The analysis of the cause of neck pain is similar to that of headache. First, the anatomic components are distinguished, then the various etiologies are applied to each (Table 48). Moving from the skin to the spinal cord layer by layer, we encounter the fascia, muscles, arteries, veins, brachial and cervical plexus, and lymph nodes. Next are the esophagus, trachea, and thyroid gland. Finally, there is the cervical spine encircling the spinal cord and meninges and designed to allow uninfringed exit of the cervical nerve roots.
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Neck pain |
Taking each of these structures and applying the etiologic categories of MINT, we can arrive at a respectable differential diagnosis of neck pain. Inflammation and trauma are the principal causes. The skin may be involved by herpes zoster, cellulitis, contusions, and lacerations. An infected bronchial cleft cyst may occasionally be the offender. In the muscle and fascia, one encounters fibromyositis, dermatomyositis, and trichinosis as well as traumatic contusions and pulled or torn ligaments (strains). The muscles may be involved by tension headache, poor posture, and occasionally by epidemic myalgia. Meningitis causes nuchal rigidity and neck pain. Torticollis causes painful spasms, but the jerking of the neck makes the condition obvious.
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TABLE 48. Neck Pain |
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The arteries of the neck are infrequently tender or painful as are most aneurysms (aside from dissecting aneurysms) unless they compress adjacent structures. Arteritis is unusual here, but a common carotid thrombosis may be tender and painful. Referred pain from angina pectoris is not uncommon.
As with the arteries, it is rare for the jugular veins and smaller veins of the neck to cause pain by thrombosis or rupture; however, it occasionally happens in superior vena cava obstruction. In contrast, the lymph nodes are a frequent site of neck pain. They are usually enlarged and tender in association with pharyngitis, otitis media, sinusitis, dental abscesses, and mediastinitis.
The brachial plexus may be involved by a primary neuritis or by compression from a scalenus anticus syndrome, a Pancoast tumor, the clavical (costoclavicular) syndrome, or a cervical rib. More often, the roots are compressed by diseases of the spine, such as a herniated disk, fracture, cervical spondylosis, tuberculous or nontuberculous osteomyelitis, and primary or metastatic tumors of the spine and spinal cord. In the case of the spinal cord, one should also remember the meninges as a cause of neck pain in meningitis, arachnoiditis, and subarachnoid hemorrhage. Rheumatoid arthritis of the spine will cause neck pain without compression.
The esophagus is not usually a cause of neck pain, but pain may be referred to the neck from a hiatal hernia or subdiaphragmatic abscess. Pulsion diverticula of the esophagus may also compress adjacent structures and cause painful symptoms. Like the esophagus, the trachea is an infrequent source of neck pain, but occasionally acute laryngotracheitis will be the source of severe pain. Finally, subacute thyroiditis and inflammatory or obstructive lesions of the salivary glands may be the offenders in neck pain, even though the patient complains of a sore throat.
Approach to the Diagnosis
The patient who presents with neck pain most commonly has a cervical sprain or muscle contraction headache. However, we must rule out more serious pathology such as meningitis, subarachnoid hemorrhage, herniated disks, and neoplasms before we send the patient home with a collar and a bag of pills. This means checking for nuchal rigidity, doing a thorough neurologic examination, and checking for a thyroid or lymph node mass. If the neurologic examination is abnormal, referral to a neurologist or a neurosurgeon is indicated before ordering expensive diagnostic tests.
If the neurologic examination is normal and there are no neck masses or other significant findings, conservative treatment may be initiated without ordering expensive diagnostic tests. However, most physicians consider it wise to at least do plain films of the cervical spine. Careful and close follow-up is necessary so that something serious is not missed in these cases. When the pain persists despite adequate medical therapy, an MRI of the cervical spine should be done as well as an Electromyogram (EMG). Again, it is wise to consult a neurologist first. Always keep in mind that the pain may be referred from the heart, lungs, esophagus, or gallbladder. Act accordingly.
Other Useful Tests
1. CBC
2. Sedimentation rate (subacute thyroiditis)
3. FT4, thyrotropin (subacute thyroiditis)
4. Chest x-ray (neoplasm, mediastinal tumor)
5. Exercise tolerance test (coronary insufficiency)
6. Arthritis panel
7. Chemistry panel (bone metastasis)
8. Serum protein electrophoresis (multiple myeloma)
9. Upper GI series and esophagram (reflux esophagitis and hiatal hernia)
10. Gallbladder sonogram (cholecystitis)
11. MRI of the cervical spine (herniated disk)
12. Cervical myelogram (tumor, herniated disk)
13. Bone scan (osteomyelitis, metastasis, small fractures)
Case Presentation #69
A 45-year-old Filipino female nurse complained of pain in the neck that began after turning a patient over in bed. Two weeks prior to admission, the pain began radiating down her right arm.
Question #1. Utilizing your knowledge of anatomy, what is your differential diagnosis?
Neurologic examination revealed loss of sensation to touch, pain in the right thumb, and diminished right biceps reflex.
Question #2. What is your diagnosis now?
