Pain Specialists. The caring doctors at our pain clinic have received extensive training in foremost pain management techniques and will consult with you to develop a pain management system that works for you.