Neck Pain

People with neck pain often describe it as a persistent ache. It can also be stabbing or burning. In chronic neck pain, patients often describe the painful area as sensitive to the touch or report that mild pressure seems to hurt more than they should. Sometimes, numbness and tingling can occur in one or both arms. Headache too can result from chronic neck pain.

Additionally, persistent muscle tension is typically associated with neck pain. The body’s normal response to pain is for the muscles to tighten up. After awhile, this persistent muscle tension can begin to ache as well.

What are the acute causes of neck pain?

There are many potential causes of neck pain. Stress and muscle tension can cause neck pain. Accidents and injuries, such as whiplash, can as well. In rare cases, infection and cancer can cause neck pain.

Spinal disc degeneration, such as disc herniations, disc bulges, and the like, are commonly thought in practice to be a cause of a new onset of neck pain too. This diagnosis, however, is controversial because these conditions are common in people without pain.^{3, 4, 5} In other words, because degenerative changes of spine so commonly occur in people without pain, these conditions, even if they show up on a scan following an accident, may have been there before the accident, never having caused any problems, as they don’t with so many people without neck pain. As a consequence, it remains uncertain whether the finding of a degenerative change of the spine is what causes pain; such changes of the spine may simply be present, causing no symptoms as is the case with many people, and the true cause lies elsewhere.

These kinds of findings are called “incidental findings.” An incidental finding is one that might possibly be the cause, but as it turns out is not the actual cause; it’s an irregular finding that is simply present, not causing any problems.

It’s sort of like if you woke up one morning and your bike was missing from your garage. You know that the neighbor kids were playing outside last night and you think that they must have stolen the bike. Later, though, the police return your bike, stating that they caught some altogether different person. The presence of the neighbor kids last night would be an incidental finding – they were indeed present, but they in fact were not causing any problems.

Similarly, the findings of degenerative changes in the spine are common in people with neck pain, but it might be due to the fact that they’re common in everyone – with or without neck pain. We have no current way to know when or if the findings of degenerative changes in someone with neck pain are in fact the true cause of neck pain or if they are simply incidental findings.

What are the causes of chronic neck pain?

As with acute neck pain, a common explanation for chronic neck pain is degenerative disc disease in the cervical spine (i.e., the neck). Again, however, the explanation is controversial because degenerative changes of the spine are as at least as common among people without pain as they are for people with pain. As such, their presence on a CT or MRI scan is not sufficient to know that it is the cause of pain.

Spine surgeons and interventional pain physicians typically employ the notion of degenerative disc disease to explain the occurrence of chronic neck pain. They understand the problem addressed above: that the finding of degenerative changes on a scan is not sufficient to know that they are the cause of pain. So, these types of providers attempt to correlate the reported symptoms of neck pain with the observed degenerative changes on scans as a way of trying to differentiate degenerative changes of the spine that are painful from those that are not painful. However, this practice is open to the possibility of considerable error.

Take two hypothetical patients, A and B. Both patients A and B have chronic neck and right arm pain. They are evaluated and given an MRI scan. Patient A has a protruding disc that pinches a nerve on the right side of the disc and the nerve that is pinched is one that runs down the right arm. Patient B also has a protruding disc that pinches a nerve, but it is pinched on the left side of the disc; the nerve that is pinched is one that runs down the left arm. Many providers who uphold the view that degenerative disc disease is a common cause of chronic neck or back pain would conclude the following about patients A and B: patient A’s symptoms correlate with the MRI findings and patient B’s symptoms do not correlate with the MRI findings. As such, they might conclude that patient A’s findings are the cause of the chronic neck and right arm pain and patient B’s findings are incidental – they do not cause patient B’s chronic neck and right arm pain.

Are patient A’s findings on MRI the cause of the chronic neck and right arm pain? It might seem reasonable to assume that they are until one recalls that these findings can also occur without symptoms.^{6, 7, 8, 9} It is therefore possible that the findings on MRI and the reported symptoms of patient A are coincidental. So, are the findings the cause of the symptoms or are they incidental to the symptoms? It is currently not possible to say one way another with any high degree of certainty.

A different explanation for chronic neck pain involves the notion of central sensitization.^{10, 11, 12} Central sensitization occurs when the nervous system, including the brain, becomes stuck in a persistent state of reactivity that makes the nervous system highly sensitive to stimuli, in this case, to the neck. As such, simple movements, like turning one’s head or walking or riding in a car, which shouldn’t be painful, are in fact painful. Other things too, which shouldn’t be painful, can become painful as well, like simple bumps to the neck, or massage, hugs, or even touch. It’s like the nervous system is stuck in a 'hair trigger' mode. This heightened sensitivity of the nervous system is called hyperalgesia and is a hallmark of central sensitization.

As an explanation of chronic pain, central sensitization should be differentiated from the cause of acute pain. As described above, many things can initially (or acutely) cause neck pain. Once the nervous system gets up-regulated into a persistent state of heightened sensitivity, central sensitization maintains pain on a chronic course, even if the initial injury has long since healed.

Chronic pain rehabilitation providers typically adhere to an understanding of the nature of chronic neck pain as involving central sensitization. Chronic pain rehabilitation programs are a traditional, interdisciplinary treatment for chronic pain that include multiple therapies, including cognitive behavioral therapies, pool therapies, mild aerobic exercise, relaxation exercises, medication management, and tapering of opioid medications. The target of the therapies included in a chronic pain rehabilitation program is the nervous system. The therapies aim to down-regulate the nervous system, thereby reducing central sensitization and therefore pain.

Is there a cure for chronic neck pain?

Whether they conceptualize chronic neck pain as due to degenerative changes of the spine or central sensitization or both, most healthcare providers agree that there is no cure for chronic neck pain.

Treatments for chronic neck pain have therefore three main goals:

• Reduce pain
• Increase function, such as returning to work
• Reducing reliance on the healthcare system

These goals are standard across most chronic pain therapies.

A number of therapies and procedures have been developed for the management of chronic neck pain. It is important to know how effective these treatments are. The following information is a review of the research literature on their relative effectiveness.

Chronic pain rehabilitation programs

Chronic pain rehabilitation programs (CPRP’s) are largely considered the most effective treatment for chronic pain in general, including chronic neck pain. Research consistently shows the following:

• CPRP’s reduce pain by about 30% while at the same time allowing patients to stop taking opioid pain medications
• CPRP’s successfully lead 40-60% of patients to return to work
• CPRP’s have high rates of reducing the need for further healthcare (such as on-going opioid management, or further surgeries or procedures)^{13, 14, 15} 

CPRP’s are a traditional interdisciplinary treatment that usually occurs on a daily basis over the course of three to four weeks. Most every major metropolitan area has a CPRP.

Physical therapy

In a recent meta-analysis, Bertozzi, et al.¹⁶ found that therapeutic exercise was moderately effective for chronic neck pain. They indicate that the results of their study are consistent with previous, similar studies.

Epidural steroid injections

Research on the outcomes of epidural steroid injections for chronic neck pain is limited. A review by independent experts systematically searched the professional literature for research supporting the use of epidural steroid injections for chronic neck pain. They found one published, clinical trial, which they judged to be of low quality. It showed a modest benefit.¹⁷ 

Rhizotomy

Research on rhizotomy, or radiofrequency denervation, for chronic neck pain is also limited. It has been proven ineffective for low back pain.^{18, 19} A review by independent researchers determined that there was limited evidence for the effectiveness of rhizotomy in neck pain, having found only a three published studies that were short in duration, and had “deficiencies in patient selection, outcome assessments, and statistical analyses.”²⁰ 

Spine surgeries

Spine surgery is a common treatment for neck pain, especially when it is associated with pain in one or both arms. There are, however, few studies on the effectiveness of surgeries for neck pain. A review that systematically searched the published research found only two studies.²¹ One was study was a trial of fusion plus decompression surgery or decompression surgery alone. It compared a group of patients who obtained one of the two surgeries with a group of patients with the same condition who obtained either physical therapy or the use of a neck brace. The study showed that surgery was helpful at the 3-month follow-up, but at one-year follow-up there was no difference between the two groups, suggesting that surgery was no better than physical therapy or use of a neck brace. The other study compared a group of patients who had fusion and decompression surgery to a group of patients who obtained only the use of a neck brace and anti-inflammatory medications. This study found no difference between the two groups at two-year follow-up. The reviewers conclude that there is not enough research evidence to know whether cervical surgery is effective or not.

A few years later, another group of researchers reviewed the research on surgery for neck pain and found that neck surgery was no better than less invasive therapies for neck pain.²²

References

1. Guez, M., Hildingsson, C., Nilsson, M., & Toolanen, G. (2002). The prevalence of neck pain. Acta Orthopaedica, 73, 455-459.

2. Bovim, G., Schrader, H., & Sand, T. (1994). Neck pain in the general population. Spine, 19(12) 1307-1309.

3. Stadnik, T. W., Lee, R. R., Coen, H. L., Neirynck, E. C., Buisseret, T. S., & Osteaux, M. J. (1998). Annular tears and disk herniations: Prevalence and contrast enhancement on MR images in the absence of low back pain. Radiology, 206, 49-55.

4. Boos, N., Rieder, R., Schade, V., Spratt, K. F., Semmer, N. & Aebi, M. (1995). The diagnostic accuracy of magnetic resonance imaging, work perception, and psychosocial factors in identifying symptomatic disc herniations. Spine, 20(24), 2613-2625.

5. Boden, S. D., McCowin, P. R., Davis, D. O., Dina, T. S., Mark, A. S., & Wiesel, S. W. (1990). Abnormal magnetic-resonance scans of the cervical spine in asymptomatic subjects: A prospective investigation. Journal of Bone & Joint Surgery, 72(8), 1178-1184.

6. Humphreys, S. C., Hodges, S. D., Patwardhan, A., Eck, J. C., Covington, L. A., & Sartori, M. (1998). The natural history of the cervical foramen in asymptomatic individuals aged 20-60 years as measured by magnetic resonance imaging: A descriptive approach. Spine, 23(20), 2180-2184.

7. Radhakrishnan, K., Lithy, W. J., O’Fallon, W. M., & Kurland, L. T. (1994). Epidemiology of cervical radiculopathy: A population-based study from Rochester, Minnesota, 1976 through 1990. Brain, 117(2), 325-335.

8. Matsumoto, M., Fujimura, Y., Suzuki, N., Nakamura M., Yabe, Y., & Shiga, H. (1998). MRI of cervical intervertebral discs in asymptomatic subjects. Journal of Bone & Joint Surgery, British Volume, 80(1), 19-24.

9. Healy, J. F., Healy, B. B., Wong, W. H., & Olson, E. M. (1996). Cervical and lumbar MRI in asymptomatic older male lifelong athletes: Frequency of degenerative findings. Journal of Computer Assisted Tomography, 20(1), 107-112.

10. Curatolo, M., Arendt-Nielsen, L., & Petersen-Felix, S. (2004). Evidence, mechanisms, and clinical implications of central hypersensitivity in chronic pain after whiplash injury. Pain, 20(6), 469-476.

11. Sheather-Reid, R. & Cohen, M. L. (1998). Psychophysical evidence for a neuropathic component of chronic neck pain. Pain, 75(2-3), 341-347.

12. Sjors, A., Larsson, B., Persson, A. L., & Gerdie, B. (2011). An increased response to experimental muscle pain. BMC Musculoskeletal Disorders, 12, 230. doi: 10.1186/1471-2474-12-230.

13. Flor, H., Fydrich, T. & Turk, D. C. (1992). Efficacy of multidisciplinary pain treatment centers: A meta-analytic review. Pain, 49, 221-230.

14. Gatchel, R., J., & Okifuji, A. (2006). Evidence-based scientific data documenting the treatment and cost-effectiveness of comprehensive pain programs for chronic non-malignant pain. Journal of Pain, 7, 779-793.

15. Turk, D. C. (2002). Clinical effectiveness and cost-effectiveness of treatments for patients with chronic pain. The Clinical Journal of Pain, 18, 355-365.

16. Bertozzi, L., Gardenghi, I., Turonic, F., Villafane, J. H., Capra, F., Guccione, A. A., & Pillastrini, P. (2013). Effect of therapeutic exercise on pain and disability in the management of chronic nonspecific neck pain: Systematic review and meta-analysis of randomized trials. Physical Therapy, 93(8), 1026-1036.

17. Peloso, P. M., Gross, A., Haines, T., Trinh, K., Goldsmith, C. H., & Burnie, S. J. (Updated March 14, 2007). Medicinal and injection therapy for mechanical neck disorders. In Cochrane Database of Systematic Reviews, 2007(3). Retrieved August 16, 2013.

18. van Wijk, R. M., Geurts, J. W., Wynne, H. J., Hammink, E., Buskens, E., Lousberg, R., Knape, J. T., & Groen, G. J. (2005). Radiofrequency denervation of lumbar facet joints in the treatment of chronic low back pain: A randomized, double-blind, sham lesion-controlled trial. Clinical Journal of pain, 21, 335-344.

19. Leclaire, R., Fortin, L., Lambert. R., Bergeron, Y. M., & Rosignol, M. (2001). Radiofrequency facet joint denervation in the treatment of low back pain: A placebo-controlled clinical trial to assess efficacy. Spine, 26, 1411-1416.

20. Niemisto, L., Kelso, E. A., Malmivaara, A., Seitsalo, S., & Hurri, H., (Updated February 27, 2002). Radiofrequency denervation for neck and back pain. In Cochrane Database of Systematic Reviews, 2003(1). Retrieved August 16, 2013.

21. Nikolaidis, I, Fouyas, I. P., Sandercock, P. A., & Statham, P. F., (Updated December 14, 2008). Surgery for cervical radiculopathy or myelopathy. In Cochrane Database of Systematic Reviews, 2010(1). Retrieved August 17, 2013.

22. van Middelkoop, M., Rubinstein, S. M., Ostelo, R., van Tulder, M. W., Peul, W., Koes, B. W., & Verhagen, A. P. (2013). Surgery versus conservative care for neck pain: A systematic review. European Spine Journal, 22(1), 87-95. doi: 10.1007/s00586-012-2553-z

Date of publication: June 23, 2012

Date of last modification: October 13, 2018