Neck Pain Treatment
By: Lali Sekhon MD, PhD, MBA and Vadim Goz, MD
I have neck pain. What should I do?
Neck pain is common and usually self-limiting. The majority of us will get neck pain at some stage in our life and thankfully it’s usually self-limiting with no specific treatment required. If you get neck pain, avoid activities that require heavy lifting. Simple over the counter anti-inflammatories such as Ibuprofen or naproxen, are a great first step for most patients. Physical therapy is usually very beneficial as they will try manual therapy, traction, heat, ice and other modalities. If the pain does not settle, talk to your primary care provider (PCP). Your PCP may prescribe muscle relaxants, stronger anti-inflammatories, as well as occasionally oral steroids for inflammation. If at all possible, try and to avoid narcotics.
When should I be worried?
The so-called ‘red flags’ include severe weakness in arms or hands, unsteadiness when you walk, electric shocks down the arms when you look up. If you have new onset of pain with fevers or a history of cancer it (this) is concerning. These often need immediate assessment by one’s PCP, urgent care, or ER provider. Typically, imaging is ordered, often x-rays and an MR scan.
When is surgery needed?
Rarely- 70% of patients settle with conservative therapy. If there is severe pinching of the spinal cord, severe or persistent arm pain or weakness, surgery plays a role. This is commonly performed from the front of the neck and may be a fusion or a disc replacement. Surgeries from the back of the neck are more common as we get older.
What about seeing a chiropractor?
For pure neck pain, if you want to see a chiropractor it is ok, but we would suggest avoiding any manipulation, or cracking. Chiropractic manipulation of the neck carries a small chance of tearing important blood vessels to the brain that are in the neck. Our preference is to suggest physical therapy over chiropractic manipulation. If you have arm pain or weakness, you probably need a specialist evaluation with an MR scan of the neck before any chiropractic treatments.
I’m having an epidural shot. What does that mean?
Epidural means space around the nerves. In pregnant women that space is filled with local anesthetic and pain medication. More commonly, epidurals are done for neck and arm pain upon failure of initial conservative therapy. In this setting, cortisone (a potent anti-inflammatory) is injected.
If there is neck and arm pain that fails initial conservative therapy, then typically an MR scan is ordered. After it is reviewed, your PCP (less common), pain physician or surgeon (commonly) may order an epidural. An epidural injection is done by a trained pain specialist and typically involves lying on your stomach while a needle is inserted (with x-ray control) in the back of the neck after the neck is numbed. The epidural procedure takes about 5 minutes, and most people go home after 30 minutes. There may be an immediate effect, but typically the cortisone effect peaks 1 week after the injection. The cortisone settles irritation, caused by pinching, and is best given/monitored in an acute setting. If you’ve had neck pain for 30 years, it may not help as much as if you’ve only experienced lower back pain for one month.
How many epidurals is too many?
No one knows. Steroids can suppress the immune system and soften one’s bones. Typically, reassessment is warranted after the first epidural. Try not to get more than 3-4 in the same area in a year. If you find yourself at that point, it is worth discussing if other possible treatments such as surgery may offer a more durable solution.