What is neck pain ?

Pain in the neck region resulting in loss of function. Pain in the neck is not only a very common complaint but also is only second to common cold in sickness absenteeism. It is believed that about 85 % of general population will have at least one episode of back pain in their lifespan.

What are the causes of neck pain ?

The aetiology/cause of neck pain is multifactorial, there is no evidence to prove/disprove the quantitative effect of one or other. The risk factors for neck pain can be:

•Aging: as a part of the normal age related degenerative process.
•Life style: Stress and emotional tension, poor posture -standing for long periods of time or sitting incorrectly—can cause neck pain, heavy physical work, lifting or forceful movement, bending, or awkward positions can real hurt your neck.
•Injuries and Accidents: Injury to muscle , ligaments , or soft tissue can lead to neck pain .Fracture in spinal bone in a fall or a car accident also is a common cause. If you have osteoporosis, a condition that weakens your bones, you’re much more prone to fracturing a bone.
• Obesity : along with weak abdominal muscles often disrupt the spine’s balance, causing your neck to bend uncomfortably to compensate

Neck pain is also caused by a specific spinal conditions like

Slip disc,
• Cervical spinal stenosis,
• Cervical facetal arthritis,
• Cervical spondylosis,
• Primary spinal tumours,
• Spinal Metastatic tumours,
• Infections,
Tuberculosis,
• Spinal Fracture and
• Metabolic causes- otseomalacia

What is the Anatomy of neck / cervical Spine ?

Human Spine is made of up 33 bones (vertebrae) that are cushioned by discs. These vertebrae are divided by region: neck (cervical spine), mid-back (thoracic spine), and low back (lumbar spine). At the lower end spine ends at the terminal bone of sacrum and the coccyx, which is commonly called your tailbone. Discs are present between these bones. The disks protect the bones by absorbing the shocks from daily activities like walking, lifting, and twisting. Each disk has two parts – a soft, gelatinous inner portion (nucleus pulpous) and a tough outer ring (annulus fibrosis). Facet joints are on the posterior side (back) of your vertebrae. These joints (like all joints in your body) help movement and are very important for flexibility. Together, the vertebrae and discs form a tunnel through which the spinal cords and nerve paThe neck (cervical spine) consists of 7 small vertebrae which links the skull to the thorax. These 7 bones integrate with the help of many small joints and not only handle the weight of the skull (4-5kgs) but also provides the extensive movements possible at the neck. Your neck also houses the upper part of your spinal cord, nerve roots, and an elaborate system of arteries and veins. The nerves in your neck help the brain communicate with your shoulders, arms, and chest. The arteries and veins circulate blood between the brain and the heart. All in all, your neck is amazing and intricate. However, because it has such freedom of movement, it’s at a high risk for pain and injury.

What are the Common Symptoms associated with Neck Pain ?

With neck pain you may have symptoms such as:

• Neck soreness on one or both sides
• Burning pain
• Tingling sensations
• Stiffness
• Pain around your shoulder blades
• Pain, numbness, or weakness in your arm
• Trouble swallowing, talking, writing, or walking – cervical myelopathy
• Headache
• Dizziness
• Nausea
• Blurred vision
• Fever
• Night sweats
• Tiredness
• Unintentional weight loss

When do i need to have a physician opinion ?

Most of the neck pain patients shall improve with simple pain management measures. However one should seek medical attention if your neck pain persists and seek immediate attention if you have neck pain with any of the following emergency signs (RED FLAGS ):

1. Pain is getting significantly worse
2. Pain affects every day activities
3. Severe symptoms
4. Associated Fever or constitutional symptoms
5. Groin or leg weakness or numbness
6. Arm or hand weakness, tingling, or numbness
7. Loss of bowel or bladder control

What are the treatment options for neck pain ?

There are different options to treat back pain depending on the severity and duration of symptoms . They may comprise of one or many :

1. Drugs & Medications
2. Physical Therapy
3. Spinal Bracing
4. Spinal Injections
5. Spine surgery
6. Physiotherapy

Drugs, Medications, to relieve neck pain :
Medication alone is not the ultimate solution to your neck pain, however during emergency or during severe pain these medicines may help you curb the suffering.

Acetaminophen :
Your doctor may call this an analgesic, but most of us refer to acetaminophen medications as painkillers. They don’t help reduce inflammation, though.

NSAIDs (non-steroidal anti-inflammatory drugs) :
These will help reduce swelling (or inflammation) while relieving your pain; that’s how NSAIDs differ from acetaminophen. If an over-the-counter NSAID is an option for you, you have plenty to choose from. You can use ibuprofen, aspirin; however seek medical advice before you take any medicine.

Muscle Relaxants :
If you have chronic back pain caused by muscle spasms, you may need a muscle relaxant, which will help stop the spasms

Anti-depressants :
As surprising as it may seem, anti-depressants can be effective drugs for treating pain because they block pain messages on their way to the brain. They can also help increase your body’s production of endorphins, a natural pain killer.

Opioids :
In the most extreme cases, and only under careful supervision, you doctor may also prescribe an opioid, such as morphine or codeine.

Medication Warning :
As with all medications, you must follow your doctor’s advice precisely. Never mix over-the-counter and prescribed drugs without consulting your doctor.

Physical Therapy to Relieve Neck Pain :
a. Passive Therapy
i. Massage
ii. Heat Therapy /Cold /Ice Packs
iii. Local Ointments application
iv. SWD/ TENS /IFT
v. Traction
b. Active Therapy – exercises
1. Strengthening exercises for neck muscles

Passive Treatments :

• Deep Tissue Massage :Deep tissue massage relieves deep muscle tension and spasms, which develop to prevent muscle motion at the affected area.
• Hot and Cold Therapy :Both hot and cold therapies offer their own set of benefits, and your physical therapist may alternate between them to get the best results. This reduces inflammation, muscle spasms and pain.
• TENS (transcutaneous electrical nerve stimulation) : Uses electrical current to stimulate your muscles and reduces muscle spasms and is generally believed to trigger the release of endorphins, which are your body’s natural pain killers.
• Traction :Reduce the effects of gravity on the spine. the intent is to reduce the disc herniation and is usually performed in the cervical or lumbar spine.
Active Treatments :Help to reduce recurrent pain but will also benefit your overall health.
Flexibility :Learning proper stretching and flexibility techniques will prepare you for strength exercises. Flexibility helps your body move easier by warding off stiffness.
Muscle strengthening: Strong muscles are a great support system for your spine and better handle pain.

Spinal Injections :
There Are various Injection techniques used to alleviate pain in patients with persistent neck pain

• Root Block Injection
• Epidural Injection
• Facet Block Injection

Epidural Steroid Injection : An epidural steroid injection sends steroids—which are very strong anti-inflammatories—right to the nerve root that’s inflamed. This is a pain management therapy, so it’s best to have a well-trained pain management specialist do the injection. You’ll probably need 2-3 injections; generally, you shouldn’t have more than that because of the potential side effects of the steroids.

Spinal Bracing :

Spinal bracing utilises these primary objectives:

• Controlling back pain by limiting motion and unloading discs, vertebrae and other spinal structures by compressing the abdomen
.
• Stabilising weak or injured structures by immobilising the spine.
• Providing three-point force systems to provide correction or prevent progression of a deformity.
Different type of braces are classified based on the rigidity and are – Flexible, Rigid or Semi-rigid.
• Flexible orthoses or corsets are prescribed for relief of low back pain associated with degenerative disc disorders, trauma, or postural deformities. Rigid stays and inserts can be added to restrict motion and act as a postural reminder.
• Rigid orthoses are commonly custom fabricated and provide the most support to the area being treated. A body jacket or TLSO controls motion in all planes.A two piece front and back design is commonly used post operatively for ease of application while a front or back opening single piece design is commonly utilised when treating scoliosis.

Different types are :
• Corset braces
• Hyperextension braces
• Moulded jackets
• Neck braces
• Rigid braces
• Sacroiliac and lumbosacral belts
• Trochanteric belts
• Thoracolumbosacral orthoses (TLSO)

Caution :
Long time usage of corsets / belts can lead to muscular atrophy due to disuse.
Please consult your specialist before using a corset/ belt for your spinal problem.

Surgery for Neck Pain :

Only 5% of people need surgery to treat neck problems. Your pain may be severe, but most sprains and strains do not require surgery. Surgery is reserved for the most severe cases of back pain (spinal cord impingement, structural deformity, severe cases of spinal stenosis)

a. Surgery- Surgery is often required for patients whose symptoms are worsening over 2-3 weeks, and patients are not responding to conservative treatment. Emergency surgery is required for patients who have lost bowel / bladder control. The options of surgery are
• Cervical Decompression
• Spinal Fusion (ACDF )
• Disc replacement surgery

The spine surgery advised for Back pain can be performed in many different ways. The success rates of surgery in herniated disc is 99 % and with invention of modern technology and minimal invasive surgery techniques it nears 100 %. Spine surgery can be performed in different manners:

• Conventional Open surgery
• Minimal Invasive Spine surgery – Key hole spine surgery
Endoscopic Spine Surgery
• Microscopic spine surgery
• Micro endoscopic spine surgery

Decompression includes-
•Foraminotomy: A procedure that removes the bony compression over foramina (the area where the nerve roots exit the spine) to increase the size of the nerve pathway.
Laminoplasty: A procedure make more room for the spinal canal.
•Laminotomy: A procedure that removes only a small portion of the lamina (a part of the vertebra) to relieve pressure on the nerve roots.
•Discectomy: A procedure that removes a disc through a very small incision using a microscope.
Laminectomy: A procedure for treating spinal stenosis by relieving pressure on the spinal cord.

Spinal Fusion: The surgery intends to stabilise a unstable segment responsible for pain , this may involve putting some screws in your spine to increase stability.

Artificial Cervical Disc Replacement: This is a new development in spine surgery. This involves implanting an artificial cervical disc after the discectomy. This is being used instead of fusion and spinal instrumentation. The advantage is that an artificial disc enables a patient to retain normal neck movement after surgery. Previously, if the patient had two or more vertebrae fused, neck motion would be greatly reduced. Cervical discs still are a fairly new technology; however, early results are encouraging.