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Aspecifieke nekpijn: diagnose en behandelingPublished by: KCELast published: 2013Douleurs cervicales aspécifiques : diagnostic et traitementPublished by: KCELast published: 2013

In patients with symptomatic cervical spondylosis, there are three main clinical syndromes:

  • Axial neck pain

  • Cervical spondylotic radiculopathy (CSR)

  • Degenerative cervical myelopathy (DCM)

The last two syndromes may overlap and both include degrees of axial neck pain.[3]​​[12][13][24]

Neck pain may be acute or chronic, and may occur with or without neurologic symptoms due to radiculopathy and/or myelopathy. It is the most common symptom, and the most easily treatable.

The evidence about the effects of individual interventions for these clinical syndromes is often contradictory because of the poor-quality randomized controlled trials (RCTs) conducted in diverse groups and the tendency for interventions to be given in combination.[3][24][47]

Most treatments are symptomatic and have no effect on the underlying cervical spondylosis or affect the long-term nature of the cervical degenerative changes. Many treatments are only effective in the short term.[22]

Axial neck pain

First-line treatment of acute (<6 weeks), nontraumatic axial neck pain is physical therapy, including cervical traction.[48][49]​ The degree of axial neck pain can be assessed by simple outcome measures to determine the effects of subsequent treatment.[40][48][49][50][51]​ It is unclear whether patient education alone is helpful for treatment.[52][53]​ Complementary and alternative treatments demonstrate minimal long-term efficacy.​[54]​​

Physical therapy

Physical therapy is the first-line treatment for axial neck pain.[22] Advice on posture, sleeping position, daily activities, work and hobbies, stretching exercises, mobility exercises, and head, neck, and shoulder exercises may benefit individual patients.[48][49]

Although physical therapy is of most value in the first 6 weeks, it can be continued intermittently as required to treat exacerbations of pain or chronic pain beyond 6 weeks.

Analgesia

Depending on the severity of pain, the use of nonsteroidal anti-inflammatory drugs (NSAIDs; e.g., ibuprofen, naproxen, diclofenac, meloxicam) may be beneficial in individual patients.[47]

Cyclo-oxygenase-2 (COX-2) inhibitors (e.g., celecoxib) may be preferred in patients with a history of gastroesophageal reflux disease (GERD) or peptic ulcers.

There is no clinical efficacy difference between various NSAIDs, but many patients tolerate one better than others or may have individual-based treatment preferences. NSAIDs are associated with an increased risk of cardiovascular thrombotic events and gastrointestinal toxicity (bleeding, ulceration, perforation). NSAIDs should be used at the lowest effective dose for the shortest effective treatment course.

Acetaminophen may be used in patients who have a contraindication to the use of NSAIDs, but should be used with caution in patients with hepatic impairment.

Muscle relaxants and maneuvers

If muscle spasm is a feature of the pain, muscle relaxants and maneuvers (including heat, massage, and cervical pillows) may be beneficial in some patients.[55] There is no clinical efficacy difference between various muscle relaxants.

Trigger-point injections

These injections are usually performed by either a radiologist (under computed tomography [CT] or fluoroscopy control) or a pain management anesthesiologist (under fluoroscopic control) as needed.[56]

A long-acting corticosteroid preparation is usually added to a long-acting local anesthetic.[3][57]

In practice, trigger-point injections to local muscle, fascia, and/or ligaments (using local anesthetic) may be considered medically necessary if trigger points have been identified by palpation. If this option does not improve the patient's condition and cervical facet-mediated pain sources are suspected based on both physical exam and imaging, then image-guided cervical facet joint injections (intra-articular injections to the joint(s) using a mixture of local anesthetic and a corticosteroid, or alternatively, diagnostic medial branch nerve blocks, followed by therapeutic radiofrequency ablation/denervation) may be considered if medical management consisting of at least activity modification, physical therapy, analgesia, and muscle relaxants have not succeeded in alleviating the patient's pain.

Other therapies

Additional treatment modalities include transcutaneous electrical nerve stimulator, chiropractic treatment, acupuncture, and other, less orthodox approaches, particularly electrotherapy, laser therapy, and cervical spine manipulation therapy.​[35][48][51][55]​​[58][59][60]​​[61][62][63][64]​ Although these approaches may be beneficial for symptomatic relief in some patients, high-quality evidence supporting their use in this setting is lacking.[3][12][60][61][65] In addition, some of these therapies may entail additional risks; for example, cervical manipulation can be associated with serious neurologic complications.[51][61]

Chronic pain

Chronic neck pain (>6 weeks) may be managed by continuing these symptomatic treatments if they improve the patient's discomfort. Axial neck pain is starting to receive consideration for cervical arthroplasty, although this procedure is not Food and Drug Administration-approved for axial neck pain alone.[13][66]​ Physicians should refer to attending surgeons on indications for the procedure in their region. In general, surgery is not helpful for treatment of neck pain, but the evidence is of low quality.[67]

Cervical spondylotic radiculopathy (CSR)

Radiating arm pain can be severe and is initially managed with oral analgesia combined with physical therapy and cervical traction.[12]​​[22]​​​​​

Analgesia

NSAIDs are typically used first-line, with escalation to an opioid or gabapentin if the patient’s pain remains uncontrolled.

Escalation to an opioid (e.g., hydrocodone or oxycodone) should only be considered if the patient’s pain is not adequately controlled with nonopioid analgesics, muscle relaxants, physical therapy, and image-guided interventional spine injections to decrease reliance of this drug class.

Gabapentin may be used as a second-line option for neuropathic pain. Patients should be cautioned regarding potential sedation or cognitive adverse effects at the beginning of treatment. Once the patient's symptoms have improved, the dose may be tapered.

Physical therapy

All patients with cervical radicular pain who have physical difficulty with daily activities should be offered physical therapy, including posture correction, stretching exercises, and active range-of-movement exercises.[22]

Physical therapy and particularly cervical traction can help to enlarge foramina narrowed by cervical spondylosis. It may provide further room for nerve roots and subsequently decrease the severity of the nerve tightness (hence partially alleviating the radicular pain).[29] Traction regimen of 12-18 pounds for 30-45 minutes several times a day is recommended.

Oral corticosteroids

Oral corticosteroid therapy may benefit individual patients.[22] Usually limited to 8-10 days due to systemic toxicity, but can be helpful as an adjunctive initial treatment to decrease nerve irritation and radicular pain.​[22]​​​[26][57]

Subsequent interventions

In most patients (around 75%), severe arm pain will spontaneously relent by 4-6 weeks. The pain eventually resolves with conservative measures, but it may take 1-2 years to completely disappear.[13][25][68]

Depending on the timing and outcome of first-line treatments, subsequent more invasive treatments may consist of epidural corticosteroids or cervical nerve root block at the suspected level to maintain a positive effect from the oral corticosteroids, or surgical nerve decompression.[13][25][26][28]​​​[35]​​​​​[62][65][69]

Epidural treatments

Epidural anesthesia or cervical nerve root block should be administered by a fellowship-trained or board-certified interventional spine specialist, who may be an interventional radiologist, pain management physician (generally anesthesia trained), physiatrist (physical drug & rehabilitation), and/or neurologist.

Surgical nerve decompression

If the pain does not resolve and if all symptoms, signs, and diagnostic studies converge to indicate pressure on a single nerve root, then surgical nerve decompression may be helpful.[13][25]​​[26][28]​​​

There are a variety of surgical approaches for nerve decompression. Either anterior cervical discectomy with fusion (ACDF) or posterior nerve decompression procedures are generally selected, based on the patient's symptoms, number of levels of involvement, and specific anatomy from the cervical MRI scan. A minimum of 2-3 months of conservative therapy is usually required. Because significant weakness or neurologic change is rarely associated with radiculopathy, the primary decision for considering surgical decompression is the patient's subjective degree of pain and the significance of the discomfort.

Another approach is cervical arthroplasty, where an artificial disk is placed instead of a bone graft and plate to avoid a fusion and retain motion; multiple randomized studies have been carried out, but these procedures are not yet routinely performed everywhere.[70][71]​ Despite these multiple randomized studies, there is not yet any clear evidence regarding improved relief of radicular arm pain with arthroplasty compared with ACDF. However, although there are no clear data yet on the prevention of adjacent segment stenosis over time, arthroplasty may provide a lower rate of reoperation compared with ACDF.[70][71][72]

Degenerative cervical myelopathy

Surgical decompression is the preferred first-line acute treatment in patients with moderate and severe symptoms who are good surgical candidates, although two RCTs do not show any short-term benefit for mild to moderate myelopathy.[27][33][38] Surgical treatment of all levels of cervical myelopathy is considered the standard of care in the US, with supporting evidence from one prospective multicenter study.[26][28]​​[73] Surgical decompression is therefore typically offered to all patients on presentation, although there is variability between individual surgeons. Due to this bias and the worry that patients may experience irreversible deterioration if surgical decompression is delayed, no randomized surgical trials for cervical myelopathy are planned in the US.[37]

Surgical treatment

Adequate treatment of the severe underlying degenerative joint disease (DJD) usually requires fusion or immobilization of the segments, leading to loss of range of motion of the cervical spine.[26][28]​​​​​ With anterior approaches, adjacent segments often develop DJD over time, leading to adjacent segment stenosis. With posterior approaches there can be either instability (following laminectomy alone) or near complete loss of cervical range of motion, with the typical extensive posterior fusion needed. Furthermore, decompression surgery typically only stabilizes spinal cord function (with only mild improvement in symptoms) because there is usually existing permanent damage to the spinal cord at the time of surgery. The trend is consequently toward earlier surgery, while the patient has more of a chance of returning to normal function, or surgery while the patient is asymptomatic.[26]​​[28][33][36]​​[37]​​​​

Conservative treatment

Conservative treatment is the preferred treatment for patients who are poor surgical candidates. In some countries, although not in the US, conservative treatment is used for those who have mild symptoms.

The approach is immobilization in a hard cervical collar.[36]​ This conservative treatment has been shown to be equivalent (over 1-3 years) to surgical decompression in patients with mild to moderate myelopathy.[33]

Pharmacologic treatment

There are no long-term drug treatments that are helpful in management of degenerative cervical myelopathy; short-term corticosteroids may be used as a bridge prior to possible surgical decompression, but for <2 weeks due to their side-effects profile.

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