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NECK PAIN
Dr. Editha C. Dizon

One of the most common problem that anyone can

encounter.
There are different structures in the cervical area which
can contribute to the etiology of neck pain.
REVIEW OF ANATOMY

VERTEBRAE

7 cervical - lordosis

12 thoracic

5 lumbar

5 sacral (fused)
3-5 coccygeal bones

Two curves:
o 2 Primary

Present at birth

Thoracic kyphosis

Sacral kyphosis
o 2 Secondary
o Develops later on
o Cervical lordosis

Develops once a child

learned how to extend the
o neck and how to control the neck up.
o Lumbar lordosis

When a child learned how to

stand at 10-12 months old.
Any changes in the curvature of the spine can be functional,
anatomical defect, congenital problem or can be seen in the x-ray.

o Axis
o C7
Typical cervical spine
o C3-C6

CERVICAL VERTEBRAE

Small body

Facets in transverse plane

Short bifid spines

Transverse foramen where the vertebral artery,

vertebral vein, and sympathetic nerve plexus passes
through

Klippel-Feil Syndrome is a condition wherein there are fusion of

cervical vertebra. The range of motion may still be normal
because the joints below and above will compensate for the loss
of motion.

C3-C7 SEGMENT

Vertebral bodies are wider anteriorly

Facets are oriented in oblique fashion

o Advantage:

SCIWORA Spinal Cord Injury

without Radiologic Abnormality

This is possible in the cervical spine.

C5-C6 produces the greatest flexion-extension followed

by C6-7 segment
o C7 has long spinous process; can be palpated
o This is the most common site involved in
osteoarthritis or degenerative disease due to
active movement (galaw ng galaw)

C2-3 and C3-4 segments produces lateral bending and

axial rotation
THORACIC VERTEBRAE (not discussed)

OSSEOUS STRUCTURES

Atypical cervical spine

o Atlas

Doesnt have a body, it is a ring-like

structure.

When combined together, it makes up

the:

Yes joint, atlanto-occipital

joint between the occiput
and atlas

No joint, atlanto-axial joint

between C1 and C2 complex
REHABILITATION MEDICINE: NECK PAIN DRA. DIZON (2016)

Heart shaped body

Long spines oriented inferiorly
Facets for ribs
transverse process

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LUMBAR VERTEBRAE (not discussed)

Massive kidney- shaped body

Facets in sagittal plane
Broad spines oriented posteriorly

SACRAL VERTEBRAE (not discussed)

5 sacral segments fused

Triangular shape

SPINAL NERVES/ROOTS

31 pairs

cauda equina - roots

FUNCTIONAL UNIT OF SPINE: 2 vertebra and 1 intervening disc

Flexion
Extension

COCCYX (not discussed)

Ends at L1-L2 (adult) the lumbar tap is done at the level

between L3-L4, the roots are the one hit and it
regenerates (PNS)

bigger vertebral foramina

smaller vertebral formina

Vestigial tail

LIGAMENTS

Anterior longitudinal ligament (ALL)

Posterior longitudinal ligament (PLL)

o Tectorial membrane continuation of PLL (what
the PLL is called when it is at the cervical spine)

Ligamentum flavum
o yellow ligament
o in between one lamina or vertebra to the other

Interspinous ligaments
o connects one spinous process to the other
o above supraspinous ligament

Ligamentum nuchae
o in the cervical area and the extension of the
supraspinous ligament

In a case of a disc herniation causing a root impingement,

what position of the neck will aggravate / relieve the pain?

Extension (provocative test) worsen the pain

Flexion relief of pain

INTERVERTEBRAL DISCS

Annulus fibrosus
o An outer fibrous tissue of the intervertebral disc

Nucleus pulposus
o Inner part
o Made up of gelatinous matrix
(glycosaminoglycans)

In slip disc, the nucleus pulposus is extruded out. Before that can
happen, it means that annulus fibrosus is torn for your substance
to seep out.
The problem is not in the root itself, but the extruded nucleus
pulposus compresses the root which cause the pain.

The width of the ALL and PLL depends on the width of the
vertebra. The width of the ALL remains the same as it travels from
the cervical to the lumbosacral area whereas the PLL tapers down
as it reaches the lumbosacral area.
Significance: In terms of herniated disc as far as the cervical area
is concern. Where does the disc will herniate?
Cervical area
o disc will herniate LATERALLY
Lumbosacral area
o disc will herniate at the POSTEROLATERAL
AREA
o herniated disc can hit some roots
SPINAL CORD

normally shorter than the vertebral column

REHABILITATION MEDICINE: NECK PAIN DRA. DIZON (2016)

Neural arch posterior segment, site of orifice for spinal

cord (enclosed the spinal cord)
No IV disc between C1 and C2
No discs within sacrum (fused, giving rise to
sacrococcygeal complex)

BLOOD SUPPLY

Vertebral arteries
o Comes from the vessels of abdominal aorta

Spinal arteries
o Anterior spinal arteries (1 only)

Supplies the anterior 2/3 of the spinal

cord
o Posterior spinal arteries (2)

Supplies the posterior 1/3 of the spinal

cord

Comes from the vertebral bodies

If transected, patient can walk, normal

sensory perception but:
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Lack balance because of (-)

proprioception
(-) 2-point discrimination
(-) vibratory perception

Segmental arteries
o Artery of Adamkiewicz

Most significant which a very big

tributary or radicular artery

Found between T9 to L2

Significance: if theres a surgical

procedure involving the abdomen and
this artery gets injured, the patient will
end up with Anterior Spinal Cord
Syndrome.
Anterior Spinal Cord contains:

Corticospinal tract

Anterior spinothalamic tract

Lateral spinothalamic tract

CERVICAL PAIN SYNDROMES

Cervical Sprain and Strain

Cervical Disc Disorders
Cervical Spondylosis and Stenosis
Myofascial Pain Syndrome
o Fibromyalgia syndrome
o Can occur at any part of the body depending on
where you will find the trigger points
1. CERVICAL STRAIN AND SPRAIN

Strain involves the muscles and tendons

Sprain involves the ligaments
Most commonly encountered cervical disorder
Female, 30-50 years of age
Most common causes:
o Whiplash Injury
o hyperextension injury

The patient will present as:

paraplegic
bilateral sensory affectation
intact posterior column
(normal vibration,
proprioception, 2-point
discrimination)

WHIPLASH INJURY

Among the structures in the spinal area, which structures can

generate pain?
Skin highly sensitive
Subcutaneous fat
Muscles
Ligaments except LIGAMENTUM FLAVUM
o It does not generate pain but it can be calcified
wherein it will not move with the bony
structures. Because of that, it can cause
narrowing of the canal leading to canal stenosis.
Later, the patient will present with some
neurological deficits (can be peripheral or
central).
Intervertebral disc (Annulus fibrosus)
o only the outer 1/3 of the annulus fibrosus is
innervated
o others NOT generators of pain

REHABILITATION MEDICINE: NECK PAIN DRA. DIZON (2016)

Neck stiffness with occipital headache (usually the origin

is in the suboccipital area; sometimes the patient
complains of dizziness)
CHARACTERISTIC: Pain is felt 24 hours post-injury

Muscles involved: all located at the paracervical area

o Longus colli
o Scalene
o Sternocleidomastoids
o Trapezius
o Levator scapula

Symptoms:
o Neck pain/stiffness 60-95% with occipital
headache - most common complaint
o Injuries to muscles and ligaments
o Head, facial pain with fatigue, irritability, blurry
vision, dizziness, tinnitus, nausea 60-70%
o Difficulty in swallowing and chewing
o Hoarseness
o Abnormal sensation
o Shoulder and other extremity pain
o Back pain

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Associated Problems
o Persistent cervical radicular pain
o Nerve root and cord damage
o Cervical vertigo
o TMJ arthropathies

PATHOPHYSIOLOGY

Normally, there is enough tight of the IV disc therefore a

person maintains a certain size or diameter of the
intervertebral foramina. In herniated disc, the disc slips
backward and depending on how much herniation it has,
then the nerves can be compressed as it exits from the
foramina.
In degenerative changes, during aging the disc can be
compressed and loses water. When it is compressed, the
foramina will also get smaller and this has a greater
chance of compressing the nerves that exits.

Diagnostics:
o not usually requested except for medicolegal
purposes
o evaluate patient after 48 hours if there is
neurological deficit
Management
o Rest for the first 1-2 days
o Cervical brace (soft)
o Analgesics / NSAIDs
o For the first 24-48 hours, apply ice compress.
Warm compress on the 2nd-3rd day.
o Encourage the patient to move the neck.
2. CERVICAL DISC DISORDERS

Also known as:

o Internal Disc Disruption (IDD)
o Herniated Nucleus Pulposus (HNP)
o Laymans: Slip disc
Younger patients tend to have herniated disc or early
post-traumatic arthritis.
Adult/Older patients tend to have degenerative disc
changes.

CERVICAL RADICULOPATHY

Most common consequence of a HNP or DDD

(+) pathology in the root can be very painful

o the root can be compressed by a herniated disc
or narrowing in the intervertebral foramina
(which can be caused by osteophytes which
can be seen in degenerative joint disease)
patient will complain of motor and sensory
deficits

Pain radiating from the neck to the arm

Motor weakness, sensory deficits, obtunded DTRs

Warning signs
o UMN signs (not only the roots are involved but
also the spine)

Cauda equina syndrome

- bladder and bowel incontinence
- saddle anesthesia (loss of
sensation (anesthesia) restricted
to the area of the buttocks,
perineum and inner surfaces of
the thighs)

(+) UMN signs indication for surgery

Can be due to:

o Trauma
o Infection
o Degenerative process

Discitis narrowed space between the vertebra intervertebral

foramina also narrows

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Categories of HNP
o Stage 1: Bulge

The nuclear material is pain free, it is

only the outside of annulus fibrosus
that is innervated. What causes the
pain in a herniated disc is actually the
nuclear material compressing on the
root, not the disc itself.
o

Stage 2: Protrusion

The nuclear material goes beyond the

margin wherein the PLL is located at
the lateral side. A protruded disc goes
beyond the ligament.

Stage 3: Extrusion

Theres already a tear in the annulus

fibrosus and theres a leakage of the
nucleus pulposus.

Stage 4: Sequestration

A part of the nucleus pulposus gets

separated and later on dries up
(dessicated).

Dessicated resolved
compression pain relief

Ligamentum flavum hypertrophy

Facet joint hypertrophy

Sometimes, there will be bridging of osteophytes kissing

osteophytes (neurologic deficit).

Neurologic sequelae are noted if the canal is <12 mm in

diameter
Involvement of the spinal cord
Neurogenic bowel and bladder function
Gait disturbances
Leg weakness and spasticity
Impotence and altered sexual function

3. CERVICAL SPONDYLOSIS AND STENOSIS

4. MYOFASCIAL PAIN SYNDROME
CERVICAL SPONDYLOSIS

Degenerative changes in IV disc and vertebral bodies

Can also occurs in the elderly with degenerative

It is the site of the lesion that distinguishes from

osteoarthritis
CERVICAL OSTEOARTHRITIS

Zygapophyseal and uncovertebral joints

In patients more than 40 years old

A degenerative disease
PATHOPHYSIOLOGY

Dehydration of IV disc will make the space smaller

Development of traction spurs due to loss of elasticity of
ligaments
Spurs formation sometimes fuse together called
osteophyte, impeding movements

REHABILITATION MEDICINE: NECK PAIN DRA. DIZON (2016)

Can cause local and referred pain

Sensory, motor and autonomic signs and symptoms
caused by myofascial
trigger points
Usually involves the upper trapezius
Components:
o Myofascial trigger points

Usually a nodule on an area that when

you palpate it will send off
paresthesias.

(+) Jump sign

involuntary
reaction
to
stimulation of a tender area
or trigger point

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TORTICOLLIS
How to differentiate with Radiculopathy?
In myofascial pain syndrome, the electric shock-like
sensation is limited to the localized trigger point, while in
radiculopathy it has to originate from the neck travelling
like an electric shock-like sensation to the extremity
because it will follow the distribution of the nerve root.

o
o

Sometimes located in a very taut

muscle band (board-like)
Muscle spasm
Tender group of dense muscles
FIBROMYALGIA

Sometimes overlapping with myofascial pain syndrome,

but if there are already disturbances in sleep then it is
already a fibromyalgia.
Very complex because:
o Very chronic
o Very difficult to treat
o Sometimes you will not see any organic about it
but then patient will tell you there is pain all over
Symptoms:
o Generally, there is pain all over
o Sometimes
associated
with
headache,
dizziness or dysmenorrhea in females
o Widespread musculoskeletal aching
o Multiple widespread tender points

Wry neck or stiff neck

Affects sternocleidomastoid and sometimes the
scalene
Most common cause: prolonged improper posture or
position of the neck especially when sleeping (Prone
position)
Two types:
o Congenital torticollis

In children, it is mistaken as a tumor

because of the bulge

Do not know what is the cause, some

babies are born with it. Regresses
over time, sometimes respond to
stretching. If not, myotomy is done to
release the muscle because the facial
bone structure can be altered and will
not grow while the affected side
lengthens.
o

Acquired torticollis

Will not get well unless the primary

cause is treated.

Causes: acute tonsillitis, sore throat,

adenitis, diphtheria

Acute traumatic/inflammatory

Chronic,
infectious,
neoplastic must rule out the
tumors of

the
posterior
fossa
(retropharyngeal)

Arthritis

Cicatrical

Spasms
TIETZES SYNDROME

Dolometer
o

pain

ACR Criteria:
o History of chronic widespread pain 3 months
o Patients must exhibit 11 of 18 tender points

Very objective way of quantifying

perception
For fibromyalgia: 4 kg/pressure

Also called costal chondritis

Inflammation of the ribs and the cartilages in between
costal connections
Painful inflammation of the:
o Costochondral
o Manubriosternal
o Sternoclavicular
Characterized by:
o Point tenderness very characteristic, the
patient is able to tell where is the exact pain
o Swelling
o Pain is dependent on certain position
Young and middle-aged
Worse with inhalation
o It involves the ribs, more of inspiration and less
of expiration.

If you have it, just leave it alone. It will resolve. You can give antiinflammatories but leave it alone.

REHABILITATION MEDICINE: NECK PAIN DRA. DIZON (2016)

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EVALUATION OF CERVICAL PAIN PATIENTS
HISTORY

Chief complaints
o Cervical pain
o Upper extremity paresthesias and pain
o Headache and visual disturbances

History of Present Illness

o Onset, duration, origin and distribution
o Mechanism of injury
o Temporal relationship
o Limb weakness
o Bowel and bladder habit changes

Past Medical History

Social History

Functional History

Review of Systems

NEUROLOGICAL EXAM

Sensory testing

Manual muscle testing

o Deltoid, Biceps: C5-C6
o Triceps: C7
o Wrist extension: C6
o Finger flexion: C8
o Abductor of the small finger: T1
Reflexes
o Biceps: C5-C6
o Brachioradialis: C6-C7
o Triceps: C7

First and foremost, you ask if there is any history of trauma

because sometimes it's not a very significant dramatic trauma and
it can only be just a repeated trauma like sleeping in the car or
sleeping in class. If you have degenerative changes, these
repetitive movements can lead to cervical myelopathy, meaning to
say the spinal cord can also be involved.

PHYSICAL EXAMINATION

Observation
o Alignment of spine

If there is neck pain, look at the attitude of the patient. If

he uses his whole body to look at you, then you know
that it is quite painful.
If he does not move his neck, then you know there might
be muscle guarding.

Degree of lordosis

Normally, the neck is slightly curved (lordotic). When it

loses its lordotic characteristic, you call it straightening
of the spine or reversal of the cervical lordosis which
is the most common cause because you have spasms
on your paracervical muscles (Myospasm).

Palpation
Range of Motion
o Flexion 60 - chin should be able to touch the
angle of Louie except for double chin

Pain on flexion = ligament

Pain + resistance = muscles = strain

o Extension 75 - tilt back as far as possible. If
patient
complains,
the
vertebra
are
compromised

Hyperextension causes narrowing of

the intervertebral foramina
o Rotation 80
o Lateral bending 45 - opposite side pain
(muscle); same side pain (nerve)

REHABILITATION MEDICINE: NECK PAIN DRA. DIZON (2016)

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Pathologic reflex
o To rule out spinal cord involvement
o UMN signs

Watch out for spasticity

Look for hyperreflexia

Hoffmans Sign

Most critical finding that will

point to a myelopathy

Check for clonus

Lhermitte /Brudzinski/Kernigs Sign

To rule out meningeal irritation

When neck is bend, pain is usually felt

going down the spine.

Lhermittes Sign

Provocative
o Spurlings Test

Turning the head on the side, if theres

radiculopathy a patient will feel a
radiating pain.
o

For low back pain:

Straight leg raising (Lasegues Test)

Gaenslens Test for sacroiliac

pathology

Faber/Patricks Test for hip joint

pathology
DIAGNOSTIC STUDIES

Head Compression Test

The foramina will be smaller, there will

be radicular type of pain

Head Distraction Test

Relieve
pain
spondylosis

from

REHABILITATION MEDICINE: NECK PAIN DRA. DIZON (2016)

Cervical spine x-ray

o Done if theres a history of trauma and the pain
persists for more than 2 weeks, to find out if
there are other problems
o AP view

Look at the spine whether it is straight

or not. If it is deviated laterally, then
there is scoliosis

Look at the height of the vertebra,

intervening
space,
where
the
intervertebral disc is located. Make
sure that the heights are more or less
the same.

Look for any structural abnormalities

No intervertebral disc = fused

cervical

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o

Lateral

Look for the curvature (lordosis),

height and intervertebral spaces,
where the foramina are located

If the problem is at the joints of

Luschka = Cervical Osteoarthritis

If it is at the disc = Cervical

Spondylosis

In requesting contrast, also

creatinine for renal function
Cervical spine cord

request

for

Electromyography (EMG-NCV)
o Extension of Physical Examination
o To document the extent of the nerve and
muscle involvement

Why still request for EMG if you already have MRI?

Because usually the MRI result is not positively correlated to a
disease.

Oblique

Best view requested primarily check

for the patency of the intervertebral
foramina

To know if there are cervical nerve root

impingement from the spondylotic
intervertebral foramina
MANAGEMENT OF CERVICAL/NECK PAIN

Give anti-depressant to increase the mood which

increases happy hormones.

MRI
o
o
o

Best diagnostic to perform

For tissues; CT scan (bones)
Contraindication: braces, titanium plates

Muscle

Ligament

IV discs

Discography & Myelography

o Not requested anymore
o Invasive
o Allergy to dye

REHABILITATION MEDICINE: NECK PAIN DRA. DIZON (2016)

Patient education and reassurance

Explain to patient: (very important)

Course of pain

How to manage their pain

How to return to usual activity

How to minimize frequency of recurrences

Provide empathy & support

Advice to continue ordinary activities

Reduce anxiety & speed recovery

MODALITIES

For pain control

Heat vasodilation effect

Superficial heating

Deep heating

Cold allows numbness

Transcutaneous Electrical Nerve Stimulation

(TENS)

electrical induced anesthesia

stimulates large myelinated fibers so that

it will close the gate and no depolarization
will happen once the pain pathways
constantly gone

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Cervical Traction

Intermittent

25 or 35 lbs or of body weight

Stop about 25 or 30 lbs

Position it neck flexion at about 20 degrees

Continuous

Contraindications: Acute pain and instability, severe

osteoporosis, history of malignancy

No pain should be felt in mandibular area

also used as anti-seizure

influence substance P
Side effects: drowsiness, sleepy

Tailor your medications according to the

patient's occupation.

Topical treatment (Lidocaine, Indomethacin)

MYOFASCIAL PAIN AND TRIGGER POINT

INJECTIONS

Lumbar Traction

Intermittent or continuous

50% of body weight

Contraindication: Acute pain and instability

Spinal Orthoses

Use for 2 reasons:

Provides feedback so that the affected does not

move as much

Provides warmth that aids for muscle relaxation

It is not advised to use for more than 3-5 days

especially if you have spinal instability, due to
deconditioning of muscles.
Cervical collar

Soft, Hard, Philadelphia, Thomas

May be use during the acute phase

Short period only

Irritate foci in skeletal muscle causes both local and

referred pain
Causes:
o Acute trauma or overload
o Chronic overwork and fatigue
o Altered neurologic input
Dry needling
o Locate for the trigger point, then inject the
needle and try to twist it around, then pull up and
inject a different contrast and release
Acupuncture
o Several needles on pressure points
Ischemic Compression
o Compress the trigger point causing ischemia
and suddenly release it, hoping for a reflex
vasodilation
STEROID INJECTION AND OTHER SPINAL
PROCEDURE

Should be followed by stretching otherwise pain or

spasm will come back
EXERCISES

Cervical exercises:
o Calliet neck exercises isometric exercises
(apply resistance) to strengthen the muscles
o Proper neck posture
Stretching exercises

MEDICATIONS

NSAIDs
o Notorious for causing gastritis
o Also check for renal toxicity

give the more selective one (COX

inhibitors)
Muscle relaxants (Eperisone, Diazepam, Tizanidine)
Anti-spastics
Others
o Anti-depressant (TCA, SSRI)
o Opioids
o Anticonvulsant (Gabapentin)

Favorite

Pregabalin

approved by FDA for chronic

pain

very good for fibromyalgia

REHABILITATION MEDICINE: NECK PAIN DRA. DIZON (2016)

Goal:
o
o
o
o
o
o
o

Prevent deconditioning
Reduce the chance of recurrence
Reduce risk of developing chronic pain and
disability
Positive outcome in treatment of chronic low
back pain
Purpose is to strengthen and increase
endurance of muscle
Motor training
Treatment of deficits of the kinetic chain

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MYOFASCIAL RELEASE

Massage
Make sure that after, the affected side is stretched.
Stretch along the movement or plane of the muscles
Relaxation and stress reduction
Therapeutic benefit of touch
Beneficial effect on the structures and function
POSTURAL TRAINING

Correct faulty posture

o In standing lumbar lordosis or flat back
o In sitting prolonged lateral flexion, overuse of
hip flexion during sitting, sitting with knee higher
than hips in tall patients causing excessive
lumbar lordosis
o Long standing lordosis hip flexors become
tight, abdominal muscles long and weak
LUMBAR STABILIZATION

During recovery phase: establishes motor patterns and

build endurance
Curl ups
Leg lift
Oblique strengthening
Bridging
SPINAL MANIPULATION

No statistical & clinical significance showing advantage

in pain relief & functional status
POSTURAL TRAINING

No significant benefit as compared with analgesics,

exercise & physical therapy
SURGERY

If you have a radiculopathy, one of the indications for

emergency is Cauda Equina Syndrome. This is when you
have cervical myelopathy, then lose bowel and bladder
control, for the males you have erectile dysfunction. You
complain of back pain then suddenly may erectile dysfunction
that should be a red flag sign that you dont only have a root
problem but you are already affecting your spinal cord.
Usually it necessitates surgical intervention.
Annulus fibrosus cannot be sutured back.

Discectomy
o The disc sequestered is removed and does
fusion if several layers are involved.
Anterior cervical discectomy and fusion
Foraminotomy
o Make a hole
Laminectomy
o the lamina is removed

Sources: Lecture notes, PowerPoint, recording, Jen M. trans

Hi sa mga Carmine buddies: Sazzy, JP, Chut, Kat at April. Hello din pala kay Paulo
Singh. Good luck!

#MPP #JAPC
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