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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Advantages of this procedure include

• No requirement for hospital stay or prolonged rehabilitation
• Normal activities can generally be resumed soon after the procedure with little recovery time
• Less pain can lead to improved functionality and reduced medication requirements
• Lasting pain relief for and a low complication rate

Chronic back and neck pain

Spine is made up of a number of vertebrae which are stacked one above the other. These vertebrae are cushioned anteriorly by the disc and join with each other posteriorly at joints called the facet joints. There are two facet joints at each level. Wear and tear, degeneration of these joints can lead to back or neck pain. This condition is called facet joint arthritis or facet arthropathy. Pain originating from facet joint arthritis is generally described as a dull ache accompanied by stiffness. It is not uncommon for the pain in lower back to radiate along the back of thighs up to the knee joint. Similarly pain from lower neck (cervical) joints can radiate to in between the shoulder blades or the shoulder joint and that from upper neck joints can cause headaches.

Pain sensations form the facet joints are transmitted to brain via nerves called the medial branches. These nerves are the target in the radiofrequency treatment

Radiofrequency ablation involves placing special needles, using x-ray guidance, close to the nerves carrying pain sensation from the affected facet joints. Using specialised equipment a small area of these nerves is heated using the electric current produced by radio waves. This reduces the pain signals being transmitted by the nerves to the brain resulting in pain relief. This is a day care procedure performed under local anaesthesia and can provide long lasting pain relief.

Dr. Manocha has been formally trained in performing this procedure in the U.K. and U.S. The technique he uses is the same as advocated by International Spine Society giving you the best chances of having a successful outcome.

Consult Best Pain Specialist In Delhi, Dr. Amod Manocha.

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Some common causes include –

• Muscle sprain, spasm/ increased tension
• Poor posture and work ergonomics
• Incorrect positioning of the neck while sleeping
• Aging: Degenerative disc disease and spinal osteoarthritis become more common as we age
• Injuries/ Whiplash: Whiplash neck involves sudden jolting of neck forwards and backwards and is commonly observed in vehicular accidents. This can cause excessive stretching of neck muscles, ligaments or other injuries which can be associated with neck pain.

Neck pain can be a part of more widespread medical issues such as in fibromyalgia, arthritis, ankylosing spondylitis, infections, cancer etc. You can approach Pain Management Specialists in Delhi for diagnosing your problem and suggesting suitable solutions

It is advisable to seek early medical attention if you experience any of the following

• Persisting symptoms or severe pain not responding to usual care or medications
• Pain starting after fall, injury
• New onset numbness, weakness or tingling in arms
• Gait or balance problems
• Loss or urine or stool control
• Signs of infection/ meningitis
• Pain worse at night time/interfering with your sleep

Some of the pain management techniques for neck pain include:

Lifestyle changes: Incorrect/ ignored posture while working on laptops mobiles etc can put excessive cervical spine strain leading to pain. Certain professions can be more prone to develop neck pain. Simple posture awareness and improvement, taking regular breaks can go a long way in reducing symptoms.

Medications: Anti-inflammatory drugs such as ibuprofen or naproxen and pain relievers like acetaminophen may initially be prescribed by your doctor. Sometimes medications like muscle relaxants or stronger painkillers may also be suggested by your doctor.

Physical Therapy: Regular exercise, good posture, stretching can help to reduce/ prevent to prevent unwanted stress and tension to your neck muscles. Heat or cold application may be used during the initial phases of injury to facilitate your recovery and physical exercise. Depending on the severity, time since injury and your recovery the specialist may recommend limiting normal physical activity or slow range-of-motion exercises or strengthening exercises.

There is research evidence supporting the use of specific strengthening exercises as part of a routine practice for chronic neck pain, cervicogenic headache and radiculopathy.

Ergonomics & Posture
Simple posture changes and better workplace ergonomics can help in preventing/reducing neck pain. Measures include adjustment of furniture height and computer position such that

• Eyes point directly at the top third of the screen
• Forearm is parallel to floor
• Feet should be flat on the floor with thighs parallel with the floor

While sitting in office chair it’s a good practice to have back aligned against the back of the office chair and avoid slouching. Avoid sitting in one place for too long. Taking regular breaks to walk around and stretch is a good practice.

Relaxation techniques: relationship between stress and increase pain is well known and easily appreciated by most patients. Measures to deal with stress and anxiety help in more effective pain management.

Massage Therapy: The evidence supporting the use of massage therapy is limited although some people do find it useful in the short term. Massage can help in relaxing, loosening of muscles but it is important to remember that wrongly done massage can lead to harm.

Acupuncture: Certain people find Acupuncture helpful in neck pain management. When performed correctly it is a low risk procedure. The traditional acupuncture is based on the theory of restoring the energy balance in body and removing any blockages to the flow of energy.

Injections/ other interventions such as Radiofrequency ablation: These would depend on the cause of neck pain and actual pathology. They have been explained in more detail in the neck & arm pain section under treatments, on my website- removemypain.com

Ignoring persisting symptoms can aggravate the situation leading to chronic pain with reduced functionality. So, if your pain persists and does not respond to usual lifestyle changes and painkillers then seek medical opinion on time.

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