To understand a bit more about these pains it is essential to have an understanding of the anatomy of the neck. The neck or the cervical region consists of seven bones (vertebrae) stacked one above the other. There are labelled as C1-C7, where C stands for cervical and 1-7 are the numbers to identify the level being referring to. These vertebrae are separated from one another by discs which are like cushions allowing the spine to move freely.

Each vertebra encloses a hollow space which lines up with the space of the vertebrae above and below, running along the entire length of the spine. This hollow space is called the spinal canal and houses the spinal cord which is a thick bundle of nerves connected to the brain. Between every two vertebrae there are openings on the sides called the foramina. A pair of spinal nerves (one on each side) exit through these foramina and supply a specific part of the body for example the nerves coming out of the neck would go to the arm and hands. When these nerves are irritated, either inside the spine or as they come out of the spine, it leads to the pain being felt in the area supplied by the nerve and this explains when we get arm pain whereas the actual problem lies in the neck.

CAUSES

The main causes of pressure or irritation of the nerves in the neck include

• Disc problems such as bulging of discs can press on nearby nerves
• Age related wear and tear/degeneration. This can cause narrowing (stenosis) of the openings between the vertebrae  and pressure on the nerves as they exit the spine
• Instability of the neck. Loss of normal spinal alignment can cause compression of nerves 
• Other causes. Less common causes include infection, tumours and fractures

Cervical radiculopathy is seen more commonly in middle-aged people and injury, poor posture can further contribute to this.  In younger age groups this problem is majorly due to ruptured disc or injuries.   

SYMPTOMS

Pain from a pinched nerve may be felt in both the arm and the neck or may be limited to just the neck or arm. Although the root of the problem lies in the spine, the symptoms may be felt in the area where the nerve that is irritated travels such as the shoulder, the arm, or the hand. By looking at where the symptoms are, the pain specialist can usually tell which nerve is involved. Symptoms include: 

• Burning, sharp, squeezing, aching or electric shock like pain
• Tingling or pins and needles sensation in the arm or hand 
• Numbness or loss of feeling in arm or hand
• Shoulder, arm or hand weakness
• Increased pain travelling down the arm with neck movements such as looking up towards the ceiling (extension) or on turning the head

INVESTIGATIONS

MRI scans are the most useful investigation to confirm the diagnosis and assess severity. MRI is better than x-ray because in addition to the bones, it can also show the nerves and discs, giving a detailed picture of the spine. Other investigations such as Nerve conduction velocity (NCV), electromyography (EMG), x-rays and CT scans are sometimes requested.

TREATMENT

Most individuals with cervical radiculopathy get significantly better within 6-12 weeks, with good recovery in 4-6 months. For some however this can be a long-lasting problem. Ignoring persisting symptoms can aggravate the situation leading to chronic pain with reduced functionality. Treatment of this condition required multimodal approach with a combination of lifestyle changes, medications, physical therapy and injections. Surgical intervention is required in very few patients and there are specific indications for surgery. Presence of pain alone is not an indication for surgery.

Some of the pain management techniques include:

Lifestyle changes: These include activity modification, giving up smoking, being mindful of one’s posture and simple ergonomic changes. Incorrect posture while working on laptops, mobiles etc can cause excessive cervical spine strain with certain professions being more prone to develop neck pain. Simple measures such as adjustment of furniture height and computer position can go a long way in reliving symptoms. Taking regular breaks to walk around and stretch is a good practice.

Medications: Anti-inflammatory drugs, muscle relaxants, painkillers acting on the nerves (neuropathic agents) may all be used depending on the source of pain and severity of symptoms. Sometimes stronger painkillers may also be suggested by your doctor.

EPIDURAL INJECTION (Nerve Block)

The aim of this injection is to deliver the anti-inflammatory medicine in the epidural space, close to the affected nerve. Epidural space is a fat filled space present in the spine, between the bone and a protective sac around the spinal nerves. Epidural injections are effective procedures and may help in rapid recovery by reducing inflammation. These medicines may also help by reducing the sensitivity of the nerves carrying the pain signals. The relief from these injections may be short term or long term, lasting from days to years. In some cases it may even be permanent if the original problem responsible for pain heals. There is some evidence pointing to recurrence of symptoms in up to one-third of patients with cervical radiculopathy following initial treatment and repeated injections over one year may have a synergistic effect on pain relief. The goal of these injections is to reduce pain so that you can resume normal activities and engage in a physical therapy program.

The procedure involves the following steps

Step 1: Positioning and preparation

An IV drip is placed and patient is positioned on the x-ray table. Monitors for recoding the vital signs such as heart rate, blood pressure and oxygen levels are attached. The procedure area at the back of the neck is cleaned with antiseptics and drapes are placed around it to keep it clean. Local anaesthetic is used to numb the treatment area to reduce any procedural discomfort. The patient remains awake during the procedure as this helps to provide feedback to the physician performing the procedure and enhances the safety of the injection.

Step 2: Performing the injection

The problem area is localised using x-ray guidance. A needle is then slowly directed into the epidural space using real time x-ray guidance. These x-rays are visualised real time on a monitor attaches to the x-ray machine. Once the needle is correctly placed, a dye (contrast agent) is then used to verity needle position. A mixture of local anaesthetic and anti-inflammatory medicine (steroid) is then given. After the injection is complete the needle is removed and a small dressing is applied.

Step 3: Post procedure

After the procedure, monitoring is continued for some time.  Most people are discharged home after a few hours and are able to resume full activity from the next day. Simple painkillers such as paracetamol can be used for any discomfort around the injection site. The effect of injections can take some days to manifest and keeping a record of how your pain changes is advised. A post procedure follow up appointment is usually scheduled after a few days and it is important that you attend this appointment.

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