Because of anatomical differences, females are particularly vulnerable to such trauma. Girls' necks are longer than boys' and the male neck is 50 percent stronger and has a 20 percent greater circumference than the female. Girls are more likely to lose their balance during play, striking the floor with their knees locked, jarring the spine.
Neck injuries can occur in any sport but high school soccer and basketball are most notable for injury to the neck. Because the cervical spine is the most mobile portion of the spinal column, its seven vertebrae are easily injured. Even the neck of a giraffe (which also has seven vertebrae) can be seriously traumatized; at one zoo, an 11-year-old giraffe stretched its neck over a gate, turning it at a 90-degree angle over a 6.5-foot sup and tangling it in a rope, choking itself to death.
The diagnosis of a pain in the neck requires a detailed history, including the occurrence of any injury as well as the nature and timing of pain and referral pattern.
Physical examination includes looking for any limitation in normal cervical range of motion as well as conducting a complete neurological survey. Essential laboratory tests, including rheumatoid factors, where rheumatoid arthritis is suspected, can be helpful. Plain X-rays may reveal structural problems or other pathology. Further imaging including CT scans or MRI can pinpoint the nature and level of a lesion. Electrical studies of the upper extremities may assist in diagnosing specific nerve involvement.1
Mechanical Neck Pain
Mechanical neck pain is due to conditions that adversely affect the joints of the cervical spine. These include 1) strains and sprains, 2) so-called "whiplash" (flexion-extension injury), 3) torticollis (acute or congenital) and 4) osteoarthritis.
Flexion-extension injury due to a rear-end auto collision stresses all the soft-tissue structures in the cervical spine. This includes supporting structures such as ligaments and muscles, as well as vascular components, nerves, and even the spinal cord. Excessive range of motion occurs with hyperextension injuries compared with those flexing the neck. In hyperextension, the occiput strikes the posterior thorax while the chin hits the chest with hyperflexion.
Because hyperextension excursion is so much greater, the anterior structures of the neck are especially vulnerable in acceleration injury. However, spinal cord injury is greater with flexion because the axis of motion for flexion and extension lies anterior to the neural axis. Elongation of the spinal cord is required when flexion occurs and as flexion proceeds the spinal cord begins to unfold, eventually undergoing elastic deformation.
In contrast, during extension the spinal cord is relatively shortened. The head weighs approximately 10 pounds, and acute rapid flexion and extension can also cause a compression injury as the head compresses the cervical spine as it passes over neutral during flexion-extension movement. This may be severe enough to produce fractures or dislocations.
Congenital torticollis may follow organization and scarring of a hematoma in a ternocleidomastoid muscle. This will, at the least, require stretching and possibly a cast correction. Excision is sometimes necessary for definitive release. Acute torticollis due to trauma or exposure to cold can be treated initially with ice, which has a numbing effect (it sometimes hurts) and physiologically may act like acupuncture or TENS, followed by moist heat, cervical support and anodynes.
Osteoarthritis is a common cause of neck pain. It is often accompanied by morning stiffness, pain increasing with activity and decreasing with rest. Chronic neck strain due to forward head posture increases the compressive force on the articular cartilage of the cervical facet joints, resulting in loss of the compression-decompression cycle necessary for maintaining articular cartilage health. In osteoarthritis, there is a reduced concentration of chondroitin sulfate, and that which does exist has decreased chain length.
In contrast, rheumatoid arthritis is an autoimmune disease generating an inflammatory synovial pannus. Chemical diagnosis can be established and treatment includes appropriate medications. Surgery (cervical arthrodesis) is an option for advanced arthritis of either type.2
Neck Pain With Shoulder Pain
Neck pain with shoulder pain is distinctive in its pattern and quality.3 Patients describe an aching, annoying pain, though any variety of pain (e.g., sharp, burning, pinching) may be present. Such pain is usually aggravated by postural change, and patients have difficulty identifying the source.
As with neck pain, neck and shoulder pain may be barometric sensitive. Patients who stand and walk in a slumped position place strain on their cervical spine. There is a synergistic relationship between tension in the abdominal wall and the scapular retractors. Weakness of the abdominal wall can result in inferior collapse of the chest. This change in the abdomen-chest relationship places the scapulae in a more protracted position with resulting lengthening of the scapular retractors and subsequent strain to the cervical spine. Such posture in the extreme can cause compression of the brachial plexus between the clavicle and the first rib.
Acute neck and shoulder pain can be initiated by twisting, stretching or other neck stress. Pain may be referred from the diaphragm as well as from the head and neck to the shoulder area. Pain can also be referred through the greater or lesser occipital nerves, resulting in occipital tension cephalhia. Treatment in these cases usually includes a change of work habits, exercises and a figure-of-eight shoulder support. Heavy breasts may tug on the shoulders, causing an increase in thoracic kyphosis and shoulder pain. An appropriate supportive brassiere can help here.
Fibrositis is caused by an anatomic segment moving under stress. It is common in females aged 30 to 50. There is vague pain related to tension. There may be fibrofatty herniation through overlying fascia. Patients also may have generalized fatigue and sleep difficulties. The treatment is to break the vicious cycle of pain-spasm-pain by trigger point steroid injections, physical therapy and medications.
Referred pain to the shoulder can be due to cardiac disease, pulmonary tumor, acute or chronic cholecystitis, or an irritable diaphragm. Neck pain with radiculitis is found most frequently secondary to a herniated disc4 or cervical neoplasm. "Red flags" for a space-occupying lesion include unremitting pain, nocturnal pain, fever and chills, anemia and weight loss. If there is history of previous malignancy, the lesion is a tumor until proven otherwise. Appropriate workup, including indicated imaging, can diagnose these conditions.5
Injury to the cervical spine results in local swelling.6 There is fluid congestion with disruption of blood flow leading to regional acidity causing pain with muscle tightness and spasm.
Arachidonic acid affects leukotrienes, which stimulate white blood cells to produce chemical mediators. This cycle can be broken with corticosteroids, which reduce the production of arachidonic acid, or aspirin, which blocks the production of prostaglandins.
Therapy for neck problems includes a conservative program of neck care, which instructs the patient to avoid the spectator's posture and to use ice for acute and moist heat for chronic pain.
The use of chairs with high backs and neck supports is recommended. The patient can fashion a soft cervical support out of a rolled towel. An appropriate neck-supporting pillow is suggested.
Neck exercises stress general range of motion, as well as isometric drill. Physical therapy offers heat, massage and motorized cervical traction. Home traction of 12 to 15 pounds with the neck in flexion is often useful. Medications include anodynes, NSAIDs, muscle relaxers and a steroid dosepak.7 TENS and/or Botox for severe unremitting muscle spasm may be necessary. Acupuncture (which increases endorphin production and acts through alteration of the pain control system) has also proven efficacious.
A variety of cervical orthoses is available for neck support. In prescribing such an appliance, we must ask what we are treating-pain, spasm or instability? Soft collars do not restrict motion. However, they do provide comfort and some psychological support.
More rigid cervical orthoses include the Philadephia collar. Generic collars have become available. One is the Atlas collar, which is identical to its cousin, the Aspen, but less costly.
There is also the "C" Breeze collar, a rigid cervical orthosis that has added adjustability allowing the orthotist to extend cervical length.
In terms of patient compliance, the Atlas, Miami "J", and Aspen are generally rated highest in patient comfort and satisfaction. Patients often prefer the "feel" of these collars and appreciate the convenience of replacing and laundering the cervical pads.
To further control cervical motion, a poster-type orthosis is necessary. A number of rigid cervical collars add a thoracic extension to accomplish greater rigidity. When both rotation and lateral flexion must be restricted, a cervicothoracic orthosis (CTO) is recommended. For patients requiring the most stability from their orthosis, a halo is prescribed.
While most cervical orthoses are used to restrict motion, there are some that only offer support. These are used in the management of weakness caused by such neuromuscular diseases as myotonic dystrophy and amyotrophic lateral sclerosis.
Familiarity with the causes of neck pain and the pathophysiology and pathomechanics of diseases of the neck, as well as the basics of a differential diagnosis and the variety of treatment options available, can help relieve a patient's neck pain and make its management less of a "pain in the neck" for the practitioner.
1. Bland, J. (1987). Disorders of the cervical spine: Diagnosis and medical management. Chapter 1: Epidemiology and demograohics. Phylogenesis and Clinical Implications. Philadelphia: WB Saunders Co.
2. Robinson, R., Walke, A., Ferlic, E., & Wiecking, D. (1962). The results of anterior interbody fusion of the cervical spine. Journal of Bone and Joint Surgery, 44a, 1569-1587.
3. Bland, J. (1987). Disorders of the cervical spine: Diagnosis and medical management. Chapter 11: Differential diagnosis and specific treatment. Philadelphia: WB Saunders Co.
4. Simpson, J., & An, H. (1994). Degenerative disc disease of the cervical spine. In An, H., Ed. Surgery of the Cervical Spine. Baltimore: Williams & Wilkins.
5. Borenstein, D., Wiesel, S., & Borden, S. (1996). Neck pain: Medical diagnosis and comprehensive management. Chapter 1: Anatomy and biomechanics of the cervical spine. Philadelphia: WB Saunders Co.
6. Borenstein, D., Wiesel, S., & Borden, S. (1996). Neck pain: Medical diagnosis and comprehensive management. Chapter 9: A standard approach to the diagnosis and treatment of neck pain. Philadelphia: WB Saunders Co.
7. Robinson, R., Walke, A., Ferlic, E., & Wiecking, D. (1962). The results of anterior interbody fusion of the cervical spine. Journal of Bone and Joint Surgery, 44a, 1569-1587.
Irwin M. Siegel works in the Department of Neurological Sciences at Rush University Medical Center, Chicago. Gene Bernardoni is CEO, Ballert Orthopedic in Chicago.