Dr. John Drew Laurusonis asked:




There are many different ways to look at neck pain. It is traditionally described as pain over the back of the neck, and rightfully so, since it is the upper part of the spine. It can be described as acute or chronic depending on how long it has been present; acute pain recently started and is less than 6 weeks and chronic pain over a prolonged period of time, usually at least 6-8 weeks. There is different mechanism for each one. In the category of acute pain, it is usually an injury as a result of an accident or contact sport mishap. It could include fractures or dislocations of the cervical vertebra, abrupt ruptures of a disc, or damage to the spinal cord which runs through a channel in the vertebrae. Causes of chronic pain could include gradually progressive arthritis, degeneration over time of a cervical disc, or as the result of long-standing inflammation of muscles and ligaments. An example of chronic pain would be that felt by a person who works all day with the neck flexed forward (i.e. hours and hours of working at a computer terminal). That could cause a disc or two to degenerate and set up inflammation, stress, or, arthritis. It is interesting that many people with chronic depression or anxiety develop chronic pain neck.

It would be useful to look at the structure of the neck in a layer by layer fashion to look for root causes of neck pain. The skin may be involved, for instance, if there are shingles or an infectious process such as a furuncle. Deep in the skin, there can be swollen or tender lymph nodes.  The next lower depth is the trapezius muscle, which runs from its attachment at the upper neck and lower occiput of the skull down to its attachments over the mid-thoracic vertebrae. Lots of nerve fibers run through the body of the trapezius, and can be pinched when there is a muscle spasm. There are layers of muscles at angles to each other which control movement of the neck and head; any one or all of these layers of muscle can be strained or torn. Finally we come to the level of the cervical vertebrae themselves. There are seven cervical vertebrae, with C1 and C2 called the upper cervical spine, and C3 to C7, the lower. C1 and C2 are specially formed to balance the head and allow it to rotate. All the vertebrae have ligamentous structures which hold the vertebrae together at the front, sides and back. The vertebrae have facets which are the articulating joints of one vertebra on another. The front part of the vertebrae comprises the vertebral bodies for maximal strength to this part of the spine. The vertebral bodies have discs between them which are a tuff jelly-like substance inside with tough fibrous sheaths outside to absorb axial shock and loading on the spine between each vertebrae. Nerves run out of the spine at the level of each disc and travel through the brachial process to the arms. Canals in the back of the vertebral bodies the bones form a canal through which the spinal cord runs and is protected by the bones of all the vertebrae. This is very basic anatomy, but it does allow one to visualize the part of the cervical spine where pain and/or dysfunction arise.

Unfortunately, human beings have discovered an infinite number of ways to injure their cervical spines. These might include being “rear-ended” in their vehicle, crashing it, or rolling it over. They might fall off a ladder or a hang-glider, or dive into a shallow pool. In sports they might “spear tackle” or have their neck twisted in wrestling. The list goes on and on. The important thing is that if you encounter someone with either a neck injury or unconsciousness, don’t move their neck. Stabilize it with sandbags or rolled up clothes without moving it at all. Call 911 immediately as paramedics have the specialized knowledge and equipment to move a neck-injured person. The wrong move could result in a permanent paralysis with all its disastrous consequences.

The neck-injured person is usually examined first in an emergency room. The physician can order special x-rays to clear the spine or initiate more specialized care and further x-rays. Unstable fractures, dislocations, and disc ruptures are usually handled by spinal orthopedic, or neurosurgeons, who will decide if surgical intervention is necessary. Surgical treatments can include fusion of the spine, or removal of bone or disc material which might be pressing on the nerves or spinal cord. In the case of muscle and soft tissue sprains of the neck, a general physician can usually initiate care. This might include initiating the immobilization of cervical collars, and prescribing anti-inflammatory medicines like naproxen and muscle relaxants like cyclobenzaprine.

Physical therapy or physical medicine is an important adjunct over the entire spectrum of neck maladies. It might involve the application of heat after 10-12 days and cold initially, instructions in gentle neck stretches and range of motion exercises, deep massage, or other mild treatments. It can involve the entire rehabilitative process after a serious injury to the spinal cord or nerve roots.

Chronic neck pain often requires a different approach, and may involve physical therapy. As mentioned neck pain can result from chronic tension of anxiety or depression. Certain anti-depressants are effective for this kind of chronic pain. If there is an arthritic condition, this needs to be investigated and the appropriate therapy prescribed. Sometimes the pain may be a postural process which can be the object of treatment. Chronic work postures can be addressed with things like ergonomic chairs and more favorable placement of computer screens. Everyone undergoes narrowing and degeneration of the cervical disc as they age, and these can be addressed with medication and physical measures. It is important to have enough sunlight, calcium and vitamin D to prevent osteoporosis and vertebral collapses. Sleeping on a correct mattress and pillow may relieve certain kinds of arthritic and disc pain.

Neck health requires one’s constant attention to activities and general health. Regular exercise, proper nutrition, and maintenance of a healthy posture will go a long way toward preventing neck pain. Non-therapeutic activities such as horseback riding with a fall, or roller coaster are not permitted. It is always the case in medicine, as it is in the case of the neck that an ounce of prevention is worth a pound of cure.

John Drew Laurusonis M.D.

 



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