Simple Neck pain
- The neck region extends from the back of the head all the way down to between the shoulder blades (T4), and from the back of one shoulder to the back of the other.
- Simple Neck Pain implies pain arising due to relatively minor problems with the muscles, ligaments and joints of the neck. It implies also that there is no spinal nerve root involvement (trapped / pinched nerve, slipped disc).
- The pain can come on after a minor injury or sprain. In many cases no injury can be identified, with the pain coming on say just after sleeping badly in bed at night (see Postural Neck Ache).
- Investigations and tests (X-rays and MRI scans) only show age related changes, reassuring the doctor and patient that no serious damage has been done.
- 90% of all episodes of simple neck pain get better within 2 weeks with conservative management (analgesics, keep it moving, avoid excessive rest).
- What is the cause of the pain ? - The sprained part is usually in the superficial part of the spine (muscle, joint or ligament). The sprained tissue becomes inflamed, causing pain signals to be sent to the spinal cord.
- If the incoming pain signals are strong enough and go on for long enough, processing centres (dorsal horn) in the spinal cord become sensitised, sending out signals to the muscles in the vicinity of the sprain to contract to produce muscle spasm. This is initially a protective reflex which may prevent further injury to the sprained part.
- If the muscles in the area are contracting quite strongly, then the tension receptors in the local muscles and joints are activated. Strong signals from the tension receptors can be interpreted in the spinal cord as pain, adding to the pain signals from the inflamed tissue. These two kinds of signal combine together to keep the spinal cord dorsal horn in a sensitised state, and also keeping the spinal muscles in a contracted state through a feedback loop. The sequence of events can be therefore summarised in the diagram below:-
- Muscle spasm is a type of cramp, and like any other cramp in the body it hurts, causing restricted painful neck movements. Over a variable period of time the initial sprain heals, reducing the signals to the spinal cord, and also reducing the degree of spinal cord dorsal horn sensitisation. Once this sensitisation has declined, the outward signals to the muscles in the area of the sprain also lessen, allowing the pain and muscle spasm to resolve naturally.
- Why did my neck pain not improve in 2 weeks ? - In about 10% of adults the neck pain continues despite healing of the initially sprained area. In this situation there is a perpetual loop as shown below, without there being any sprain or inflammatory process involved. This situation may leave individuals susceptible to further sprains due to the neck muscles being in a contracted and shortened state, and also due to there being pre-existing dorsal horn sensitisation.
Postural Neck Ache
- Treatment - the following treatments, available in the pain clinic, may be useful for simple neck pain:-
- Complex Neck Pain implies pain arising from more complicated causes in the neck. Investigations (X-rays and MRI scans) often show anatomical problems (in addition to age related changes), and may also indicate that the spinal nerve roots are being irritated.
- Why does the pain go down my arm ?
- Muscle spasm in the neck can cause referred pain to radiate down the arm. The pain appears in the arm even though there isn't anything wrong with it. It occurs because of a shared nerve supply between the part of the neck affected and the part of the arm (See Referred Pain).
- A common muscle in the shoulder to cause pain in the arm is infraspinatus. Computer mouse users frequently develop trigger points within this muscle.
- In 5% of people the arm pain is associated with numbness, tingling and weakness. These symptoms are more likely to be associated with a problem affecting the spinal nerve roots in the neck, and require further investigation. (See Spinal Nerve Root Pain and MRI Scans).
- Why does my neck ache more when I'm stressed ?
- It appears that the muscles, particularly at the back of the shoulder and the back of the head, are the tension meters of the mind. The more stress we have the knottier these muscles become, particularly on the non-dominant side of the body.
- It also appears that muscle pain, sleep function, and emotions are closely linked to one another. A problem in one area may cause the other two to malfunction. Please look at the sections on muscle pain in the neck, emotions, and sleep for more information.
Computer Seating Advice
- Postural Neck Ache usually occurs when the neck is held in an abnormal posture for too long e.g. sitting for hours in an uncomfortable car/train/airplane seat or sleeping on an uncomfortable mattress or when the equilibrium of the spine is unbalanced e.g. by having one leg longer than the other.
- The muscles, joints and ligaments of the spinal column are packed full of position and stretch receptors, which are constantly monitoring and maintaining posture.
- People who suffer from postural neck pain usually have some ongoing problem with the equilibrium of the spine, and quite frequently have areas where the spinal cord dorsal horn shows pre-existing sensitisation. When these sensitised areas are held in abnormal positions for prolonged periods, there is stimulation of the spinal stretch and position receptors, increasing the signals going to the spinal cord.
- As the spinal cord dorsal horn is already partly sensitised, it more readily becomes fully sensitised by the extra signals coming in. The result is that there is an increase in the out-going signals to the local spinal muscles, producing muscle spasm and pain.
- The situation can normally be resolved by moving and stretching the affected parts of the spine, so that the position and stretch receptors no longer respond by firing off excessively, allowing the dorsal horn to be less sensitised. This may explain why people with postural neck pain become auto-manipulators, frequently clicking and stretching their necks to obtain relief.
- For a useful list of pillows and neck aids, please look at "Posture Aids" at www.o-s-l.com.
Sitting in front of a computer for hours with bad seating and posture frequently leads to muscular pain in the neck, shoulders and upper thoracic spine. Please look at the following advice on how to set up your computer workstation :-
- Most desks have a fixed height and therefore cannot be altered.
- It is important therefore that you have a height adjustable chair so that your arms can operate the keyboard comfortably.
- Selecting the right chair is important. To achieve good lumbar support, there should be a gap between the seat and lumbar support to allow your buttocks to protrude backwards. You should always sit with your bottom pushed as far back as possible into the seat to allow the lumbar support to contact your back comfortably. Don't be tempted to sit on the edge of the seat as you will not have any lumbar support and this will cause you to slouch more easily. Slouching in the upper thoracic area is the commonest cause of neck pain.
- The back support should be high and long enough so that your back is supported from the mid lumbar region all then way up to the shoulder blade level.
- We all have different thigh lengths. Should you be shorter in the thigh than normal then you should look for a chair with a shorter seat measurement from front to back, otherwise you will not be able to sit back far enough in the chair to achieve good lumbar support.
- The rake (reclined angle) of the back rest should be adjusted between 100°-110° .
- The height of the chair should be adjusted so that when you're typing at your keyboard, your forearms are horizontal (similar to good posture for a piano player).
- If you're short in the thigh department and find that when you've set your chair height correctly, your feet are dangling and not able to touch the floor, you need a foot stool. The foot stool should be adjusted so that you can rest your feet comfortably on it without feeling the front of the chair digging into the back of your thighs.
- Adjust the armrests (if fitted) so that your shoulders are relaxed. If your armrests are in the way, remove them.
- An articulating keyboard tray can provide optimal positioning of input devices. However, it should accommodate the mouse, enable leg clearance, and have an adjustable height and tilt mechanism. The tray should not push you too far away from other work materials, such as your telephone.
- Pull up close to your keyboard.
- Position the keyboard directly in front of your body.
- Determine what section of the keyboard you use most frequently, and readjust the keyboard so that section is centred with your body .
- The tilt of your keyboard is dependent upon your sitting position. Use the keyboard tray mechanism, or keyboard feet, to adjust the tilt. If you sit in a forward or upright position, try tilting your keyboard away from you at a negative angle. If you are reclined, a slight positive tilt will help maintain a straight wrist position.
- Wrist rests can help to maintain neutral postures and pad hard surfaces. However, the wrist rest should only be used to rest the palms of the hands between keystrokes. Resting on the wrist rest while typing is not recommended as this may cause Carpal Tunnel Syndrome. Avoid using excessively wide wrist rests, or wrist rests that are higher than the space bar of your keyboard.
- Place the mouse as close as possible to the keyboard. Placing it on a slightly inclined surface, or using it on a mouse bridge placed over the 10-keypad, can help to bring it closer.
- If you do not have a fully adjustable keyboard tray, you may need to adjust your workstation height, the height of your chair, or use a seat cushion to get in a comfortable position. Remember to use a footrest if your feet dangle.
Monitor, Document, and Telephone
- Incorrect positioning of the screen and source documents can result in awkward postures. Adjust the monitor and source documents so that your neck is in a neutral, relaxed position.
- Centre the monitor directly in front of you, above your keyboard.
- Position the top of the monitor approximately 2-3” above seated eye level. If you wear bifocals, lower the monitor to a comfortable reading level.
- If your screen is too high, try moving the computer box onto the floor, adjusting the screen height with different sized books or boxes.
- If your screen is too low, try place it on top of your computer box, and if necessary insert a book or box between the PC on the screen base.
- Sit at least an arm's length away from the screen and then adjust the distance for your vision.
- Reduce glare by careful positioning of the screen.
- Place screen at right angles to windows
- Adjust curtains or blinds as needed
- Adjust the vertical screen angle and screen controls to minimize glare from overhead lights
- Other techniques to reduce glare include use of optical glass glare filters, light filters, or secondary task lights
- Position source documents directly in front of you, between the monitor and the keyboard, using an in-line copy stand. If there is insufficient space, place source documents on a document holder positioned adjacent to the monitor .
- Place your telephone within easy reach. Telephone stands or arms can help.
- Use headsets and speaker phone to eliminate cradling the handset.
Pauses and Breaks
- Once you have correctly set up your computer workstation use good work habits. No matter how perfect the environment, prolonged, static postures will inhibit blood circulation and take a toll on your body.
- Take short 1-2 minute stretch breaks every 20-30 minutes. After each hour of work, take a break or change tasks for at least 5-10 minutes. Always try to get away from your computer during lunch breaks.
- Avoid eye fatigue by resting and refocusing your eyes periodically. Look away from the monitor and focus on something in the distance.
- Rest your eyes by covering them with your palms for 10-15 seconds.
- Use correct posture when working. Keep moving as much as possible.
Mechanical Imbalance due to abnormalities of lower leg function can contribute to neck pain in the following ways:-
Lower Limb Length Inequality (short leg) on one side causes the pelvis to tilt towards that side. This produces a series of compensatory spinal curves from the low back up to the top of the neck, with associated muscle imbalance, back and neck pain. The leg length difference may need to be greater than 1/2" before it causes major problems, although lesser differences can still be symptomatic. The cause may be due to:-
Anatomical Shortening with a measurable difference between the two legs. This can be due to leg fractures, hip and knee problems in childhood OR simply being born that way.
- Correcting the shortening with a shoe heel raise of the appropriate height (start with half the difference).
- Spinal Manipulation can also be useful to re-set the dysfunctional areas of spinal muscle spasm that may occur in the compensatory curves in the lumbar, thoracic and cervical spine.
Functional Shortening is where there is no measurable difference in leg lengths, but with functional shortening of certain leg muscles groups, or due to a fallen inside arch of the foot.
- Identifying, stretching and re-training the shortened muscle groups (iliopsoas, quadriceps, hamstrings, gastrocnemius).
- Spinal Manipulation can be useful for the neck pain in the short term.
- Shoe heel raises are not useful in this group as there is no true leg shortening. Arch supports may help.
- The degree of tissue injury from a whiplash accident (Flexion / Extension Injury ) is directly related to the speed and direction of the impact.
- The human head weighs about 16 pounds (mainly water), supported with relatively weak neck muscles, and therefore cannot resist sudden deceleration / acceleration forces. It is said that whiplash injury is more common in women, directly related to the lower strength of their neck muscles.
- Frontal impact causes initial forwards flexion movement followed by extension backwards (Rear impact causes the exact reverse). Side impacts cause first side bending towards the side of the impact, and then followed by side bending away from it.
- Modern cars have increasingly more rigid safety cages with crumple zones front and rear. The more rigid the safety cage the more of the force of the impact is transferred to the car's occupants. Without a rigid safety cage, high speed crashes would often result in death. Now more people are surviving high speed crashes only to have more severe whiplash injuries (which would you choose ?).
- Timing of air bag deployment and positioning of head restraints are also crucial in determining the magnitude of the whiplash. As well as having both driver and passenger front airbags, many cars are now fitted with curtain airbags which specifically deploy during side impacts.
- Women may be prone to neck injury aggravated by the driver's airbag as they generally sit closer to the steering wheel than men. The timing of the airbag deployment may be miscalculated leading to more sudden deceleration during a crash than if they had been sitting further away from the steering wheel.
- It is important that women adopt the correct driving position, trying to avoid sitting too close to the centre of the steering wheel where the airbag is located. Smaller women should have cars with adjustable seat height and steering wheel angle. See TRL and VSRC for more information.
Mild Whiplash Injury
- Mild whiplash injuries occur during low impact accidents. During the forwards flexion phase of the injury, a minor sprain may occur to the muscles at the back of the neck and shoulders (see sub-occipital, trapezius, levatore scapulae).
- During the extension backwards phase of the injury, a minor sprain may occur to the muscles at the front of the neck (see scalene muscles, and sternocleidomastoid).
- Minor sprains can cause an awful lot of neck pain and stiffness in the early stages, but thankfully most settle down within a few weeks with or without treatment. Those with prior neck problems may be vulnerable to more protracted pain and stiffness due to pre-existing dorsal horn sensitisation.
- Oral analgesics
- Soft collars can be used in the early stages when there is severe pain. Beware collar dependency - excessive use of a collar for managing pain may result in worse neck stiffness due to lack of movement, and also severe neck muscle wasting due to lack of use. I would recommend only using a collar in the very early stages.
- Gentle neck exercises - once the severe pain has begun to settle (after 48 hours), then this is the time to begin stretching the neck in all directions. The sooner you start, the quicker the recovery.
- Heat application during stretching is also useful.
- Gentle massage may help, but in my experience the neck muscles are too sore in the early stages.
- TENS may be helpful but avoid placing the pads over the front of the neck.
- Acupuncture for specific muscular trigger points can help
- Trigger Point Injections (TPIs) including Botox may be helpful if the symptoms haven't settled by 2 weeks.
- Spinal Manipulation is indicated for secondary neck stiffness once the muscle tearing injury has settled. It is important not to have manipulative treatment whilst the neck muscles are still inflamed. Those with spinal nerve root symptoms in the arms should have a neck MRI scan prior to starting treatment to exclude a cervical disc lesion.
Moderate Whiplash Injury
At higher speeds the severity of the muscle sprain increases producing more severe neck pain and stiffness which lasts longer. All of the treatments mentioned above may help. In addition the following injuries can occur:-
- Cervical Disc Prolapse - caused by a rupture of the posterior disc annulus. This can cause dermatomal arm pain, numbness, tingling and weakness due to spinal nerve root irritation / pinching / compression. Further investigation with a neck X-ray and a neck MRI scan is advised before embarking on treatment. Cervical epidural injections and decompressive / fusion surgery may be indicated.
- Foraminal Pinching - Side impacts and severe extension injuries can cause injury to the spinal nerve roots as they leave the spinal canal exit holes (foramina). During the injury the dimensions of the exit holes in the spine are reduced causing nerve injury / trapping / irritation. May show up on an MRI scan. Treatment with cervical epidural injections and spinal nerve root blocks may help. EMG may be helpful in deciding the extent of the nerve injury - partial vs. complete nerve transection.
- Posterior Spinal Ligament Injury - partial tearing of the posterior interspinous and supraspinous spinal ligaments can mimic a cervical disc prolapse by causing severe neck pain associated with referred pain (and sometimes tingling, but never weakness and numbness) in the arm in the specific dermatomal distribution. X-rays and neck MRI scans are important to help rule out a disc prolapse. Ligament injuries of this type rarely show up on investigations, the only positive sign being extreme tenderness over the midline bony ligament attachment points to the spinous processes. Pressure at this point can also reproduce the referred pain pattern in the arm. Treatment with prolotherapy is indicated for those injuries not settling spontaneously.
- Cervical Facet Joint Syndrome - a sprain of the cervical facet joint capsule can produce severe pain and stiffness in the neck. It can also occur in isolation or in combination with the other two injuries above. Referred pain down the arm in a specific dermatomal pattern is common. Excluding a cervical disc prolapse with an MRI scan is important. An isotope bone scan may help to identify the inflamed joint, as neck X-rays are unhelpful in localising the source of the pain. Cervical facet joint injections can be useful. In the absence of joint disruption, spinal manipulation may also help reduce muscle spasm and improve the range of neck movements.
Severe Whiplash Injury
Extremely high speed or forceful whiplash injuries can cause physical disruption to structures in the neck. In addition to a severe degree of muscle tearing with the usual pain, tenderness and stiffness, the following injuries can occur:-
Spinal Ligament Syndrome
- Vertebral fractures with disruption of the anterior and posterior longitudinal ligaments. These injuries frequently cause damage to the spinal cord and require immediate spinal surgery to prevent permanent paralysis from the neck downwards. Lesser injuries can occur with pull-off fractures to the edges of the anterior aspect of the vertebral body. These often produce a characteristic X-ray appearance.
- Massive cervical disc protrusion requiring surgical decompression and fusion.
- Disruption to the cervical facet joints and posterior ligaments, causing cervical instability. This also requires stabilisation with a cervical fusion.
Facet Joint Syndrome
- Whiplash injury can cause partial tearing of the supraspinous and interspinous ligaments in the neck.
- Cervical Subluxation can occur in those with rheumatoid arthritis where severe destructive changes occur in the facet joints causes the vertebra to slip out of alignment (similar to Spondylolisthesis in the lumbar spine). The vertebral slip forwards places extra strain on the supporting posterior spinal ligaments.
- Chronic neck pain with restricted movements. Referred pain may occur in the arms according to the level affected. Both conditions may also be associated with spinal nerve root impingement, and therefore investigation with X-rays and an MRI scan is advised.
Spinal Nerve Root Pain
- Mechanism - a small proportion of people have complex neck due to inflammation of one or more of the small spinal joints (facet joints , ). X-rays may show arthritic changes in the joints, but there is a poor correlation between the degree of wear and the severity of the pain. There is also a poor correlation between the part of the spine on the X-ray which shows the arthritic joints, and where the actual pain is when the back is examined clinically. An isotope bone scan may give a better correlation by showing up inflammation as increased joint blood flow .
- Groups at Risk - Facet joint syndrome is more common in the elderly where there may be associated loss of disc height at the level concerned. It is more common at the C4/5, C5/6, and C6/7 levels. It is also more common in those people with inflammatory spinal disease (ankylosing spondylitis, psoriasis, systemic lupus etc). People with long standing spinal imbalance may be more prone to developing facet joint inflammation due to differential wear on one side of the spine.
- Symptoms - neck ache is often worse after keeping still in one position for too long. It is usually better keeping the neck on the move. The pain may be associated with frequent cracking or clicking of the facet joints. More be provoked by neck extension (bending backwards). May be a cause of referred pain to the arms (non-nerve root).
- Treatment initially consists of injecting the facet joint diagnostically with a solution containing local anaesthetic and steroid. These pain relief injections need to be performed under X-ray screening. If there is a positive outcome to this diagnostic test, then facet joint radio-frequency denervation (rhizolysis) should be considered next (see Facet Joint Injections).
- See Spinal Nerve Root Pain for Brachialgia (Cervical Radiculopathy) caused by Annular Tears, Disc Prolapse, and Foraminal Stenosis.
Referred pain from the cervical spine
- Structures in the spine other than discs and nerves (e.g. Paravertebral Muscles, Facet Joints, Spinal Ligaments) can refer pain to other areas of the body.
- This occurs because the affected part of the spine shares the same nerve supply as the area that the pain is referred to, making the brain believe the source of the pain is somewhere else.
- Spinal structures with a nerve supply originating from C4 to T1 refer pain to the arms.
Referred pain to the cervical spine
Failed Spinal Surgerry
- Spinal Causes
- Upper thoracic spine muscle spasm can often refer pain upwards to the neck region. This is typical of muscle pain where the cause of the pain is found at its origin (where it starts), and where the brain seems to think that it's coming from its insertion (where it ends). In general thoracic spine problems above T4 refer upwards to the neck region, and below T4 refer downwards to the lumbar region.
- If practitioners concentrate on where the pain is referred to i.e. the neck region, they will miss the cause of the problem, which is often much lower down.
- Those with chronic spinal and nerve root pain who did not obtain relief from surgical intervention (cervical discectomy, cervical decompression, anterior cervical fusion), are often labelled as "Failed Spinal Surgery". This group also includes those who feel that surgery may have worsened their condition.
- Where conservative treatments (Acupuncture, TENS, Exercises, Manipulation, Facet Joint Injections, Prolotherapy, Epidural Injections, Nerve Root Blocks), and maximal oral drug therapy (see Analgesic Flow Chart) have failed to improve the pain, two further options include Spinal Cord Stimulation or an implanted Intrathecal Morphine Pump.