by Gerard Hall
As with most musculoskeletal problems, the diagnoses of arthritic conditions can be divided into those that are inflammatory and those that are mechanical. Inflammatory causes of neck pain are much less common and include ankylosing spondylitis, rheumatoid arthritis, polymyalgia rheumatica, infections and, rarely, malignancies. Mechanical causes are more frequently encountered and are generally due to structural dysfunction of the upper spine, including intervertebral disc disease and facet joint disease. Postural neck pain is the most common of all, especially amongst the young and middle aged and in patients with deskbound jobs.
There are several types of inflammatory arthritis, mediated through the immune system, which can result in neck pain. Inflammatory pain is typically worse at night and early mornings and during prolonged periods of inactivity. Stiffness in the mornings is a prominent and important feature, often improving once the patient is up and about and more active. Exercise generally improves inflammatory symptoms, as will anti-inflammatory drugs such as Ibuprofen and Diclofenac.
This condition typically affects males in their twenties and thirties and tends to cause more low back pain than neck pain. When it affects women it may predominate in the upper spine causing pain and stiffness in the neck and thoracic spine. Ankylosing Spondylitis (AS) has a strong genetic basis and is associated with the HLA-B27 gene, for which there is a blood test available.
It is important to distinguish this condition from the more common mechanical causes of neck pain as the treatment differs. The diagnosis is supported by blood tests, X-rays and MRI scanning.
Anti-inflammatory drugs and mobilisation exercises have an important role and we now have a relatively new group of drugs, anti-tumour necrosis factor (anti-TNF), which are effective in patients who have a more serious form of AS. If left untreated, AS can result in permanent fusion of the spine.
Rheumatoid Arthritis (RA) is one of the more common types of inflammatory arthritis and its prevalence is about 1 in 50 in the UK. It may occur at any age but is more frequently seen in young and middle aged women.
Thanks to more rapid therapeutic intervention with better drugs, RA is not the disabling condition it once was, though there are still some unfortunate cases for whom treatment can be difficult. The upper neck can be affected in RA, possibly leading to neurological complications. It is very unusual for a patient to first present with RA with neck pain, typically it is the small joints of the hands and feet that are initially affected.
This condition, affecting one in six patients who have psoriasis, may overlap with AS and present as inflammatory pain in the spine, occasionally affecting the neck. Treatment of the spinal condition is similar to AS and those patients who also have arthritis affecting other joints may require other drug treatments.
Polymyalgia Rheumatica (PR) affects the over-60 age group and typically presents as sudden onset pain and stiffness of the neck and upper arms. The thighs may also be involved and morning stiffness is a dominant symptom. It may be associated with inflammation of the cranial arteries, called temporal arthritis. A blood test will usually show high levels of inflammatory markers, called ESR and CRP. It responds well to low dose steroids and 80% of patients are able to withdraw drugs within 18-24 months.
Infections and malignancy
Fortunately, these are unusual causes of neck pain. An infection of an invertebral disc may present with severe pain, fevers and constitutional malaise. Malignancies can present with back pain, through secondary metastatic deposits or infiltration of the bone marrow, though isolated neck pain is rare.