Neck Pain
Neck pain, much like lower back pain, can have a variety of causes. Often neck pain is self-limiting and improves without surgical intervention. However, there are situations that evaluation by a medical provider is warranted in an urgent fashion:
- Trauma
- Fever or chills
- Difficulty with your balance
- Weakness or frequent dropping of objects
- Numbness in arms, legs or face
- Radiating pain into your arms
- Change in your bowel or bladder function
The following list includes some of the more common problems that can contribute to neck pain.
Muscle Strain
There are numerous paraspinal muscles and ligaments that can cause or contribute to back pain. These muscles provide structural support for the spine and assist in movement. A muscle strain occurs when fibers become stretched or torn. A ligament sprain is a similar finding, with similar symptoms. The pain is typically localized in the back and may worsen with movement. Muscle spasm can lead to significant pain and stiffness in the neck and back.
Treatment
Muscle strains and ligament sprains can be managed conservatively, with medications and activity modification. Physical therapy programs will focus initially on exercises that minimally stress the back and then on exercises that condition the trunk muscles.
Cervical Disc Herniation
The intervertebral disc is made up of a fibrous outer layer called the annulus fibrous and a soft inner layer called the nucleus pulposus. In the cervical spine, each of the seven vertebral bodies is separated by an intervertebral disc. The cervical disc can be bulging, when it extends beyond the peripheral limits of the disc space. It can also be herniated, when the soft inner portion displaces outside of its normal boundaries. Disc herniations can compress a spinal nerve root, causing pain, numbness or weakness into one of the arms. This type of pain is called radiculopathy. Large herniated discs may also cause compression of the spinal cord, which can lead to difficulty walking and feeling off balance.
Diagnosis
The diagnosis of cervical disc herniation is similar to the process for lumbar disc herniation. The presentation of the patient symptoms combined with clinical examination is the first approach. Then an MRI scan is ordered to visualize the disc material and nerve structures. If you are unable to have an MRI, a myelogram and CT scan will be ordered.
Treatment
Conservative treatments include medications and physical therapy. Surgery may also be indicated, when conservative treatments fail or if you develop a neurological deficit.
This cervical spine MRI shows a disc herniation from a sagittal view, causing some pressure towards the spinal cord.
Cervical Stenosis
Cervical stenosis is a narrowing of the spinal canal in the upper region, which results from a combination of ligament thickening, joint overgrowth, disc bulging and a change in the curvature of the spine. It can cause neck pain with radiculopathy and/or myelopathy. Patients may begin to drop objects from their hands and walk with a discoordinated gait. A change in bowel or bladder function may also occur.
Diagnosis
The clinical examination of a patient with cervical stenosis provides important information to the physician about any possible pressure on the spinal cord. Imaging studies include MRI scans, to view the spinal cord and nerves, and also x-rays to see the bony structures in this region. If you are unable to have an MRI scan, a myelogram and CT scan are necessary to view the nerves.
Treatment
Conservative treatments include medications, physical therapy and injections. Surgery may be necessary to decompress the spinal cord and nerves.
Clinical Images
The sagittal view on this cervical spine MRI does not show any significant pressure on the spinal cord. You can see the white fluid, which protects the spinal cord.
This cervical MRI shows stenosis at multiple levels in the spine. You can see from the sagittal view that the space which is normally occupied by the spinal cord has become smaller.
Spondylolysis
A congenital failure of the neural arch to form together is termed spondylolysis. These patients have a defect in the pars interarticularis region of the vertebrae. Spondylolysis leads to slippage, or spondylolisthesis. Often, patients are asymptomatic. However, back pain with or without radiculopathy may develop.
Diagnosis
The best test to visualize spondylolysis is a plain CT scan. X-rays and MRI scans can suggest spondylolysis, but the CT scan is a more definitive test.
Treatment
The treatment of spondylolysis is often conservative, including medications, physical therapy and sometimes a brace. Surgery, when indicated, involves a fusion procedure to stabilize the region.
Clinical Images
This is a CT scan from the lumbar spine, viewed as if you were looking at the spinal canal from the top-down. Notice how the white bone forms a ring. This ring encloses the spinal canal.
Compare this CT to the previous image. Notice in the red circles, the bony ring is interrupted.
Cervical Myelopathy
Myelopathy occurs when there is compression of the spinal cord due to narrowing of the canal. When the compression occurs in the cervical spine, patients typically have a combination of spinal cord and nerve root compression. There may be weakness and wasting of the hand muscles, with slow hand and finger movements. Fine motor movements may appear to be clumsy. Due to the spinal cord compression, patients also typically have weakness in the legs and difficulty walking. The leg reflexes may be spastic. Urinary urgency is also common. When the compression occurs in the thoracic spine, patients may lack the symptoms in the hands and arms. Predominant complaints are typically leg weakness and difficulty walking with urinary urgency. Myelopathy can be caused by severe stenosis secondary to arthritis, which is more likely to occur in the cervical spine. However, spinal tumors can also lead to myelopathy.
Diagnosis
Clinical presentation of myelopathy is often the first step in diagnosis. The MRI will confirm the diagnosis, and is often necessary to visualize the severity of the stenosis. Myelogram with CT scan can be done if MRI is not able to be performed.
Treatment
When a patient presents with myelopathy secondary to cervical or thoracic stenosis, often surgery is necessary to prevent further damage to the spinal cord. Sometimes steroids are used to decrease swelling before surgery. The type of surgical procedure depends on the location of the stenosis, but often involves decompression.
Clinical Example
This patient presented with pain and weakness in the hands and also difficulty with walking. Notice on this cervical MRI there is a white-colored spot within the spinal cord. This spot represents signal changes in the spinal cord, which can indicate swelling.