The Curbsiders podcast

#435 Neck Pain with Dr. Anthony Mikula

April 15, 2024 | By

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A real pain in the neck (Get it?! We have fun.)

Protect your neck!  Learn how to evaluate a patient with neck pain, and differentiate between mechanical neck pain, radiculopathy, and myelopathy. You’ll learn who should be reassured, who should see a surgeon, and what nonoperative options are available.  We’re joined by Dr. Anthony Mikula @anthony_mikula from Mayo Clinic. 

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Show Segments

  • 00:00 Introduction 
  • 06:14 Anatomy and Pain Generators
  • 09:58 Approach to Neck Pain
  • 22:57 Differentiating Radiculopathy from Non-Specific Neck Pain
  • 24:05 Management of Mechanical Neck Pain
  • 27:36 Indications for Imaging
  • 29:21 Terminology and Explanation of Spondylosis, Spondylolisthesis, and Spondylolysis
  • 30:48 Diffuse Idiopathic Skeletal Hyperostosis (DISH)
  • 32:23 Imaging Terminology and Plain Films
  • 36:19 Pathophysiology of Cervical Radiculopathy
  • 38:34 Physical Examination for Cervical Radiculopathy
  • 44:54 Diagnostic Work-up for Radiculopathy
  • 51:53 Interventions for Cervical Radiculopathy
  • 53:53 Considerations for Surgery
  • 57:49 Recognizing Cervical Myelopathy
  • 01:00:17 Natural History of Myelopathy
  • 01:02:25 Referral and Treatment for Myelopathy
  • 01:09:28 Summary and Takeaways

Neck Pain Pearls

  1. The causes of neck pain can be broadly categorized as mechanical pain (usually myofascial), cervical radiculopathy, or cervical myelopathy
  2. Most cases of mechanical neck pain and cervical radiculopathy will resolve over time.  Physical therapy can be helpful for both of these conditions.
  3. Mechanical neck pain is usually myofascial in etiology.  Radiculopathy and myelopathy are generally secondary to compression from degenerative changes in the spine.
  4. The physical examination for neck pain should focus on provocative maneuvers, reflex testing, and strength testing to determine level of pathology and to rule out myelopathy.
  5. Advanced imaging is not needed for most cases of neck pain, but MRI should be performed if there is suspicion for myelopathy
  6. Cervical myelopathy is often initially overlooked, and may be attributed to normal aging by patients.  It can manifest as hand clumsiness, gait instability, and urinary retention.
  7. Surgery may be helpful for refractory cases of radiculopathy, and is usually offered to patients with evidence of myelopathy.

Neck Pain – Notes 

Anatomy and Potential Pain Generators

A reminder that there are seven cervical vertebrae, with eight pairs of cervical nerves exiting from the spinal cord, which is protected by the vertebral column.  The cervical nerves are named according to the vertebra beneath them, which differs from the lumbar spine, with the C8 nerve sitting between the C7 and T1 vertebrae.  

Dr. Mikula separates neck pain into three broad categories: mechanical neck pain, cervical radiculopathy, and cervical myelopathy.  Mechanical neck pain is often myofascial in etiology, but you can also develop arthritic changes of the vertebrae, as well as degeneration of the intervertebral discs, both of which may contribute to pain.  Encroachment of the nerves as they exit the spinal cord can lead to radiculopathy, which often includes pain as a symptom.  Encroachment of the spinal cord itself, known as cervical myelopathy, leads primarily to dysfunction.

Terms and Conditions Apply

Spondylosis simply refers to degenerative arthritis changes of the spine.  Spondylolisthesis is when there is slippage of one of the vertebrae relative to the inferior vertebra.  Anterolisthesis is when the vertebra slips anteriorly, and retrolisthesis, ironically enough, is when the slippage is posteriorly.  Spondylolysis refers to a fracture through the pars, typically in the lumbar spine.  Annoyingly, this can lead to spondylolisthesis, so you can have both.  Diffuse idiopathic skeletal hyperostosis (DISH) is a systemic condition characterized by ossification along the spine that can lead to pain and stiffness.  It is associated with metabolic disorders such as diabetes, obesity, and dyslipidemia (Le at al, 2021).  Myelomalacia refers to “softening” of the spinal cord, and is demonstrated by T2 hyperintensity on MRI, signifying spinal cord pathology..

Physical Examination for Neck Pain

When a patient presents with neck pain, Dr. Mikula will check their strength, check for reflexes and pathological signs like Hoffman and Babinski, and observe the patient’s gait.  He is specifically looking for neurologic deficits and evidence of spinal cord pathology.  When evaluating for radiculopathy, remember that C6 is the “six-shooter,” so symptoms will affect the thumb and index finger.  C7 innervates the middle finger and C8 the pinky, although there may be some variations.  C5 pathology may manifest as deltoid weakness, and there may be diminished biceps and brachioradialis reflexes.  C6 pathology may manifest as biceps weakness and weakness in wrist extension, and C7 impacts triceps extension and the triceps reflex. C8 impacts grip strength and finger flexion.

The Spurling test is sensitive and specific for cervical radiculopathy and is performed by placing the patient’s neck into lateral flexion and extension (Childress and Becker, 2016), then applying gentle downward axial compression.  A positive test is reproduction of radicular symptoms.

The Babinski test is performed by running a dull, pointed instrument (e.g., dull point of a reflex hammer) up the lateral plantar side of the foot from the heel to the toes and across the metatarsal pad to the big toe.  An abnormal Babinski is dorsiflexion or fanning of the toes (Ambesh et al., 2017).  The Hoffman test is performed by holding the patient’s hand in a neutral position and flicking the middle finger downward.  In an abnormal test, there is involuntary flexion of the thumb and/or index finger, and this indicates possible upper motor neuron disease or cord compression.  This test is not sufficient to diagnose myelopathy, and about 3% of the population has a positive Hoffman without cervical pathology (Malanga et al., 2003).  Patients with moderate myelopathy may have difficulty with ambulation and general unsteadiness.

Dr. Mikula also checks Achilles and patellar reflexes, which will be diminished with lower motor neuron pathology and hyperreflexic with upper motor neuron disease and myelopathy.

Dr. Mikula will also palpate over the posterior neck, and reproduction of the patient’s neck pain points more towards myofascial pathology.

Mechanical Neck Pain

Mechanical neck pain is quite common, and presents without neurologic deficit.  It is often difficult to discern what the specific pain generator is, but it is usually due to muscular or ligamentous factors related to posture, poor ergonomics, or chronic muscle fatigue (Rao, 2002).  Radiculopathy from neuroforaminal stenosis is typically unilateral, so if the pain radiates to both shoulders, this may suggest myofascial pain.  Patients with red flags or high-risk features such as history of malignancy or injection drug use may warrant more aggressive work-up and imaging, as would patients with frank neurologic deficits.

Mechanical neck pain often resolves with time , and exercise can also be helpful (Cohen, 2015).  NSAIDs can also be used in the absence of contraindications like kidney disease.  Some patients may benefit from acupuncture or massage therapy, or referral to Pain Management, who may be able to offer trigger point injections, facet injections, or medical branch blocks or radiofrequency ablation of the nerves, but evidence to support these is mixed (Cohen, 2015).

In the absence of radiculopathy, symptoms of myelopathy, or red flags, imaging is typically not necessary for mechanical neck pain.  

Cervical Radiculopathy

Cervical radiculopathy occurs when there is impingement or compression of a cervical nerve root as it exits the spine.  This can be due to disc herniation, or simply from the degenerative changes of aging.  Patients may report alleviation of their pain that occurs with elevation of the arm above the head, a maneuver that may relieve some of the pressure on the nerve root (Childress and Becker, 2016).  Radicular nerve pain will typically radiate down the arm in a pattern dictated by the affected nerve.  The pain may be described as burning or lancinating.  Dr. Mikula will try to localize the affected nerve based on the symptomatology discussed above.  The majority of patients with cervical radiculopathy will experience improvement or resolution of their pain in six to twelve weeks (Cohen, 2015), so reassurance is important here.

If symptoms persist for over six weeks, consider ordering an MRI without contrast of the cervical spine to evaluate (McDonald et al., 2019).  Significant weakness or other neurologic deficits should prompt more urgent imaging.  Plain films or CT scans are more useful for surgical planning than for diagnosis in cervical radiculopathy.  There is not good evidence to support the use of electromyography for the diagnosis of cervical radiculopathy (Bono et al., 2010), but it may help reveal underlying carpal tunnel syndrome or ulnar myelopathy.

Nonoperative treatment of cervical radiculopathy involves physical therapy, nonsteroidal antiinflammatory medications, and massage (Cohen, 2015).  Epidural steroid injections can also be helpful for some patients, and may be diagnostic as well if the patient reports good relief.  Surgical intervention is typically reserved for patients for whom conservative measures have not helped, and who have persistent symptoms.  Patients with classic symptoms that correlate with imaging findings tend to do well with surgery (Mummaneni et al., 2019).

Cervical Myelopathy

Cervical myelopathy refers to compression of the spinal cord at the cervical level of the spinal column, which results in dysfunction that may include hand clumsiness and gait disturbance.  This can result from trauma in younger patients, but more typically results from arthritic changes of the cervical spine in older adults.  Patients may report progressive clumsiness of the hands, and may report difficulty buttoning their shirt, typing on their smartphone, and writing.  Patients may also report difficulty with ambulation and urinary retention, the latter being a late finding (Williams et al., 2022).  The progression of myelopathy is typically insidious, and patients may attribute these changes to normal aging.  Once patients begin to experience symptoms, they tend to progress in a stepwise manner.  The Japanese Orthopedic Association score can be used to determine severity of myelopathy symptoms (Tetreault et al., 2017).  

If cervical myelopathy is suspected, cervical MRI is indicated.  If this shows central canal stenosis, they should be evaluated by a spine surgeon.  While this evaluation should be reasonably prompt, this is typically not a surgical emergency.

The treatment of myelopathy is primarily surgical, and most patients experience some degree of improvement relative to their current symptoms.  Patients with evidence of myelopathy are usually offered surgery to halt the progression of myelopathy and preserve function (Fehlings et al., 2017).

Goal

Listeners will develop a framework for approaching the evaluation and management of neck pain.

Learning objectives

After listening to this episode listeners will…  

  1. Develop a framework for the evaluation of mechanical neck pain, cervical radiculopathy, and cervical myelopathy
  2. Take a hypothesis-driven history to elucidate common causes of neck pain
  3. Perform an evidence-based physical examination to guide the diagnosis of common causes of neck pain
  4. Develop an evidence-based approach for the management of mechanical neck pain
  5. Appropriately utilize imaging to diagnose common causes of neck pain
  6. Recognize indications for surgical intervention in patients presenting with neck pain

Disclosures

Dr. Mikula reports no relevant financial disclosures. The Curbsiders report no relevant financial disclosures. 

Citation

Williams PN, Mikula A, Watto MF. “#435 Neck Pain”. The Curbsiders Internal Medicine Podcast. thecurbsiders.com/category/curbsiders-podcast April 15, 2025..

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Episode Credits

Written and Produced by: Paul Williams, MD, FACP
Show Notes: Paul Williams, MD, FACP
Infographic and Cover Art: Paul Williams, MD, FACP
Hosts: Matthew Watto MD, FACP; Paul Williams MD, FACP
Reviewer: Leah Witt, MD
Showrunners: Matthew Watto MD, FACP; Paul Williams MD, FACP
Technical Production: PodPaste
Guest: Anthony Mikula, MD

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The Curbsiders are partnering with VCU Health Continuing Education to offer FREE continuing education credits for physicians and other healthcare professionals. Visit curbsiders.vcuhealth.org and search for this episode to claim credit.

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