The taxonomy of the International Association for the Study of Pain (IASP) lists some 60 recognized causes of neck pain.4 These, and others, can be grouped as shown in Table 36.2. Tumors, infections, and aneurysms constitute the "red flag'' conditions of the neck because they threaten serious neurological or systemic sequelae.
Neck pain can occur in patients with known rheumatoid arthritis, but it is unlikely to be the sole presenting feature. Less than 2 percent of patients with rheumatoid arthritis have neck pain as their only feature.33 Rheumatoid arthritis becomes potentially serious if it affects the C1-2 joints, but even then the prognosis is favorable.34 Gout and the seronegative spondylarthropathies (anky-losing spondylitis, Reiter's syndrome, and psoriatic arthritis) can each involve the neck, but are rare causes of neck pain in patients without other manifestations of these conditions.
Tumors, infections, and metabolic disorders are very uncommon causes of neck pain. Although their prevalence has not been explicitly established, the failure of large radiological surveys to detect such conditions35, 36 implies that their prevalence is less than 0.4 percent in primary care.
Headache is the most common presenting feature of internal carotid artery dissection, but neck pain has been the sole presenting feature in some 6 percent of cases.37,38 In 17 percent of patients, headache may occur in combination with neck pain.38 Neck pain has been the initial presenting feature in 50-90 percent of patients with vertebral artery dissection, but is usually also accompanied by headache, typically in the occipital region although not exclusively so.37,39 Although the typical features of dissecting aneurysm of the aorta are chest pain and cardiovascular distress, neck pain has been reported as the presenting feature in some 6 percent of cases.40,41
Although considered common and feared as a cause of neck pain (for medicolegal reasons), fractures of the neck are actually not common. In accident and emergency settings, only about 3 percent of patients suspected of having a fracture prove to have fractures upon cervical radiography.42,43 44 45 46 47
Missing from Table 36.2 are cervical spondylosis and cervical osteaoarthrosis. Although hallowed by tradition, these entities are not valid causes of neck pain. The radiological features of these conditions are normal age changes. They correlate poorly with neck pain.35 Indeed, cervical osteoarthrosis is more common in subjects with no neck pain.48
For patients with neck pain whose cause is not apparent, the IASP recommends the rubric cervical spinal pain of unknown origin, as an honest diagnosis.4 Zygapophysial joint pain and discogenic pain are specific subsets of what otherwise might be known as "mechanical'' neck pain, but their diagnosis requires invasive procedures such as zygapophysial joint blocks and disk stimulation (see under Invasive techniques below).
Although favored by many, there is no evidence that trigger points are a cause of neck pain. Even in the hands
Table 36.2 The causes of neck pain grouped according to whether they are common and serious.
Rheumatoid arthritis Ankylosing spondylitis Reiter's syndrome Psoriatic arthritis Crystal arthropathies
Cervical spinal pain of unknown origin Acceleration-deceleration injuries of the neck Zygapophysial joint pain Discogenic pain
Spinal infections Dissecting aneurysms Spinal hematomas Metabolic disorders of experts, the diagnosis is unreliable,49 and the absence of a criterion standard means that its validity cannot be tested. Furthermore, trigger points in the neck do not satisfy the prescribed criteria for a trigger point. They are characterized solely by tenderness and reproduction of pain, in which regard they cannot be distinguished from tenderness of underlying zygapophysial joints.50
Acceleration-deceleration injury, or whiplash, is perhaps the most common traumatic basis for neck pain. In population studies, a large proportion of patients attribute their neck pain to an injury incurred in a motor vehicle accident.16
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