Epidemiology

Prevalence

• A UK study found that 18% had neck pain at the time of the survey, and half of those (58% of the symptomatic patients responded) still had pain when asked one year later.^[1]
• X-ray findings suggest that 90% of men older than 50 years and 90% of women older than 60 years have evidence of degenerative changes in the cervical spine.^[2] The boundary between normal ageing and disease process is difficult to define.^[3]
• Both sexes are affected equally, but problems begin earlier in males.

Presentation

Symptoms

• Cervical pain worsened by movement.
• Referred pain (occiput, between the shoulder blades, upper limbs).
• Retro-orbital or temporal pain (from C1 to C2).
• Cervical stiffness - reversible or irreversible.
• Vague numbness, tingling or weakness in upper limbs.
• Poor balance.

Signs

• Limited range of movement (forward flexion, backward extension, lateral flexion, and rotation to both sides).
• Minor neurological changes like inverted supinator jerks (unless complicated by myelopathy or radiculopathy).
• Poorly localised tenderness.

Radiculopathy^[4]

Suspect this where there is unilateral neck, shoulder, or arm pain approximating to a dermatome. There may be accompanying changes in sensation or weakness in related muscles. Note: pain or paraesthesia radiating into the arm is a nonspecific sign for nerve root pain.

• There may be postural asymmetry with the patient flexing their head to decompress the nerve root.
• Neck movement may be restricted.
• Dural irritation can be demonstrated with the Spurling test (flexion of the neck laterally, rotation and pressure on the top of the patient's head) - typical radicular pain is reproduced if the test is positive.
• The most commonly affected nerve roots are between the C5 to C7 levels.
• Sensory symptoms (shooting pains, numbness, hyperaesthesia) are more common than weakness.
• Reflexes are usually diminished at the appropriate level (biceps - C5/6, supinator - C5/6, or triceps - C7).

Differential diagnosis

• Other nonspecific neck pain lesions, eg acute neck strain, postural neck ache or whiplash.
• Malignancy - primary tumours, secondary deposits or myeloma.
• Infections, eg osteomyelitis or tuberculosis.
• Mechanical lesions; disc prolapse.
• Fibromyalgia.
• Psychogenic neck pain.
• Inflammatory disease, eg rheumatoid arthritis.
• Metabolic diseases eg Paget's disease of bone, osteoporosis.

Investigations

Most patients do not need further investigation and the diagnosis is made on clinical grounds alone.

• Plain X-ray of cervical spine showing formation of osteophytes, narrowing of disc spaces with encroachment of intervertebral foraminae. This is not diagnostic as these findings are common in normal middle-aged patients.
• Patients with neurological abnormality will need magnetic resonance imaging (MRI) of the cervical spine at an early stage, particularly if they have progressive myelopathy, radiculopathy or intractable pain. High-signal intensity lesions on MRI indicate a poor prognosis.^[2]

Management

There is little robust evidence to support many of the commonly used treatments. Most GPs will employ a 'wait and see' strategy, expecting a favourable natural course supported by medication, or referral to a physiotherapist.^[6]

General measures^[7]

• For the first 3-4 weeks, provide reassurance that neck pain is common and is likely to resolve. The patient should be advised to keep active, maintain their normal activities and to avoid the use of a cervical collar. Strongly discourage prolonged absence from work.
• Advise against driving if the range of neck movement is restricted.
• Patients should be advised to use only one firm pillow at night.
• Identify and address psychosocial factors that increase the risk of chronicity and disability, eg underlying concerns about the neck pain, unrealistic expectations of treatment, disabling sickness behaviour, mood disorders.
• Similarly, identify and address workplace-associated risks for developing neck pain. Offering postural advice on daily activities, work and hobbies may be helpful for some patients.
• Where symptoms are more prolonged (4-12 weeks), refer to physiotherapy for a multimodal treatment strategy (see under 'Mechanical' below) and consider referral to a psychologist or occupational health doctor.
• Where symptoms have become chronic (>12 weeks), continue examining psychosocial factors, consider referral to a pain clinic or, where there are nerve root symptoms, consider referral for assessment for surgical intervention.

Mechanical

There is moderate evidence that multimodal care (mobilisation, manipulation and various exercise regimens) provide short- and long-term benefit for those with mechanical neck pain.^[8]

• Yoga, the Pilates method, and the Alexander Technique all improve neck posture, but their value in treating neck pain is uncertain.
• The use of cervical exercises has been advocated in patients with cervical spondylosis. Key components include stretching and strengthening exercises concentrating on the musculature of the cervical and shoulder-thoracic area.^[9] The optimum exercise programme has not been defined.
• There is moderate evidence that acupuncture decreases neck pain more than sham treatments.^[10]
• There is no conclusive evidence about the effectiveness of traction compared with a range of other treatments in patients with chronic neck pain.^[11] Traction has been widely used, because it was thought to immobilise the cervical region and widen the foraminal openings.^[12]

Pharmacological

• When pain is severe, analgesics and anti-inflammatory agents are widely used, despite evidence of no clear benefit.^[13]
• Low-dose tricyclic antidepressants, like amitriptyline 10-30 mg per night, are also used where the pain is not responsive to standard analgesics.^[5]

Surgical

Indications for surgery include:

• Progressive neurological deficits.
• Documented compression of the cervical nerve root, spinal cord, or both.
• Intractable pain.

However, the outcome of decompressive surgery is often disappointing, especially for myelopathy complicating cervical spondylosis. While progression of the neurological deficit may be slowed by surgery, lost function may not recover or symptoms may progress at a later date. Poor outcome after surgery may reflect irreversible damage to the cervical cord or compromise to the vascular supply to the cord.^[5] A recent Cochrane review concluded that there is currently insufficient evidence to determine whether the risks of surgery are outweighed by benefits, such as more rapid relief of pain, and low-grade evidence that surgical patients do no better than those receiving conservative management in the longer-term.^[14]

Epidural injection in the cervical region is effective for treatment of chronic intractable pain of cervical origin but is more invasive than in the lumbar region.^[15] It may be considered where surgical intervention is not an option.^[16]

Prognosis

Cervical spondylosis progresses slowly. It is a chronic joint disability, especially when it is associated with neuronal compression. However, most with acute neck pain do well. A Dutch study found that a year after primary care consultation for this problem, approximately three quarters are 'much improved'. However, just under half still had some ongoing symptoms. Over half who had been off work when first seen, had gone back to work within a week. GP advice to 'wait and see' was associated with a higher rate of recovery than referral to either physiotherapy or specialist.^[17] The best predictors of an unfavourable outcome one year after presentation with neck pain are severity of the initial pain and concomitant back pain.^[18][19] About 10% of affected people go on to develop chronic neck pain, although this figure is much higher in some studies.