Blog & research

Pain in the neck: A guide to managing neck pain for GPs

This article on managing neck pain is based on a presentation Dr Raj Reddy delivered in association with the I-MED Radiology Network in October 2023 in Sydney. While the information is for GPs, other healthcare professionals, including those in allied health, may also find it useful.

If healthcare professionals would like an opinion on a case, including triage recommendations, please contact Dr Reddy’s team at BrainSpine Neurosurgery on (02) 9650 4132. Send any relevant imaging to enquiries@brainspine.com.au.

 


A practical approach to managing and treating cervical spine conditions for the family physician.

Case study

A previously fit and well 56-year-old male IT professional, who participates in a number of sporting activities in his spare time, was experiencing worsening neck pain over 2 weeks following a dental procedure. He was sent to ED after initial assessment by his general practitioner (GP) and underwent a CT scan of his neck. The scan showed some mild degenerative changes, but no significant acute pathological changes. The patient was discharged home.

However, over the next 4 weeks, he experienced worsening neck pain. He also developed neurological symptoms with loss of dexterity, and sensory changes in his upper limbs. He developed fevers, chills and rigors, before presenting to ED again. There, he had another CT scan, which showed a marked difference compared to the scan he had 4 weeks prior.

The latest scan showed erosion of the vertebral bodies, loss of disc space, and pre-vertebral swelling. There was also a change in spinal alignment with a kyphotic deformity. That prompted an MRI with contrast. The MRI, being an investigation that better assesses soft tissue, detected an abnormal process causing destruction of the discs, pronounced swelling around the affected area, and contrast enhancement.

His diagnosis was now apparent. He had discitis, which had progressed into a complex, multi-level discovertebral infection (with discitis and  osteomyelitis). This had led to a kyphotic deformity and instability resulting in spinal cord compression.

Learnings

Taking a thorough history and examination

It is important to not only take a good history and examination but to critically analyse both. For example, the first time the male presented to ED, the doctor noted his recent dental procedure but did not appear to consider the possible complications that it may have lead to, such as bacteraemia, which can cause delayed infection. Also, it is unusual for a healthy, athletic person to complain of neck pain, and should have raised the red flag of sinister pathology.

Imaging and test types

CT scans are useful screening tools that are particularly effective at screening bones, while MRIs are much better at screening soft tissue including discs, nerves and the spinal cord. However, MRIs can be more difficult to access from a GP perspective. So, if relying on a CT, it is important to be aware of the limitations of the investigation.

It would also have been useful to take the male’s ESR (erythrocyte sedimentation rate) and/or CRP (C Reactive Protein) on initial presentation, as these markers of inflammation may have been raised. Again, it is important to be aware that these tests are also non-specific, and may also provide false-positive/negative results.

Clinical and radiographic follow-up plan

Having a diagnosis is critical to safe patient care. If one is not possible at initial presentation, then ensuring clinical and radiographic follow-up provides a safety net making it less likely to miss a critical diagnosis.

It would have been ideal for the patient in this case study to have been instructed to see their GP if their symptoms had not improved in 2-4 weeks, or, given a referral for an outpatient MRI and instructed to follow up the results with their GP.

Diagnosing neck pain

 

There are many possible causes of neck pain, so to help with a diagnosis, begin by considering which group their symptoms fit into. The key groups include:

  • Radiculopathy – this is indicative of nerve root compression. Ask whether the patient has nerve root symptoms; such as numbness, paraesthesia (pins and needles, tingling), pain or muscle weakness.
  • Myelopathy – spinal cord compression. This can be subtle and insidious, and includes loss of dexterity and fine motor skills, and clumsiness. It can progress to involve gait. Eventually it can progress to weakness.
  • Axial neck pain – this may be caused by many different sources, but most of the time the cause is not sinister.
  • Combination of the above.

Examinations

When examining the patient, aim to identify the following:

  • Sensory changes – ascertain which dermatomal pattern of change
  • Motor weakness – again, with a focus on identifying the myotomal pattern
  • Reflexes – particularly concerning myelopathy (hyperreflexia) or absent reflexes.
  • Myelopathy – including gait and reflex changes. These are falling into the red flag territory so you may consider sending the patient to the ED or calling a neurosurgeon to see urgently.

Investigations

The usual pathway for determining the cause of neck pain is as follows:

  1. Cervical spine X-ray
  2. Cervical spine CT scan
  3. Cervical spine MRI
  4. Other imaging:
    1. SPECT/bone scans
    2. Dynamic X-rays
    3. Myelogram, for people who can’t have MRIs. It produces good imaging though is invasive and has limitations of identifying pathology within neural tissue.
  5. Nerve conduction studies – these help to distinguish between conditions of the peripheral nerves and spinal nerves.

Sources of spine pain

There are many anatomical sources of spine pain, including:

  • Discs
  • Facet joints
  • Muscle
  • Tendons
  • Ligaments
  • Vessels
  • Bone-referred pain
  • Organs

The sources of pain can also be pathological including:

  • Degenerative reasons
  • Trauma
  • Instability
  • Congenital
  • Inflammation
  • Infection
  • Psychosomatic

The vast majority of neck pain complaints will be caused by degenerative conditions, but thinking pathologically will better help to identify red flags, which indicate conditions such as infection, inflammation and tumours.

However, remember that sometimes the cause of neck pain cannot be established, and having neck pain does not always mean a patient needs treatment.

Illustration of a person holding their neck that is in pain.

Identifying red flags

The following red flag symptoms and risk factors require critical analysis as to possible significant pathology and may necessitate immediate, urgent referral to a tertiary hospital or specialist.

  • Progressive neurological deficit, including bowel and bladder dysfunction and unsteady gait
  • Trauma
  • Pain in patients less than 50 years of age (people who normally wouldn’t have spinal symptoms)
  • Patients with a history of cancer
  • Constitutional symptoms, such as fever and weight loss
  • UTI or other infection, IV drug use or TB exposure
  • Immune suppression
  • Steroid use

Frontline healthcare management

Once you can rule out red flags, it is recommended to manage patients experiencing neck pain in the following way:

  • Assess the patient’s history, plus conduct an examination and investigation.
  • Advise on modifying activities to alleviate pain.
  • Advise physical therapy, including physiotherapy and exercise physiology.
  • Advise it is best to continue with daily activities and exercise as much as possible – where once bed rest was prescribed, evidence now shows it is sensible to rest only a little. It is best to continue with daily activities and exercise as much as possible.
  • Advise simple analgesia, including paracetamol and nonsteroidal anti-inflammatory drugs (NSAIDs).

Avoid opioids where possible. Sometimes they may be suitable to manage acute episodes, in which case it is important to define the prescription period and form a plan for the patient to wean off them.

If the patient is experiencing nerve pain, consider the following:

  • Neuropathic pain medication can be effective, but it is important to be aware about its side effects, including slower cognitive function and weight gain in some.
  • Targeted cortisone injections (blocks), including nerve and facet joint blocks, have a role in general practice, and it is not always essential for a medical specialist to recommend them. However, if it is unclear which nerve to inject, contact a specialist for advice.
  • Obtain a surgical opinion urgently for progressive neurological deficits such as myelopathy.
  • Consider referring your patient to a pain specialist to help manage complex patients, particularly if potential psychosocial issues exist, and if there are no major structural issues.

Cervical spinal surgery

If a patient needs cervical spinal surgery, the surgeon may do any or all of the following 3 things:

  • Decompress the affected neural structures
  • Realign the spine
  • Stabilise the spine
Posterior and anterior surgical approaches

There are broadly two approaches to cervical spine surgery: anterior and posterior.

Posterior approach

The posterior approach was used more in the past when there was not access to the technology we have now for anterior operations (such as the operating microscope). The posterior approach is generally a cheaper operation because it does not require hardware, which is expensive. This makes it easier to obtain approval for insurance, work cover and CTP claims.

The main posterior approach to cervical spine surgery is a foraminotomy, which involves drilling the lateral mass and facet joint to access the foramen, to allow decompression of the nerve. However, if too much bone is drilled away, this creates instability and more pain. Meanwhile, if not enough is drilled, the nerves remain compressed.

Surgeons also only have about a 90-degree view of the nerve when performing a posterior foraminotomy, so while it has a role, it is important to consider its drawbacks.

The posterior laminectomy is more suitable than a posterior foraminotomy for certain conditions, such as compression of the spinal cord, more so than the spinal nerve roots. Particularly, when there is pathology over a number of segments and the spine is stiff and not going to degenerate any further (almost fused on its own), it can be effective. But if posterior laminectomy is used inappropriately, for example, on a young patient who has had a tumour removal, structural problems may result, which can be challenging to fix.

Anterior approach

Anterior spinal surgery is considered the superior approach because it has:

  • Biomechanical advantages – the surgeon is both directly decompressing the nerve (by freeing up the cause of the compression) and indirectly decompressing it (by restoring the height of the collapsed disc and therefore increasing the size of the foramen). It also allows a larger view of the nerve.
  • Low morbidity – the patient experiences less pain because the surgeon is working between normal muscle planes rather than cutting muscle off the spine.
  • Cosmesis – patients tend to heal well following an anterior laminectomy compared with the posterior approach where patients are more likely to experience muscle atrophy.

However, it can be challenging to access certain levels when using an anterior approach, such as C3 and higher levels, in which case a surgeon should use the posterior approach.

Anterior cervical surgery

Two common anterior cervical operations include:

  • Anterior cervical discectomy and fusion, or ACDF
  • Total disc replacement, or TDR

Another anterior cervical procedure is the corpectomy, where the surgeon removes a vertebral body, but this is less common than an ACDF or TDR.

ACDF versus TDR

There are two main ways to treat serious disc conditions in the cervical spine: an anterior cervical discectomy and fusion (ACDF) or a total disc replacement (TDR).

A TDR – replacing a damaged disc with an artificial one – may first appear preferable on the understanding that artificial discs have been designed to mimic natural disc movement to help reduce the stress on the adjacent motion segment, and perhaps contribute to preserving range of spinal movement.

However, it is important to consider all available evidence. In a study that has since been cited in support of the artificial disc market, lead author Alan S. Hilibrand and his team investigated whether a fusion stiffened the spine and resulted in the deterioration of the disc adjacent to the level at which fusion was carried out (adjacent segment disease). They found that there was about a 2-3% chance per year of the adjacent segment deteriorating and causing symptoms, requiring further surgery.

However, the detailed discussion and conclusion has been less cited, which was that the authors could not exclude that progressive spondylosis/degeneration was also likely to cause adjacent segment disease rather than the fusion alone.

So, surgery with a view to fusion can be suitable in the appropriate patient.

ACDF technique

Under a general anaesthetic, the surgeon makes a small transverse or longitudinal incision at the front of the neck. The exact location of the incision depends on which spine levels are affected.

The surgeon dissects between the oesophagus, trachea, carotid arteries and jugular veins. The surgeon then comes down to the front of the spine and removes the affected discs. This allows decompression of the spinal cord, and the nerve roots bilaterally. Finally, an interbody device is placed to achieve fusion.

Previously, surgeons removed bone from the patient’s hip for the bone graft. This still occurs in trauma situations but most modern surgeons do not do this routinely. There are a number of implants available that function well. Their use avoids patient complaints about their hip bone graft site hurting more than their neck.

Many implants are available with only minor variances. However, surgical technique and patient selection is more important than the brand of hardware used.

Plates were used at the front of the spine a lot, but nowadays surgeons insert them much less since they are not always necessary. If they are used, they should be counter sunk (ensuring they are flush) and be as short as possible to avoid encroaching on the adjacent motion segment.

TDR technique

Under general anaesthetic, the surgeon makes a small incision at the front of the neck, then reaches the affected part of the spine.

The surgeon will remove the affected disc or discs, and any loose disc material or other structures compressing the spinal nerves and cord. They will enlarge the vertebral foramen and ensure optimal disc space so they can insert and secure the artificial disc into place.

Several artificial discs are available for TDRs but it is important to be aware about the drawbacks of this procedure. The main downside is that patients need much longer follow-up afterwards.

Surgeons now understand that some commonly used artificial discs may result in delayed, long-term complications. Consequently, people are having them removed. In the US, patients have also begun bringing class actions.

A TDR is primarily recommended to shield the stress being placed on the adjacent segment above and below the affected disc. It is a misconception that a TDR allows for greater movement of the spine following surgery than fusion. A one-level fusion, which is most common, will allow about the same level of mobility as a one-level TDR does.

ACDF and TDR: risks, benefits, hospitalisation and post-op care

Benefits and outcomes

Most patients (85%) report an improvement in their radicular arm symptoms after an ACDF or TDR.

About 10% of patients experience little to no change.

Symptoms in about 5% of patients will worsen. This means they may need a posterior operation so the surgeon can completely free up the affected nerve.

Risks

The general risks of an ACDF or TDR include anaesthetic risks, infection and DVT, as with any procedure and hospitalisation.

Risks specific to an ACDF or TDR include:

  • Hoarse voice – this is common but it will be long term in 5% of people.
  • Swallowing issues – this is common but it will be long term in 5% of people.
  • Interscapular pain – this is common and may occur because of change to the biomechanics of the spine by increasing the collapsed disc height. This can take anywhere from a couple of days to a couple of months to improve as the facet joints get used to the changes.
  • Haematoma, causing airways problems – this is rare, and while it hasn’t occurred during my operations, it may happen once a year in any given hospital.
  • Adjacent segment changes. It is still common to cite the data of Hilibrand’s paper: there is a 2-3% risk per year of developing symptoms due to changes at the level above or below the surgically treated levels.

Hospitalisation

Most people who have an ACDF or TDR will only need one or two levels addressed. They will be admitted to hospital on the day of surgery.

An ACDF or TDR typically takes 1-2 hours to complete. A 3 or 4 level operation may take about 2.5-3 hours.

Patients are observed hourly for 4 hours in recovery, then they are transferred to the ward for 4 hourly observations. Most patients are able to mobilise once they are in the ward.

Most patients return home within 1-3 days.

It is best practice to obtain imaging such as an X-ray or CT scan before they are discharged from hospital.

Patients are also assessed by physiotherapists to make sure they are stable, safe and comfortable before they leave.

Post operative care

Returning to regular activities

Most surgeons do not want a person who has had an ACDF or a TDR to do too much in the first 4 weeks, and advise them to modify their regular activities during this time.

It’s best that they not drive for a week or two.

Wound care

Most times, the wound will have internal dissolvable stitches so the patient will need to keep it dry for 3-4 days. There are some waterproof dressings that help with this.

Collars

Most people don’t use collars and I do not recommend them unless I am doing a 3 or 4 level reconstruction.

Medications

It is preferable that patients wean off their medication as soon as possible. However, it is important that the patient can function properly before they do this. It is best that the patient undertakes rehabilitation and physiotherapy with the support of their medications rather than being in too much pain to do this.

Clinical follow-up

Clinical follow-up varies between patients but typically follows this pattern:

  • Practice nurse will typically call patients a week or two after surgery.
  • First follow-up consultation between 4 to 6 weeks.
  • Second follow-up consultation 3 months afterwards.
  • Third follow-up consultation 6 to 9 months after the second consultation.

We obtain X-rays for the second post-operative consultation, and a CT for the third post-operative consultation.

If something is not going to plan, I have a low threshold to obtain further imaging, since it is important to understand what is occurring given that things can change.

Case study result

To treat the osteomyelitis and discitis in the 56-year-old male, we removed 4 of the vertebral bodies. As this is a long segment to reconstruct, we utilised iliac crest from his hip and placed that in the space we had created, then secured a large plate on the front of the spine. The patient was then repositioned for a further posterior operation, and lateral mass screws inserted into the back of the spine provided circumferential stability. He was able to return home after 3 days.

12 months after his operation, his CT scan was showing good fusion. Clinically, he had excellent range of motion, despite a multilevel operation.

Soon after, he began returning to his regular activities, and he has since recommenced extreme skiing.

Conclusion

The key elements in the management of neck pathology are as follows:

  • Actively look for the red flags.
  • Neurological deficits dictate the need for imaging and specialist consultation.
  • Call a spinal specialist for support and recommendations if unsure.
  • Not all treatment algorithms end with surgery.
  • Surgical intervention is safe and highly effective for appropriate patients.


Illustration by Injury Map under a Creative Commons license.