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Chronic Neck Pain: Difference between revisions

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'''Massage''': Low level evidence that stand-alone massage has immediate or short-term effectiveness for pain and tenderness. Low level evidence that ischaemic compression and passive stretch may have been more effective in combination rather than individually for pain reduction.<ref>Patel KC, Gross A, Graham N, Goldsmith CH, Ezzo J, Morien A, Peloso PM. Massage for mechanical neck disorders. Cochrane Database Syst Rev. 2012 Sep 12;(9):CD004871. doi: 10.1002/14651858.CD004871.pub4. PMID: 22972078.</ref>
'''Massage''': Low level evidence that stand-alone massage has immediate or short-term effectiveness for pain and tenderness. Low level evidence that ischaemic compression and passive stretch may have been more effective in combination rather than individually for pain reduction.<ref>Patel KC, Gross A, Graham N, Goldsmith CH, Ezzo J, Morien A, Peloso PM. Massage for mechanical neck disorders. Cochrane Database Syst Rev. 2012 Sep 12;(9):CD004871. doi: 10.1002/14651858.CD004871.pub4. PMID: 22972078.</ref>
'''Exercise:''' This is a messy area. Exercise can be separated into support element (cardiac/pulmonary/metabolic), base element (extensibility/mobility/strength/endurance), modular element (patterns/synchronisation/proprioception/co-ordination), biomechanical element (static/dynamic stabilisation), cognitive/affective element (learning ability/compliance/motivation/emotional). In acute neck pain there is no evidence for exercise therapy. In chronic neck pain there is low evidence that the following are not effective: breathing exercises, general fitness training, stretching, feedback exercises combined with pattern synchronisation, and postural exercises. Mindfulness exercises minimally improved function but not global perceived effect at short term.<ref>Gross A, Kay TM, Paquin JP, Blanchette S, Lalonde P, Christie T, Dupont G, Graham N, Burnie SJ, Gelley G, Goldsmith CH, Forget M, Hoving JL, Brønfort G, Santaguida PL; Cervical Overview Group. Exercises for mechanical neck disorders. Cochrane Database Syst Rev. 2015 Jan 28;1:CD004250. doi: 10.1002/14651858.CD004250.pub5. PMID: 25629215.</ref>
Moderate quality evidence supports the following in chronic neck pain:
* Cervico-scapulothoracic and upper extremity strength training to improve pain of a moderate to large amount immediately post treatment and at short-term follow up
* Scapulothoracic and upper extremity endurance training for slight beneficial effect on pain at immediate post treatment and short-term follow up. The NNT was 4. The patient puts an elastic band under their feet, and abducts their arms to 90 degrees of shoulder abduction and 30 degrees of shoulder horizontal flexion. The elbows are slightly flexed. This is done for 2 minutes, as a single set, five times per week.<ref>Andersen LL, Saervoll CA, Mortensen OS, Poulsen OM, Hannerz H, Zebis MK. Effectiveness of small daily amounts of progressive resistance training for frequent neck/shoulder pain: randomised controlled trial. Pain. 2011 Feb;152(2):440-446. doi: 10.1016/j.pain.2010.11.016. Epub 2010 Dec 21. PMID: 21177034.</ref>
* Combined cervical, shoulder, and scapulothoracic strengthening and stretching exercises varied from a small to large magnitude of beneficial effect on pain at immediate post treatment and up to long term follow up and a medium magnitude of effect improving function at both immediate and short term follow up
* Cervico-scapulothoracic strengthening/stabilisation exercises to improve pain and function at intermediate term
'''Manipulation:'''


'''Pharmacological''': Muscle relaxants, analgesics, and NSAIDs have limited evidence and unclear benefits. Lidocaine injection into myofascial trigger points was superior to placebo with an NNT of 3 for short term benefit of two weeks. Botox was ineffective. <ref>Peloso P, Gross A, Haines T, Trinh K, Goldsmith CH, Burnie S; Cervical Overview Group. Medicinal and injection therapies for mechanical neck disorders. Cochrane Database Syst Rev. 2007 Jul 18;(3):CD000319. doi: 10.1002/14651858.CD000319.pub4. Update in: Cochrane Database Syst Rev. 2015;5:CD000319. PMID: 17636629.</ref>
'''Pharmacological''': Muscle relaxants, analgesics, and NSAIDs have limited evidence and unclear benefits. Lidocaine injection into myofascial trigger points was superior to placebo with an NNT of 3 for short term benefit of two weeks. Botox was ineffective. <ref>Peloso P, Gross A, Haines T, Trinh K, Goldsmith CH, Burnie S; Cervical Overview Group. Medicinal and injection therapies for mechanical neck disorders. Cochrane Database Syst Rev. 2007 Jul 18;(3):CD000319. doi: 10.1002/14651858.CD000319.pub4. Update in: Cochrane Database Syst Rev. 2015;5:CD000319. PMID: 17636629.</ref>
'''Surgery:'''
'''Multi-disciplinary Treatment''': There is no evidence of benefit, and this includes high intensity treatment.<ref>Karjalainen K, Malmivaara A, van Tulder M, Roine R, Jauhiainen M, Hurri H, Koes B. Multidisciplinary biopsychosocial rehabilitation for neck and shoulder pain among working age adults. Cochrane Database Syst Rev. 2003;(2):CD002194. doi: 10.1002/14651858.CD002194. PMID: 12804428.</ref>
'''Cognitive Behavioural Therapy''': No clinically meaningful benefit.<ref>Monticone M, Cedraschi C, Ambrosini E, Rocca B, Fiorentini R, Restelli M, Gianola S, Ferrante S, Zanoli G, Moja L. Cognitive-behavioural treatment for subacute and chronic neck pain. Cochrane Database Syst Rev. 2015 May 26;(5):CD010664. doi: 10.1002/14651858.CD010664.pub2. PMID: 26006174.</ref>


'''Radiofrequency Neurotomy''': Highly effective in the context of concordant positive blocks.
'''Radiofrequency Neurotomy''': Highly effective in the context of concordant positive blocks.

Revision as of 14:31, 5 July 2021

This article is a stub.

Chronic neck pain is defined when neck pain has persisted for more than three months. Around 20-40% of patients with acute neck pain continue on to have chronic neck pain.

Aetiology

See also: Causes and Sources of Neck Pain
Prevalence Studies of Pain Sources in Chronic Neck Pain
Study Patients Blocks Relief Proportion
Barnsley 1995[1] Whiplash Concordant comparative MBB 100% 54%
Lord 1996[2] Whiplash Placebo-controlled MBB 100% 60%
Speldewinde 2001[3] Variety Concordant comparative MBB ≤ 1/10 36%
Manchikanti 2002[4] Variety Concordant comparative MBB 75% 60%
Yin 2008[5] Variety Concordant comparative MBB 100% 55%
Yin 2008[5] Variety Provocative discography 7/10

(pain not relief)

16%

Idiopathic Neck Pain

Idiopathic neck pain refers to neck pain that arose insidiously, i.e. in the absence of a specific inciting event or other explanation. Anatomically the muscles, discs, and joints of the cervical spine are all possible nociceptive generators, however there there is a lack of research into the pathophysiology of how pain might arise from these structures

Muscles: Muscle sprain as a cause of neck pain fits better in the acute setting rather than the chronic setting, as muscle injuries heal quickly. Muscle pain has been hypothesised to be a cause of chronic pain using terms such as muscle spasm, chronic muscle ischaemia, and trigger points. However there is no agreed method of diagnosis.

In chronic neck pain there is often muscle dysfunction. There is reduced activity of the deep cervical flexor muscles (longus cervicis and capitis), increased activity of the superficial flexors (sternocleidomastoid), and increased activity of the accessory neck muscles (anterior scalenes and trapezius). The reasons for this pattern is unclear but it is likely a secondary phenomenon, rather than the primary cause of pain.

Intervertebral Discs: With age there is disc dehydration and osteophytosis, however this has not been shown to be linked to pain. Without trauma, it is not clear why a disc should become painful, or if indeed it does at all.

Synovial Joints: The most likely source of nociception in chronic idiopathic neck are the synovial joints of the neck. These are the facet joints, atlanto-axial joints, and atlanto-occipital joints. However, imaging findings of osteoarthritis of the synovial joints don't correlate with pain, and so diagnosis is made with diagnostic local anaesthetic injections.

Post-traumatic Neck Pain

Main article: Chronic Post-Traumatic Neck Pain

The aetiology of chronic pain is clearer in the setting of whiplash and trauma in general.

Muscles: Muscles are unlikely to be implicated as a primary cause of persistent cervical pain following trauma.

Intervertebral Discs: The anterior annulus fibrosis can be torn or avulsed from the vertebral body in extension injuries. These injuries are likely to be painful, but may only be apparent in vivo rather than on imaging.

Synovial Joints: The zygapophyseal joints and lateral atlanto-axial joints are susceptible to extension injuries. Injuries include meniscoid contusions, intra-articular haemorrhage, capsular tear, annulus tear, subchondral articular fractures, and articular pillar fractures. These injuries are likely to be painful, but again are often not apparent on imaging.

Alar and Transverse Ligaments: Severe trauma can result in rupture of the suboccipital ligaments. The main clinical features are instability of the axis or spinal cord injury. In less severe trauma, there is radiological evidence that the alar and transverse ligaments can be injured in whiplash. Injury to the alar ligaments was more common than the transverse ligaments. Also alar ligament injury wasn't found in controls, while transverse ligament injury was found in controls. It isn't clear whether injury to these ligaments can result in chronic neck pain or, because they are at C1, cervicogenic headache.

Psychological Factors

There is no evidence to support the view that chronic neck pain, whether post-traumatic or not, is secondary to somatization, conversion disorder, malingering, hypochondriasis, or due to secondary gain. A psychosocial label is not falsifiable, i.e. it cannot be refuted, and so it a belief rather than a valid diagnosis. For many patients a biomedical diagnosis cannot be made, but the Musculoskeletal Medicine view is generally that this is due to the infancy of research in this area, rather than the primary cause being nebulous psychosocial factors.

Clinical Features

Red Flags
  • Significant trauma (eg. fall in osteoporotic patient, motor vehicle accident)
  • Infective: (eg. fever, meningism, immunosuppression, intravenous drug use, exotic exposure, recent overseas travel)
  • Constitutional: (eg. fevers, weight loss, anorexia, past or current history of malignancy)
  • Iatrogenic: Recent surgery, catheterisation, venipuncture, manipulation
  • Neurological: Symptoms/signs especially of upper motor neuron pathology, vomiting
  • Genitourinary/Reproductive: UTI, haematuria, retention, uterine, breast
  • Endocrine: Corticosteroids, diabetes, hyperparathyroid
  • Gastrointestinal: Dysphagia
  • Integumentary: Infections, rashes
  • Cardiorespiratory: Cough, haemoptysis, chest pain, shortness of breath, diaphoresis, ripping/tearing sensation (dissection), CVD risk factors, anticoagulants
  • Rheumatological: History of rheumatoid arthritis (atlanto-axial disruption)
  • Awkward posture (atlantoaxial rotatory subluxation in children)


Ask the patient to complete a pain drawing. The area of pain can help indicate the affected segment.

Investigations

Imaging

In general there is no link between cervical degenerative joint disease and pain. However, there is a slight clinical significance with degenerative disc (but not facet osteoarthritis) findings at the C5/6 level. There is also an association with marked (level 3) degenerative changes and neck pain.

Recently radiologists and surgeons are frequently using CT scintigraphy. This modality has 'concept validity.' It can detect small occult fractures and tumours. However it shows increased blood flow, not pain. It tends to miss cases where the pain is arising from soft tissue damage, for example capsule tears.

Diagnostic Blocks

Medial branch blocks are the gold standard for evaluation of zygapophyseal joint pain, looking for concordant positive blocks. The most commonly affected joints by far are C2-3 and C5-6.

The third occipital nerve block is for evaluation of pain arising from the C2-3 zygapophyseal joint. This nerve also innervates semispinalis capitis and a small region of skin over the suboccipital region. The TON crosses the joint in a variable way, and the needle placement reflects this variability. Successful block is indicated by a patch of numbness.[6] Ultrasound rather than fluoroscopic guidance is an emerging technique and appears to be quite accurate with similar success rates between 95-100%. It was quicker and required fewer injections than fluoroscopy.[7][8]

C3-4 is quite uncommon to be affected on its own. The method of investigation is C3-4 medial branch blocks.

For the lateral atlanto-axial joints, the joint gets innervation from both the ventral and dorsal side. Therefore for this joint, the technique is infiltration of local anaesthetic into the joint itself. This is potentially hazardous. This is because if the needle is too medial then it can enter the dural sac and if the needle goes through the middle of the joint it may hit the C2 dorsal ganglion. The injection is done laterally. The vertebral artery lies over the lateral quarter of C1-2 in 1% of cases and this can be checked on imaging. Overpenetration is another risk, therefore the initial target is bone to indicate safe depth before moving it into the joint.

Discography

Cervical discography is a technically demanding procedure and is very rarely done in New Zealand. Discography should only be considered if medial branch blocks have been done first and they are negative. This is because the false positive rate of disc stimulation is 67%.[9] With imaging, disc degeneration is most common at C5-6 and C6-7 but positive disc stimulation occurs just as commonly at C3-4 and C4-5, and so it is important not to just target the sites with abnormal radiological findings.[10] The risk of discitis is 0.13% when prophylactic antibiotics are used, and 0.66% if not used.

The diagnosis of cervical discogenic pain can be made when

  1. Disc stimulation has been correctly performed
  2. Cervical zygapophyseal joint pain has been excluded at the segments being investigated
  3. Stimulation of the target disc reproduces concordant pain
  4. The pain that is reproduced is at least 7/10
  5. Stimulation of adjacent discs does not reproduce the patient's pain

Treatment

TENS: low quality positive evidence for a modest reduction in pain. It must be high amplitude and high intensity with 4Hz frequency and 250Ts duration in order to be effective. [11]

Education: There is no benefit of education. Self-care strategies, ergonomics, exercise, self-care, relaxation vs no treatment or rest or physiotherapy or CBT was of no benefit.[12]

Traction: There is no statistically significant difference.[13]

Massage: Low level evidence that stand-alone massage has immediate or short-term effectiveness for pain and tenderness. Low level evidence that ischaemic compression and passive stretch may have been more effective in combination rather than individually for pain reduction.[14]

Exercise: This is a messy area. Exercise can be separated into support element (cardiac/pulmonary/metabolic), base element (extensibility/mobility/strength/endurance), modular element (patterns/synchronisation/proprioception/co-ordination), biomechanical element (static/dynamic stabilisation), cognitive/affective element (learning ability/compliance/motivation/emotional). In acute neck pain there is no evidence for exercise therapy. In chronic neck pain there is low evidence that the following are not effective: breathing exercises, general fitness training, stretching, feedback exercises combined with pattern synchronisation, and postural exercises. Mindfulness exercises minimally improved function but not global perceived effect at short term.[15]

Moderate quality evidence supports the following in chronic neck pain:

  • Cervico-scapulothoracic and upper extremity strength training to improve pain of a moderate to large amount immediately post treatment and at short-term follow up
  • Scapulothoracic and upper extremity endurance training for slight beneficial effect on pain at immediate post treatment and short-term follow up. The NNT was 4. The patient puts an elastic band under their feet, and abducts their arms to 90 degrees of shoulder abduction and 30 degrees of shoulder horizontal flexion. The elbows are slightly flexed. This is done for 2 minutes, as a single set, five times per week.[16]
  • Combined cervical, shoulder, and scapulothoracic strengthening and stretching exercises varied from a small to large magnitude of beneficial effect on pain at immediate post treatment and up to long term follow up and a medium magnitude of effect improving function at both immediate and short term follow up
  • Cervico-scapulothoracic strengthening/stabilisation exercises to improve pain and function at intermediate term

Manipulation:

Pharmacological: Muscle relaxants, analgesics, and NSAIDs have limited evidence and unclear benefits. Lidocaine injection into myofascial trigger points was superior to placebo with an NNT of 3 for short term benefit of two weeks. Botox was ineffective. [17]

Surgery:

Multi-disciplinary Treatment: There is no evidence of benefit, and this includes high intensity treatment.[18]

Cognitive Behavioural Therapy: No clinically meaningful benefit.[19]

Radiofrequency Neurotomy: Highly effective in the context of concordant positive blocks.

References

  • Bogduk, Nikolai, and Brian McGuirk. Management of acute and chronic neck pain : an evidence-based approach. Edinburgh New York: Elsevier, 2006.
  1. ↑ Barnsley et al.. The prevalence of chronic cervical zygapophysial joint pain after whiplash. Spine 1995. 20:20-5; discussion 26. PMID: 7709275. DOI.
  2. ↑ Lord et al.. Chronic cervical zygapophysial joint pain after whiplash. A placebo-controlled prevalence study. Spine 1996. 21:1737-44; discussion 1744-5. PMID: 8855458. DOI.
  3. ↑ Speldewinde et al.. Diagnostic cervical zygapophyseal joint blocks for chronic cervical pain. The Medical journal of Australia 2001. 174:174-6. PMID: 11270757. DOI.
  4. ↑ Manchikanti et al.. Prevalence of cervical facet joint pain in chronic neck pain. Pain physician 2002. 5:243-9. PMID: 16902649.
  5. ↑ 5.0 5.1 Yin & Bogduk. The nature of neck pain in a private pain clinic in the United States. Pain medicine (Malden, Mass.) 2008. 9:196-203. PMID: 18298702. DOI.
  6. ↑ Kwon, Hyun-Jin et al. “Anatomical analysis of the distribution patterns of occipital cutaneous nerves and the clinical implications for pain management.” Journal of pain research vol. 11 2023-2031. 25 Sep. 2018, doi:10.2147/JPR.S175506
  7. ↑ Eichenberger U, Greher M, Kapral S, Marhofer P, Wiest R, Remonda L, Bogduk N, Curatolo M. Sonographic visualization and ultrasound-guided block of the third occipital nerve: prospective for a new method to diagnose C2-C3 zygapophysial joint pain. Anesthesiology. 2006 Feb;104(2):303-8. doi: 10.1097/00000542-200602000-00016. PMID: 16436850.
  8. ↑ Finlayson RJ, Etheridge JP, Vieira L, Gupta G, Tran DQ. A randomized comparison between ultrasound- and fluoroscopy-guided third occipital nerve block. Reg Anesth Pain Med. 2013 May-Jun;38(3):212-7. doi: 10.1097/AAP.0b013e31828b25bc. PMID: 23558370.
  9. ↑ Bogduk N, Aprill C. On the nature of neck pain, discography and cervical zygapophysial joint blocks. Pain. 1993 Aug;54(2):213-217. doi: 10.1016/0304-3959(93)90211-7. PMID: 8233536.
  10. ↑ Grubb SA, Kelly CK. Cervical discography: clinical implications from 12 years of experience. Spine (Phila Pa 1976). 2000 Jun 1;25(11):1382-9. doi: 10.1097/00007632-200006010-00010. PMID: 10828920.
  11. ↑ Martimbianco ALC, Porfírio GJ, Pacheco RL, Torloni MR, Riera R. Transcutaneous electrical nerve stimulation (TENS) for chronic neck pain. Cochrane Database Syst Rev. 2019 Dec 12;12(12):CD011927. doi: 10.1002/14651858.CD011927.pub2. PMID: 31830313; PMCID: PMC6953309.
  12. ↑ Gross A, Forget M, St George K, Fraser MM, Graham N, Perry L, Burnie SJ, Goldsmith CH, Haines T, Brunarski D. Patient education for neck pain. Cochrane Database Syst Rev. 2012 Mar 14;(3):CD005106. doi: 10.1002/14651858.CD005106.pub4. PMID: 22419306.
  13. ↑ Graham N, Gross A, Goldsmith CH, Klaber Moffett J, Haines T, Burnie SJ, Peloso PM. Mechanical traction for neck pain with or without radiculopathy. Cochrane Database Syst Rev. 2008 Jul 16;(3):CD006408. doi: 10.1002/14651858.CD006408.pub2. PMID: 18646151.
  14. ↑ Patel KC, Gross A, Graham N, Goldsmith CH, Ezzo J, Morien A, Peloso PM. Massage for mechanical neck disorders. Cochrane Database Syst Rev. 2012 Sep 12;(9):CD004871. doi: 10.1002/14651858.CD004871.pub4. PMID: 22972078.
  15. ↑ Gross A, Kay TM, Paquin JP, Blanchette S, Lalonde P, Christie T, Dupont G, Graham N, Burnie SJ, Gelley G, Goldsmith CH, Forget M, Hoving JL, Brønfort G, Santaguida PL; Cervical Overview Group. Exercises for mechanical neck disorders. Cochrane Database Syst Rev. 2015 Jan 28;1:CD004250. doi: 10.1002/14651858.CD004250.pub5. PMID: 25629215.
  16. ↑ Andersen LL, Saervoll CA, Mortensen OS, Poulsen OM, Hannerz H, Zebis MK. Effectiveness of small daily amounts of progressive resistance training for frequent neck/shoulder pain: randomised controlled trial. Pain. 2011 Feb;152(2):440-446. doi: 10.1016/j.pain.2010.11.016. Epub 2010 Dec 21. PMID: 21177034.
  17. ↑ Peloso P, Gross A, Haines T, Trinh K, Goldsmith CH, Burnie S; Cervical Overview Group. Medicinal and injection therapies for mechanical neck disorders. Cochrane Database Syst Rev. 2007 Jul 18;(3):CD000319. doi: 10.1002/14651858.CD000319.pub4. Update in: Cochrane Database Syst Rev. 2015;5:CD000319. PMID: 17636629.
  18. ↑ Karjalainen K, Malmivaara A, van Tulder M, Roine R, Jauhiainen M, Hurri H, Koes B. Multidisciplinary biopsychosocial rehabilitation for neck and shoulder pain among working age adults. Cochrane Database Syst Rev. 2003;(2):CD002194. doi: 10.1002/14651858.CD002194. PMID: 12804428.
  19. ↑ Monticone M, Cedraschi C, Ambrosini E, Rocca B, Fiorentini R, Restelli M, Gianola S, Ferrante S, Zanoli G, Moja L. Cognitive-behavioural treatment for subacute and chronic neck pain. Cochrane Database Syst Rev. 2015 May 26;(5):CD010664. doi: 10.1002/14651858.CD010664.pub2. PMID: 26006174.
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