Neck Pain

The neck (or cervical spine) performs a very important function of supporting the head and allowing full motion of the neck; and at the same time, it must also protect the delicate spinal cord. Your neck bone consists of seven individual bone (vertebra) with a soft cushion (disc) between each of them. Every time you nod or shake your head, these vertebrae and discs work together to allow the mobility. Muscles of your upper back and your shoulders are attached to these neck bones.

Causes of neck pain
When is it serious?
What are the treatment options?
– Conservative options
– Surgical options
Conclusion
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Causes of neck pain
There are many structures in the neck that can result in neck ache and pain. These are the common causes:

1. Postural causes – this is the most common cause of neck pain. Prolonged postures of the neck in an unnatural position, such as falling asleep on the sofa or prolonged working on the computer (especially laptops) with the neck bent forward.
2. Wear and tear (Spondylosis) – this refers to the wearing out (degeneration) of the intervertebral disc that acts as cushions between the individual neck bones. When the disc wears out,
   it can no longer support the neck as well as it used to. The body tries to repair this by forming extra bone to act as supports and these are known as bone spurs (osteophytes). It is these osteophytes that cause compression on the nerves and spinal cord that result in some of the more severe symptoms.
3. Disc herniation – when the disc wears out, it can also protrude outwards and it is this protrusion that results in the sharp arm pain sometimes experienced by sufferers of acute disc prolapse. This may also cause tingling in the arms and hands. In more severe cases, there is even weakness in the upper limbs.
4. Inflammation – this refers to conditions like rheumatoid arthritis. This inflammatory process usually affects the fingers as well as other big joints like the knee joint. In the neck, it usually affects the upper cervical spine resulting in instability and pain.
5. Traumatic injuries – this can range from minor sprains to severe injuries including whiplash injuries in car accidents.
6. Other rare causes like infection, tumours and congenital abnormalities.

When is it serious? Most of the time, the pain is self limiting- meaning that it will reduce over time with simple medications like paracetemol or NSAIDs with simple stretching exercises.

It becomes serious when you have one or more of the following symptoms:

1. Weakness – this means there is an actual nerve compression with damage to the nerve fibres. If left untreated, paralysis may occur and be permanent.
2. Numbness or tingling – occasional numbness that goes away after a short period may be a sign of early nerve compression. If the numbness is persistent, it means nerve damage has already taken place and muscle weakness will soon follow.
3. Loss of bladder and bowel control – this is a very serious situation that warrants immediate admission to hospital and surgery. The presence of sudden incontinence means severe spinal cord or roots compression that if left untreated, will result in permanent disability.
4. Persistent pain or neck movement – the pain from neck sprains usually last from several days to one to two weeks. If the pain persists in severity and worsens over time, especially if it is associated with a fall or accident, there may be an undiagnosed neck fracture with instability.
5. Pain that radiates down the arms – this radicular pain is caused by the nerve root being squashed (usually due to herniated disc). Initially, it may just be pain but with time, tingling and weakness will develop.

What are the treatment options?
The main aim of the doctor would be to exclude serious conditions that can cause permanent damage. He/she will go through the history and perform an examination including a neurological examination to determine the state of the spinal cord and nerves. The next step is imaging studies.

There are several alternatives available:

1. X-rays – This is simple and inexpensive but yields limited information. It is most useful to look for presence of fractures and misalignment of the spine.
2. CT scans – This is a good tool for looking at bony details but does not give sufficient information on the disc and spinal cord. This is usually reserved for those with metallic implants like pacemakers who cannot have MRIs.
3. MRI – Usually the investigation of choice as it provides a clear view of the state of nerve roots and spinal cord.

Treatment is always conservative first before resorting to surgery.
Conservative options include:

• Rest (use of collar for a few days to reduce motion)
• Simple analgesia like paracetemol, NSAIDs or the newer COX-2 inhibitors
• Exercises – stretching and strengthening
• Hot packs
• Modification of lifestyle
• Physiotherapy including traction or mobilization

Surgery is sometimes needed when the above methods fail to provide relief or when there is danger of permanent nerve or spinal cord damage.

Surgical options include:

• Fusion – A procedure where the damaged disc is removed and bone is inserted between the vertebrae to fuse the level. This relieves the pressure on the nerve and spinal cord but it also increases the stress to the disc above and below the operated level.
• Arthroplasty (artificial disc replacement) – This is the newer approach where after disc removal, an artificial disc is inserted. This performs the same function as the disc by allowing motion at the operated level and reduces the damage to the adjacent discs.
• Laminectomy/Laminoplasty – this is a time tested way to reduce pressure on the spinal cord over a large area by removing part of the bone. This surgery is performed from the back of the neck.
• Facet Blocks and radiofrequency neurotomy – this is a minimally invasive technique to reduce neck pain. A fine needle is inserted from the side of the neck and local anaesthesia and a very small dose of steroids is injected to give relief to neck pain.
• Disc nucleoplasty – this is one of the latest minimally invasive methods to treat mild prolapsed disc and neck pain caused by disc degeneration. It involves using coblation technology to remove disc material.

Conclusion
It is important to take good care of the neck by developing a proper posture in the way we sit, work and play. Once degeneration starts, it is not reversible. The good news is if we start taking proper care, the degeneration can be slowed down and it may be years before any intervention may be needed.