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Neck Pain

By

Peter J. Moley

, MD, Hospital for Special Surgery

Last full review/revision Nov 2020| Content last modified Nov 2020
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Along with low back pain Low Back Pain Low back pain and neck pain are among the most common reasons for health care visits. The pain usually results from problems with the musculoskeletal system—most notably the spine, including... read more Low Back Pain , neck pain is a very common reason for health care visits. The pain usually results from problems with the musculoskeletal system—the spine, including the bones of the spine (backbones, or vertebrae) and the muscles and ligaments that support it. Some disorders cause only neck pain. Other disorders can cause neck and low back pain. Occasionally, neck pain results from a disorder, such as meningitis Introduction to Meningitis Meningitis is inflammation of the layers of tissue that cover the brain and spinal cord (meninges) and of the fluid-filled space between the meninges (subarachnoid space). Meningitis can be... read more , that does not involve the musculoskeletal system.

The neck's flexibility makes it susceptible to wear and tear and to injuries that overstretch it, such as whiplash. Also, the neck has the critical job of holding up the head. Poor posture makes that job more difficult. Thus, neck pain, like back pain, is common and becomes more common as people age. For pain located in the front of the neck, see Sore Throat Sore Throat Sore throat is pain in the back of the throat. The pain can be severe and is usually worsened by swallowing. Many people with sore throat refuse to eat or drink. Sometimes pain is also felt... read more Sore Throat .

The part of the spine that is in the neck is called the cervical spine. It consists of seven back bones (vertebrae), which are separated by disks made of jelly-like material and cartilage. The cervical spine contains the spinal cord Spinal Cord The spinal cord is a long, fragile tubelike structure that begins at the end of the brain stem and continues down almost to the bottom of the spine. The spinal cord consists of bundles of nerve... read more . Along the length of the spinal cord, spinal nerves emerge through spaces between the vertebrae to connect with nerves throughout the body. The part of the spinal nerve nearest the spinal cord is the spinal nerve root. Muscles and ligaments in the neck support the spine.

Causes of Neck Pain

Common causes

Common causes of neck pain include

Spasms of the neck muscles are common and may occur on their own or after an injury, even a minor injury.

Cervical spinal stenosis describes the condition in which the space inside the spine canal becomes narrowed. In the cervical spine this results in compressing the thecal sac, often the spinal cord, and/or its nerve roots. The usual cause is a combination of osteoarthritis Osteoarthritis (OA) Osteoarthritis is a chronic disorder that causes damage to the cartilage and surrounding tissues and is characterized by pain, stiffness, and loss of function. Arthritis due to damage of joint... read more Osteoarthritis (OA) , disk degeneration, and thickening of the soft tissues in the neck.

Herniated disks Herniated Disk A herniated disk occurs when the tough covering of a disk in the spine tears or ruptures. The soft, jelly-like interior of the disk may then bulge out (herniate) through the covering. Aging... read more Herniated Disk can cause neck pain. The disks between each of the vertebrae have an outer layer of cartilage (a tough, fiber-like tissue) and a soft, jelly-like interior. If a disk is repeatedly squeezed by the vertebrae above and below it, the outer layer may tear (rupture), causing pain. The interior of the disk can bulge out through the tear (herniate). The bulging disk can push on or even damage the spinal nerve root next to it. Rarely, the disk compresses the spinal cord.

Injuries may occur during routine activities (for example, lifting, exercising, moving in an unexpected way) or result from trauma such a fall or car crash. Often no specific injured structures are identified with imaging tests, but doctors presume that some muscles and/or ligaments have been affected.

Fibromyalgia Fibromyalgia Fibromyalgia is characterized by poor sleep, fatigue, mental cloudiness, and widespread aching and stiffness in soft tissues, including muscles, tendons, and ligaments. Poor sleep, stress, strains... read more is a common cause of pain, sometimes including neck pain. This disorder causes chronic widespread pain in muscles and other soft tissues in areas besides the neck.

Less common causes

Less common causes of neck pain that are serious include

Spasmodic torticollis Dystonia is characterized by long-lasting (sustained) involuntary muscle contractions that may force people into abnormal positions—for example, causing the entire body, the trunk, limbs, or... read more is also a less common cause but is not as serious as some causes. It is a severe type of spasm of a specific neck muscle that causes the head to tilt and rotate into an abnormal position. Sometimes the spasms are rhythmic, causing the head to jerk. The cause may be unknown or may be due to certain drugs or hereditary disorders.

Evaluation of Neck Pain

The following information can help people with neck pain decide whether a doctor's evaluation is needed and help them know what to expect during the evaluation. In the evaluation, doctors first try to identify serious disorders.

Warning signs

In people with neck pain, certain signs are cause for concern. They include

  • Loss of strength or sensation in the arms and legs—possibly a symptom of nerve damage

  • Fever

  • Night sweats

  • Headache

  • Lethargy or confusion

  • Chest discomfort

  • Sudden sweating or difficulty breathing

  • Pain that is triggered by exertion or worsens during exertion

When to see a doctor

People with warning signs or difficulty or pain when swallowing should see a doctor immediately.

Other people can wait a few days or call their doctor to discuss how soon they need to be seen.

What the doctor does

Doctors first ask questions about the person's symptoms and medical history. Doctors then do a physical examination. What they find during the history and examination often suggests a cause of the neck pain and the tests that need to be done (see Table: Some Causes and Features of Neck Pain Some Causes and Features of Neck Pain Along with low back pain, neck pain is a very common reason for health care visits. The pain usually results from problems with the musculoskeletal system—the spine, including the bones of the... read more ).

The physical examination focuses on the spine and nervous system (neurologic examination Neurologic Examination When a neurologic disorder is suspected, doctors usually evaluate all of the body systems during the physical examination, but they focus on the nervous system. Examination of the nervous system—the... read more ) to look for signs of nerve root or spinal cord compression Compression Fractures of the Spine In a compression fracture of the spine, the drum-shaped part (body) of one or more back bones (vertebrae) collapses into itself and becomes squashed (compressed) into a wedge shape. Most compression... read more Compression Fractures of the Spine . Signs of nerve root compression include muscle weakness, abnormal reflexes (tested by tapping the tendons around the elbow and wrist), decreased sensation in parts of the body other than the head, inability to urinate Urinary Retention Urinary retention is inability to urinate or incomplete emptying of the bladder. People who have incomplete emptying of the bladder may have urinary frequency or urinary incontinence. If the... read more , and incontinence of urine Urinary Incontinence in Adults Urinary incontinence is involuntary loss of urine. Incontinence can occur in both men and women at any age, but it is more common among women and older people, affecting about 30% of older women... read more Urinary Incontinence in Adults or incontinence of stool Fecal Incontinence Fecal incontinence is the loss of control over bowel movements. Fecal incontinence can occur briefly during bouts of diarrhea or when hard stool becomes lodged in the rectum (fecal impaction)... read more . Doctors may ask the person to move the neck in certain ways.

With information about the pain, the person’s medical history, and results of a physical examination, doctors may be able to determine the most likely causes:

Table
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Testing

Often, testing is not necessary because most neck pain is caused by muscle spasm and strains, which doctors can typically diagnose based on the examination. Testing is usually done if doctors suspect certain other disorders (see Table: Some Causes and Features of Neck Pain Some Causes and Features of Neck Pain Along with low back pain, neck pain is a very common reason for health care visits. The pain usually results from problems with the musculoskeletal system—the spine, including the bones of the... read more ).

Treatment of Neck Pain

Specific disorders are treated.

General measures for neck pain

Measures include

  • Taking drugs that relieve pain

  • Applying heat or cold to the painful area

  • Modifying activities

  • Light exercise as tolerated

If more pain relief is needed, doctors may prescribe opioid analgesics Opioid Analgesics In some cases, treating the underlying disorder eliminates or minimizes the pain. For example, setting a broken bone in a cast or giving antibiotics for an infected joint helps reduce pain.... read more , but, if prescribed, opioids should be used only for a short duration because long-term use of opioid analgesics can actually increase sensitivity to pain and cause side effects, such as drowsiness, confusion, and constipation, and risk the development of a substance use disorder Substance Use Disorders Substance use disorders generally involve behavior patterns in which people continue to use a substance despite having problems caused by its use. The substances involved tend to be members... read more . Muscle relaxants, such as carisoprodol, cyclobenzaprine, diazepam, metaxalone, or methocarbamol, are sometimes used, but their usefulness is controversial. Muscle relaxants are not recommended for older people, who are more likely to have side effects.

Avoiding aggravating activities, such as sitting for extended periods of time (particularly when also using a computer, phone, or other electronic device), may help. Using good posture and body mechanics when standing, sitting, lying down, or doing any activity is important. People are taught how to stand, sit, and sleep in ways that do not strain the neck. People who sleep on their side should use a pillow to support the head and neck in a neutral position (not tilted down toward the bed or up toward the ceiling). People who sleep on their back should use a pillow to support, but not raise, the head and neck. People should avoid sleeping on their stomach. People may also wear a neck brace (cervical collar) to keep the neck still and help relieve pain. Doctors or physical therapists Physical Therapy (PT) Physical therapy, a component of rehabilitation, involves exercising and manipulating the body with an emphasis on the back, upper arms, and legs. It can improve joint and muscle function, helping... read more may suggest stretching and strengthening exercises, including strengthening exercises for the upper back.

Other measures to reduce neck pain

People with pain that radiates into one arm and involves symptoms of nerve damage, such as arm and leg weakness, may require more intensive treatment. Traction Traction Professional rehabilitation therapists treat pain and inflammation. Such treatment makes movement easier and enables people to participate more fully in rehabilitation. Techniques used include... read more can help. Corticosteroids, given orally and occasionally by epidural injection, have been used to reduce symptoms.

For spasmodic torticollis, physical therapy or massage can sometimes temporarily stop the spasms. Drugs (including the antiseizure drug carbamazepine and some mild sedatives such as clonazepam, taken by mouth) can usually relieve the pain. But drugs control spasms in only about one third of people. If the pain is severe or if posture is distorted, botulinum toxin (a bacterial toxin used to paralyze muscles) may be injected into the affected muscles.

Surgery for neck pain

People who have a compressed spinal cord or spinal nerve due to a herniated disk in the neck and severe weakness or pain may require surgery. Surgical removal of the disk (diskectomy) and surgery to fuse vertebrae together (called cervical or spinal fusion) are the most common treatments. However, success rates are about the same for people who are treated with either nonsurgical or surgical options. The effectiveness of surgery for neck pain due to other disorders depends on the cause.

Key Points about Neck Pain

  • Most neck pain is caused by sprains and muscle spasms and resolves completely.

  • Many of the disorders that can cause low back pain can cause neck pain.

  • People with warning signs, such as numbness or arm and leg weakness, should see a doctor immediately.

  • Most neck pain can be relieved by over-the-counter analgesics and modification of activities.

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