Neck Pain (Pain Cervical region)
Neck pain is one of the common reasons for for hospital visit to the patient especially adolescents to old age.1 in 3 people suffer this condition every year. Acute neck pain is not an alarming condition and it should go away within a week or two weeks. Most of the times it is postural problem like working in a computer or studying books for a prolonged period. Until and unless it is associated with other alarming symptoms and signs, it should not worry us.
Normal Cervical Vertebrae
Cervical Vertebrae comprises of seven individual vertebral bones with discs in
between.
Figure 1- Anatomy Cervical Spine
Following are the signs and symptoms of acute neck pain
Pain
Inability to move neck
Alarming signs
Fever
Numbness, tingling sensation on extremities
Weakness of extremities
Incontinence of stool and urine
Night pain
Imbalance while walking and fall injury
Diagnosis of exact cause of the disease is explored like any other cases with history, physical examination and investigations in some cases. History about age, onset of illness and all symptoms are asked. On examination tone of paracervical muscles, bony tenderness, range of motion of neck and neurological evaluation of the extremities are done. In needful cases with alarming signs, Complete blood count (CBC), Erythrocyte Sedimentation Rate (ESR), X-ray of Neck are done preliminarily. Further, if needed CT scan and MRI of Cervical scan are sent if preliminary reports clue any underlying serious illness.
Then most of the times, cause of Neck pain is one out of following.
1. Poor posture during activities of daily life, Muscle sprain
2. Cervical Spondylitis
3. Tuberculosis of Spine
4. Inlammatory Arthritis – Rheumatoid Arthritis
5. Disc Herniation
6. Cervical Canal Stenosis
7. Spondylolisthesis
8. Tumor of Spine
Discussion on some causes of Neck Pain and their treatment
1. Poor posture during activities of daily life, Muscle sprain
Patient is told about neck care instructions. Avoid prolonged work on computer, maintain eye monitor height adjustment so as to avoid excess neck flexion.
Treatment
1. Non Pharmacologic Treatment
Neck strengthening Exercises are taught to prevent recurrences and ease pain.
TENS decreases pain.
Traction
2. Pharmacologic Treatment
NSAIDs (e.g. T. Aceclofenac)
2. Cervical Spondylitis
It’s due to disc degenerative changes, osteophytes formation and changes in adjacent soft tissues. It may cause pain around neck and radiating pain to head, arms up to hands. There may be associated dizziness or weakness of hand and clumsy walking.
Treatment is same as above.
Treatment
1. Non Pharmacologic Treatment
Neck strengthening Exercises are taught to prevent recurrences and ease pain.
TENS decreases pain.
Traction
2. Pharmacologic Treatment
NSAIDs (e.g. T. Aceclofenac)
Epidural injections
3. Tuberculosis of Spine
TB Cervical Spine is less common comprising 3-5 % of Spinal TB. They present with cervical pain, deformity, loss of motion in neck and neurologic deficit which may be para- or tetraplegia, hemiplegia or monoplegia.
Complications of the disease itself and surgery can be fatal. That’s why we have to be vigilant when we are dealing with cervical spine TB.
In the absence of gross deformity or neurological deficit TB of the spine is a medical disease and should be treated with antitubercular medication, rest and mobilization with suitable orthosis
A. In the absence of deformity, neurological deformity,
Rest, Orthosis
Anti-Tubercular Medicine
B. worsening neurological deficit and or progressive deformity
Decompression,
Anterior spinal instrumentation to support the collapsed anterior weight-bearing column of the cervical spine
Anti-tubercular Medicine
4. Disc Herniation
As the age advances, disc in between each two vertebrae loses water content and it becomes no more an efficient cushion and outer portion Annulus Fibrosis tears apart. Then central part called nucleus polposus, gelly part comes out of it and compresses the nerve root.
Figure 2. Disc Herniation
Treatment
80 % cases can be managed conservatively.
1. Non pharmacologic Therapy
Rest, TENS,USG Massage
2. Medicine
NSAIDs
Epidural injection
3. Surgery
Anterior Cervical Disectomy and Fusion (ACDF)
Or Disc replacement without fusion
Posterior Cervical Dissectomy
4. Inlammatory Arthritis – Rheumatoid Arthritis
Cervical spine may be involved in Rheumatoid arthritis leading to three different patterns of instablitiy atlantoaxial subluxation, atlantoaxial impaction, and subaxial subluxation. However, neurological involvement is less common.
Treatment
1. Patient education, regular radiographic follow-up,
2. Disease modifying anti-rheumatic drugs (DMARDs)
3. Surgical intervention
A.Atlantoaxial Subluxation
C1 -2 Fusion
Anterior atlantodental interval (AADI) between 6-10 mm
Posterior atlantodental interval (PADI) less than 13-14 mm
B.Subaxial subluxation
Improvement of spine alignment and decompress the cord (Multiple level cervical Laminectomy and fusion, Polyaxial Lateral mass screw with connecting rods)
6. Cervical Canal Stenosis
Disc protrusion, spondylophyte , thickened ligamentum flavum , hypertrophy of dorsal facets and congenital stenosis are the causes of Cervical canal stenosis.With increasing population of advanced age , these are commonly encountered. It might lead to myelopathy.No singe gold standard treatment is sufficient to deal this problem.
Data are insufficient to show the benefit of surgery in these cases.
Treatment
1.With mild cervical myelopathy
Wait and see
With realtively wide cervical canal and normal sensory evoked potential
2.Surgery
Results best when done in 3 months of myelopathy. The number of affected segments, the neutral position of the cervical spine, the severity of accompanying neck pain, and the surgeon’s confidence decide the approach.
A.Ventral Appproach
Resection of the vertebral disk protrusion and removal of the spondylophytes
Corpectomy (higher initial morbidity)
B.Dorsally
Removing the ligamentum flava or hypertrophic facets
Laminoplasty (gave more neck pain in a study)
7. Spondylolisthesis
Degenerative Spondylolisthesis in Cervical spine are rare.
Its one vertebrae slips over other anteriorly.
Treatment
A.Conservatively first.
B.Surgery
When there are cord compression or deteriorating neurology or severe pain
The aims of treatment
Spinal cord decompression (ventral, dorsal or both), correction and fusion.
e.g. 1.Open Laminectomy
2.Posterior Fusion
3.Anterior Cervical Discectomy with Fusion
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