Neck Pain Care Pathway

8. Diagnostic Criteria for Neck Pain Amenable to Conservative Care

 

Diagnosis requires a thorough understanding of the patient's condition. It integrates patient stories; clinical findings; risk factor evaluations; and physical, psychological, social, and environmental aspects of pain.

 

A. Common Neck Pain

(Other terms used to describe common neck pain: non-specific neck pain, cervical strain/sprain, mechanical cervicalgia, facet joint irritation, whiplash associated disorders (WAD) I-II, degenerative changes/osteoarthritis, myofascial pain).

• Definition: Common neck pain that is not due to serious underlying pathology requiring medical attention such as infection, tumor, or fracture and is typically amenable to conservative care (e.g., education, manual therapy, exercise).

• Prevalence: Approximately 90% of all neck pain cases.

• Risk Factors: Include psychosocial factors (e.g., stress, lack of social support, anxiety, depression); sociodemographic factors (e.g., female sex, older age); physical factors (e.g., repetitive strain, poor posture, prolonged periods of sitting or using computers and mobile devices); lifestyle factors (e.g., low physical activity, obesity); work-related factors (e.g., heavy physical labour, awkward postures).

• Prognostic Factors for Delayed Recovery: Include high pain intensity at onset, high levels of disability, poor general health, history of neck pain, psychological factors (e.g., fear of movement, anxiety, depression), poor coping strategies, low social support, job dissatisfaction.

• Pain Location: Typically localized to the neck and upper shoulders.

• Duration: Pain can be acute (lasting less than 6 weeks), subacute (6 to 12 weeks), or chronic (more than 12 weeks). The duration of the complaint informs subsequent treatment recommendations. For example, consider adding low-level laser therapy for chronic common neck pain, and supervised strength training for acute neck pain with radiculopathy. If there is a history of previous conservative treatment, imaging may be considered for chronic common neck pain, while referral may be considered for chronic neck pain with radiculopathy.

• Signs and Symptoms:

• Pain can be sharp, dull, shooting, or aching.

• Pain intensity can vary from mild to severe.

• Pain may be aggravated by specific movements, postures, or activities and relieved by others.

• There may be associated muscle stiffness or spasms.

• Referred pain into the arms may or may not be present.

• Physical and Neurological Examination: Pain reproduced by tests. Typically, no neurological deficits. If present, they are mild and do not follow a specific nerve root distribution.

 

• Note: Common neck pain represents the most frequent causes of neck pain with similar mechanisms, clinical symptoms and signs in a primary care setting. Evidence suggests that identifying the specific nociceptive cause of common neck pain is difficult. However, breaking down common neck pain into different categories helps in guiding treatment strategies and managing patient expectations.

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1. Cervical Facet Joint Irritation / Mechanical Cervicalgia

• Definition: Inflammation or degeneration of the facet joints in the cervical spine.

• Prevalence: Common in middle-aged and older adults.

• Risk Factors: Aging, previous neck injuries, repetitive spinal stress.

• Pain Location: Localized to the neck, may radiate to the shoulders or arms.

• Duration: Chronic with periods of exacerbation.

• Signs and Symptoms:

  • Pain exacerbated by extension or turning head.

  • Morning stiffness and pain relieved by rest.

• Physical and Neurological Examination: Tenderness over the facet joints, pain with extension and rotation, positive tests (e.g., cervical Kemp’s, compression), no neurological deficits.

 

2. Whiplash (WAD I, II), Cervical Strain / Sprain

• Definition: A constellation of neck-related clinical symptoms presenting after a whiplash (acceleration-deceleration) injury.

• Prevalence: Common in westernized countries.

• Risk Factors: Sporting injuries, falls, motor vehicle collisions.

• Pain Location: Neck pain possibly radiating to head and upper extremities.

• Duration: Many people recover quickly, while some may experience intermittent symptoms for an extended period.

• Signs and Symptoms: Varied symptoms that may include neck pain, neck stiffness, interscapular pain, upper extremity complaints (pain, weakness, numbness), jaw pain, headache, dizziness, psychological distress, and memory or cognitive changes.

• Physical and Neurological Examination: Tenderness over cervical musculature, restricted cervical range of motion, positive tests (e.g., cervical Kemp’s, compression), no neurological deficits.

 

3. Osteoarthritis

• Definition: Degenerative joint disease affecting the cervical spine.

• Prevalence: Common in older adults.

• Risk Factors: Aging, obesity, joint injuries, repetitive stress, genetic predisposition.

• Pain Location: Localized or referred pain in the neck.

• Duration: Chronic with episodic flare-ups.

• Signs and Symptoms: Pain worsens with activity, relieved by rest; morning stiffness.

• Physical and Neurological Examination: Reduced range of motion, crepitus and joint swelling, positive tests (e.g., cervical compression, Spurling’s), no neurological deficits unless advanced.

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4. Myofascial Pain Syndrome

• Definition: A chronic pain disorder caused by sensitivity and tightness in the myofascial tissues.

• Prevalence: Common in adults, especially those with sedentary lifestyles or repetitive motion activities.

• Risk Factors: Poor posture, stress, muscle overuse, direct muscle injury.

• Pain Location: Muscle pain in neck and shoulders, potentially referred pain.

• Duration: Chronic, with variable intensity.

• Signs and Symptoms: Trigger points in muscles, painful on compression

• Physical and Neurological Examination: Taut bands and trigger points, no neurological deficits.

 

B. Neck Pain with Radicular Pain (Radiculopathy) (from disc protrusion/herniation, WAD III, foraminal stenosis)

• Definition: Involves the irritation or compression of a nerve root in the cervical spine, manifesting as pain, numbness, or weakness radiating down the arm, often following a specific nerve distribution.

• Prevalence: Less than common neck pain.

• Risk Factors: Include lifting heavy objects, driving, operating vibrating equipment, older age, neck trauma, frequent diving from a board.

• Prognostic Factors for Delayed Recovery: High pain intensity at onset, high levels of disability, poor general health, history of neck pain, psychological factors (e.g., fear-avoidance behaviors, anxiety, depression), poor coping strategies, low social support, job dissatisfaction.

• Pain Location: Typically originates in the neck and radiates down the arm, potentially as far as the hand, often following a specific dermatomal pattern.

• Duration: Can be acute or chronic, with acute episodes potentially becoming recurrent or chronic if not managed appropriately.

• Signs and Symptoms:

  • Sharp, shooting, or burning pain radiating down the arm, potentially associated with numbness, tingling, or weakness in the affected limb.

  • Pain may be exacerbated by specific movements such as bending the head forward, lifting, coughing, or sneezing.

• Physical and Neurological Examination: Sensory deficits, muscle weakness, and altered reflexes in the affected limb, corresponding to the involved nerve root. Positive tests include Spurling’s, neck distraction, Bakody/shoulder abduction sign, Valsalva, and upper limb tension tests.

 

1. Neck Pain with Radicular Pain (Radiculopathy) (from disc protrusion/herniation, WAD III)

• Definition: Displacement of disc material that causes irritation or compression of nerve roots.

• Prevalence: Common cause of neck pain with radiculopathy, particularly in younger adults.

• Risk Factors: Heavy lifting, repetitive activities, smoking, obesity.

• Pain Location: Neck radiating down arm.

• Duration: Acute or chronic, with episodes lasting weeks to months.

• Signs and Symptoms: Sharp, shooting, or burning pain; numbness, tingling, weakness associated with a nerve root.

• Physical and Neurological Examination: Sensory deficits, muscle weakness, and altered reflexes in the affected limb, corresponding to the involved nerve root. Positive tests include Spurling’s, neck distraction, Bakody/shoulder abduction sign, Valsalva, and upper limb tension tests.

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2. Neck Pain with Radicular Pain (Radiculopathy) (from foraminal stenosis)

• Definition: Encroachment (e.g., facet joint osteoarthritis, cysts, degenerative disc disease, spondylolisthesis, congenital) of the neuroforamen on one or both sides that causes irritation or compression of nerve roots.

• Prevalence: Common cause of neck pain with radiculopathy, particularly in older adults.

• Risk Factors: Older age, history of neck trauma.

• Pain Location: Neck radiating down arm.

• Duration: Chronic, with episodes lasting weeks to months.

• Signs and Symptoms: Sharp, shooting, or burning pain; numbness, tingling, weakness associated with a nerve root.

• Physical and Neurological Examination: Sensory deficits, muscle weakness, and altered reflexes in the affected limb, corresponding to the involved nerve root. Positive tests include Spurling’s and cervical distraction tests.