[Harrison]

While doing some research, I found the following page was expired...but I found an archived (cached) page. There is some useful diagnostic information herein. It's also (er, was) one of the few places on the Internet where you will find a doctor admitting that Lyme disease (et al pathogens) can directly cause a cervical spine disorder! Does anyone else find it significant that a rheumatologist is admitting this?!

Some of the formatting was funky, so I'll attach a PDF of this content too. I am guessing this was written in 2003. It was published the GWU web site in 2004 and removed in 2005.
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Management of Neck Pain: A Primary Care Approach
DAVID G. BORENSTEIN, George Washington University

Among the many disorders that cause neck pain, biomechanical stress is the most common. Nonoperative therapies offer relief in most patients within three months. Those with chronic or radicular pain require additional evaluation and multiple therapies for effective relief. Systemic illness and spinal compression require prompt intervention to prevent serious complications.

Dr. Borenstein is Clinical Professor of Medicine, The George Washington University Medical Center, Washington, D.C.

A common complaint evaluated by primary care physicians, neck pain affects about 10% of the population of the United States every year. Although cervical spine disorders have a diverse etiology (Table 1), biomechanical disorders that occur secondary to overuse, trauma, or deformity are the most common cause of neck pain. Typically, these disorders are characterized by correlating exacerbation or alleviation of symptoms with certain physical activities.

Table 1. Causes of Cervical Spine Disorders

Biomechanical
Neck strain
Herniated disk
Spondylosis
Myelopathy
Myelopathy

Infectious
Osteomyelitis
Diskitis
Meningitis
Herpes zoster
Lyme disease

Referred
Thoracic outlet syndrome
Pancoast's tumor
Esophagitis
Angina
Vascular dissection

Neurologic
Brachial plexitis
Peripheral entrapment
Neuropathies
Reflex sympathetic dystrophy

Rheumatologic
Rheumatoid arthritis
Ankylosing spondylitis
Psoriatic arthritis
Reiter's syndrome
MyelopathyEnteropathic arthritis
Polymyalgia rheumatica
Fibromyalgia
Myofascial pain
Diffuse idiopathic skeletal hypertrophy
Microcrystalline disease

Neoplastic
Osteoblastoma
Osteochondroma
Giant cell tumor
Hemangioma
Metastases
Multiple myeloma
Chondrosarcoma
Chordoma
Gliomas
Syringomyelia
Neurofibroma

Miscellaneous
Paget's disease
Sarcoidosis

Most biomechanical disorders of the cervical spine have a natural history of improvement. More than 50% of patients will have decreased pain in two to four weeks; 80% will be asymptomatic in two to three months, and most will improve without requiring diagnostic x-rays or laboratory tests. Such studies are reserved for patients with histories or physical findings that suggest cord or nerve root compression or systemic illness. These disorders are uncommon causes of neck pain but require thorough evaluation and immediate treatment.

Spinal Compression

Cervical myelopathy occurs secondary to compression of the spinal cord or nerve roots in the spinal canal. Only one third of patients complain of neck pain. Although cervical myelopathy is rare, one form, spondylitic myelopathy, is the most common cause of spinal cord dysfunction in patients older than age 55. The location, duration, and size of lesions influence the severity and distribution of symptoms. Compression usually results from a combination of osteophyte growth and degenerative disk disease. Symptoms may involve all limbs and include difficulty in walking and urinary or fecal incontinence.

The most frequent presentation is arm and leg dysfunction. Older patients may describe leg stiffness, foot shuffling, and a fear of falling. Common findings include weakness of the appendages, spasticity, fasciculations, and hyperreflexia, clonus, and Babinski's reflex in the lower extremities.

Many imaging techniques can be used for diagnosis. Plain x-rays reveal advanced degenerative disease with narrowed disk spaces, facet joint sclerosis, and osteophytes; computed tomographic (CT) myelograms can distinguish osteophytes from protruding disks, and magnetic resonance imaging (MRI) can detect the extent of spinal cord compression (Figure 1). Plain x-rays are the most convenient test to use but do not reveal nerve compression. CT myelograms are used presurgically to identify bone, disks, and canal space.

Cervical spondylitic myelopathy has a gradual progression; severe myelopathy seldom develops in patients who do not exhibit signs at presentation. Although some patients improve with conservative therapy, those with progressive myelopathy require surgery to prevent further cord compression, vascular compromise, and myelomalacia. Obviously, surgery is most effective when performed before severe neurologic deficits develop.

Systemic Illness

Positive responses to one or more questions about systemic symptoms accompanying neck pain necessitate additional evaluations.

Tumors. Pain with fever or weight loss suggests the presence of a tumor or infection. Pain that is greatest at night or with recumbency is associated with infiltration of the spinal cord and tumors of the vertebral column. Patients with neurologic signs should undergo MRI of the central nervous system. A spinal cord tumor appears as a single mass; in contrast, demyelinating disease produces multiple lesions.

Patients who have nocturnal pain without neurologic signs may have a bone tumor. Benign tumors tend to affect the posterior elements of vertebral bodies. If plain x-rays are unable to detect alterations in vertebral architecture, bone scans are sensitive alternatives for revealing lesions over the entire axial skeleton. CT scans can locate suspected tumors not detected with other imaging methods. All tumors should be biopsied and treated; surgical excision is preferred for accessible tumors.

Spondyloarthropathies and Other Rheumatic Diseases produce early-morning neck stiffness that lasts for hours. Patients usually have extensive disease in other articular locations. Flexion-extension views reveal the presence of C1-C2 subluxation. Women with spondyloarthropathy may have neck disease without low back pain. A Ferguson view of the pelvis is a useful test to detect sacroiliitis if neck x-rays do not reveal syndesmophytes or squaring of vertebral bodies. Patients with polyarthritis can be identified with bone scans and erythrocyte sedimentation rate (ESR) measurement; treatment requires maximum doses of nonsterodial anti-inflammatory drugs (NSAIDs). Joint instability warrants bracing or surgical fusion if neural dysfunction is documented.

Polymyalgia rheumatica occurs predominantly in women older than 60 years. In such patients, pain is often localized to the proximal muscles of the shoulders and thighs. An elevated ESR is the most common laboratory finding. Treatment with daily low-dose corticosteroids is often effective.

Visceral Source of Pain. Patients may have neck pain secondary to cardiovascular, gastrointestinal, or neurologic disorders. Vascular lesions in the neck (carotodynia) can cause localized pain. Esophageal disorders should be considered if neck pain occurs when patients are eating; posterior esophageal lesions may affect the prevertebral space to produce pain. An esophagram can identify abnormalities of peristalsis or structure; endoscopy may detect intrinsic esophageal lesions. Neurologic disorders may involve cranial nerve lesions that cause cervical spine and facial pain.

Nonoperative Therapies
Patients without systemic disorders should be treated with nonoperative therapy for three to six weeks. Among the available therapies, NSAIDs can decrease the pain and inflammation that is associated with localized disease. Although agents with rapid onset and good analgesic effect are preferred, those with sustained-release properties may offer better relief with fewer tablets per day. Muscle relaxants do not affect peripheral muscles but do offer additional relief for patients with increased paracervical muscle contractions; physicians should in- form patients of these drugs' potential sedative effect. Temperature modalities may also be useful. Ice massage for 10 minutes provides additional analgesia in some cases, whereas application of heat may decrease muscle tightness and improve range of motion in others. Injection of a mixture of 1 mL of semisoluble corticosteroid and 3 to 5 mL of lidocaine into the area of maximum tenderness in the paravertebral musculature or trapezii may be another way to decrease pain.

Patients should understand that the eventual goal of therapy is a return to normal neck motion. This may be difficult to accomplish. Patients often prefer to wear a cervical collar and limit motion. Short-term immobilization is useful--particularly at night, when movement during sleep causes pain. A soft collar that supports but does not extend the neck is an appropriate treatment; however, its use should decrease as neck pain diminishes. The use of a collar with cervical hyperextension should be severely limited; in contrast, patients with disk herniations will require full-time collar immobilization to limit radicular pain for longer periods.

Most patients, including those with cervical radiculopathy, improve and return to normal activity within two months. Patients who are still symptomatic after six weeks of nonoperative treatment are separated into two groups--those with neck pain and those with arm pain as the major complaint.

Neck Pain as the Major Complaint

Patients with pain only in the cervical area, trapezii, and shoulders may have one of many disorders. The different types of relevant biomechanical neck pain may be differentiated by characteristics summarized in Table 2.

Table 2. Selected Characteristics of Biomechanical Neck Pain (See PDF)

Strain causes pain in the middle or lower portion of the posterior neck. The pain may be diffuse or localized to both sides of the spine. Physical examination reveals local tenderness in the paracervical muscles, decreased range of motion, and loss of cervical lordosis. No abnormalities are found with neurologic or shoulder examinations. X-rays of the spine may be normal or reveal a loss of lordosis. Laboratory test results are normal.

Therapy for chronic cervical strain includes NSAIDs, muscle relaxants, local injections, and exercises (including strengthening and range-of-motion). The choice and dosage of NSAIDs may be modified for patients with severe chronic pain.

Cervical Spondylosis (Osteoarthritis) is associated with disk degeneration and approximation of articular surfaces. Instability causes osteophyte formation in the uncovertebral and zygapophyseal joints, and diffuse pain may radiate from the neck to the shoulders, occipital area, or the interscapular muscles. Physical examination may reveal midline tenderness and pain at the limit of motion with extension and lateral flexion.

Radiographic findings are significant only if they correlate with the patient's clinical signs and symptoms. Plain x-rays of the cervical spine typically demonstrate intervertebral narrowing and facet joint sclerosis. MRI reveals degenerative cervical disk disease in more than 50% of patients 40 years of age or older. Scans are indicated in patients who have persistent pain that radiates to the shoulders; imaging serves to locate nerve impingement for subsequent treatment.

Patient education is essential for pain management. Most patients have a relapsing course with recurrent exacerbations of acute neck pain; hence, therapy requires a balance between stability and maintenance of motion. Range-of-motion exercises maximize neck flexibility; cervical collars decrease pain by restricting neck movement. NSAIDs and local injections may help to diminish neck and referred pain.

Cervical Hyperextension (Whiplash) is an acceleration-deceleration injury to the soft tissue structures in the neck. Common causes include rear-impact motor vehicle accidents, falls, and diving accidents and other sports injuries. Paracervical muscles are stretched or torn, and the sympathetic ganglia may be damaged, resulting in Horner's syndrome, nausea, hoarseness, or dizziness; intervertebral disk injuries occur with severe trauma.

The first symptoms occur 12 to 24 hours after trauma. Patients experience stiffness and pain with motion; they may also have difficulty in swallowing or chewing. Physical examination reveals soreness, paracervical muscle contraction, and decreased range of motion. Neurologic examination is often unremarkable, but radiographs can reveal loss of cervical lordosis. In severely injured patients, structural damage identified on x-rays mandates immediate stabilization.

Nonnarcotic analgesics, NSAIDs, and muscle relaxants reduce pain and facilitate neck movement. Treatment of most whiplash injuries includes use of a cervical collar for a minimal period of time. The collar is removed as soon as pain relief is obtained. Longer use of collars has resulted in delayed recovery. The Quebec Task Force on whiplash-associated disorders showed that prolonged use of cervical collars resulted in increased pain, decreased range of motion, and a longer recovery. Patients whose symptoms last for more than six months usually have a zygapophyseal joint injury and rarely experience significant improvement.

When fever or weight loss develops during nonoperative management, patients should undergo x-ray evaluation to assess bone integrity. If x-rays are negative, MRI or CT scans may locate the lesion and guide placement of biopsy needles.
Elevated ESR or C-reactive protein values identify patients with inflammatory lesions. The ESR may also be monitored during therapy to document improvement. Antibiotics are the treatment of choice for osteomyelitis and diskitis in the absence of neural compromise or paracervical abscess.

Fractures. Pain directly over the bony structures (vertebral arch or body) of the cervical spine is usually a sign of fracture or expansion of bone; physical examination can locate the point of maximum tenderness. Conditions that replace bone with abnormal cells or increase mineral loss from trabeculae predispose patients to fractures that occur spontaneously or with minimal trauma and result in localized pain.
Imaging techniques can identify the location of fractures if the physical examination is equivocal. Bone scans are helpful when x-rays of the neck are normal. MRI can identify the presence of malignant cells that do not stimulate osteoblast activity (e.g., myeloma). Biochemical and hematologic tests may detect perturbations of calcium meta- bolism or the presence of hemo- globinopathies; as noted, an elevated ESR is common with inflammation.

Fibromyalgia. Patients without systemic disorders should be examined for tender or trigger points. Such patients will have normal ESRs but experience localized pain with pressure (tender point) or radiation of muscle pain distal to the area of pressure (trigger point). Tender points are associated with a generalized pain syndrome, fibromyalgia; trigger points are associated with myofascial pain syndrome.
Patients with fibromyalgia benefit from aerobic exercise and antidepressants; those with myofascial disorders improve with injections of combined anesthetic and semisoluble corticosteroid. If patients do not have muscle tenderness, they should undergo a complete psychosocial evaluation. In patients with psychiatric disturbances, conversion reactions or substance dependence often are the cause of neck pain.

Arm Pain as the Major Complaint

Disk Herniation. In patients with arm pain refractory to nonoperative management, the underlying cause often is pressure from a herniated disk or hypertrophic bone and secondary inflammation of the nerve roots. Herniation can result from sudden exertion, as in heavy lifting. Neck pain is minimal or absent, and the injury causes pain that spreads from the shoulder to the forearm and hand and is sometimes severe enough to limit arm use.

Physical examination will detect increased radicular pain with any maneuver that narrows the intervertebral foramen and places tension on the affected nerve, such as compression, extension, or lateral flexion of the cervical spine (Spurling's sign).
Neurologic examination will reveal sensory abnormalities, reflex asymmetry, or motor weakness correlated with the affected spinal nerve root and degree of impingement. The characteristics of radicular pain caused by nerve root compression are summarized in Table 3.

Table 3. Characteristics of Radicular Pain Caused by Cervical Nerve Root Compression

Nerve Root
Area of Pain
Sensory Loss
Motor Loss
Reflex Loss
C5
Neck to outer shoulder, arm
Shoulder
Deltoid
Biceps, supinator
C6
Outer arm to thumb, index finger
Index finger, thumb
Biceps
Biceps, supinator
C7
Outer arm to middle finger
Index, middle fingers
Triceps
Triceps
C8
Inner arm to ring and little finger
Ring, little fingers
Hand muscles
None

MRI is the best technique to locate disk herniation and nerve root impingement; electromyography and nerve conduction tests will document nerve dysfunction and differentiate peripheral entrapment syndromes (e.g., carpal tunnel syndrome) from spinal nerve impingement.

Therapy includes controlled physical activity, firm cervical collars, NSAIDs, and traction. Patients may require full-time collar immobilization to limit radicular pain for weeks at a time. Those with recalcitrant pain may also obtain relief from epidural corticosteroid injections at the level of nerve impingement documented by MRI. Low-dose oral corticosteroids (10 mg to 15 mg/day) may be considered for patients who refuse epidural injections. Corticosteroids should be used for a limited period; dosage is tapered slowly once radicular symptoms have resolved. Many patients' arm symptoms resolve within three months.

When there is unequivocal evidence of nerve root compression (i.e., physical findings corroborated by MRI or CT findings), surgical decompression should be considered. Some studies suggest that patients who undergo such surgery do better than those who do not. Although nonoperative management of patients with radicular pain may prevent progression to cervical myelopathy, some patients nevertheless experience persistent arm pain. When performed in selected patients with good technique, surgery is successful for more than 90% of cases. In one study, for example, anterior diskectomy with fusion achieved excellent outcomes in 94% of patients.

Other Causes. Patients with arm pain that occurs with exertion should undergo a vascular evaluation. If chest pain occurs in conjunction with arm pain, coronary artery disease (CAD) should be investigated with an electrocardiogram and a stress test; positive stress test results (reproduction of arm pain) confirm the presence of CAD. Exertional pain limited to the arm suggests thoracic outlet syndrome. Adson's test can detect the impingement. The test is performed by taking the patient's pulse at the wrist. While the pulse is continuously palpated, the arm is then abducted, extended, and externally rotated. The patient takes a deep breath and turns the head toward the arm being tested. Compression of the subclavian artery results in a marked diminution of the radial pulse. Patients with thoracic outlet syndrome may benefit from isometric shoulder girdle exercises, improved posture, and restriction of arm movement above the head. Surgery is helpful in a minority of patients who do not respond to other therapy.

Patients with persistent arm pain, numbness, and weakness require an apical view chest x-ray to rule out Pancoast's tumor, which invades the inferior portions of the brachial plexus and causes pain by compression of local neural tissues. Such patients require palliative radiation therapy.

Chronic Neck Pain

Patients without a specific diagnosis are considered to have chronic neck pain. Education, patience, and encouragement are important components of therapy. Chronic pain management requires convincing the patient that the goal of therapy is to maximize physical function. A combination of therapies is necessary to reach this goal. Exercise programs that improve aerobic conditioning and range of motion are helpful. Patients may benefit from an increased NSAID dosage or switching to a different NSAID. Tricyclic antidepressants offer additional pain relief mediated through the central nervous system. Narcotic analgesics are generally discouraged but may be used at a specified effective dose to treat patients who experience an acute exacerbation of pain. The goal for these patients is gradual decrease of dosage and eventual discontinuance of narcotic analgesics.

Patients with chronic pain should be encouraged to return to some form of work. Movement aids the adaptive process by improving function and countering the inactivity that can exacerbate pain. The appearance of new symptoms or marked exacerbation of preexisting complaints are indications for reevaluation.

Conclusion

Many disorders are implicated in neck pain, but biomechanical problems of the cervical spine are the most common cause. Diseases affecting the cervical spine are rare but important causes of pain; certain symptoms and signs help to identify the more serious clinical conditions. Most patients improve with nonoperative therapy within three months; only about 10% of patients require surgical intervention.
Selected Reading

Aker PD et al: Conservative management of mechanical neck pain: Systemic overview and meta-analysis. BMJ 313:1291, 1996
Bell GR, Ross JS: The accuracy of imaging studies of the degenerative cervical spine: Myelography, myelo-computed tomography, and magnetic resonance imaging. Semin Spine Surg 7:9, 1995
Bernhardt M et al: Cervical spondylitic myelopathy. J Bone Joint Surg 75A:119, 1993
Borenstein DG, Wiesel SW, Boden SD: Neck Pain: Medical Diagnosis and Comprehensive Management, WB Saunders, Philadelphia, 1996, pp 161-437
Brodsky AE: Cervical angina: A correlative study with emphasis on the use of coronary arteriography. Spine 10:699, 1985
Ferrante FM et al: Clinical classification as a predictor of therapeutic outcome after cervical epidural steroid injection. Spine 18:730, 1993
Herkowitz HN, Kurz LT, Overholt DP: Surgical management of cervical soft disc herniation: A comparison between the anterior and posterior approach. Spine 15:1026, 1990
Lehto IJ et al: Age-related MRI changes at 0.1 T in cervical discs in asymptomatic subjects. Neuroradiol 36:49, 1994
Lindgren K, Oksala I: Long-term outcome of surgery for thoracic outlet syndrome. Am J Surg 169:358, 1995
Martel W: The occipito-atlanto-axial joints in rheumatoid and ankylosing spondylitis Am J Roentgenol 86:223, 1961
Praemer A, Furner S, Rice DP: Musculoskeletal Conditions in the United States. American Academy of Orthopaedic Surgeons, Park Ridge, Ill., 1992, pp 23-33.
Redford JB, Patel AT: Orthotic devices in the management of spinal disorders. Phys Med Rehabil 9:709, 1995
Spitzer WO et al: Scientific monograph of the Quebec Task Force on whiplash-associated disorders: Redefining "whiplash" and its management. Spine 20(suppl 8):1S, 1995
Watt I, Cummins B: Management of rheumatoid neck. Ann Rheum Dis 49:805,1990


Was originally published here: http://www.uphs.upenn.edu/medicine/Medicine/Jaeger_Archive/neck_pain.htm