Opinion statement
Chronic axial neck pain and cervicogenic headache are common problems, and there have been significant advances in the understanding of the etiology and treatment of each. The severity and duration of pain drives the process. For patients who have had slight to moderate pain that has been present for less than 6 months and have no significant motor loss, strength training of anterior, posterior, and interscapular muscle groups coupled with body mechanics training is prescribed. After 8 weeks, if the patient is better, exercises are continued at home or in a gym. If the patient is not better, physical therapy is continued for up to 8 more weeks. In patients with motor loss or severe pain, radiographs and magnetic resonance imaging (MRI) should be ordered at the initial visit. In patients with slight to moderate pain who are not better by 4 to 6 months, plain radiographs of the neck and MRI should be ordered. Based on the results, a spinal injection is usually prescribed. If MRI reveals spinal stenosis of the central or lateral canal, or a disc herniation, an epidural corticosteroid injection should be ordered. If the epidural provides good relief, the patient can be referred for more aggressive physical therapy and repeat the epidural as needed up to a maximum of three times. If there is no pathology within the canal, medial branch blocks and intra-articular steroid injections can be ordered based on the joints that are most tender or where disc space narrowing is greatest, or MRI or radiographs are recommended. If there is excellent relief from the medial branch block and joint injections, repeat when the steroids wear off. If there is good relief again, but pain recurs, medial branch radiofrequency neurotomy is recommended. For patients with one or two level disc degeneration that has not responded, a psychologic evaluation and discography is recommended. If there are no significant psychologic abnormalities, and one or two (rarely three) painful discs, surgical consultation is recommended. Adjunctive low-dose opioid analgesics, nonsteroidal anti-inflammatory drugs, and perhaps tricyclic antidepressants are used to supplement the program at mid- and late stages.
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References and Recommended Reading
Bovim G, Schrader H, Sand T: Neck pain in the general population. Spine 1994, 19:1307–1309.
Borghouts JA, Koes BW, Vondeling H, Bouter LM: Costof-illness of neck pain in The Netherlands in 1996. Pain 1999, 80:629–636.
Merskey H, Bogduk N: Classification of Chronic Pain, edn 2. Seattle: IASP Press; 1994.
Dwyer A, Aprill C, Bogduk N: Cervical zygapophyseal joint pain patterns. I: a study in normal volunteers. Spine 1990, 15:453–457.
Aprill C, Dwyer, Bogduk N: Cervical zygapophyseal joint pain patterns. II: a clinical evaluation. Spine 1990, 15:458–461.
Schelhaus KP, Smith MD, Gundry CR, Pollei SR: Cervical discogenic pain: prospective correlation of magnetic resonance imaging and discography in asymptomatic subjects and pain sufferers. Spine 1996, 21:300–312.
Schellhaus KP, Garvey TA, Johnson BA, et al.: Cervical discography: analysis of provoked responses at C2-C3, C3-C4, and C4-C5. AJNR 2000, 21:269–275.
Slipman CW, Plastaras C, Patel R, et al.: Provocative cervical discographic symptom mapping. Paper presented at the 21st Annual Meeting of the Cervical Spine Research Society. New York; December 4, 1993.
Chabot MC, Montgomery DM: The pathophysiology of axial and radicular neck pain. Semin Spine Surg 1995, 7:2–8.
Edwards CC, Riew D, Anderson PA, et al.: Cervical myelopathy: current diagnostic and treatment strategies. The Spine Journal 2003, 3:68–81.
Rao R: Neck pain, cervical radiculopathy, and cervical myelopathy: pathophysiology, natural history, and clinical evaluation. J Bone Joint Surg Am 2002, 84:1872–1881.
Bogduk N, Marsland A: The cervical zygapophysial joints as a source of neck pain. Spine 1988, 13:610–617.
Bogduk N, Aprill C: On the nature of neck pain, discography and cervical zygapophysial joint blocks. Pain 1993, 54:213–217.
Bogduk N, Lord SM: Cervical zygapophyseal joint pain. Neurosurg Q 1998, 8:107–117.
Schwarzer AC, Wang S, O’Driscoll D, et al.: The ability of computed tomography to identify a painful zygapophyseal joint in patients with chronic low back pain. Spine 1995, 20:907–912.
Mercer S, Bogduk N: The ligaments and anulus fibrosus of human adult cervical intervertebral discs. Spine 1999, 24:619–628.
Bogduk N, Windsor M, Ingus A: The innervation of the cervical intervertebral discs. Spine 1988, 13:2–7.
Grubb SA, Kelly CK: Cervical discography: clinical implications from 12 years of experience. Spine 2000, 25:1382–1389. This is a review of the authors’ experience with cervical discography with respect to surgical planning. They recommended that all discs should be studied and found more cases in which surgery was not recommended than it was recommended.
Whitecloud TS, Seago RA: Cervical discogenic syndrome: results of operative intervention in patients with positive discography. Spine 1987, 12:313–316.
Palit M, Schofferman J, Goldthwaite N, et al.: Anterior discectomy and fusion for the management of neck pain. Spine 1999, 24:2224–2228. This is a prospective cohort series of the results of ACDF in well-selected patients with refractory severe discogenic neck pain. Pain scores decreased by more than 50%, function scores improved approximately 40%, and 79% of patients were satisfied with their outcomes.
Garvey TA, Transfeldt EE, Malcolm JR, Kos P: Outcome of anterior cervical discectomy and fusion as perceived by patients treated for dominant axial-mechanical cervical spine pain. Spine 2002, 27:1887–1895.
Haldeman S, Dagenais S: Cervicogenic headaches: a critical review. The Spine Journal 2001, 1:31–46.
Nilsson N: The prevalence of cervicogenic headache in a random population sample of 20 to 59 year olds. Spine 1995, 20:1884–1888.
Sjaastad O, Fredriksen TA, Pfaffenrath V: Cervicogenic headache: diagnostic criteria. Headache 1990, 30:725–726.
Sjaastad O, Fredriksen TA, Pfaffenrath V: Cervicogenic headache: diagnostic criteria: the Cervicogenic Headache International Study Group. Headache 1998, 38:442–445.
Lord S, Barnsley L, Wallis B, Bogduk N: Third occipital headache: a prevalence study. J Neurol Neurosurg Psychiat 1994, 57:1187–1190.
Dreyfuss P, Michaelsen M, Fletcher D: Atlanto-occipital and lateral atlanto-axial joint pain patterns. Spine 1994, 19:1125–1131.
Bogduk N: Letter to the editor. Spine 1999, 24:308.
Schofferman J: What to Do For a Pain in Your Neck: A Fireside Book. New York: Simon and Schuster; 2001.
Sweeney TB, Prentice CP: Cervico-thoracic muscular stabilization techniques. In Spine Care: Diagnosis and Conservative Treatment. Edited by White AH, Schofferman J. St. Louis: Mosby; 1995.
Ylinen J, Esa-Pekka T, Nykanen M, et al.: Active neck muscle training in the treatment of chronic neck pain in women. JAMA 2003, 289:2509–2516.
Randlev A, Ostergaard M, Manniche C, et al.: Intensive dynamic training for females with chronic neck/ shoulder pain: a randomized trial. Clin Rehabil 1998, 12:200–210.
Berg HE, Berggren G, Tesch PA: Dynamic neck strength training effect on pain. Arch Phys Med Rehabil 1994, 75:661–665.
Highland TR, Dreisinger TE, Vie LL, Russell GS: Changes in isometric strength and range of motion of the isolatd cervical spine after eight weeks of clinical rehabilitation. Spine 1992, 17:S78-S82.
Silverman JL, Rodriquez AA, Agre JC: Quantitative cervical flexor strength in healthy subjects and in subjects with mechanical neck pain. Arch Phys Med Rehabil 1991, 72:679–681.
Evans R, Bronfort G, Nelson B, Goldsmith CH: Two-year follow-up of a randomized clinical trial of spinal manipulation and two types of exercise for patients with chronic neck pain. Spine 2002, 27:2383–2389.
Jordan A, Bendix T, Nielsen H, et al.: Intensive training, physiotherapy, or manipulation for patients with chronic neck pain. Spine 1998, 23:311–319.
Schofferman J: Medication management for severe refractory low back pain. In Orthopedic Knowledge Update (OKU) Spine-2. Edited by Fardon DF, Garfin SR. Chicago: AAOS Press; 2001.
Castagnera L, Maurette P, Pointillart V, et al.: Long-term results of cervical epidural steroid injection with and withoug morphine in chronic cervical radicular pain. Pain 1994, 58:239–243.
Bush K, Hillier S: Outcome of cervical radiculopathy treated with periradicular/epidural corticosteroid injections: a prospective study with independent clinical review. Eur Spine J 1996, 5:319–325.
Lord SM, Barnsley L, Wallis BJ, Bogduk N: Percutaneous radio-frequency neurotomy for chronic cervical zygapophyseal joint pain. N Engl J Med 1996, 335:1721–1726. This prospective randomized controlled study demonstrated the high success rate of radiofrequency neurotomy for cervical facet joint pain. The median duration of relief was 267 days, and, when pain recurred, the procedure could be repeated.
Lord S, Barnsley L, Bogduk N: Percutaneous radiofrequency neurotomy in the treatment of cervical zygapophysial joint pain: a caution. Neurosurgery 1995, 36:732–739.
Barnsley L, Lord S, Wallis B, Bogduk N: Lack of effect of intraarticular corticosteroids for chronic pain in the cervical zygapophyseal joints. N Engl J Med 1994, 330:1047–1050.
Schofferman, Garges K, Goldthwaite N, et al.: Upper cervical anterior discectomy and fusion improves discogenic cervical headaches. Spine 2002, 27:2240–2244.
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Feng, F.L., Schofferman, J. Chronic neck pain and cervicogenic headaches. Curr Treat Options Neurol 5, 493–498 (2003). https://doi.org/10.1007/s11940-996-0017-7
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DOI: https://doi.org/10.1007/s11940-996-0017-7