_________________________________________________________________________ Neck Pain in Adults
Cervical spine x-rays are indicated for all high-risk and low-risk patients [19; 108; 110]. CT and/or MRI is recommended for patients with one or more high risk factors, or one or more low-risk factors and inability to rotate neck 45° left and right. The Congress of Neurological Surgeons recommends CT and MRI for cervical spinal injury in patients with cervical spondylitis, even after minor trauma [111; 112]. No-risk patients do not need imaging. Other indications for cervical spine MRI include [103; 110]: • Suspicion of cord compression • Neurologic signs or symptoms, even if x-ray is negative • Ligament or disk injuries suggested by x-ray, CT or clinical findings • Suspected nerve root compression, disk herniation or cord contusion following neck injury • Assessment of red-flag conditions LABORATORY TESTING Unless red flag conditions are suspected, laboratory tests are seldom needed in the evaluation of neck pain [103]. TREATMENT OF NECK PAIN Practice guidelines for primary care are consistent in recommended management of acute neck pain [7; 102; 103]. After red flag causes and radiculopathy are ruled out, the neck pain condition is given a nonspecific diagnosis. Patients should then be instructed to take over-the-counter analgesics (e.g., acetaminophen, nonsteroidal anti-inflammatory drugs [NSAIDs]) if needed and to avoid bed rest and maintain activity. Patients should also be reassured their neck pain is benign, time-limited, and has an excellent prognosis. If pain worsens at any time, clinicians should consider specialist referral. If pain persists three to six weeks later, a brief psychosocial assessment is performed to assess “yellow flags,” and patients are referred to physical therapy. This standard guidance has merits of simplicity for clinicians, the benefits of remaining active, and the spontaneous resolution of acute neck pain in some patients. However, some assumptions may be inaccurate, such as the benign, self-limiting nature of most neck pain and patient access to, or availability of, specialist pain providers. Several systemic barriers interfere with patient access to pain therapy, including [113; 114]: • The acute nationwide shortage of pain specialist physicians • The limited availability in some areas of trained physical, psychological, or occupational therapy providers
• Insurance non-coverage of nonpharmacologic pain therapies, restrictive coverage that fragments and delays therapy continuity, and/or deductibles that are unaffordable Poorly controlled acute pain can have negative consequences that include delayed recovery, disrupted sleep, and impaired physical and social functioning that diminishes the quality of life. Regardless of origin, poorly managed acute pain can transition to chronic pain [115]. Pain should be treated at once if it impairs functioning, and treatment options should be discussed clearly with the patient to prevent unrealistic expectations and possible disappointment [71]. The adverse impact of chronic pain on mortality captures the gravity of this state and importance to control. In one observational follow-up study, patients with noncancer chronic pain who attended an outpatient pain clinic from 2004–2012 were followed until May 2019. During a mean 10.4-year follow-up of 1,498 patients, 296 died. Of these, standardized mortality ratios among patients in the youngest age group (18 to 49 years of age) was significantly higher than that of the general population: 2.6 for men and 2.9 for women. Women 60 to 69 years of age had a mortality ratio of 2.3. Low baseline health-related quality of life and poor ratings in psychosocial dimensions were associated with an increased risk of death [116]. PATIENT EDUCATION As noted, acute neck pain guidelines recommend that clinicians educate and reassure patients of the typically benign nature and self-limited course of nonspecific neck pain and the importance of maintaining activity and movement. Education and counseling may also include spine anatomy and proper postures, pain perception neuroscience, pain coping strategies, and resumption of normal activities. Education interventions may add small benefits to physiotherapy but should not be used alone due to ineffectiveness [8; 117]. For patients who are not proficient in English, it is important that information regarding the etiology of their pain and pain management resources be provided in their native language, if possible. When there is an obvious disconnect in the communication process between the practitioner and patient due to the patient’s lack of proficiency in the English language, an interpreter is required. Interpreters can be a valuable resource to help bridge the communication and cultural gap between patients and practitioners. Interpreters are more than passive agents who translate and transmit information back and forth from party to party. When they are enlisted and treated as part of the interdisciplinary clinical team, they serve as cultural brokers who ultimately enhance the clinical encounter. In any case in which information regarding treatment options and medication/treatment measures are being provided, the use of an interpreter should be considered. Print materials are also available in many languages, and these should be offered whenever necessary.
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