Why do I have neck pain?

There are many reasons for neck pain, some very common, and others quite rare. The problem may be on the skin of the neck, or deep in the middle of the neck, inside the spinal cord. Each of the problem presents with some particular features, which helps a doctor figure out the cause. More information is needed to better answer this questions. In this article are brief descriptions of some of the conditions that may cause neck pain. Starting with the skin and going deeper, most structures in the neck are covered. A brief outline of treatment for each condition is also provided.

What conditions on the skin may cause neck pain?

Usual causes include sunburn, shingles, neuralgia (irritation of a nerve), a bug bite, or an infection.

Treatment: Depends upon the cause. May include local applications, pain meds, or medicine for an infection.

What conditions of muscles may cause neck pain?

In the back of our neck are sets of long vertical muscles constantly holding our head up. Somewhat similar muscles in the front of our neck help them. Without this support, the head may fall to one side. Conditions that may tighten, weaken or inflame these muscles may cause neck pain. Muscles frequently get tighten or inflamed from underlying arthritis of spine. An inflammatory condition of muscles called Polymyositis may cause widespread muscle pain, including the neck muscles. Neck muscles frequently get tightened with emotional stress, which may also result in constant pain.

Normally, muscles on both sides of the neck keep a balance to keep the head in the middle. In some conditions, a set of muscles may be too active compared to its opposite side, and may constantly turn the head to a side, resulting in neck pain. This condition is called cervical dystonia, and is discussed later.

Treatment: Neck hygiene, proper exercises, pain management; and more specific treatment depending upon the cause.

What is cervical paraspinal muscle spasm?

Paraspinal means next to the spine. Many neck muscles are close to the spine for providing physical support to it, and to keep the neck in proper position. Sometimes they are too tight, which may happen due to an abnormal shape of the spine putting too much pressure on them, or it may also happen with chronic psychological stress and tension, in which case it may be the reason for abnormal shape of the spine. It may cause chronic and difficult to treat neck pain. It may simply be diagnosed by feeling patient’s neck and assessing underlying muscle tension. It can be confirmed by an x-ray, where one notices change in the curvature of the spine. Normally, spine in the neck has a forward curve, mild in men and more prominent in women. In this condition, this curve flattens, at time making the spine straight, and sometimes creating a reverse curvature. Its reason may also include chronic or childhood neck injury; from a fall, auto accident, or contact sports.

Treatment: Spine hygiene, neck exercises, pain management.

What is Torticollis or Cervical Dystonia?

Normally, tension on muscles of both sides of the neck is balanced to keep the head in the middle. In some conditions, some muscles may be too active, tightening a group of muscles and constantly turning the head to one side. This condition is called Cervical Dystonia (or Torticollis). Its real reason is unclear, and seems to be a problem with the central control (in the brain), instead of in the nerves or the muscles.

Treatment: Botox treatment to slightly weaken the overactive set of muscles.

What conditions of spine may cause neck pain?

Before talking about the spine conditions, an overview of normal spine structure is provided as follows:

The Normal Spine

Basically, spine is made up of bones or vertebrae, put one on top of each other. In most of the spine, the main part of vertebrae, or its body, do not touch other vertebrae and have a good amount of space in between. Each of this space between two adjacent vertebrae is filled by a structure we call disc. For understanding, imagine disc as a tennis-ball type of structure with a thick wall, with its inside full of a jelly like material, and somewhat compressed from outside. Now imagine putting about 25 vertebrae one on top of each other, with discs in between. This creates a very flexible but very unstable structure. Thick strong tendons, like bands of thick cloth, wrap around this whole structure to make it stable. The bodies of many vertebrae also extend arms-like projections towards the back, away from the body. These projections somewhat fold downwards and make joints (facet joints) with each other to provide further stability to the spine. One can easily see and feel these projections in a person with back bent over, especially in a well-toned body. Spine in a young person is a very flexible and stable structure, which many teenagers do not hesitate to show-off.

Spine is usually divided in four parts: cervical (in the neck), thoracic (in the middle), lumbar (lower back), and sacral in the lowest part of back and in the pelvis. With aging, many changes take place in the spine. One early change is somewhat drying up of the jelly-like material within the discs, making it less flexible. So is the reason that you may not find an effective gymnast after teen years. As we grow older, spine changes itself from made-for-flexibility to made-for-strength. In varying degrees, the process of drying up of disc material continues. An MRI done even in the so-called healthy adult individuals, with no back symptoms, may reveal degeneration of discs, which is not necessarily a disease. With drying up of disc material, and with wear and tear from different activities one may have undertaken during active years of life, discs change their shape. They become somewhat flattened, less flexible, and rough around the edges instead of round and smooth. In later age, they also shrink in size, making people loose some height. All these are so-called normal changes with aging. We have not found a way to stop or reverse these changes.

Other than strength and stability, one of the main functions of the spine is that it acts as a conduit for all the large wiring from brain to different areas of the body. The long wires, or the tracts in medical terminology, are lumped together in a structure called spinal cord. Other than the first, at each level, in-between two vertebrae some of its extension or connection come out to reach their destination.

Back or neck pain may happen with a variety of problems with discs or the vertebrae, some of them are described below.

Why neck pain is so common?

Some parts of our spine are more at risk of a problem than others, especially from mechanical reasons. This is because some parts of our spine are more mobile than others. The neck or the cervical spine is quite mobile designed to move our head in different directions. The middle or the thoracic part of the spine is relatively less mobile because of the ribs attached on either side. The lumbar part of the spine is also quite mobile helping us walk, run, lift, and twist. The lowest part of the spine, the sacral area, has minimal amount of movement. Most of the problems from mechanical causes happen either in the neck (cervical spine) or the back (lumbar spine). Even in these two areas some joints are more at risk than others. In the neck or the cervical spine, the lowest two joints (between C6 and 7, and C5 and 6) are the ones usually affected.

What does a disc bulge mean?

Imagine disc as a tennis-ball type of structure with a thick wall, with its inside full of a jelly like material, and somewhat compressed from outside. A disc may bulge out due to too much pressure, e.g., from falling, auto accidents, weight lifting, contact sports, or overstretching. In this condition, because of too much vertical pressure on the disc, the tennis-ball bulges out but is still intact. Disc bulges are commonly seen on MRIs of back, and seldom cause any real trouble. For disc bulge to cause a significant issue, it has to be big enough to break the cloth-like tendons wrapped around the spine. Disc bulge(s) may also be an indication of a previous injury and a weakened spine.

Treatment: Reassurance and education, spine hygiene, back strengthening exercises. Rarely, it may require a surgical treatment.

What is disc herniation?

In case of sudden too much pressure on a disc, e.g., from falling, traffic accident, contact sports, weight lifting, or overstretching, the thick outer wall of the disc may develop a tear or a slit like hole, through which a part of the jelly-like material from inside the disc (the tennis-ball) may come out. Once out, it has no way to return back. The tear may seal and heal up but the disc material stays outside. If that disc material is away from any nerves, the patient may just notice some localized back pain for a few days. On the other hand, if this material is close to a nerve it may impact its function. Presence of disc as a foreign body may also trigger an inflammatory response that may affect any close-by nerve(s). Depending upon the trapped nerve-root, patient may feel strong pain and/or numbness traveling down an arm. If the nerve is pressed too hard or inflamed, it may loose its function. The muscles it is taking messages to may not work, and patient may develop weakness of those muscles. In neurological literature, this condition of “pinched nerve in the neck,” is called a cervical radiculopathy. It can be diagnosed based upon its typical pain history, and physical examination showing loss of strength, or a reflex. It can be confirmed by doing an EMG/nerve conduction study, and the cause of the problem can be discovered by an MRI scan.

A large disc herniation, other than pressing a nerve, may also put pressure on the spinal cord. This is called cervical radiculo-myelopathy, which, if happens acutely, can be a neurosurgical emergency. Myelopathy means problem with the spinal cord.

Treatment: Minor herniation may self-heal after a few days of pain, and may just be found as a finding on MRI. A little larger requires pain management, anti-inflammatory meds, therapy, and exercise. Some may benefit from a local injection to resolve inflammation. Larger ones, and the ones compromising a nerve or the spinal cord, require surgical treatment, sometimes emergently.

What is spinal spondylosis or spinal spondylitis?

I am putting these terms here because many patients read their MRI reports and come asking about it. Many times, the physician ordering the scan may not have good understanding of these terms either.

As described in detail above in the description of a normal spine, at each level in-between two vertebrae, a pair of nerves comes out of the spine. Pairs are named based upon their location, like right and left C5 in the neck, and L5 in the lower back. Some patients develop a chronic process either due to a genetic tendency or from chronic or multiple traumas, usually a combination of both. In this process, discs get too dehydrated; loose their malleability (flexibility), and their size and height. They bulge, and may also herniate at multiple sites. Exposed to chronic stress, some parts of the adjacent bones get thicker, and may build extra bone structure (or bone spurs), the osteophytes. Medical term for all this process together is spondylosis. In many people, it is a painless process, at least to a certain extent. Frequently, the neck gets irritated or inflamed, causing local pain. If any of the nerves get trapped in this process, sharp pain travels down from neck to the shoulder and arm. The terms of spondylitis or spondyloarthritis imply inflammation in this process. MRI scan may reveal all or part of the changes described above.

Treatment: For spondylosis, spine hygiene, and back strengthening exercises. Spondylitis (or spondyloarthritis) may require additional pain management. Surgery is needed if a nerve or the spinal cord is compromised.

What is cervical spinal stenosis?

Typically chronic changes of spinal spondylosis (discussed above) may cause narrowing of the holes where the nerves come out, or sometimes narrowing of the whole spinal canal, pressing on the spinal cord. Many times there is additional problem from previous surgeries. This process of narrowing is called cervical spinal stenosis. Patients in this condition may have continuous pain, or pain in a certain posture, due to pressure on the nerves coming out at each level. If nerves are not pinched, it can be a relatively painless process slowly narrowing the pathway or the conduit where the spinal cord is passing through. This may last for years to decades. In some patients, the tightening may get so severe that the spinal cord is flattened, and sometimes permanently injured. Patient may feel unsteady, with stiff and weaken legs, and may loose control of bladder function. If left untreated, this condition may lead to paralysis below the neck or below the waist, depending upon the level of spine involvement.

This condition is diagnosed by its typical symptoms, and abnormal findings on examination. EMG/nerve conduction studies can also be helpful. MRI helps to visualize the whole process, confirm the diagnosis, and assess its severity, especially if there is suspicious of spinal cord involvement.

Treatment: It depends upon exact pathology. Most are managed with therapy, pain management, and neck hygiene measures. Some require surgery.

What are facet joints, and can they cause neck pain?

As I stated above in the description of the normal spine, part of vertebrae extend backwards and make joints with the vertebra underneath. These are small joints, though similar in structure to larger joints like a knee joint. They help with stabilizing the spine. Sometimes patients have inflammation in one or many of these joints. Like arthritis, its symptom is back pain in localized area, with no radiation towards the shoulder or the arm, and with no abnormal neurological findings. A CT or an MRI scan can help in diagnosis.

Treatment: Regular exercise, spine hygiene, back strengthening exercises, and pain management. Sometimes a local injection in the joint may also help.

Can spine infection cause neck pain?

Any part of the spine may be infected, usually from a bacterial infection, causing progressively worsening severe localized pain, tenderness, and other symptoms and signs of infection.

Treatment: Antibiotics or appropriate drugs to kill the offending organism(s), pain management, and sometimes surgery.

What about cancer in the spine?

A cancer may start in the spine (primary cancer), or it may be from a different area of the body (a metastatic cancer), resulting in progressively worsening pain, weakness, and other neurological malfunction, without symptoms and signs of infection.

Treatment: Pain management, steroids, surgery, radiation, chemotherapy (depending the type of cancer).

And what about fracture of a vertebra?

Trauma may cause fracture of a vertebra, which is diagnosed with an X-ray or a CT scan. MRI scan can help to find if neurological structures are affected.

Treatment: Neck collar, pain management, spine hygiene, sometimes surgery.

What problems with the covering (meninges) of the spinal cord may cause pain?

A viral or bacterial infection, or a cancer may selectively affect the covering or the dura mater. It may become an abscess or a mass of cancer causing pressure on the spinal cord or the nerve roots. These conditions may present as neurosurgical emergencies, as they may cause permanent disability, if left untreated.

Treatment: Emergency surgery, and depending upon the cause, antibiotics, chemotherapy, pain meds.

Can a problem with the spinal cord cause neck pain?

Spinal cord diseases are usually painless presenting as neurological symptoms such as numbness, weakness, unsteadiness, or loss of bladder control. Sometimes, neck pain is a part of it. It may also cause indirect neuropathic type of pain.

Treatment: Depends upon the cause, and pain management.

Can a problem with spinal fluid cause neck pain?

An infection, inflammation or a cancer may spread to the spinal fluid resulting in neck pain and many other symptoms.

Treatment: Depends upon the cause, e.g., antibiotics for bacterial infection, chemotherapy for cancer.

Can stress cause neck pain?

Stress and depression are common cause of back and neck pain. Some patients, due to their genetic makeup and previous life-experiences, are more at risk for somatic or physical symptoms from psychological causes. There may be multiple mechanisms involved, including muscle spasms, abnormality of pain perception mechanisms, and hormonal factors. Diagnosis is made by appropriate history, and physical examination. Formal testing usually is inconclusive.

Treatment: Reassurance, education, counseling, spine hygiene, medicines.

 

Does fibromyalgia cause neck pain?

Neck and back pain is probably the most common symptom of fibromyalgia. It is understood to be due to change in pain perception mechanisms. Formal testing may not be useful. It is a diagnosis based upon particular symptoms and findings on physical examination.

Treatment: Reassurance, education, counseling, spine hygiene, regular light exercise, pain management. Also treatment of any underlying psychological disorder.

What condition of head may cause neck pain?

The best example is migraine. Neck pain is a common symptom of migraine. Other example is meningitis, which is not difficult to diagnose.

Treatment: Depends upon the cause.

What is Spine Hygiene?

Hygiene means taking all possible measures to keep the spine healthy and strong. It may include following:

a. Proper posture: Learn to maintain proper posture while walking, sitting, at work especially on a computer, while doing heavy physical work, or lifting heavy objects. Wrong posture may lead to significant neck and back pain, and more serious issues with spine. Generally speaking, proper posture is when there is minimum pressure on the spine.

b. Defensive driving: Sudden stop and go type of driving, or any accident leading to sudden stopping, is a significant risk factor for spine problems. Patients with spine problem should be extra careful and avoid over-speeding, and sudden stop-and-go type of driving. It may also be wise, if affordable, to avoid driving or riding in small lighter cars.

c. Weight management: Maintain normal weight for your height: Extra weight is a sustained pressure on the spine, especially if it is not balanced (e.g., big belly or large breasts).

d. Proper sleeping place: Avoid a mattress that is too soft, or sleeping in a soft cushioned couch, or in any bed that causes neck or back pain. Use a proper sized pillow. Men usually prefer a pillow little higher than women. A pillow is of appropriate size if no stress or pain is felt after sleep. We spend almost 1/3rd of our life sleeping; make sure bedding is appropriate.

e. Avoid dangerous activities: Avoid sports and activities that may put the spine at risk, e.g., Football, weight lifting, diving, jumping, especially bungee jumping, mountain biking, etc.

f. Exercise: Adopt a regular back and neck exercise regimen that may help the spine.

What is neck exercise regimen?

In case a problem with neck already exists, exercises may have to be modified and designed for the type of problem. In general, any back and neck exercise regimen should have three goals: a. strengthening supporting muscles, b. maintaining proper posturing, and c. keeping the neck flexible. This should include a mixture of stretching, strengthening, and flexibility exercises. I am sorry for not including details of these exercises here, as it is a significant topic by itself. I may try to do it sometimes later. Consider seeing a physical therapist for guidance.

Where else may I get more information about this topic?

American Academy of Neurology
American Academy of Physical Medicine & Rehabilitation
American Orthopedic Society for Sports Medicine
Centers for Disease Control and Prevention