Chronic Neck Pain: A Primary Care Approach

This transcript has been edited for clarity. 

Matthew F. Watto, MD: Welcome to The Curbsiders. I'm Dr Matthew Frank Watto, here with my great friend and America's primary care physician, Dr Paul Nelson Williams. We're going to be talking about the evaluation of chronic neck pain, which is a really common complaint in primary care. So, Paul, what are the three buckets of neck pain? 

Paul N. Williams, MD: Well, as our listeners probably know, neck pain is extraordinarily common. There are three big buckets. There is mechanical neck pain, which is sort of the bread-and-butter "my neck just hurts" — probably the one you're going to see most commonly in the office. We'll get into that in just a second. 

The second bucket is cervical radiculopathy. We see a little bit more neurologic symptoms as part of the presentation. They may have weakness. They may have pain.

The third type of neck pain is cervical myelopathy, which is the one that probably warrants more aggressive follow-up and evaluation, and potentially even management. And that is typically your older patients in nontraumatic cases, who have bony impingement on the central spinal cord, often with upper motor neuron signs, and it can ultimately be very devastating. It's almost a spectrum of presentations to worry about in terms of severity and outcomes.

We'll start with the mechanical neck pain. It's the one that we see the most commonly in the primary care office. We've all dealt with this. This is the patient who's got localized neck pain that doesn't really radiate anywhere; it kind of sits in the middle of the neck. In fact, if you actually poke back there where the patient says "ouch," you're probably in the right ballpark. The etiology and pathophysiology, weirdly, are still not super–well-defined, but it's probably mostly myofascial in etiology. And as such, it often gets better no matter what you do. It will probably get better with time.

You are not going to have neurologic deficits with this type of neck pain. There's not going to be weakness, or radiation down the arm, or upper motor neuron signs. No one is mentioning the urinary symptoms with this. You can treat it with NSAIDs and physical therapy, which may be necessary if it persists. Massage can sometimes be helpful, but basically you're just kind of supporting the patients through their own natural healing process. Physical therapy might help with the ergonomics and help make sure that they position themselves and move in a way that does not exacerbate the underlying structures. That is probably the one that we see the most and in some ways is probably the easiest to manage. 

Watto: This is the one that we generally should be least worried about. But cervical radiculopathy, which is the second bucket, is not as severe as cervical myelopathy, so it's kind of in between the two. Cervical radiculopathy is basically the patient who has neck pain that's going down one arm or the other, usually not both arms because that would be weird for them to have symmetric radiculopathy. It's a nerve being pinched somewhere, usually more on one side than the other. 

The good news for patients is that the natural history is that it's going to get better over time, almost no matter what we do. I almost think of this akin to sciatica. Usually sciatica and cervical radiculopathy do not have any motor weakness along with them. It's really just the pain and maybe a little bit of mild sensory symptoms. So, you can reassure the patient that this usually goes away. Our guest said he sometimes gives gabapentin for this. That's not my practice. I would be more likely to refer to physical therapy or try some NSAIDs if they're really having trouble functioning or maybe some muscle relaxants. But they aren't going to need to go to surgery. 

What about cervical myelopathy, Paul? Do those patients need surgery? 

Williams: Yes.The idea with cervical myelopathy is to keep it from progressing. It typically occurs in older patients. It's like arthritis — a sort of bony buildup that compresses on the spinal cord itself. These patients will often have neck pain but not always. It's also associated with impairments in motor function and other neurologic deficits. So, the patients may report that they have difficulty buttoning their buttons or managing fine-motor skills. They may have radicular symptoms down their arms. They may have an abnormal physical examination. They may have weakness on exam, but they'll have a positive Hoffmann's test where you flick the middle finger and look for flexion of the first finger and the thumb. They may have abnormal tandem gait, or patellar or Achilles hyperreflexia. Their neuro exam will not be normal much of the time, and in later cases because it's upper motor neuron disease, they may even report urinary symptoms like urinary hesitancy or just a feeling of general unsteadiness of the gait, even though we're at the cervical level. If you suspect myelopathy — and the trick is to think about it and recognize it when you see it — then you should send them for an MRI. If it persists or they have rapid regression, you get the MRI and refer them to neurosurgery. It's not necessarily a neurosurgical emergency, but things should move along fairly briskly once you've actually identified it. 

Watto: Dr Mikula made the point that if someone comes to you in a wheelchair, they are probably not going to regain the ability to walk. You're really trying to prevent progression. If they are already severely disabled, they're probably not going to get totally back to full functioning, even with surgery. You're just trying to prevent things from getting worse. That's the main reason to identify this and get the patient to surgery. 

We covered a lot more about neck pain. This was a very superficial review of what we talked about with Dr Anthony Mikula. Click here to listen to the full podcast.