Causes and Sources of Neck Pain

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The source of the pain refers to the anatomical structure which has nociceptive activity leading to pain perception. A lot is known about possible sources, but not a great amount about actual sources of neck pain. The cause of the pain is the disease process or disorder that is responsible for the nociceptive activity. A lot is known about rare causes, but not common causes of neck pain.

Sources

• Any structure that has a nerve supply may become a source of pain
• The innervated structures are the: facet joints, atlanto-occipital joints, atlanto-axial joints, transverse ligament, posterior neck muscles, cervical intervertebral discs, vertebral bodies, anterior and posterior longitudinal ligaments, the dura mater of the cervical spinal cord, the prevertebral muscles, and the vertebral and carotid arteries.
• In acute neck pain, it is not known how often each structure is a source of pain.
• In chronic neck pain, some data are available.

Causes

• Textbooks often list possible causes of neck pain, but without any evidence to support the causes nor prevalence rates
• Most causes listed in textbooks are either rare or controversial.

Serious but Rare Causes

Serious but rare causes are tumours and infections

• Tumours - can grow and threaten the spinal cord, compromise the vertebral column stability, or metastasize.
• Infections of the bones, joints, discs, and meningitis of the cervical dura mater - can become septic, or form an abscess that threatens the spinal cord or vertebral column stability.
• These are usually recognisable on imaging and/or clinical grounds.
• There are no experimental data, but rather clinical experience that treatment results in resolution of the neck pain
• There are no studies indicating the prevalence of tumours and infections, but are likely quite rare.
• There is limited information as to the effect on spinal osteomyelitis and epidural abscess as it specifically applies to the neck rather than the spinal column in general.
• Bogduk estimates that the prevalence of undiagnosed tumours or infections is substantially less than 0.4%.
• Epidural abscess: may present with neck pain prior to neurological signs. Usually the cause is iatrogenic or from a distant source.
• Epidural haematoma: this can occur spontaneously or after a trivial event such as sneezing or straining. Theories as to the cause include epidural vein or artery rupture and increase in epidural pressure. Risk factors are anticoagulant therapy including excessive garlic consumption. The presenting feature may be simple neck pain, but imaging should wait until definite neurological signs which usually occur within hours of pain onset. This is a neurosurgical emergency with the aim of decompressing the cord.

Valid but Rare or Unusual Causes

• Rheumatoid Arthritis: this may involve the upper cervical spine, but the diagnosis is usually already evident by this stage because usually peripheral manifestations occur prior to cervical disease. C1-2 segment involvement can be a serious threat but has a favourable prognosis
• Ankylosing Spondylitis: This usually occurs late in the disease process and so the diagnosis is usually already evident. 10% present with neck pain as the initial manifestation.
• Reiter's Syndrome: Cervical spine involvement is uncommon, and usually affects the S1-2 segment and craniocervical junction.
• Psoriatic Arthritis: Similar to rheumatoid arthritis and ankylosing spondylitis. Rare to have neck pain alone
• Gout and other crystal arthropathies: spinal involvement is rare.
• Polymyalgia Rheumatica: The neck can be involved but it does not by definition only involve the neck
• Calcific Tendinitis of the Longus Colli Muscles: Also known as retropharyngeal tendonitis. There is inflammation and oedema of the upper portions of longus colli (not just the tendons, so its a misnomer) from C1-C4 and sometimes down to C6. Very rare 1 in 400,000 per year. Often calcification opposite C2 vertebra. Bogduk thinks that the calcium is an epiphenomenon rather than the cause of pain.
• Cervical Spine Fractures: Prevalence of less than 0.4%.

Summary

• Any structure in the cervical spine that is innervated is a potential source of pain
• Cervical spondylosis is not a legitimate cause of neck pain
• Serious and identifiable causes of neck pain are rare
• The causes of common neck pain are unknown

Bibliography

• Bogduk, Nikolai, and Brian McGuirk. Management of acute and chronic neck pain : an evidence-based approach. Edinburgh New York: Elsevier, 2006.