At one point or another in their lives, most people will experience some degree of neck pain. Most neck pain is acute, results from sudden trauma like whiplash or a muscle strain or sprain, and heals in relatively short time.
In other instances, neck pain may be chronic and indicative of an underlying systemic problem that requires more detailed treatments as opposed to initial conservative methods like pain medications, heat/ice therapy, and other non-surgical options.
Stephen Montgomery, MD, and Grant Cooper, MD, are contributing authors to Spine-health who often treat patients with neck pain. In the following article, both doctors discuss neck pain in greater detail, including:
- different types of neck pain
- neck pain causes
- neck anatomy
- neck pain symptoms and diagnosis
- common neck pain characteristics
- neck pain examination procedures.
Different Types of Neck Pain: Acute vs. Chronic Neck Pain
Dr. Cooper: Dr. Montgomery, I’d like to present you with what I think is a typical case of a patient with neck pain, and then walk through how you would diagnose and ultimately treat this patient. But, before we begin, set the stage for us if you will. What causes most cases of neck pain and just how common a problem is it?
Dr. Montgomery: Well, we see a variety of spinal conditions. The majority of patients that present have low back pain, so lower back pain is much more common than neck pain. We also see a large number of patients who present with either acute or chronic neck pain, sometimes associated with other symptoms--headaches, pain into the shoulder—so neck pain is very common. Millions of patients suffer from that in the United States and all around the world.
Common Causes of Neck Pain
Dr. Cooper: When people come in with neck pain, say it’s a person with acute neck pain, neck pain that’s only been lasting for several weeks or certainly less than three months. What is the most common cause of that? Is it just a muscle sprain?
Dr. Montgomery: These patients tend to have a variety of presenting complaints. I would say that the majority of patients come in with an insidious onset, in other words, symptoms that have come on rather gradually. There is a small subset of patients of course who present with an acute traumatic event—they’ve been in an accident of some kind, a lifting episode—but I would say that the majority in my experience come in with a spontaneous onset. They may wake up in the morning, turn around during daily activity, and have sudden pain that comes on in that fashion.
Dr. Cooper: It just kind of comes on… When they present, are there investigations that can be done? Does the medical community know what’s actually causing it, or in other words, what is the pathology underlying the symptoms?
Dr. Montgomery: I would say, granted, we probably have a better handle on patients with neck symptoms than we do say in the low back area. We can make a diagnosis in the great majority of patients. Unfortunately, there is a small group that we are unable to come up with a very specific anatomic diagnosis for, but there are a variety of anatomic reasons that patients present with neck pain and, once they’re evaluated, we can come up with a treatment algorithm.
Dr. Cooper: So, the cause is generally identifiable, if not in all patients?
Dr. Montgomery: Certainly not in all patients. I would say in the majority perhaps we can have a pretty good idea of what initiated the symptoms, and then what part of the patient’s anatomy may be the source of their discomfort.
Anatomy of the Neck
Dr. Cooper: Are there one or two parts of the patient’s anatomy that stand out, that most people end up having as the cause of the pain, or is it just all over the board, too hard to say which structure in the neck is causing the most neck pain?
Dr. Montgomery: Well, we always try to be as specific as we can in coming up with an anatomic diagnosis. So, we can talk about the various parts of the cervical spine (of the neck) and we can talk about the soft tissues, that is the muscles, the ligaments, the soft tissue supporting structures. We can talk about the bony structures, the bones and the joints of the neck. We can talk about the disc, the shock absorber between the bones of the neck. Or, we can talk about the neural elements, or the spinal cord and the nerve roots. And many times we can be reasonably certain about which part of the anatomy is contributing to the pain. At the same time, in can involve more than one part of the anatomy.
Neck Pain Symptoms and Step-by-Step Diagnosis
Dr. Cooper: Okay, now let’s walk through a patient with a more typical case of neck pain, someone who is, say, a 50-year-old male, and he comes to you and says, “Hey, I’ve had this crick in my neck, maybe I wrenched it to the side the other day, or a few weeks ago, and the pain is just not going away. If anything, it’s getting worse. I’ve tried taking Advil, I’ve tried taking Tylenol, but it’s not getting better. Doc, can you help me?” What would be your approach to this patient?
Dr. Montgomery: Well, certainly we want to take a complete history to see if there are any signs or symptoms that the patient may exhibit that would be a concern. I’ll just run down a brief list. Certainly if patients have neck pain, then we’d like to know if they have any associated symptoms, and one in particular that we would ask about is whether they have radiating symptoms, pain that may go into their shoulder or their arm, any associated numbness, tingling, weakness in the arms. That would be an important symptom.
Dr. Cooper: What might that tell you, if they have those kinds of symptoms?
Dr. Montgomery: Well, we would be concerned if patients had radiating pain, or what we call radicular symptoms, pain radiating into their shoulder and arms, because with this there might be some nerve involvement, like a pinched nerve, and that can come from various causes in the neck.
Dr. Cooper: Now, suppose this is a patient who doesn’t have those symptoms. He says, “Nope, no pain radiating down into my arm or hand, no weakness, no numbness, no tingling. Just this boring neck pain.”
Dr. Montgomery: Well, then we’d have to ask additional questions about whether it was causing pain at night, whether it caused morning stiffness, whether it got better as the day went along, what things made it better, what things made it worse. We would want to know aspects of the patient’s social history. In other words, what sort of work do they do, do they do heavy manual labor, do they sit in front of a computer, do they have a vigorous regular exercise program, or do they get no exercise? All of these questions can lead us to try to pinpoint what part of the anatomy may be the source of the pain.
Dr. Cooper: Certainly. Now, pain at rest or pain at night, is that a worrisome symptom?
Dr. Montgomery: Well, it can be. If it awakens people in the middle of the night, then sometimes it can be related to their sleeping habits, how they sleep, or the different postures when they sleep. Sometimes night symptoms can be a little bit more of a concern if it’s a constant night symptom. This would get back to the issue of whether there’s any systemic illness going on, diabetes or cancer or some other illnesses that may be a little bit more of a concern.
Dr. Cooper: Okay. Now suppose this patient says, “Nope, no night pain. I’ve just got this terrible neck pain that comes on during the day. I sit in front of a computer all day, I don’t exercise much, and the pain seems to get worse during the day and it’s better when I can rest my neck.” What kinds of things does that lead you to and what might you consider doing next in terms of physical exam or imaging?
Dr. Montgomery: Well, if we’ve done our history and we have a pretty good sense of just localized symptoms, as you outline in this particular instance, and they don’t have radiating pain, and we’ve done a complete history and a review of systems and questioned them about their exercise habits, their social history, any systemic illnesses, then we’re going to proceed to the physical examination.
There are some very standard things that health care providers do to evaluate patients with neck complaints. We’re going to examine the patient for range of motion, how much motion they have compared to a normal group of patients, we’re going to palpate the soft tissue to see if there’s any evidence of muscle spasm or discrete areas of tender tissue that may be present, we’re going to check them for vascular supply, in other words, do they have adequate blood supply in their extremities. We’re going to check their neurological status, reflexes, muscle power and sensation. We’re going to check other areas, the shoulder, the elbow, the wrist, to make sure there’s nothing else that may be contributing to some of the pain in the neck, so that’s an important part of a thorough physical examination
In This Article:
Characteristics of Neck Pain
Dr. Cooper: And what are the most common findings that you have during a physical exam? Is the range of motion usually restricted? Are there usually tender spots?
Dr. Montgomery: The majority of patients with neck pain are going to be in their middle years, I’d say we tend to see patients in their 50s, 40s-50s-60s perhaps, and many times they’ll have some restricted range of motion. Some of that can be attributed to some underlying wear and tear thing, some underlying arthritic condition. Some of it can be from inflammation of the soft tissue. Some of it can be from deconditioning, lack of exercise, as well as poor posture. As far as the soft tissue, many patients will exhibit trigger points or areas of tenderness in some of the soft tissue structures in and around the neck.
Common Neck Examination Procedures
Dr. Cooper: Okay. So, let’s say that you’ve taken your history, and it’s the patient that we’ve been describing with basically this isolated neck pain that gets worse during the day, especially when he’s at the computer. You do your physical exam and you find just what we were just talking about with the decreased range of motion and maybe some tender points if not trigger points. What’s next?
Dr. Montgomery: Well, if they’ve come to a health care practitioner who deals with spinal conditions, almost always x-rays are going to be the next thing that we do for diagnosis. These would be plain x-rays of the neck, cervical x-rays, and we usually get a set of four x-rays to look at the bony anatomy. This gives us information on whether there’s underlying wear and tear changes in the neck, whether there are signs of degeneration of the discs, spurs in the neck. Those would be the most common things that we’d be looking for.
Dr. Cooper: Do you ever look for perhaps more serious pathologies, like a fracture or cancer, and how often do those turn up?
Dr. Montgomery: Yes, I would say that the history would give you a pretty good indication whether or not there’s been a major traumatic episode. If we deal with the patients let’s say who have been involved in motor vehicle accidents, what we call whiplash injuries or soft tissue injuries in the neck, it would be unusual to see any bony injury in my experience. So any sort of fracture of the neck would be very uncommon. While we see osteoporotic fractures, or fractures from osteoporosis in the lower part of the spine, the thoracic spine or the low back, they’re much less common in the cervical region. I would say that fractures would be a fairly uncommon scenario with the patient that you’ve outlined.
Dr. Cooper: So the patient gets the x-ray and let’s say that we see what I would presume is the more common scenario of some degenerative changes in the neck. Is that right, first of all? That the most common thing to see on x-ray is some decreased disc space and some other osteoarthritic changes?
Dr. Montgomery: That’s correct. We mentioned that the group of patients many times who present with neck symptoms are going to be in their 40s-50s, and by that time all of us are going to have a little bit of wear and tear, comes with the birthdays rolling around. I could anticipate seeing a little narrowing, perhaps some minor spurring. Now, there’s quite a great deal of variation in that. Some folks in their 30’s can have some changes like that, but that’s not common. It’s usually a little bit later, and we would anticipate seeing those, but if we see widespread wear and tear or degenerative changes, that would perhaps point us towards that as the cause of some of the patient’s symptoms.
Additional disclaimer: Spine-health.com does not offer medical advice or treatment. This information does not replace the physician-patient relationship, and the information is not medical advice or treatment. It should only be considered as a physician's opinion. Patients should always seek the advice of a trained health professional for back pain or any health condition. Please note that the contents of this section have not been peer reviewed by Spine-health.com’s Medical Advisory Board.