By Matthew Michaels, MD
Board Certified, Physical Medicine & Rehabilitation
Orthopedic Center of Illinois
The spine and the neck
The spine is an enormously complex structure. Each segment includes three separate joints comprised of the cartilaginous intervertebral disc and the paired facet joints — the latter of which are located towards the back and to either side of the spine. The spine is divided into three segments, Cervical (Neck), Thoracic (rib cage area), Lumbar (low back). For now we will focus on the neck, which for our purposes will include the junction between neck and head as well as between the cervical and thoracic areas.
There are seven neck (cervical) vertebrae but only six cervical discs, including the disc between the bottom neck bone (C7) and the part of the spine to which the ribs attach (thoracic spine – T1). The top two vertebrae lack a disc and form the direct attachment of the skull to the neck.
The remainder of the cervical spine comprises the five additional vertebrae (C3-C7), six cervical discs (C3-T1), and the paired facet joints at every level (12 in total). The cervical spine also houses and protects the spinal cord, cervical nerve roots, blood vessels to the base of the brain, and too many ligaments, tendons, and muscles to list.
When you move your neck, every structure plays a role and every structure influences the structures adjacent to it. Injury to any one structure will affect the surrounding structures, causing pain as well as changes in motion and posture. If the primary injured structure in your neck has lost motion or caused changes in posture to avoid pain (called antalgic posturing), the neck will feel stiff and painful even after the primary structure has recovered. The pain will then persist until normal range of motion and normal posture have been restored. Most of this restoration in posture and movement has to be done actively (meaning you do it for yourself with expert instruction).
We know the cervical discs and facet joints have the most potential for injury. (People are frequently diagnosed with “muscle strain” as a cause of their pain, but it is far more likely that the pain in your muscle is a reaction to an injured disc or facet joint). It is also important to note that injuries to the neck tend to cause pain that radiates elsewhere, to the head, shoulder arm and hand, or even down to the mid back. Whichever is injured in your case can only be determined through a thorough history and physical exam — and possibly through the use of diagnostic injections. Diagnostic injections “block” specific joints or nerves (in other words, they make them numb). While these structures are numb, we reassess your pain. If the pain goes away entirely after numbing, we can say your pain is likely coming solely from that joint.
Which structure is injured will be dependent upon the manner of injury, as well as your age and any previous injuries. Obvious potential causes of neck pain include car accidents and falls — traumatic events involving immense force to the body in a short period of time.
A more common type of injury results from minor trauma and prolonged forces, such as when you wake up with a “crick” in your neck. This likely means you slept for hours in an awkward position that you would have moved out of if you’d been awake. It’s also important to note that previous (incompletely resolved) injuries increase your risk for future injury.
We know that facet joint cartilage and intervertebral discs don’t have blood supplies of their own. Instead, these structures derive nutrition from fluids flowing in and out of them. We also know that motion is critical to facilitate inward and outward movement of these nourishing fluids. As such, any structure that’s moving poorly for any reason becomes prone to accelerated degeneration and arthritis. Furthermore, loss of motion at one joint puts an increased burden on the adjacent structures.
Finally, it’s important to be aware that injury to any of these structures can cause compression of or injury to the spinal nerves and/or spinal cord. Your doctor should evaluate your condition to be certain there are no such injuries. For now, we’ll discuss simple injuries to the neck that don’t involve the nerve structures.
We first establish a general diagnosis through a thorough history and physical exam, along with plain X-rays (MRI scans are generally needed only when there are signs of neurological injury – this decision should be made by your
doctor). Plain X-rays will check for changes in your normal
spinal curves, underlying arthritic changes, and any areas that may have become unstable. Treatment will then consist of medication to reduce inflammation, as well as physical therapy to help restore motion and normalize your posture.
There are many consequences to neck pain. Among the worst of these are motion restrictions and changes in posture that happen as we involuntarily try to reduce the pain. Unfortunately the body’s tendency to lean away from pain is generally counterproductive, leading to prolonged pain and degenerative changes. For this reason, we use physical therapy to teach you about your underlying problem and about the behavioral and motion changes that have resulted from it.
Physical therapy is the crux of your treatment and is usually enough to eliminate pain and return you to normal life.
Some people, though, will not respond to simple physical therapy, and others will find the therapeutic process too painful to tolerate even while using anti-inflammatory medication. In these circumstances, we employ spinal injection techniques to diagnose the specific structures causing the problem. During this process, we make targeted structures numb and then reevaluate your pain. The initial injection generally involves steroids to control inflammation. If the targeted joints are painful and inflamed, this injection is often enough to settle your pain and allow you to make progress in therapy.
In many cases, the initial injection does little more than eliminate or drastically reduce pain for a few hours or days. This is helpful diagnostically, but it’s not enough to provide long-term relief. In this event, we move on to a procedure called a “medial branch nerve block” (MBNB). This targets the medial branch nerves of the neck, which connect to the facet joints and convey pain signals from them
If your pain is effectively blocked by MBNB, you then become a candidate for a procedure called radiofrequency ablation (RFA). RFA is an outpatient non-surgical procedure in which the tip of a special needle is used to heat the medial branch nerves, injuring the targeted nerve but not killing it. When the nerve is injured, it cannot send pain signals until it heals (which typically takes six to nine months). If the procedure is effective (as it is in 70% of cases), you’ll use the interval in which your pain is relieved to return to therapeutic efforts to normalize motion and posture.
If facet joint injections and MBNB fail to provide even short-term relief, the underlying source of pain is likely the cervical disc. In this case, when injections, therapy, and medication have failed to produce adequate relief, you become a potential surgical candidate.
Neck pain often causes secondary problems such as tight knots in the muscles of the neck and shoulder. For this reason, many people with neck injuries come to the doctor complaining of shoulder pain or upper back pain. When this happens, your doctor should thoroughly evaluate your neck for contributing injuries to the shoulder itself.
There are also many people with chronic headaches who have been misdiagnosed with migraine, stress, or tension headache, when in fact they have headache referred from the neck. Most often this involves the C2-3 or C3-4 facet joints. This type of headache can often be effectively resolved by treating it as a referred or radiating pain from neck structures.
We’ve also seen patients with chronic dizziness resulting from neck pain, arthritis, and postural changes. If you’ve been evaluated for dizziness by an ENT doctor and, or neurologist but haven’t been given a diagnosis or treatment that relates to the inner ear or central nervous system, you should consider seeing an interventional physiatrist for evaluation.
1. If your neck pain is accompanied by difficulty with balance or walking, weakness in your arm or difficulty controlling your bowel or bladder, you should see a doctor as soon as possible.
2. Most neck pain originates in the cervical facet joint or cervical disc (muscle strain is typically a secondary problem in spinal pain).
3. Most neck pain involves changes in motion and posture that must be corrected.
4. Physical therapy to educate you about the nature of your pain and how posture and behavior contribute is the crux of treatment.
5. In some circumstances spinal injection techniques may be necessary to diagnose and to treat your pain to facilitate the therapeutic process.
6. Occasionally surgical intervention will be the best treatment for your condition.