Epidemiology

Spine conditions, including neck pain, were estimated to have a $193.9 billion cost in 2002 to 2004. They are the second most expensive musculoskeletal health care condition, following arthritis and joint pain. In comparison to low back pain, there are fewer epidemiologic studies on neck pain available for review, and risk factors are better established for low back pain than for neck pain. Despite this, it is known that many risk factors are common to both low back and neck pain, and that the prevalence of neck pain increases with age and is more common in women than in men. In addition, several demonstrated risk factors for neck pain have been identified, as noted in Box 1 .

History

When taking a history, the presence of multiple red flags should raise suspicion and indicate the need for further investigation. Although red flags have not been specifically formulated for patients with neck pain, low back pain red flags are commonly applied. Red flags and yellow flags identified by history or physical findings indicate the need for further evaluation with laboratory tests or imaging. These flags are listed in Boxes 2 and 3 . In any given patient, associated social, psychological, and emotional factors must be considered in addition to, and sometimes more than, organic factors.

When taking a history from patients complaining of neck pain, a few basic qualities of the pain should be elicited, including location, radiation, severity, alleviating factors, aggravating factors, onset, and associated symptoms.

Location: Is the pain in the upper, middle, or lower cervical spine? Is the pain over the spinous processes or over the paravertebral muscles? Is the pain unilateral or bilateral?

Radiation: Does the pain radiate, and if so, where does it radiate? Not only can cervical radiculopathy cause radicular pain but muscle irritation and facet-mediated pain may also cause referred pain in the upper extremities.

Severity: Extremely severe pain could be associated with several conditions, including neuralgic amyotrophy, radiculopathy, or cancer.

Alleviating factors: What makes the pain better? A little known clinical sign is the abduction relief sign, in which abduction of the ipsilateral arm over the head may improve the pain in cervical radiculopathy (patients may even say they sleep in that position). Neck pain is typically reduced when patients are recumbent, but if the pain is not reduced by recumbency, then vertebral column infections and metastatic cancer should be considered.

Aggravating factors: What makes the pain worse? Pain that worsens when patients turn and look ipsilateral to the pain can be associated with facet mediated pain or radiculopathy. Pain with contralateral neck motion can be the result of muscle strain or other myofascial pain.

Associated symptoms: Is there also numbness or tingling in an arm or hand? The presence of arm or hand paresthesias along with neck and upper extremity pain may be indicative of cervical radiculopathy, neuropathy, or brachial plexopathy. However, it is common for patients to have mechanical neck pain with coexisting carpal tunnel syndrome. Patients with brachial plexopathy can present with severe shoulder and upper extremity pain, which is then followed by significant weakness and atrophy. These patients do not frequently present with neck pain or worsening of symptoms with head/neck movement. On the basis of history alone, it can be difficult to distinguish brachial plexopathy from cervical radiculopathy.

Onset: When did the pain start? Details about the onset may help determine any sentinel events associated with the pain. Identifying the onset will also help determine the acuteness of the pain and its relationship to trauma (eg, within 24 hours of a motor vehicle accident). Trauma, heavy lifting, repetitive lifting, or long automobile rides may cause radiculopathy.

Nighttime symptoms: Does the pain awaken patients at night and do patients wake up with neck pain in the morning? Any of the possible causes of pain can awaken patients at night, but neck position during sleep must be carefully considered. Do patients use a pillow with good neck support?

Is there pain in the thoracic and lumbar spine? Patients with ankylosing spondylitis may present with nighttime neck and back pain with reduced lateral mobility and an elevated erythrocyte sedimentation rate. Is there stiffness, especially in the morning? Excessive morning stiffness can be present with ankylosing spondylitis as well as rheumatologic conditions, such as polymyalgia rheumatica.

Is there weakness, and if so, where? Potential neurologic causes of weakness include cervical radiculopathy, neurologic amyotrophy, and spinal cord tumor. Weakness in the lower extremities may indicate cervical spondylosis associated with spinal cord compression, tumor, syrinx, or other causes of myelopathy. Is there bladder or bowel dysfunction, which would also be consistent with cervical spinal cord involvement? Is there pain in the lower limbs? Diffuse aching or burning pain may be associated with cervical cord compression. Differentiating peripheral neuropathy, cauda equina syndrome, and cervical myelopathy purely on the basis of the history can be difficult if not impossible.

Previous testing and treatment: Which diagnostic tests have been performed? Which treatments have been completed and were they helpful? This information helps determine which diagnostic tests may still be indicated and provides a basis for a treatment plan. What pain medications are patients taking and are they helping relieve the pain? Have patients been evaluated and treated with a physical therapist?

Past medical history and review of systems: Do patients have a history of coronary heart disease, gastroesophageal reflux disease, or hypertension? If the neck pain radiates to the left arm, is worsened with activity, and improves with rest, then have patients had a cardiac workup? A history of hypertension may preclude the use of some medications such as nonsteroidal antiinflammatories (NSAIDs) or bisphosphonates. Gastrointestinal conditions may also preclude use of NSAIDs. Have patients experienced weight loss or decreased appetite, which could be caused by cancer or a metastatic disease? Are patients taking any lipid-lowering medications, which could cause aching as a complication? If patients are women of childbearing age, then are they pregnant or breastfeeding? This information is crucial in defining testing and treatment limitations. Are patients suffering from depression or anxiety that could be exacerbating symptoms or making treatment difficult? Home or occupational stress is often associated with disability from neck pain.

Social history: Do patients have a history of illicit drug abuse or addiction to prescription medications? Are patients currently working or on disability? Neck pain is commonly encountered in jobs requiring prolonged posturing either at a desk or on an assembly line. Is this a job-related injury? Is legal action pending? If this is a worker’s compensation case, then is the case still open? In patients whose accident or injury occurred several months before the initial visit, the consultation may be motivated by legal purposes rather than by desire for diagnosis and treatment. Prospective studies have demonstrated that psychosocial factors are important in patients with whiplash injuries.

Smoking cigarettes is associated with an increased risk of spine pain. It is also important to inquire about patients’ social support network, including family and friends.

History

When taking a history, the presence of multiple red flags should raise suspicion and indicate the need for further investigation. Although red flags have not been specifically formulated for patients with neck pain, low back pain red flags are commonly applied. Red flags and yellow flags identified by history or physical findings indicate the need for further evaluation with laboratory tests or imaging. These flags are listed in Boxes 2 and 3 . In any given patient, associated social, psychological, and emotional factors must be considered in addition to, and sometimes more than, organic factors.

When taking a history from patients complaining of neck pain, a few basic qualities of the pain should be elicited, including location, radiation, severity, alleviating factors, aggravating factors, onset, and associated symptoms.

Location: Is the pain in the upper, middle, or lower cervical spine? Is the pain over the spinous processes or over the paravertebral muscles? Is the pain unilateral or bilateral?

Radiation: Does the pain radiate, and if so, where does it radiate? Not only can cervical radiculopathy cause radicular pain but muscle irritation and facet-mediated pain may also cause referred pain in the upper extremities.

Severity: Extremely severe pain could be associated with several conditions, including neuralgic amyotrophy, radiculopathy, or cancer.

Alleviating factors: What makes the pain better? A little known clinical sign is the abduction relief sign, in which abduction of the ipsilateral arm over the head may improve the pain in cervical radiculopathy (patients may even say they sleep in that position). Neck pain is typically reduced when patients are recumbent, but if the pain is not reduced by recumbency, then vertebral column infections and metastatic cancer should be considered.

Aggravating factors: What makes the pain worse? Pain that worsens when patients turn and look ipsilateral to the pain can be associated with facet mediated pain or radiculopathy. Pain with contralateral neck motion can be the result of muscle strain or other myofascial pain.

Associated symptoms: Is there also numbness or tingling in an arm or hand? The presence of arm or hand paresthesias along with neck and upper extremity pain may be indicative of cervical radiculopathy, neuropathy, or brachial plexopathy. However, it is common for patients to have mechanical neck pain with coexisting carpal tunnel syndrome. Patients with brachial plexopathy can present with severe shoulder and upper extremity pain, which is then followed by significant weakness and atrophy. These patients do not frequently present with neck pain or worsening of symptoms with head/neck movement. On the basis of history alone, it can be difficult to distinguish brachial plexopathy from cervical radiculopathy.

Onset: When did the pain start? Details about the onset may help determine any sentinel events associated with the pain. Identifying the onset will also help determine the acuteness of the pain and its relationship to trauma (eg, within 24 hours of a motor vehicle accident). Trauma, heavy lifting, repetitive lifting, or long automobile rides may cause radiculopathy.

Nighttime symptoms: Does the pain awaken patients at night and do patients wake up with neck pain in the morning? Any of the possible causes of pain can awaken patients at night, but neck position during sleep must be carefully considered. Do patients use a pillow with good neck support?

Is there pain in the thoracic and lumbar spine? Patients with ankylosing spondylitis may present with nighttime neck and back pain with reduced lateral mobility and an elevated erythrocyte sedimentation rate. Is there stiffness, especially in the morning? Excessive morning stiffness can be present with ankylosing spondylitis as well as rheumatologic conditions, such as polymyalgia rheumatica.

Is there weakness, and if so, where? Potential neurologic causes of weakness include cervical radiculopathy, neurologic amyotrophy, and spinal cord tumor. Weakness in the lower extremities may indicate cervical spondylosis associated with spinal cord compression, tumor, syrinx, or other causes of myelopathy. Is there bladder or bowel dysfunction, which would also be consistent with cervical spinal cord involvement? Is there pain in the lower limbs? Diffuse aching or burning pain may be associated with cervical cord compression. Differentiating peripheral neuropathy, cauda equina syndrome, and cervical myelopathy purely on the basis of the history can be difficult if not impossible.

Previous testing and treatment: Which diagnostic tests have been performed? Which treatments have been completed and were they helpful? This information helps determine which diagnostic tests may still be indicated and provides a basis for a treatment plan. What pain medications are patients taking and are they helping relieve the pain? Have patients been evaluated and treated with a physical therapist?

Past medical history and review of systems: Do patients have a history of coronary heart disease, gastroesophageal reflux disease, or hypertension? If the neck pain radiates to the left arm, is worsened with activity, and improves with rest, then have patients had a cardiac workup? A history of hypertension may preclude the use of some medications such as nonsteroidal antiinflammatories (NSAIDs) or bisphosphonates. Gastrointestinal conditions may also preclude use of NSAIDs. Have patients experienced weight loss or decreased appetite, which could be caused by cancer or a metastatic disease? Are patients taking any lipid-lowering medications, which could cause aching as a complication? If patients are women of childbearing age, then are they pregnant or breastfeeding? This information is crucial in defining testing and treatment limitations. Are patients suffering from depression or anxiety that could be exacerbating symptoms or making treatment difficult? Home or occupational stress is often associated with disability from neck pain.

Social history: Do patients have a history of illicit drug abuse or addiction to prescription medications? Are patients currently working or on disability? Neck pain is commonly encountered in jobs requiring prolonged posturing either at a desk or on an assembly line. Is this a job-related injury? Is legal action pending? If this is a worker’s compensation case, then is the case still open? In patients whose accident or injury occurred several months before the initial visit, the consultation may be motivated by legal purposes rather than by desire for diagnosis and treatment. Prospective studies have demonstrated that psychosocial factors are important in patients with whiplash injuries.

Smoking cigarettes is associated with an increased risk of spine pain. It is also important to inquire about patients’ social support network, including family and friends.