Management of Neck Pain, An Issue of Physical Medicine and Rehabilitation Clinics , livre ebook

Physical Medicine and Rehabilitation Clinics of North America , Vol. 22, No. 3, August 2011
ISSN: 1047-9651
doi: 10.1016/S1047-9651(11)00064-7

Contributors
Physical Medicine and Rehabilitation Clinics of North America
Management of Neck Pain
Allen Sinclair Chen, MD, MPH
George H. Kraft, MD, MS
ISSN  1047-9651
Volume 22 • Number 3 • August 2011

Contents
Cover
Contributors
Forthcoming Issues
Management of Neck Pain
The Anatomy and Pathophysiology of Neck Pain
History, Physical Examination, and Differential Diagnosis of Neck Pain
Evaluation of the Patient with Neck Versus Shoulder Pain
Radiologic Evaluation of the Neck: A Review of Radiography, Ultrasonography, Computed Tomography, Magnetic Resonance Imaging, and Other Imaging Modalities for Neck Pain
The Electrodiagnostic Evaluation of Neck Pain
Cervical Radiculopathy
Cervical Facet-Mediated Pain
Cervical Spine Pain in the Competitive Athlete
Thoracic Outlet Syndrome
Neck Pain from a Rheumatologic Perspective
Conservative Treatment for Neck Pain: Medications, Physical Therapy, and Exercise
Complementary and Alternative Treatment for Neck Pain: Chiropractic, Acupuncture, TENS, Massage, Yoga, Tai Chi, and Feldenkrais
Interventional Procedures for Cervical Pain
Neck Pain from a Spine Surgeon’s Perspective
Index
Physical Medicine and Rehabilitation Clinics of North America , Vol. 22, No. 3, August 2011
ISSN: 1047-9651
doi: 10.1016/S1047-9651(11)00066-0

Forthcoming Issues
Physical Medicine and Rehabilitation Clinics of North America , Vol. 22, No. 3, August 2011
ISSN: 1047-9651
doi: 10.1016/j.pmr.2011.04.002

Preface
Management of Neck Pain

Allen Sinclair Chen, MD, MPH ,
Interventional Spine, Department of Physical Medicine and Rehabilitation, The Permanente Medical Group, Diablo Service Area, 200 Muir Road, Hacienda Building, Martinez, CA 94553, USA

Allen Sinclair Chen, MD, MPH, Guest Editor
With variable pain generators and differing responses to treatment, neck pain can pose a challenging problem for both patients and providers. Diagnostic evaluations, which include electrodiagnosis and radiologic imaging, can help evaluate underlying pathophysiology, but often do not correlate with symptomatology.
Among the myriad of treatment options, many lack strong supporting evidence, rendering the management of neck and associated radicular pain even more difficult. As such, the art of medicine and the physician-patient relationship become particularly crucial in determining proper, safe, and effective evaluation and treatment for this common complaint.
I am honored that Dr George Kraft, a teacher and mentor to me for several years, invited me to guest edit this Physical Medicine and Rehabilitation Clinics of North America issue devoted to neck pain. My aim was to present a clear and organized approach to the topic, and I am very fortunate to have gathered a truly outstanding and talented panel of contributors from around the world, and from diverse medical backgrounds.
Together, these accomplished authors have provided the reader with a concise and accurate understanding of anatomy, evaluation, and treatment options for neck and associated radicular pain. I am pleased with their individual contributions and with this issue as a whole.
Physical Medicine and Rehabilitation Clinics of North America , Vol. 22, No. 3, August 2011
ISSN: 1047-9651
doi: 10.1016/j.pmr.2011.03.008

The Anatomy and Pathophysiology of Neck Pain

Nikolai Bogduk, MD, PhD, DSc, MMed, FAFRM, FFPM (ANZCA)
Newcastle Bone and Joint Institute, Royal Newcastle Centre, University of Newcastle, PO Box 664J, Newcastle, New South Wales 2300, Australia
E-mail address: vicki.caesar@hnehealth.nsw.gov.au

Abstract
Neck pain should not, and must not, be confused with cervical radicular pain. Equating the two conditions, or confusing them, results in misdiagnosis, inappropriate investigations, and inappropriate treatment that is destined to fail. So critical is the difference that pedagogically it is unwise to include the two topics in the same book, let alone the same article. However, traditions and expectations are hard to break. In deference to habit, this article addresses both entities, but does so by underplaying cervical radicular pain so as to retain the emphasis on neck pain.

Keywords
• Neck pain • Cervical • Anatomy • Nerve supply
In preparation for considering the pathophysiology of neck pain, a critical distinction must be made. The neck is not the upper limb. The upper limb is not the neck. By the same token, pain in the neck is not pain in the upper limb, and vice versa.
For these reasons, neck pain should not, and must not, be confused with cervical radicular pain. Neck pain is perceived in the neck, and its causes, mechanisms, investigation, and treatment are different from those of cervical radicular pain. Reciprocally, cervical radicular pain is perceived in the upper limb, and its causes, mechanisms, investigation, and treatment are different from those of neck pain. Equating the 2 conditions, or confusing them, results in misdiagnosis, inappropriate investigations, and inappropriate treatment that is destined to fail.
Confusion arises because neck pain and cervical radicular pain are both caused by disorders of the cervical spine, but this common site of disease does not constitute a basis for equating the 2 conditions. In all other respects the 2 conditions are totally different.
So critical is the difference that pedagogically it is unwise to include the 2 topics in the same book, let alone the same article. Doing so, as has been the tradition, risks readers remaining confused, and applying to neck pain the interpretations, investigations, and treatment that apply to radicular pain. However, traditions and expectations are difficult to break. In deference to habit, this article addresses both entities, but does so by underplaying cervical radicular pain so as to retain the emphasis on neck pain. Cervical radicular pain is covered in a later article, and more comprehensively elsewhere. 1

Radicular pain
Perhaps surprisingly, but nonetheless veritably, little is known about the causes and mechanisms of cervical radicular pain. In the literature, cervical radicular pain has conventionally been addressed in the context of cervical radiculopathy; but radiculopathy is not synonymous with radicular pain.
Cervical radiculopathy is a neurologic condition characterized by objective signs of loss of neurologic function: some combination of sensory loss, motor loss, or impaired reflexes, in a segmental distribution. None of these features constitutes pain.
Many causes of cervical radiculopathy have been reported ( Table 1 ). They share the common feature that they compress or otherwise compromise a cervical spinal nerve or its roots. The axons of these nerves are either compressed directly or are rendered ischemic by compression of their blood supply. Symptoms of sensory or motor loss arise as a result of block of conduction along the affected axons. The features of cervical radiculopathy, therefore, are essentially negative in nature; they reflect loss of function. In contrast, pain is a positive feature, not caused by loss of nerve function.
Table 1 Possible causes of cervical radiculopathy, listed by structure and condition Structure Condition Intervertebral disc Protrusion Herniation Osteophytes Zygapophysial joint Osteophytes Ganglion Tumor Rheumatoid arthritis Gout Ankylosing spondylitis Fracture Vertebral body Tumor Paget’s disease Fracture Osteomyelitis Hydatid Hyperparathyroidism Meninges Cysts Meningioma Dermoid cyst Epidermoid cyst Epidural abscess Epidural hematoma Blood vessels Angioma Arteritis Nerve sheath Neurofibroma Schwannoma Nerve Neuroblastoma Ganglioneuroma
For this reason cervical radicular pain cannot be summarily attributed to the same causes as those of radiculopathy. Compression of axons does not elicit pain. If compression is to be invoked as a mechanism for pain it must explicitly relate to compression of a dorsal root ganglion.
Laboratory experiments on lumbar nerve roots have shown that mechanical compression of nerve roots does not elicit activity in nociceptive afferent fibers. 2, 3 Therefore, compression of nerve roots cannot be held to be the mechanism of radicular pain. However, compression of a dorsal root ganglion does evoke sustained activity in afferent fibers; but that activity occurs in Aβ fibers as well as C fibers. 2, 3 Therefore, the activity is something more than simply nociceptive. This finding underlies and underscores the particular nature of radicular pain. It is shooting, stabbing, or electric in nature, traveling distally into the affected limb, which is consistent with a massive discharge from multiple affected axons. It is commonly associated with paresthesiae; which is consistent with Aβ fibers being included in the discharge.
As opposed to compression, there are growing contentions that cervical radicular pain may be caused by inflammation of the cervical nerve roots. This mechanism might be applicable to radicular pain caused by disc protrusions, because inflammatory exudates have now been isolated from cervical disc material. 4, 5 However, inflammation cannot be invoked as the mechanism of radicular pain caused by noninflammatory lesions such as tumors, cysts, and osteophytes. For these conditions, compression of the dorsal root ganglion is the only mec