NECK PAIN

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NECK PAIN AND CHIROPRACTIC

neckpain1Thousands of Americans suffer from episodes of acute or persistent neck pain each year as a result of injury, strain, overuse or aging. The neck is more clinically referred to as the "Cervical Spine." However, a pain in the neck should not be ignored and left undiagnosed and untreated. Problems in the cervical spine, the first seven bones (vertebrae) in the neck running from the base of the brain to just above the shoulder blades, require assessment and treatment to prevent further, more permanent, damage. Chiropractic manipulation of the C-spine is often the treatment of choice and can be highly effective in treating a variety of neck pain issues.

As for us Chiropractors, the first thing we do AFTER a careful case history and initial examination of basic vitals would be to MOTION PALPATE the region to ascertain what, if any, vertebral segments are out of place. The easiest way to do this is look for a lack of normal motion in the individual segments. Thus, utilizing Motion Palpation (usually aided by X-Rays or some other form of imaging), we decide which aspects of the cervical spine need correcting. See: Lakhani E, Nook B, Haas M, et. al., "Motion Palpation Used As a Postmanipulation Assessment Tool for Monitoring End-Feel Improvement: A Randomized Controlled Trial of Test Responsiveness," J Manip. & Physio. Thera., Vol. 32 (7), Sept. 2009.

"The cervical spine is where the spinal cord lives," said Volker K.H. Sonntag, MD, a member of the American Association of Neurological Surgeons Board of Directors and a neurosurgeon practicing in Arizona. "The spinal cord is the most delicate tissue in the entire body. Even minor damage to the spinal cord cannot be repaired. Unlike low back pain, in which waiting to seek treatment may prolong the pain but usually doesn't cause any further damage, untreated spinal cord compression can lead to irreversible damage."


Three Types of Neck Pain:

There are three general types of cervical neck pain. 1) Dull pain within the neck itself that may also include radiations of pain down into the shoulder(s) and arm that often involves a herniated disc. *See diagram.  2) More of a sharp pain that may include arm and hand numbness but is primarily a pathomechanical issue.  3) Cord Compression.     I'll elaborate below:


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1) A herniated (bulging) disc in the spine pinching a nerve root in the neck often causes this first type of neck pain. Discs are found between each vertebra, or bone, in the spinal column. They serve as "shock absorbers" within the spine and have a gel-like center that makes them flexible, allowing the spine to bend and move. Some have used the analogy of a "jelly doughnut" to describe the discs in the human spine. On the outside is tough, fibrocartiledge similar to what is found in the knee or shoulder but inside is a gelatinous core made of mucopolysacharides that occasionally bulge out. However, because the discs are soft they can also bulge and become misshapen. When this occurs, they can place pressure on the spinal cord or irritate one of the nerves leading from the spinal cord out to the arms and upper torso. If the bulge becomes severe, the disc may herniate and push into the spinal canal. The result can be weakness, tingling, clumsiness and numbness in the arm and hands. Bulging discs can be caused by injuries like whiplash, stress on the spine by overuse, or by arthritis/degeneration in the spine.

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2) The second type of neck pain is often more of a pathomechanical issue which is to say, the vertebrae are out of place or not moving properly. Additionally, we often see muscular imbalance issues in the neck associated with pathomechanics. The pain can be of a sharp, stiff irritation that casuses local neck pain. In the case where the muscle imbalance leads to vertebral pathomechanics, then this can lead to shoulder and arm pain radiations. Consider this recent article that apparently ends the discussion as to whether or not there are pain receptors in the facet joints of the cervical spine (It is thought that these same receptors are located in the mid and low back as well). The facets are where the vertebrae interlock with each other. *Chen C, Lu Y, Kallakuri S, Patwardhan A, Cavanaugh JM, "Distribution of A-Delta and C fiber receptors in the Cervical Facet Joint capsule and their response to stretch," J Bone Joint Surgery 88: 1807-1816, 2006. The conclusion here is that the existence of receptors in the facet joint capsule indicates that the capsule has pain and proprioceptive sensory functions. NB: A-Delta and C fibers are the only known nerve fibers that actually conduct pain sensation back to the spinal cord. Proprioception is one's ability to ascertain one's place in time and space.

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3) Cord compression, also known as myelopathy, often occurs in the cervical spine and sometimes isn't experienced as 'pain' by patients at all. It usually involves numbness or weakness in the arms or legs, difficulty walking, loss of pain or temperature sensation in the hands and arms, poor balance and stiffness in the neck. In this case, there is pressure directly on the spinal cord. Because this type of "pain" is often not felt in the neck itself, it is easily misdiagnosed. The spinal cord has laminations of so-called "tracks" that run up and down and bring sensory signals to the brain and relay motor signals to the rest of the body from the brain. The outermost laminations involve sensory tracks for the low back and legs. Thus, if the spinal cord is compressed enough in the cervical spine, the patient will often "feel" distress in the LOW BACK or LEGS. In this scenario, the problem is NOT in the low back or legs but in the cervical spine and is a neurological event; the brain thinks the problem is lower in the body than it really is. Manipulation of the spine as well as traction are two conservative methods that often relieve cord compression in the cervical spine.

"We usually see patients with neck pain in different scenarios," Dr. Sonntag said. "One, they've been in some sort of accident and have suffered a whiplash-type injury. Two, they have a chronic injury caused by overuse, most likely caused by working at a computer for endless hours. Or they've experienced one of the first two scenarios in the past and now have arthritis or a tissue degeneration problem."

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MRI of the cervical spine with spinal cord compression


Neck Injuries:

Neck injuries, which commonly occur in automobile or sports accidents, are not to be taken lightly. These types of injuries tradtionally fall under the catagory of "Soft Tissue Injuries" because the entire injury is with muscles, ligaments and other soft tissues. On the other hand, in the rare event of a broken bone in the neck, a neurosurgical consult is indicated. "If a vertebra in the neck is broken and left untreated, injury to the spinal cord can happen hours or days after the injury," explained Edward C. Benzel, MD, a spine surgery professor and practicing neurosurgeon in Ohio. "Because of the severe consequences and irreversible nature of spinal cord injuries, extreme caution needs to be taken with anyone who has suffered a direct injury to the neck." If the spinal cord is injured or bruised the patient can be paralyzed below the site of the injury. If a vertebra in the neck is broken or cracked, neurosurgeons often will stabilize the spine by fusion and instrumentation to prevent further injury to the spinal cord. Most people thankfully don't experience this kind of injury. The majority of sufferers experience what are commonly called "soft tissue injuries." See below.

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A more common neck injury is whiplash. Chiropractic care excells at treating "whiplash" injuries as well as most of the simple strain/sprain type of neck pain issues that arise in daily living. Symptoms include neck stiffness, shoulder or arm pain, headache, facial pain and dizziness. Prompt chiropractic care utilizing some physical therapeutics but mostly manipulation of the spine is the most effective treatment for whiplash injuries even if there is a herniation of a disc in the cervical spine. If the symptoms still persist after chiropractic treatment four to six weeks later, or if there is severe weakness in the arms, hands or legs and conservative chiropractic treatment has not resolved the problem, a neurosurgical consult should be considered. *See our comprehensive page on Auto Accidents.

Degenerative Conditions :

The neck is also susceptible to osteoarthritis and degenerative disc disease, which can be caused by general wear and tear on the spine. The discs begin to lose their flexibility and ability to absorb stresses in the spine. Or, bone spurs develop on the vertebrae. In either case, the nerves in the cervical spine can become irritated or pinched, causing pain in the neck or the arms. If there is a great deal of degeneration in the cervical spine, the spinal cord and nerve roots may become compressed, causing irreversible damage.

Cervical stenosis is another condition that may result from degeneration in the spine. It occurs when the spinal canal narrows and compresses the spinal cord. If the pain from stenosis is restricted to the neck, conservative treatment is prescribed. However, if it extends into the arms or legs neurosurgeons can remove part of the vertebrae and ligaments to allow more room for the spinal cord and nerves. If there is significant degeneration in the cervical spine, the neurosurgeon can fuse the vertebrae by grafting bone or using metal plates to provide additional support and stability in the spine. Stenosis is admittedly tough for chiropractors to work with and we have traditionally had equivocal results with this painful condition.

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