by Gerard Hall
Neck pain is one of the commonest complaints that a rheumatologist sees in the clinic, especially in the City where there are so many hard-working deskbound patients. It is often seen in combination with pain in other parts of the back and neck pain should be viewed as one part of a whole organ- the spine.
It’s very uncommon to see neck pain as a presentation of a serious underlying disorder. I cannot recollect ever seeing a malignant tumour, either primary or secondary, presenting as neck pain although cancers and bone marrow diseases can sometimes present as pain in the thoracic or lumbar spine. Likewise, osteoporosis may cause fractures of the vertebrae in the thoracic spine and the lumbar spine in a more mature population but never of the neck vertebrae.
By far the commonest causes of neck pain are mechanical. These are due to either biomechanical and postural forces or because of underlying structural defects such as degeneration of the intervertebral discs or the intervertebral joints. There are a number of different terms that you may encounter which essentially refer to the same process – “wear and tear arthritis”, “osteoarthritis”, “disc disease/degeneration” and “spondylosis”. These terms describe the process of degeneration of the neck structures for which there are 3 main aetiological factors – age, genetics and serious trauma. Poor posture may cause neck or spinal pain but neither causes nor propagates premature degeneration of the neck structures.
This degenerative process is irreversible and the focus of management is to reduce the associated symptoms of pain and stiffness, not just now but also to minimise pain in the future. There is a very wide variation in the severity of pain compared with the severity of structural damage. For example, if we look at MRI scans of patients with spinal and neck pain, some may have severe degenerative changes in several discs and joints and yet have very mild pain. Conversely, we see patients who are in a lot of pain and yet there are only minor changes on scans and X-rays. The reason for this discrepancy is not entirely clear but there is no doubt that the soft tissues, the muscles and ligaments, are important structures that may drive pain. At Broadgate we have a variety of health professionals that we use to address non-inflammatory conditions. These include, chiropractors, physiotherapists, acupuncture and others.
A rheumatologist will also be looking to exclude non-mechanical causes of neck pain, especially in the under 45 year age group. These inflammatory conditions are much less common but are very important to identify. Typically, they are associated with pain that wakes the patient at night, there is a lot of stiffness in the morning and the pain eases with activity and exercise. These inflammatory disorders may be associated with a skin rash called psoriasis and with inflammatory bowel diseases such as Crohn’s Disease and Ulcerative Colitis. The diagnosis is usually made on the basis of the clinical presentation, blood tests and imaging. Most of these conditions are mediated by the immune system. There is a wide clinical spectrum and there are usually other clinical rheumatic symptoms such as joint or tendon inflammation. The treatment varies from simple anti-inflammatory drugs to more powerful therapies that interfere with the immune system, such as TNF blockers.