Identifying and Treating the Causes of Neck Pain

Published:March 24, 2014DOI:https://doi.org/10.1016/j.mcna.2014.01.015

      Keywords

      Key points

      • The first step in evaluating neck pain is to look for red flags to suggest serious underlying disease, analogous to the evaluation of low back pain.
      • It is important to distinguish mechanical neck pain from radiculopathy or myelopathy based on history and physical examination; techniques are reviewed herein.
      • The role of magnetic resonance imaging in mechanical neck pain is dubious.
      • Many conservative treatment options are available. Those options with the best support in the literature include educational videos, select exercise interventions, mobilization accompanied by exercise, some medications, and possibly, acupuncture.
      • There is no role for surgery in mechanical neck pain.
      • Patients with severe or progressive radiculopathy or myelopathy are appropriately referred for surgery; those with mild to moderate radiculomyelopathy have short-term benefits from surgery, but long-term outcomes may be similar to conservative treatment.

      Introduction

      Neck pain is a common condition, with approximately 15% to 20% of people reporting neck pain each year and 1.5% to 1.8% of adults seeking ambulatory health care for this complaint annually.
      • Guzman J.
      • Haldeman S.
      • Carroll L.
      • et al.
      Clinical practice implications of the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and its associated disorders: from concepts and findings to recommendations.
      Despite the frequency of this presenting complaint, a clear understanding of the cause and the best treatment course is often elusive. This review is aimed at primary care providers evaluating patients in clinic with the complaint of neck pain. Workup of neck pain in trauma victims is outside the scope of this review.

       Anatomy

      A brief review of the anatomy of the neck sets the stage for a better appreciation of potential causes of pain in the region. There are 7 cervical vertebrae. C1 and C2, atlas and axis, have no intervertebral disk between them. The remaining C3-7 vertebrae are connected superiorly and inferiorly to intervertebral disks, and articulate with adjacent vertebrae through 2 important joints:
      • Uncovertebral joints (also called the joints of Luschka)
      • Zygapophyseal joints (also called z-joints or facet joints)
      To help envision the important structures in the vertebrae, we can begin at C4 and imagine moving posterolaterally from the vertebral body as it arches around toward the spinous process. First, a protuberance called the uncinate process is encountered (which abuts the C3-4 intervertebral disk and C3 vertebral body, forming the uncovertebral joints and comprising the anterior wall of the intervertebral foramen for the exiting C4 spinal nerve). Second, the uncinate process is followed by a depression (which forms the inferior wall of the intervertebral foramen). Third, there is another protuberance, called the articular facet (which connects, through a true synovial joint, to the C3 vertebra to form the zygapophyseal joint and the posterior wall of the intervertebral foramen). Therefore, (1) the anteromedial wall of the intervertebral foramen is the uncovertebral joint, which is not a true synovial joint and is a frequent site of bony overgrowth, and (2) the posterolateral wall of the intervertebral foramen is composed of the zygapophyseal joint, which is a true synovial joint and provides stability to the spine.
      • Netter F.H.
      Atlas of human anatomy.

      Robinson J, Kothari M. Clinical features and diagnosis of cervical radiculopathy. Available at: http://www.uptodate.com/. Accessed September 28, 2013.

      • Carette S.
      • Fehlings M.G.
      Cervical radiculopathy.
      There are 8 cervical spinal nerves; C1-7 exit superiorly to their named vertebra. C8 exits between C7 and T1.
      • Motor efferent fibers have cell bodies in the anterior horn of the ventral spinal cord, exiting the cord to the ventral root, and then merging with sensory afferents to become the spinal nerve (a short nerve located inside the intervertebral foramen).
      • Sensory afferents ascend from the periphery. The cell bodies form the dorsal root ganglion, which is located within the intervertebral foramen, just before merging with the spinal nerve (also inside the foramen). Sensory afferents enter the spinal cord through the dorsal root.
        • Netter F.H.
        Atlas of human anatomy.
        • Carette S.
        • Fehlings M.G.
        Cervical radiculopathy.
        • Zhang J.
        • Tsuzuki N.
        • Hirabayashi S.
        • et al.
        Surgical anatomy of the nerves and muscles in the posterior cervical spine: a guide for avoiding inadvertent nerve injuries during the posterior approach.
      Other surrounding structures to highlight include:
      • The vertebral artery, which ascends adjacent laterally to the intervertebral foramina
      • The intervertebral disks, comprising a gelatinous nucleus pulposis surrounded by an annulus fibrosis, and protected in the midline from herniating into the spinal cord by the posterior longitudinal ligament
      • Cervical muscles and soft tissue

       Diagnostic Uncertainty

      Significant uncertainty still surrounds the pathophysiology of chronic neck pain, and in many cases, the chance of a clinician accurately identifying a specific cause is low.
      • Guzman J.
      • Haldeman S.
      • Carroll L.
      • et al.
      Clinical practice implications of the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and its associated disorders: from concepts and findings to recommendations.
      • Honet J.C.
      • Ellenberg M.R.
      What you always wanted to know about the history and physical exam of neck pain but were afraid to ask.
      A more critical task is to evaluate patients with neck pain for the following: cervical radiculopathy, cervical myelopathy, and dangerous underlying causes of pain (eg, cancer, fractures, osteomyelitis).
      • Honet J.C.
      • Ellenberg M.R.
      What you always wanted to know about the history and physical exam of neck pain but were afraid to ask.
      • Bogduk N.
      The anatomy and pathophysiology of neck pain.

       Categorization of Neck Pain and Associated Cervical Spine Disorders

       Radiculopathy

      Radiculopathy is the constellation of symptoms caused by dysfunction of 1 or more cervical spinal nerve roots. It is less common than mechanical neck pain, with 1 population-based study
      • Radhakrishnan K.
      • Litchy W.J.
      • O’Fallon W.M.
      • et al.
      Epidemiology of cervical radiculopathy. A population based study from Rochester, Minnesota 1876 through 1990.
      showing an average annual age-adjusted incidence of 83.2 per 100,000 people. Although noncompressive causes should be considered (eg, diabetes, herpes zoster, root avulsion), most (approximately 90%) radiculopathies result from compressive causes. In a large retrospective review at Mayo Clinic,
      • Radhakrishnan K.
      • Litchy W.J.
      • O’Fallon W.M.
      • et al.
      Epidemiology of cervical radiculopathy. A population based study from Rochester, Minnesota 1876 through 1990.
      21.9% of all radiculopathy cases were believed to have a probable cause of disk herniation (based on radiologic or surgical findings). Spondylosis is the major contributor to the remaining cases. Spondylosis usually refers to progressive, age-associated, degenerative changes of the vertebrae and intervertebral disks. These changes can lead to radiculopathy through bony hypertrophy of the uncovertebral joints and, less commonly, the zygapophyseal joints, both of which may cause narrowing of the intervertebral foramen and consequent compression of the spinal nerve.

       Myelopathy

      Myelopathy is related to narrowing of the spinal canal, most often from spondylosis (including osteophytes of the uncovertebral or zygapophyseal joints, or degenerative hypertrophy of the ligamentum flavum or posterior longitudinal ligaments). Pathophysiology may involve direct spinal cord or nerve root compression or ischemia from compression of arterial or venous supplies to the cord.
      • McCormick W.E.
      • Steinmetz M.P.
      • Benzel E.C.
      Cervical spondylotic myelopathy: make a difficult diagnosis, then refer for surgery.

       Neck pain

      Neck pain in the absence of radiculopathy, myelopathy, or clear serious underlying disease is also called mechanical neck pain, and has less well-understood pathophysiology. Among other things, this type of pain may be labeled as cervical muscle strain, myofascial pain, cervical spondylosis, cervical facet joint pain, and diskogenic pain. Because these structures are innervated, all of the muscles, synovial joints, intervertebral disks, dura mater, and vertebral arteries may theoretically generate pain.
      • Netter F.H.
      Atlas of human anatomy.
      • Bogduk N.
      The anatomy and pathophysiology of neck pain.
      Some studies attempting to more specifically delineate which of these features to implicate have focused on zygapophyseal joints and intervertebral disks. Examples of methods used include delivery of noxious stimuli (eg, saline or contrast injection) to specified structures in asymptomatic volunteers,
      • Dreyfuss P.
      • Michaelsen M.
      • Fletcher D.
      Atlanto-occipital and lateral atlanto-axial joint pain patterns.
      • Dwyer A.
      • Aprill C.
      • Bogduk N.
      Cervical zygapophyseal joint pain patterns. I: a study in normal volunteers.
      delivery of noxious stimuli to symptomatic volunteers (eg, provocation diskography),
      • Fukui S.
      • Ohetso K.
      • Shiotani M.
      • et al.
      Referred pain distribution of the cervical zygapophyseal joints and cervical dorsal rami.
      and delivery of localized anesthesia in symptomatic volunteers (eg, anesthetic block to zygapophyseal joint either directly or through medial branch blocks).
      • Aprill C.
      • Dwyer A.
      • Bogduk N.
      Cervical zygapophyseal joint pain patterns. II: a clinical evaluation.
      Some general conclusions from this research include
      • Bogduk N.
      The anatomy and pathophysiology of neck pain.
      • Cooper G.
      • Bailey B.
      • Bogduk N.
      Cervical zygapophysial joint pain maps.
      • Sehgal N.
      • Dunbar E.E.
      • Shah R.V.
      • et al.
      Systematic review of diagnostic utility of facet (zygapophysial) joint injections in chronic spinal pain: an update.
      :
      • 1.
        Zygapophyseal joints may be a source of pain in some subsets of patients with chronic neck pain caused by minor trauma or degenerative changes. The zygapophyseal joints may also produce referred pain to the head and upper extremities (referred pain is believed to stem from nociceptive afferents from facet joints that converge in the spinal cord with nociceptive afferents from other distal sites).
        • Bogduk N.
        The anatomy and pathophysiology of neck pain.
        • Cooper G.
        • Bailey B.
        • Bogduk N.
        Cervical zygapophysial joint pain maps.
        • Sehgal N.
        • Dunbar E.E.
        • Shah R.V.
        • et al.
        Systematic review of diagnostic utility of facet (zygapophysial) joint injections in chronic spinal pain: an update.
        Attempts to map typical locations of pain derived from each zygapophyseal joint have been created and revised.
        • Cooper G.
        • Bailey B.
        • Bogduk N.
        Cervical zygapophysial joint pain maps.
        The prevalence of zygapophyseal pain in a primary care clinic population has not been determined. One estimate from a small population of specialty clinic patients (based on serial positive local anesthetic blocks) was reported at 36%.
        • Speldewinde G.C.
        • Bashford G.M.
        • Davidson I.R.
        Diagnostic cervical zygapophyseal joint blocks for chronic cervical pain.
      • 2.
        Although possible, there is no strong evidence that intervertebral disks (through degenerative or other changes) are a source of pain (diskogenic pain). This area remains controversial.
        • Schellhas K.P.
        • Smith M.D.
        • Gundry C.R.
        • et al.
        Cervical discogenic pain. Prospective correlation of magnetic resonance imaging and discography in asymptomatic subjects and pain sufferers.
        • Slipman C.W.
        • Plastaras C.
        • Patel R.
        • et al.
        Provocative cervical discography symptom mapping.
        • Nordin M.
        • Carragee E.J.
        • Hogg-Johnson S.
        • et al.
        Assessment of neck pain and its associated disorders. Results of the Bone And Joint Decade 2000– 2010 Task Force on Neck Pain and its Associated Disorders.
      • 3.
        Other potential sources of pain (eg, soft tissue, muscles, arteries) have not been rigorously studied.
      These diagnostic techniques and the conclusions drawn from their use remain controversial.
      • Hogan Q.H.
      • Abram S.E.
      Neural blockade for diagnosis and prognosis.
      • Ackerman W.E.
      • Munir M.A.
      • Zhang J.M.
      • et al.
      Are diagnostic lumbar facet injections influenced by pain of muscular origin?.
      Some systematic reviews find adequate evidence to support them,
      • Sehgal N.
      • Dunbar E.E.
      • Shah R.V.
      • et al.
      Systematic review of diagnostic utility of facet (zygapophysial) joint injections in chronic spinal pain: an update.
      • Falco F.J.
      • Erhart S.
      • Wargo B.W.
      • et al.
      Systematic review of diagnostic utility and therapeutic effectiveness of cervical facet joint interventions.
      but a recent systematic review and guidelines from the Bone and Joint 2000–2010 Task Force on Neck Pain do not endorse these injection techniques as a diagnostic maneuver.
      • Guzman J.
      • Haldeman S.
      • Carroll L.
      • et al.
      Clinical practice implications of the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and its associated disorders: from concepts and findings to recommendations.
      • Nordin M.
      • Carragee E.J.
      • Hogg-Johnson S.
      • et al.
      Assessment of neck pain and its associated disorders. Results of the Bone And Joint Decade 2000– 2010 Task Force on Neck Pain and its Associated Disorders.
      Furthermore, per the literature review of this task force, there is no “evidence [that was deemed scientifically admissible] demonstrating that disk degeneration is a risk factor for neck pain.”
      • Hogg-Johnson S.
      • van der Velde G.
      • Carroll L.J.
      • et al.
      The burden and determinants of neck pain in the general population: results of the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and its Associated Disorders.
      Coauthors of related guidelines concur that there is “no evidence that common degenerative changes on cervical magnetic resonance imaging (MRI) are strongly correlated with neck pain symptoms.”
      • Nordin M.
      • Carragee E.J.
      • Hogg-Johnson S.
      • et al.
      Assessment of neck pain and its associated disorders. Results of the Bone And Joint Decade 2000– 2010 Task Force on Neck Pain and its Associated Disorders.

       Summary

      Recent guidelines state, “in most settings a simple descriptive clinical diagnosis might be preferable to a speculative tissue diagnosis as the origin of pain.”
      • Guzman J.
      • Haldeman S.
      • Carroll L.
      • et al.
      Clinical practice implications of the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and its associated disorders: from concepts and findings to recommendations.
      These guidelines propose a clinically practical grading system to guide workup and therapy by categorizing patients as follows:
      • Grade I: neck pain with no signs of major disease and no or little interference with daily activities
      • Grade II: neck pain with no signs of major disease, but interference with daily activities
      • Grade III: neck pain with neurologic signs of nerve compression
      • Grade IV: neck pain with signs of major disease

      Symptoms

       Radiculopathy

      The hallmark of radicular pain is some combination of diminished motor strength (described by about 15% of patients at presentation), reflexes, or sensation (paresthesias described by about 90% of patients at presentation) in a nerve root distribution. Lower cervical nerve roots (C5-8) are the most commonly involved in compressive radiculopathies. C7 is involved more than half the time; C6 is involved about 35% of the time.
      • Radhakrishnan K.
      • Litchy W.J.
      • O’Fallon W.M.
      • et al.
      Epidemiology of cervical radiculopathy. A population based study from Rochester, Minnesota 1876 through 1990.
      Only a few patients describe trauma or physical exertion preceding their pain.
      • Radhakrishnan K.
      • Litchy W.J.
      • O’Fallon W.M.
      • et al.
      Epidemiology of cervical radiculopathy. A population based study from Rochester, Minnesota 1876 through 1990.
      Table 1 gives a description of history and examination findings for each nerve root. This table represents a compilation of several sources of information; the most distinguishing and consistently reported findings are in bold type.
      • Netter F.H.
      Atlas of human anatomy.

      Robinson J, Kothari M. Clinical features and diagnosis of cervical radiculopathy. Available at: http://www.uptodate.com/. Accessed September 28, 2013.

      • Honet J.C.
      • Ellenberg M.R.
      What you always wanted to know about the history and physical exam of neck pain but were afraid to ask.
      • Bogduk N.
      The anatomy and pathophysiology of neck pain.
      Table 1Signs and symptoms of cervical radiculopathy by involved nerve root
      C5C6C7C8
      PainNeckNeckNeckNeck
      ScapulaScapulaScapula
      ShoulderShoulderChest
      Radial forearmMedial forearm
      HandHand
      SensationClavicle, lateral shoulder
      (Anterior forearm)(Lateral arm, forearm)(Medial forearm, arm)
      Thumb(Thumb)
      (Index finger)Index finger
      Middle finger
      (Ring finger)Ring finger
      Little finger
      (Palm)(Medial hand)
      Muscles innervatedDeltoid
      Biceps brachiiBiceps brachii
      BrachialisBrachialis
      Extensor carpi radialis longus and brevusExtensor carpi radialis longus, brevus
      Triceps brachiiTriceps brachii
      Flexor digitorum superficialis, profundus
      MotorShoulder abduction(Shoulder abduction)
      Elbow flexionElbow flexion
      Elbow extensionElbow extension
      (Forearm supination)
      (Forearm pronation)Forearm pronation
      Wrist extensionWrist extensionWrist flexion
      Finger extensionFinger, thumb extension
      Finger, thumb flexion
      Finger, thumb abduction
      Finger, thumb adduction
      Reflexes(Biceps)BicepsTriceps
      (Brachioradialis)Brachioradialis
      This table represents a compilation of several sources of information
      • Netter F.H.
      Atlas of human anatomy.

      Robinson J, Kothari M. Clinical features and diagnosis of cervical radiculopathy. Available at: http://www.uptodate.com/. Accessed September 28, 2013.

      • Honet J.C.
      • Ellenberg M.R.
      What you always wanted to know about the history and physical exam of neck pain but were afraid to ask.
      • Bogduk N.
      The anatomy and pathophysiology of neck pain.
      ; the most distinguishing and consistently reported findings are in bold type.
      Pain is not a universal symptom of radiculopathy. Pain associated with radiculopathy may occur directly if the dorsal root ganglion is compressed.
      • Song X.J.
      • Hu S.J.
      • Greenquist K.W.
      • et al.
      Mechanical and thermal hyperalgesia and ectopic neuronal discharge after chronic compression of dorsal root ganglia.
      Herniated disks, themselves, may also release inflammatory mediators, which may incite pain.
      • Carette S.
      • Fehlings M.G.
      Cervical radiculopathy.
      Although sensory symptoms like tingling may be felt in a dermatomal distribution, pain does not readily follow this same distribution. Instead, it is often deep feeling and is described as extending through the shoulder, arm, forearm, and hand (the hand being more common in C6-8 involvement).
      • Carette S.
      • Fehlings M.G.
      Cervical radiculopathy.
      • Bogduk N.
      The anatomy and pathophysiology of neck pain.
      • Radhakrishnan K.
      • Litchy W.J.
      • O’Fallon W.M.
      • et al.
      Epidemiology of cervical radiculopathy. A population based study from Rochester, Minnesota 1876 through 1990.
      • Slipman C.W.
      • Plastaras C.T.
      • Palmitier R.A.
      • et al.
      Symptom provocation of fluoroscopically guided cervical nerve root stimulation: are dynatomal maps identical to dermatomal maps?.

       Myelopathy

      Onset of symptoms of cervical myelopathy is often subtle and gradual; years may go by before the patient presents for medical care.
      • McCormick W.E.
      • Steinmetz M.P.
      • Benzel E.C.
      Cervical spondylotic myelopathy: make a difficult diagnosis, then refer for surgery.
      • Brain W.R.
      • Northfield D.
      • Wilkinson M.
      Neurological manifestations of cervical spondylosis.
      However, patients can present with sudden or episodic worsening, especially associated with trauma such as sudden hyperextension. If symptoms are mild at onset, the most common clinical course is to remain stable. Less frequently, a steady progression in symptoms is seen.
      • Kadanka Z.
      • Mares M.
      • Bednarıka J.
      • et al.
      Predictive factors for mild forms of spondylotic cervical myelopathy treated conservatively or surgically.
      • Kadanka Z.
      • Mares M.
      • Bednarık J.
      • et al.
      Approaches to spondylotic cervical myelopathy: conservative versus surgical results in a 3-year follow-up study.
      Symptoms are variable and may include
      • McCormick W.E.
      • Steinmetz M.P.
      • Benzel E.C.
      Cervical spondylotic myelopathy: make a difficult diagnosis, then refer for surgery.
      • Tracy J.A.
      • Bartleson J.D.
      Cervical spondylotic myelopathy.
      :
      • 1.
        Significant pain in the neck, shoulders, or arms (although not present in most patients)
        • Lunsford L.D.
        • Bissonette D.J.
        • Zorub D.S.
        Anterior surgery for cervical disc disease. Part 2: treatment of cervical spondylotic myelopathy in 32 cases.
      • 2.
        Gait spasticity
      • 3.
        Upper extremity numbness, which is often in a nonspecific distribution but can be dermatomal, especially with a coexisting radiculopathy
      • 4.
        Loss of fine motor control in the hands
      • 5.
        Lower extremity weakness
      • 6.
        Bowel or bladder dysfunction, including urgency, frequency, retention

       Mechanical Neck Pain

      As discussed earlier, in the absence of these nerve dysfunction syndromes, the cause of neck pain is not well understood. The prevalence of neck pain increases with age, declining again in late life, and it frequently coexists with other comorbidities such as low back pain, headache, and poor self-rated health.
      • Hogg-Johnson S.
      • van der Velde G.
      • Carroll L.J.
      • et al.
      The burden and determinants of neck pain in the general population: results of the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and its Associated Disorders.
      These same comorbidities also portend a worse prognosis. Workers’ compensation payments and work-related stress are also reported predictors of persistent pain.
      • Honet J.C.
      • Ellenberg M.R.
      What you always wanted to know about the history and physical exam of neck pain but were afraid to ask.
      Most people who present to primary care clinic with neck pain experience recurrent or persistent problems.
      • Carroll L.
      • Hogg-Johnson S.
      • van der Velde G.
      • et al.
      Course and prognostic factors for neck pain in the general population. Results of the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and its Associated Disorders.
      In one population-based study of primary care patients with neck pain,
      • Cote P.
      • Cassidy J.D.
      • Carroll L.J.
      • et al.
      The annual incidence and course of neck pain in the general population: a population-based cohort study.
      only one-third of patients reported resolution of symptoms at 1-year follow-up. Other studies suggest that between 15% and 50% of people in the general population report resolution at one year.
      • Guzman J.
      • Haldeman S.
      • Carroll L.
      • et al.
      Clinical practice implications of the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and its associated disorders: from concepts and findings to recommendations.

      Diagnostic tests/imaging studies

      Ordering imaging studies for neck pain is tricky. Although neck pain may be causing significant disability, imaging studies are often unhelpful and potentially misleading. A strong correlation between physical examination and imaging studies is paramount.
      As most investigators on this subject have advocated, the clinician’s first task is to ascertain any symptoms that might suggest serious underlying disease (such as trauma/fracture, osteomyelitis, cancer, inflammatory arthritides, or spinal cord compromise). These red flags,
      • Honet J.C.
      • Ellenberg M.R.
      What you always wanted to know about the history and physical exam of neck pain but were afraid to ask.
      • Nordin M.
      • Carragee E.J.
      • Hogg-Johnson S.
      • et al.
      Assessment of neck pain and its associated disorders. Results of the Bone And Joint Decade 2000– 2010 Task Force on Neck Pain and its Associated Disorders.
      as outlined in Box 1, should be similar to those reported in patients with low back pain.
      • Chou R.
      • Qaseem A.
      • Snow V.
      • et al.
      Diagnosis and Treatment of Low Back Pain: A Joint Clinical Practice Guideline from the American College of Physicians and the American Pain Society.
      Such symptoms warrant appropriate, expedited evaluation.
      Red flags for serious underlying disease
      • Cancer or infection
        • Fever, chills, weight loss
        • History of cancer
        • Age >50 years or <20 years
        • Intravenous drug use
        • Immunosuppression (steroids, human immunodeficiency virus, transplant)
        • Recent infection, especially with bacteremia
        • Pain that is worse when supine
        • Severe night time pain
        • Fail to improve >6 weeks
        • Tenderness over vertebral body
      • Fracture
        • Significant trauma
        • Osteoporosis
      • Systemic disease
        • History of ankylosing spondylitis or inflammatory arthritis
      • Myelopathy
        • Lower extremity spasticity
        • Bowel or bladder changes
        • Upper motor neuron signs (eg, Babinski, Hoffman)
      The second and related task is to discern any potential for spinal cord or nerve root compression. This task may be accomplished via the history and physical examination, as described in the next section (see section on symptoms also).

       Radiculopathy, History, and Physical Examination

      Findings of radiculopathy on examination might include decreased sensation as well as lower motor neuron signs (weakness, hyporeflexia, and less commonly, atrophy or hypotonia). Classically, sensory findings follow a dermatomal distribution, but in clinical practice, sensory findings on examination only follow this distribution in a few patients,

      Robinson J, Kothari M. Clinical features and diagnosis of cervical radiculopathy. Available at: http://www.uptodate.com/. Accessed September 28, 2013.

      • Radhakrishnan K.
      • Litchy W.J.
      • O’Fallon W.M.
      • et al.
      Epidemiology of cervical radiculopathy. A population based study from Rochester, Minnesota 1876 through 1990.
      probably because of significant overlap in dermatomes. Pain into the arm rarely follows a dermatomal pattern, but may run more similar to a myotomal pattern.
      • Carette S.
      • Fehlings M.G.
      Cervical radiculopathy.
      • Bogduk N.
      The anatomy and pathophysiology of neck pain.
      • Radhakrishnan K.
      • Litchy W.J.
      • O’Fallon W.M.
      • et al.
      Epidemiology of cervical radiculopathy. A population based study from Rochester, Minnesota 1876 through 1990.
      • Slipman C.W.
      • Plastaras C.T.
      • Palmitier R.A.
      • et al.
      Symptom provocation of fluoroscopically guided cervical nerve root stimulation: are dynatomal maps identical to dermatomal maps?.
      Table 1 compiles commonly reported associated findings depending on spinal nerve involved.
      • Netter F.H.
      Atlas of human anatomy.

      Robinson J, Kothari M. Clinical features and diagnosis of cervical radiculopathy. Available at: http://www.uptodate.com/. Accessed September 28, 2013.

      • Honet J.C.
      • Ellenberg M.R.
      What you always wanted to know about the history and physical exam of neck pain but were afraid to ask.
      • Radhakrishnan K.
      • Litchy W.J.
      • O’Fallon W.M.
      • et al.
      Epidemiology of cervical radiculopathy. A population based study from Rochester, Minnesota 1876 through 1990.
      • Yoss R.E.
      • Corbin K.B.
      • MacCarlty C.S.
      • et al.
      Significance of symptoms and signs in localization of involved root in cervical disk protrusion.
      In practice, the experience of pain is variable, and dermatomal/myotomal boundaries overlap significantly. Lower cervical nerve roots are more commonly affected; C7 is the most frequent.
      • Radhakrishnan K.
      • Litchy W.J.
      • O’Fallon W.M.
      • et al.
      Epidemiology of cervical radiculopathy. A population based study from Rochester, Minnesota 1876 through 1990.
      Several provocative maneuvers have been reported for cervical radiculopathy.
      • Nordin M.
      • Carragee E.J.
      • Hogg-Johnson S.
      • et al.
      Assessment of neck pain and its associated disorders. Results of the Bone And Joint Decade 2000– 2010 Task Force on Neck Pain and its Associated Disorders.
      • Rubinstein S.
      • Pool J.J.
      • van Tulder M.W.
      A systematic review of the diagnostic accuracy of provocative tests of the neck for diagnosing cervical radiculopathy.
      • Wainner R.S.
      • Fritz J.M.
      • Irrgang J.J.
      • et al.
      Reliability and diagnostic accuracy of the clinical examination and patient self-report measures for cervical radiculopathy.
      The upper limb tension test (ULTT), also called the brachial plexus tension test or test of Elvey, has been reported as the straight leg raise of the upper extremities; Rubinstein and colleagues
      • Rubinstein S.
      • Pool J.J.
      • van Tulder M.W.
      A systematic review of the diagnostic accuracy of provocative tests of the neck for diagnosing cervical radiculopathy.
      reviewed the literature and concurred that it has high sensitivity (97%), with a reasonable negative likelihood ratio (reported at 0.12, but with a large confidence interval). However, it has low specificity (22%–90%).
      • Nordin M.
      • Carragee E.J.
      • Hogg-Johnson S.
      • et al.
      Assessment of neck pain and its associated disorders. Results of the Bone And Joint Decade 2000– 2010 Task Force on Neck Pain and its Associated Disorders.
      • Wainner R.S.
      • Fritz J.M.
      • Irrgang J.J.
      • et al.
      Reliability and diagnostic accuracy of the clinical examination and patient self-report measures for cervical radiculopathy.
      • Sandmark H.
      • Nisell R.
      Validity of five common manual neck pain provoking tests.
      The ULTT is performed with the patient in a supine position. Provide (1) scapular depression with one hand, while (2) abducting the shoulder to 90°, with the elbow in 90° of flexion. (3) Supinate the forearms and wrist. Extend the wrist and fingers. (4) Push forward on the hand to laterally rotate the shoulder. (5) Extend the elbow. (6) Provocation of pain into the arm can also be further elicited in the final position by having the patient bend their head contralaterally (which should elicit or exacerbate pain)
      • Wainner R.S.
      • Fritz J.M.
      • Irrgang J.J.
      • et al.
      Reliability and diagnostic accuracy of the clinical examination and patient self-report measures for cervical radiculopathy.
      • Elvey R.L.
      The investigation of arm pain: signs of adverse responses to the physical examination of the brachial plexus and related tissues.
      ; an ipsilateral head bend should diminish pain (Fig. 1).
      • Wainner R.S.
      • Fritz J.M.
      • Irrgang J.J.
      • et al.
      Reliability and diagnostic accuracy of the clinical examination and patient self-report measures for cervical radiculopathy.
      Figure thumbnail gr1
      Fig. 1ULTT.
      (Data from Wainner RS, Fritz JM, Irrgang JJ, et al. Reliability and diagnostic accuracy of the clinical examination and patient self-report measures for cervical radiculopathy. Spine (Phila Pa 1976) 2003;28(1):52–62.)
      Neck distraction is performed by grasping under the patient’s chin while they are supine and applying a modest upward distracting force, which should relieve symptoms. Wainner and colleagues
      • Wainner R.S.
      • Fritz J.M.
      • Irrgang J.J.
      • et al.
      Reliability and diagnostic accuracy of the clinical examination and patient self-report measures for cervical radiculopathy.
      reported low sensitivity (44%) but reasonably high specificity (90%), with a reasonable positive likelihood ratio of 4.4 (although again with a large confidence interval).
      Likewise, a positive Spurling sign (Fig. 2), Valsalva (pain with 3 seconds of breath holding/bearing down), or abduction relief sign (resolution of pain with placing hand on the patient’s head) also have reasonably high specificity (86%–93%, 94%, and 75%–92%, respectively). Their sensitivity is low. They could support a diagnosis of radiculopathy in the context of corroborating history and other examination findings, but their absence does not rule out the disease.
      • Rubinstein S.
      • Pool J.J.
      • van Tulder M.W.
      A systematic review of the diagnostic accuracy of provocative tests of the neck for diagnosing cervical radiculopathy.
      • Wainner R.S.
      • Fritz J.M.
      • Irrgang J.J.
      • et al.
      Reliability and diagnostic accuracy of the clinical examination and patient self-report measures for cervical radiculopathy.
      • Tong H.C.
      • Haig A.J.
      • Yamakawa K.
      The Spurling test and cervical radiculopathy.
      • Davidson R.I.
      • Dunn E.J.
      • Metzmaker J.N.
      The shoulder abduction test in the diagnosis of radicular pain in cervical extradural compressive monoradiculopathies.
      • Viikari-Juntura E.
      • Porras M.
      • Laasonen E.M.
      Validity of clinical tests in the diagnosis of root compression in cervical disc disease.
      Figure thumbnail gr2
      Fig. 2Spurling maneuver: pain with axial pressure while head is bent ipsilaterally.

       Myelopathy, History, and Physical Examination

      In contrast to radiculopathy, the physical examination hallmarks of myelopathy are primarily upper motor neuron findings in a distribution below the level of compression. These findings may include upper or lower extremity weakness, spastic gait, and hyperreflexia. The plantar reflex (Babinski sign) and Hoffman reflex are important to perform, and their presence should alert the clinician to possible myelopathy.
      • Honet J.C.
      • Ellenberg M.R.
      What you always wanted to know about the history and physical exam of neck pain but were afraid to ask.
      The Hoffman reflex is performed by applying a quick pressure (flicking) to the middle finger and then looking for reflexive flexion of the thumb. Please note, this response can be nonpathologic in naturally hyperreflexic patients. There can be coexisting lower motor neuron findings in myelopathy because of simultaneous nerve root compression; these are classically at the level of involvement, not lower.

       Laboratory Tests and Imaging

      Blood work is rarely useful in the evaluation of neck pain, except perhaps in the evaluation of someone with red flag symptoms that suggest infection, cancer, and so forth (see Box 1).
      Plain radiographs for the evaluation of nontraumatic neck pain in primary care clinic, are rarely, if ever, useful. They should be considered only in cases in which the history and examination have yielded red flags for serious disease (in which case the need for more advanced imaging might supersede radiographs, depending on the situation). Abnormal curvature does not predict muscle spasm as sometimes believed.
      • Matsumoto M.
      • Fujimura Y.
      • Suzuki N.
      • et al.
      Cervical curvature in acute whiplash injuries: prospective comparative study with asymptomatic subjects.
      In one series of 85 patients referred for radiographs based on neck pain,
      • Heller C.A.
      • Stanley P.
      • Lewis-Jones B.
      • et al.
      Value of x ray examinations of the cervical spine.
      there were no unexpected findings of malignancy or infection. In another series of 848 patients referred for radiographs,
      • Johnson M.J.
      • Lucas G.L.
      Value of cervical spine radiographs as a screening tool.
      there were no unexpected serious diagnoses.
      MRI is clearly the test of choice if serious underlying disease, such as infection or cancer, is being considered. However, MRI findings of spinal cord or nerve root compression must be interpreted with caution and always correlated with the patient’s history and examination. Degenerative changes, herniated disks, and compression of neural structures on MRI are common, age-related findings.
      • Nordin M.
      • Carragee E.J.
      • Hogg-Johnson S.
      • et al.
      Assessment of neck pain and its associated disorders. Results of the Bone And Joint Decade 2000– 2010 Task Force on Neck Pain and its Associated Disorders.
      Review of cervical spine MRI scans performed in 100 asymptomatic patients showed herniated disks in 57% of patients older than 64 years, with spinal cord impingement in 26%. Asymptomatic spinal cord compression was observed in 7% of all the patients.
      • Teresi L.M.
      • Lufkin R.B.
      • Reicher M.A.
      • et al.
      Asymptomatic degenerative disk disease and spondylosis of the cervical spine: MR imaging.
      MRI can reliably show compression of neural structures, but these findings should then be correlated with any myelopathic or radicular symptoms.
      • Nordin M.
      • Carragee E.J.
      • Hogg-Johnson S.
      • et al.
      Assessment of neck pain and its associated disorders. Results of the Bone And Joint Decade 2000– 2010 Task Force on Neck Pain and its Associated Disorders.
      Showing degenerative changes in the absence of nerve or cord compression usually does not change management.
      Electromyography should be used in conjunction with the physical examination and MRI to evaluate a suspected radiculopathy. It has little role in evaluation of suspected myelopathy, except to rule out alternative explanations of symptoms/findings.
      • So Y.T.
      • Weber C.F.
      • Campbell W.W.
      Practice parameter for needle electromyographic evaluation of patients with suspected cervical radiculopathy: summary statement. American Association of Electrodiagnostic Medicine. American Academy of Physical Medicine and Rehabilitation.
      Diskography and diagnostic (anesthetic) injections are controversial, and, although advocated by some investigators, they are generally not recommended based on current evidence for mechanical neck pain.
      • Guzman J.
      • Haldeman S.
      • Carroll L.
      • et al.
      Clinical practice implications of the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and its associated disorders: from concepts and findings to recommendations.
      • Nordin M.
      • Carragee E.J.
      • Hogg-Johnson S.
      • et al.
      Assessment of neck pain and its associated disorders. Results of the Bone And Joint Decade 2000– 2010 Task Force on Neck Pain and its Associated Disorders.

      Differential diagnosis

      A specific cause for neck pain is frequently not found. Rare causes should be considered, especially if red flags are present in the history or physical examination to suggest these. Table 2 gives a list of common and rare causes.
      • Honet J.C.
      • Ellenberg M.R.
      What you always wanted to know about the history and physical exam of neck pain but were afraid to ask.
      • Bogduk N.
      The anatomy and pathophysiology of neck pain.
      • Nordin M.
      • Carragee E.J.
      • Hogg-Johnson S.
      • et al.
      Assessment of neck pain and its associated disorders. Results of the Bone And Joint Decade 2000– 2010 Task Force on Neck Pain and its Associated Disorders.
      • Shelerud R.A.
      • Paynter K.S.
      Rarer causes of radiculopathy: spinal tumors, infections, and other unusual causes.
      • Harinck H.I.
      • Bijvoet O.L.
      • Vellenga C.J.
      • et al.
      Relation between signs and symptoms in Paget’s disease of bone.
      • Mazières B.
      Diffuse idiopathic skeletal hyperostosis (Forestier-Rotes-Querol disease): what’s new?.
      Table 2Common and rare causes of neck pain, radiculomyelopathy or both
      Neck Pain AloneNeck Pain with Radiculopathy/MyelopathyRadiculopathy/Myelopathy Symptoms Alone
      Common
       Disk herniationxxx
       Neuroforaminal stenosis (from spondylosis, disk herniation, or both)xx
       Spinal canal stenosis (from spondylosis, large central disk herniation, ligament calcification, or combination)xx
       Nonspecific pain (also known as mechanical pain) from unknown cause; sometimes, this is labeled as cervical muscle strain, facet joint pain, and so forthx
      Rare
       Tumorxxx
       Benign tumors (hemangioma, osteoid osteoma, osteoblastoma, osteochondroma, giant cell tumor)xx
       Serious infections (diskitis, osteomyelitis, epidural abscess, septic arthritis, meningitis)xxx
       Vascular causes (eg, vertebral artery, internal carotid or aortic dissection)xxx
       Nerve root infarction (vasculitis)xx
       Trauma: fracture, root avulsion, spinal cord injuriesxxx
       Polymyalgia rheumatica/temporal arteritisxStiffness should be primary
       Inflammatory arthropathies (rheumatoid arthritis, crystal arthropathy, ankylosing spondylitis)xTypically multiple joint involvement and systemic inflammatory symptoms
       FibromyalgiaxShould not be isolated neck pain
       Synovial cystx
       TorticollisxNot necessarily painful
       Diffuse idiopathic skeletal hyperostosisxClassically painless, except at risk for cervical fractures from minimal trauma. Stiffness and dysphagia more common symptoms
       Paget diseasexCervical spine lesions only seen in 11% of patients. In a series of 180 patients, none reported neck pain and only 2 patients had spinal cord compression
      • Harinck H.I.
      • Bijvoet O.L.
      • Vellenga C.J.
      • et al.
      Relation between signs and symptoms in Paget’s disease of bone.
       Thoracic outlet syndromexx
       Shoulder diseasesx
       Multiple sclerosisx
       Amyotrophic lateral sclerosis, Guillain-Barré syndrome, normal pressure hydrocephalusx
      Noncompressive radiculopathies (rare)
       Diabetic monoradiculopathyx
       Herpes zosterx
       Lyme diseasex
       Tuberculosisxx
       Syphilisx
       Brucellosisx
       Cytomegalovirusx
       Lyme diseasex
       Histiocytosis Xx
       Sarcoidosisx
       Human immunodeficiency virus–related neuropathyx

      Treatment

      Because neck pain is a common and sometimes disabling problem, it is not surprising that numerous methods of treatment are routinely used to mitigate symptoms. The scientific literature on treatment is often sparse, conflicting or mired in methodological flaws, making it difficult for the practicing clinician to feel confident about what course of action to recommend. It is not even clear what the benefits and harms of giving a diagnostic label (such as degenerative joint disease) may be for a patient.
      Multiple challenges exist in both treating and studying the treatment of patients with neck pain. Lack of clarity on the basic understanding of the cause of neck pain without radiculopathy or myelopathy makes targeted interventions challenging. Gold standards for diagnosis of purported causes are murky. Patients with neck pain are probably a heterogeneous group of patients who respond differently to various interventions. For example, response to treatment may vary depending on (1) presence of radiculopathy, myelopathy or neither, (2) comorbid psychiatric disease or personality,
      • Van der Donk J.
      • Shouten J.
      • Passchier J.
      • et al.
      The associations of neck pain with radiological abnormalities of the cervical spine and personality traits in a general population.
      or (3) other premorbid musculoskeletal pains,
      • Hogg-Johnson S.
      • van der Velde G.
      • Carroll L.J.
      • et al.
      The burden and determinants of neck pain in the general population: results of the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and its Associated Disorders.
      to name a few. With the inherently subjective nature of pain reporting, it can be hypothesized that a patient’s preference for certain treatments (eg, if a friend had a good experience with one type of treatment) may influence a patient’s perception or reporting of pain after treatment.
      As mentioned earlier, distinctions should be drawn between mechanical neck pain, neck pain with radiculopathy or myelopathy, and neck pain with serious underlying disease (eg, fracture, cancer, infection). Treatment of patients in this final category (serious underlying disease) is often appropriately more aggressive, with excellent support in the literature. This subject is outside the scope of this discussion and we focus instead on the first two categories.
      • Guzman J.
      • Haldeman S.
      • Carroll L.
      • et al.
      Clinical practice implications of the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and its associated disorders: from concepts and findings to recommendations.
      Multiple helpful systematic reviews have been published for individual treatment methods, combinations of treatment methods, and overall surgical versus conservative treatment courses.
      • Nikolaidis I.
      • Fouyas I.P.
      • Sandercock P.A.
      • et al.
      Surgery for cervical radiculopathy or myelopathy.
      • Vernon H.
      • McDermaid C.S.
      • Hagino C.
      Systematic review of randomized clinical trials of complementary/alternative therapies in the treatment of tension-type and cervicogenic headache.
      • Hurwitz E.L.
      • Carragee E.J.
      • van der Velde G.
      • et al.
      Treatment of neck pain. Noninvasive interventions: results of the bone and Joint Decade 2000-2010 Task Force on Neck Pain and its Associated Disorders.
      • Carragee E.J.
      • Hurwitz E.L.
      • Cheng I.
      • et al.
      Treatment of neck pain. Injections and surgical interventions: results of the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and its Associated Disorders.
      • Kay T.M.
      • Gross A.
      • Goldsmith C.H.
      • et al.
      Exercises for mechanical neck disorders.
      • Gross A.
      • Hoving J.L.
      • Haines T.A.
      • et al.
      A Cochrane review of manipulation and mobilization for mechanical neck disorders.
      • Peloso P.M.
      • Gross A.
      • Haines T.
      • Cervical Overview Group
      • et al.
      Medicinal and injection therapies for mechanical neck disorders.
      • Trinh K.
      • Graham N.
      • Gross A.
      • et al.
      Acupuncture for neck disorders.
      • Patel K.C.
      • Gross A.
      • Graham N.
      • et al.
      Massage for mechanical neck disorders.
      • Kroeling P.
      • Gross A.R.
      • Goldsmith C.H.
      A Cochrane review of electrotherapy for mechanical neck disorders.
      • Graham N.
      • Gross A.
      • Goldsmith C.H.
      • et al.
      Mechanical traction for neck pain with or without radiculopathy.
      • Graham N.
      • Gross A.
      • Goldsmith C.
      Mechanical traction for mechanical neck disorders: a systematic review.
      • van der Heijden G.J.
      • Beurskens A.J.
      • Koes B.W.
      • et al.
      The efficacy of traction for back and neck pain: a systematic, blinded review of randomized clinical trial methods.
      • Fouyas I.
      • Statham P.
      • Sandercock P.A.
      Cochrane review of the role of surgery in cervical spondylotic radiculomyelopathy.
      • Karjalainen K.A.
      • Malmivaara A.
      • van Tulder M.W.
      • et al.
      Multidisciplinary biopsychosocial rehabilitation for neck and shoulder pain among working age adults.

       Conservative Treatments

      A panoply of conservative treatments are available. Typically, in the absence of severe myelopathic or radicular motor weakness, these treatments are the first attempted courses of action. Of the available options, those believed to have the weight of evidence in support include educational videos after whiplash injury; select exercise interventions; mobilization when used with exercise; some medications; and possibly, acupuncture.
      Although reassurance and education are often given at initial consultations, there is no evidence that such counseling is superior to any other noninvasive treatments for mechanical neck pain.
      • Hurwitz E.L.
      • Carragee E.J.
      • van der Velde G.
      • et al.
      Treatment of neck pain. Noninvasive interventions: results of the bone and Joint Decade 2000-2010 Task Force on Neck Pain and its Associated Disorders.
      Specifically, after whiplash injury, an educational video was shown to predict lower pain ratings at 24 weeks.
      • Brison R.J.
      • Hartling L.
      • Dostaler S.
      • et al.
      A randomized controlled trial of an educational intervention to prevent the chronic pain of whiplash associated disorders following rear-end motor vehicle collisions.
      There is low-quality to moderate-quality evidence for the use of specific cervical and scapular stretching and strengthening exercises for chronic neck pain,
      • Kay T.M.
      • Gross A.
      • Goldsmith C.H.
      • et al.
      Exercises for mechanical neck disorders.
      • Sarig-Bahat H.
      Evidence for exercise therapy in mechanical neck disorders.
      • Mior S.
      Exercise in the treatment of chronic pain.
      but not upper extremity stretching and strengthening or a general exercise program. The improvement from these stretching and strengthening exercises is often limited to immediately after treatment and decreases after the intermediate-term.
      Manual therapies encompass a range of hands-on interventions, which might typically be used by a physical therapist, occupational therapist, chiropractor, or doctor of osteopathic medicine. One type of manual therapy is joint mobilization. Joint mobilizations are a type of passive movement of a skeletal joint, graded and distinguished by positioning of the joint and velocity and amplitude of the movement. Within the spectrum of mobilizations, a high-velocity, low-amplitude thrust has several synonymous terms: manipulation, a grade V mobilization, or an adjustment. Multiple systematic reviews have looked at the evidence for joint mobilization, manipulation, or other manual therapies as a treatment of mechanical neck pain and come to slightly different conclusions. Mior
      • Mior S.
      Manipulation and mobilization in the treatment of chronic pain.
      concluded that evidence is limited and that these therapies may or may not be effective. Gross and colleagues
      • Gross A.
      • Hoving J.L.
      • Haines T.A.
      • et al.
      A Cochrane review of manipulation and mobilization for mechanical neck disorders.
      in their Cochrane review concluded that mobilization or manipulation when used with exercise is beneficial, but when performed alone is not. The Bone and Joint Task Force
      • Hurwitz E.L.
      • Carragee E.J.
      • van der Velde G.
      • et al.
      Treatment of neck pain. Noninvasive interventions: results of the bone and Joint Decade 2000-2010 Task Force on Neck Pain and its Associated Disorders.
      concluded that mobilization or exercise sessions alone or in combination with medications are beneficial in the short-term (6–13 weeks).
      Several classes of oral medications are frequently used for chronic, mechanical neck pain, including nonsteroidal antiinflammatory drugs, muscle relaxants, opiates, antidepressants, and other analgesics. They all have limited evidence and unclear benefits.
      • Peloso P.M.
      • Gross A.
      • Haines T.
      • Cervical Overview Group
      • et al.
      Medicinal and injection therapies for mechanical neck disorders.
      Two systematic reviews of acupuncture
      • Hurwitz E.L.
      • Carragee E.J.
      • van der Velde G.
      • et al.
      Treatment of neck pain. Noninvasive interventions: results of the bone and Joint Decade 2000-2010 Task Force on Neck Pain and its Associated Disorders.
      • Trinh K.
      • Graham N.
      • Gross A.
      • et al.
      Acupuncture for neck disorders.
      reported moderate-quality or inconsistent evidence of benefit compared with sham controls.
      Because of limited evidence, conclusions cannot be drawn about the effectiveness of massage,
      • Patel K.C.
      • Gross A.
      • Graham N.
      • et al.
      Massage for mechanical neck disorders.
      and multiple investigators have concluded that passive modalities (transcutaneous electrical nerve stimulation, ultrasonography, diathermy, electrotherapy) are not associated with short-term or long-term pain or functional improvements.
      • Hurwitz E.L.
      • Carragee E.J.
      • van der Velde G.
      • et al.
      Treatment of neck pain. Noninvasive interventions: results of the bone and Joint Decade 2000-2010 Task Force on Neck Pain and its Associated Disorders.
      • Kroeling P.
      • Gross A.R.
      • Goldsmith C.H.
      A Cochrane review of electrotherapy for mechanical neck disorders.
      Specifically for radiculopathy, traction has been advocated; it is intuitively believed to decrease pressure on the exiting spinal nerve. It is contraindicated in patients with significant or severe spondylosis, who have myelopathy, a positive Lhermitte sign, or rheumatoid arthritis with atlantoaxial subluxation.
      • Ellenberg M.R.
      • Honet J.C.
      • Treanor W.J.
      Cervical radiculopathy.
      A recent Cochrane review
      • Graham N.
      • Gross A.
      • Goldsmith C.H.
      • et al.
      Mechanical traction for neck pain with or without radiculopathy.
      found only one study deemed to have a low risk of bias and concluded that there was no evidence of benefit. Graham and colleagues
      • Graham N.
      • Gross A.
      • Goldsmith C.
      Mechanical traction for mechanical neck disorders: a systematic review.
      also found few high-quality trials and concluded that there was no evidence of benefit to continuous traction and low-quality evidence for intermittent traction. Others have determined that poor methodological quality precludes any conclusions.
      • Carette S.
      • Fehlings M.G.
      Cervical radiculopathy.
      • van der Heijden G.J.
      • Beurskens A.J.
      • Koes B.W.
      • et al.
      The efficacy of traction for back and neck pain: a systematic, blinded review of randomized clinical trial methods.
      In a practice environment with a dearth of high-quality evidence, perhaps patient preference should strongly influence choice of therapy. Future research is critical.

       Invasive Treatments

      Steroid injections may be considered for radiculopathy, with evidence supporting short-term symptom improvement.
      • Carragee E.J.
      • Hurwitz E.L.
      • Cheng I.
      • et al.
      Treatment of neck pain. Injections and surgical interventions: results of the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and its Associated Disorders.
      • Stav A.
      • Ovadia L.
      • Sternberg A.
      • et al.
      Cervical epidural steroid injection for cervicobrachialgia.
      For more significant manifestations of radiculopathy, steroid injections do not seem to decrease the rate of open surgery.
      • Carragee E.J.
      • Hurwitz E.L.
      • Cheng I.
      • et al.
      Treatment of neck pain. Injections and surgical interventions: results of the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and its Associated Disorders.
      Zygapophyseal injections are a controversial therapy for mechanical neck pain (without radiculopathy) and are not endorsed by the Bone and Joint Task Force.
      • Carragee E.J.
      • Hurwitz E.L.
      • Cheng I.
      • et al.
      Treatment of neck pain. Injections and surgical interventions: results of the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and its Associated Disorders.

       Surgery

      For a detailed discussion of surgical outcomes, the reader is referred to the surgical literature. There is not convincing evidence to support the role of surgery in mechanical neck pain,
      • Carragee E.J.
      • Hurwitz E.L.
      • Cheng I.
      • et al.
      Treatment of neck pain. Injections and surgical interventions: results of the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and its Associated Disorders.
      and there is wide variation in current practice with regards to who is referred for surgery.
      • Harland S.P.
      • Laing R.J.
      A survey of the perioperative management of patients undergoing anterior cervical decompression in the UK and Eire.
      For patients with severe or progressive radiculomyelopathy, surgery is appropriately considered.
      • McCormick W.E.
      • Steinmetz M.P.
      • Benzel E.C.
      Cervical spondylotic myelopathy: make a difficult diagnosis, then refer for surgery.
      In the presence of mild to moderate radiculopathy, short-term outcomes of pain relief, decreased numbness, and weakness are better with surgery compared with conservative management, but that difference disappears with longer-term (1–2 year) follow-up.
      • Fouyas I.
      • Statham P.
      • Sandercock P.A.
      Cochrane review of the role of surgery in cervical spondylotic radiculomyelopathy.
      In the presence of mild to moderate myelopathy, short-term benefits have been reported, but long-term follow-up (3 years) does not delineate benefits over conservative treatment.
      • Kadanka Z.
      • Mares M.
      • Bednarık J.
      • et al.
      Approaches to spondylotic cervical myelopathy: conservative versus surgical results in a 3-year follow-up study.
      • Carragee E.J.
      • Hurwitz E.L.
      • Cheng I.
      • et al.
      Treatment of neck pain. Injections and surgical interventions: results of the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and its Associated Disorders.
      • Fouyas I.
      • Statham P.
      • Sandercock P.A.
      Cochrane review of the role of surgery in cervical spondylotic radiculomyelopathy.

      Management

      Mechanical neck pain is frequently a chronic or recurrent problem for individual patients. Regular follow-up with a provider should focus on vigilance for clues to underlying serious disease and monitoring for the onset or progression of radiculopathy or myelopathy. Conservative management is usually the recommended course, and various options were discussed earlier. Given the lack of evidence that one conservative management tool is superior to another,
      • Van der Velde G.
      • Hogg-Johnson S.
      • Bayoumi A.M.
      • et al.
      Identifying the best treatment among common nonsurgical neck pain treatments.
      patient preference and availability can figure prominently in the decision. Other pillars of chronic pain management also apply here, such as validating the patient’s experience of pain, managing expectations of treatments, refocusing goals of treatment toward functionality, and treating comorbidities such as depression. Although it has not yet been validated in the literature,
      • Karjalainen K.A.
      • Malmivaara A.
      • van Tulder M.W.
      • et al.
      Multidisciplinary biopsychosocial rehabilitation for neck and shoulder pain among working age adults.
      considering a multidisciplinary approach seems reasonable.

      Summary/future considerations

      Future studies are needed to further understand the pathophysiology of mechanical neck pain. Robust scientific evidence is sparse on which noninvasive treatments are the most beneficial and how to better select patients for particular noninvasive or invasive treatments.

      References

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        Clinical practice implications of the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and its associated disorders: from concepts and findings to recommendations.
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        Atlas of human anatomy.
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