Axial neck pain: a surgeon’s perspective

Understanding and treating axial neck pain is both challenging and controversial. Axial neck pain is confined to the cervical, occipital or posterior scapular areas [1]. While axial neck pain typically does not radiate into the upper extremities, some patients may experience a component of referred pain to the proximal upper extremities. This should be distinguished from radicular pain, which typically extends distally down the upper extremity in a dermatomal distribution. Axial neck pain may also be associated with severe headaches with holocephalic radiation [1]. While most cases of neck pain resolve within 6 weeks with conservative treatment alone, population-based studies indicate that 10–34% of the general population have persistent chronic neck pain, with 50% complaining of occipital radiation [2–4]. In most patients, unless neck pain is accompanied by spinal instability, neurologic compromise, or severe deformity, surgical intervention has traditionally been avoided [5,6]. More recently, some authors report a benefit with surgery in a select cohort [7–9]. For the best outcome, clinicians should perform appropriate investigations to elucidate the pathophysiologic basis for pain, and base treatment decisions on this. An understanding of surgical indications and potential complications in these patients is also important. This article details the main causes of axial neck pain, including appropriate diagnostic work-up and potential interventions. Prevalence & natural history Neck pain is very common, with one population-based study reporting a 66% lifetime incidence [10]. A best evidence synthesis of the existing literature revealed a 30–50% annual prevalence of neck pain with a 1.7–11.5% annual prevalence of activity-limiting pain. Neck pain occurs more frequently in women, with a peak in middle age. Tobacco exposure and poor psychologic health also increase risk. Known disc degeneration is not a risk factor [11]. Although frustrating, axial neck pain is usually self-limited and will improve with time, conservative care and patience [5,6,12]. Unfortunately, in some cases, pain relief is incomplete and patients may suffer residual symptoms that are disabling. In patients completing 3 months of medical treatment, approximately 22–32% of patients had persistent pain [5,6,13]. Psychosocial factors are the strongest predictor associated with persistent neck pain [14].