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Neck pain can be divided into acute and chronic pain.
- Acute pain is pain that has been present for less than six weeks,
- Chronic pain is pain that has been present for over three months.
Between six weeks and three months some people still call this acute pain, some chronic pain and others create a new category, sub-acute pain.
Acute Neck Pain
Acute neck pain is most commonly idiopathic (of unknown cause) or attributed to a whiplash injury, serious causes of neck pain are rare (<1%). Degenerative changes, osteoarthrosis or spondylosis of the neck are neither causes nor risk factors for idiopathic neck pain. There is no evidence that “sprains” or “strains” of the neck muscles and ligaments occur and cause acute or chronic pain.
Approximately:
- 40% of patients recover fully from idiopathic neck pain
- 30% continue to have mild symptoms
- 30% of patients continue to have moderate or severe symptoms.
- 56% of patients fully recover within three months from the onset of acute whiplash-associated neck pain
- 80% fully recover within one – two years
- 15-40% continue to have symptoms
- 5% are severely affected.
Psychological factors are not determinants of chronicity in whiplash-associated injuries.
There is evidence that some physical therapies and staying active are the best means of treating acute neck pain. There is insufficient evidence to make a judgement on the effectiveness of acupuncture, simple analgesics, cervical manipulation and electrotherapies in acute neck pain. There is evidence that soft collars do not work in the majority of cases.
Xrays may be necessary in the acute setting in order to exclude entities such as fracture; but more often than not provide little relevant information (for example, degeneration is not particularly relevant unless there are neurological symptoms). The Canadian C-Spine Rule (Stiell et al, 2001) can be used to clinically assess whether someone needs an xray or not.
Chronic Neck Pain
The only validated cause of chronic neck pain is pain arising from the facet joints of the neck. Excellent data supports the fact that facet joint pain can be diagnosed by a series of controlled medial branch blocks on the facet joints.
[ To view a procedure go to: Cervical Medial Branch Block Video Clips]
A medial branch is a branch of a nerve that supplies the sensation to the facet joint above and below it. So each joint gets two nerves supplying it, one from above and one from below. To anesthetise one joint, two medial branches have to be blocked (put to sleep temporarily); to anesthetise two joints, three nerves need to be blocked. If a patient has concordant pain relief (ie the longer acting local anaesthetic eases their pain for longer than the shorter acting local anaesthetic) following two medial branch blocks, then the patient has a 90% chance of having significant relief from a radiofrequency neurotomy to those medial branches.
[To view a procedure go to: Cervical Radiofrequency Neurotomy Video Clip]
Disc pain is a presumptive diagnosis in neck pain. There is no validated and reliable tool that can be used to diagnose cervical disc pain.
Discography is performed in some centers (this involved placing a needle into the disc and pressurising it and seeing if this reproduces the patient’s pain, and then injecting local anaesthetic to see if the typical pain is relieved). While lumbar discography is widely practiced and has some good date supporting its use (although there is still controversy), cervical discography has very limited data supporting its use. Diagnosis of cervical disc pain is often made from changes seen on an MRI. These changes on MRI exist in the painfree population as well, so using these changes alone to diagnose the cause of neck pain can lead to the wrong diagnosis. Never the less; some patients get pain relief from a cervical fusion operation, or from a disc replacement. Some people believe that , if the facet joints have been ruled out as a source of pain, disc replacement is a better operation to fusion, as it puts less pressure on the “healthy” discs alongside the area of surgery.
Xrays and other imaging is rarely of help in diagnosing chronic neck pain, as the changes seen on imaging (and often blamed for the patients pain) are seen in the pain free population just as commonly.
Trigger points and ligament injuries have not been scientifically proven to exist as a cause of chronic pain.
Why aren’t the causes of chronic neck pain and acute neck pain the same? They may well be; it may be that muscle injuries heal, and joint injuries do not. More studies are required.
For additional information on this topic visit the section on:
References:
1. Stiell JG, Wells GA, Vandernheen KL, Clement CM, Lesiuk H, De Maio VJ, Laupacis A, Schull M, McKnight RD, Verbeek R, Brison R, Cass D, Dreyer J, Eisenhauer MA, Greenberg GH, MacPahil I, Morrison L, Reardon M, Worthington JW (2001) The Canadian C-spine rule for radiography in alert and stable trauma patients. Journal of the American Medical Association.286: 1841 – 1848.
2. Evidenced – based Management of Acute Musculoskeletal Pain. Australian Faculty of Musculoskeletal Medicine.
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Updated: January 2007
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