Mechanical Neck Pain

Non-specific neck pain arising from the cervical spine and its muscles, ligaments, facet joints and discs, with no radiculopathy, myelopathy or serious pathology. It is also called simple neck pain or non-specific neck pain.

• It is very common: point prevalence about 10 to 20%, lifetime prevalence above 50 to 70%, peaking in middle age, and affects women more than men. It is a leading cause of disability and work absence.
• Contributors: sustained poor posture (computer, smartphone use), repetitive overhead work, sedentary lifestyle, sleep position and pillow, psychological stress, previous neck injury, smoking, degenerative change (cervical spondylosis), and a history of low back pain.
• Imaging findings of degeneration are common in asymptomatic adults (above 50% in those over 40) and correlate poorly with symptoms.
• Natural history: about 50% improve within 1 to 3 months and many recur. About 30 to 50% have persistent or recurrent symptoms at 1 year.

• Dull, aching or tight pain in the posterior neck and upper trapezius, sometimes with referral to the occiput (cervicogenic headache), interscapular region or shoulder, worse with sustained postures, neck movement and at the end of the day, with morning stiffness. Tender trigger points and muscle spasm are found, and neck range of motion is limited by pain.
• No weakness, sensory loss or reflex change, and no upper motor neurone signs. Arm pain below the elbow in a root distribution suggests radiculopathy.
• Red flags needing urgent investigation:
  • Fever, night sweats, recent infection or immunosuppression, injection drug use (infection).
  • Age above 50 with new pain, weight loss, history of cancer, constant night pain (malignancy).
  • Trauma with midline bony tenderness, age 65 or over, a dangerous mechanism, paraesthesia in the limbs, or inability to rotate 45 degrees each way (fracture or ligament injury).
  • Gait disturbance, clumsy hands, bladder or bowel symptoms, Lhermitte sign, hyperreflexia, Hoffmann sign, or clonus (cervical myelopathy).
  • Sudden severe neck pain or occipital headache with dizziness, diplopia, ataxia, dysarthria or Horner syndrome (vertebral or carotid artery dissection).
  • Neck pain with chest pain, dyspnoea or jaw pain (cardiac), or with dysphagia, fever and stiffness (retropharyngeal abscess, meningitis).
  • Rheumatoid arthritis (atlantoaxial instability), and inflammatory back pain (spondyloarthritis).
• Differential diagnosis: cervical radiculopathy, cervical myelopathy, whiplash injury, facet joint arthropathy, cervicogenic headache, myofascial pain, thoracic outlet syndrome, shoulder disorders, fibromyalgia, polymyalgia rheumatica, infection, tumour, and referred visceral pain.

• Clinical, with a full neck, shoulder and neurological examination (power, sensation, reflexes, Hoffmann sign, gait). Screen for red flags and psychosocial factors (anxiety, depression, work stress, catastrophising), which predict persistence.
• No imaging is needed for uncomplicated neck pain under 6 weeks without red flags. Imaging is indicated for red flags, trauma meeting the high risk features, neurological signs, or persistent severe symptoms. X-ray (anteroposterior, lateral and open mouth) shows alignment and degeneration. MRI is the best test for suspected myelopathy, radiculopathy, infection, tumour or ligament injury. CT is used for bony injury.
• Blood tests (full blood count, CRP, ESR, glucose) when infection, inflammatory disease or malignancy is suspected.

• Reassurance, advice to stay active, and early return to normal work and activity. Avoid prolonged rest and avoid a cervical collar (it delays recovery).
• Self-care: heat (warm packs or shower) for 15 to 20 minutes, 2 to 3 times daily, gentle range-of-movement exercises every hour, regular posture breaks (every 30 to 45 minutes), ergonomic adjustment of the screen at eye level and elbows at 90 degrees, a supportive pillow that keeps the neck neutral, and sleep on the back or side.
• Analgesia:
  • Paracetamol 1 g orally 6 hourly (maximum 4 g per day).
  • NSAIDs for 1 to 2 weeks: ibuprofen 400 mg orally 8 hourly with food, naproxen 500 mg 12 hourly, or diclofenac 50 mg 8 hourly, with gastroprotection in at risk patients. Topical diclofenac 1% gel 2 to 4 g 3 to 4 times daily.
  • A short course of a muscle relaxant for spasm, for 5 to 7 days at most, at night if sedation is a problem: tizanidine 2 mg orally at night increasing to 2 to 4 mg 8 hourly, or cyclobenzaprine 5 to 10 mg at night, or diazepam 2 mg at night for 3 to 5 days. Avoid driving, and avoid in elderly patients.
  • Avoid opioids except for short periods in severe pain (codeine 30 mg with paracetamol, up to 3 days).
• Physiotherapy for pain lasting over 2 to 4 weeks, or recurrent: exercise therapy (deep neck flexor training with a craniocervical flexion technique, scapular stabilisation, neck and shoulder strengthening, stretching) combined with manual therapy such as mobilisation, performed for 6 to 12 sessions over 4 to 8 weeks. High velocity cervical manipulation is not advised, because of rare dissection and stroke risk. Acupuncture and massage give short term relief.
• Chronic neck pain (over 3 months): graded activity, cognitive behavioural therapy, and amitriptyline 10 mg at night increasing to 25 to 50 mg, or duloxetine 30 mg daily increasing to 60 mg, for pain with sleep disturbance or neuropathic features. Trigger point injections with lidocaine 1% 1 to 2 mL per point, or dry needling, give temporary relief. Medial branch blocks and radiofrequency denervation are considered in facet mediated pain confirmed by 2 diagnostic blocks, with relief of 6 to 12 months in some patients.
• Treat associated problems: cervicogenic headache, sleep, depression and work stress.
• Special groups:
  • Pregnancy: heat, posture and exercise, and paracetamol. Avoid NSAIDs after 20 weeks, and avoid muscle relaxants.
  • Elderly: avoid sedating muscle relaxants and NSAIDs in renal impairment or heart failure, and assess carefully for myelopathy and fracture.
  • Rheumatoid arthritis: examine for atlantoaxial instability before manual therapy.
  • Anticoagulation: avoid injection techniques with risk of bleeding.
• Follow up: review at 2 to 4 weeks, and again at 6 to 12 weeks. Refer to physiotherapy, sports medicine, rheumatology or spinal surgery for red flags, neurological signs, no improvement by 6 to 12 weeks, or chronic pain with major disability.