The following are possible causes we consider when a patient sees us for Neck Pain (in the back or side of the neck, not in front or the throat). The article is geared for acute neck pain of recent onset, but is also valid for chronic ongoing pain. See also Diagram — The Spine and Its Nerves.
Causes of Neck Pain
| xxxxxxCommon | xxxRare but Very Serious |
|---|---|
| โข Muscle Strain / Ligament Sprain โข Muscle Spasm (Torticollis; “Wry Neck”) โข Herniated Disk โข Osteoarthritis โข Ankylosing Spondylitis (pretty uncommon) | โข Spinal Cord Compression โข Bone Disease โข Cervical Artery Tear (“dissection”) โข Epidural Bleeding (if on “blood thinners”) โข Infections (deep) |
Strains or Sprains, and less so acute Muscle Spasm, are far-and-away the most common cause of neck pain. Muscles are tense & often tender, certain neck movements (or all of them) are painful. But our main job is to make sure there’s nothing more serious.
There could be a Herniated Disk trapping a nerve root (“pinched nerve”). In addition to the same neck pain as for simple muscle conditions, there will also be symptoms in just one arm. Maybe numbness or tingling runs down one part of the arm. Maybe some arm muscles are weak (when we test their strength against our resistance). There might be a weak reflex in the arm. If the legs are affected, we worry about dangerous compression of the spinal cord (see below).
Bone Disease, like fractures or infections, are much more serious. These usually show on x-ray. But we don’t order x-rays unless we suspect bone disease on exam: pushing or tapping on the seven spinal vertebrae hurts a lot on just one particular bone. Fever would make us worry a lot about possible bone infection.
(Actually, we hope a patient with a broken neck wouldn’t walk into our clinic for an x-ray. If so, it’d most probably be a stable fracture, that won’t injure the spinal cord, or the person would be paralyzed already. However, cancer metastases can cause “pathologic” fractures that occur subtly, with only minor or even no trauma).
The worst cause of neck pain is Spinal Cord Compression, which can cause permanent paralysis. Key symptoms include:
- Leg weakness! (weakness in one arm suggests herniated disk; but leg weakness due to neck disease has to be from the spinal cord)
- Urinary or Bowel Incontinence (large amount, not just drops or stains).
- Urinary Retention (feels need to urinate but really unable, all through the day)
- Numbness or Tingling in the genital or anal area
- Electric shock runs down the body with bending neck forward (“Lhermitte’s Sign”)
- Fever, with pain in one certain area of the neck (could be an epidural abscess)
- Patients taking “Blood Thinner” medication (not just aspirin) at special risk
A rare Cervical Artery Tear (“Dissection“) in the neck can occur from minor trauma, including physical exertion (possibly due to abrupt neck movements). The neck pain or headache is almost always on just one side, has usually come on gradually, but may occur abruptly. We’d suspect this if the person has new neurological symptoms, in particular a droopy eyelid & small pupil on one side of the face, or can’t stick their tongue out straight. Diagnosis is made by CT scan or MRI. This should be done in an ER, since dissections can cause strokes, although many get better on their own.
There are two types of Arthritis that can occur in the neck. Pain is never acute, but develops over weeks or months. The most common, Osteoarthritis, is due to old age; we diagnose it easily by x-ray. A much rarer type, Ankylosing Spondylitis, is a genetic auto-immune inflammatory disease that virtually always begins younger than 40-years-old. Its main clue is that pain is worst when getting up in the morning, and takes 30-60 min. to ease up. We suspect it if blood tests show an elevated Sed Rate (ESR) or CRP, or anemia that’s a normocytic type (not due to iron, vitamins, etc.).
As noted, most neck pain is due to Spasm, Strain or Sprain ย — ย we make the diagnosis by finding tender muscles Especially if just on one side), pain with neck movements, and nothing else.ย If there is “something else,” we probably need some sort of image:
- Symptoms of Spinal Cord Compressionย ย โย send to E.R. for MRI
- Possible Cervical Artery Tear ย โย send to E.R. for MRI / CT scan
- Tenderness over just one vertebraย ย โ ย plain x-ray (for Bone Disease)
- Weakness in one arm, usually with tingling / numbnessย ย โ ย MRI for Herniated Disk
- Fever; Immunocompromised; IV Drug Useย ย โ ย CBC, MRI to rule out deep Infection
What about just tingling in one arm, without weakness? That could also be a Herniated Disk, but without suggestion of permanent nerve damage (actual weakness in the arm is more severe). There are only 2 treatments for herniated disks:
- Time (most get better on their own in 3-4 months); and
- Surgery.
Nobody wants to do surgery without giving Time a chance. Therefore, it’s fine to wait a while before getting an MRI (why do a test if you’re not going to do anything more?).
See also Neck Pain for the clinicianโs condensed thought-process when face-to-face with a patient.