My Doctor Online The Permanente Medical Group

Symptoms

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Neck problems can generate a wide variety of symptoms, depending on which structures are irritated or injured. In fact, you may feel pain in your neck, but the actual cause may be located in a different area of your spine. Common symptoms of neck problems include:

• Pain in the neck. The quality of pain can vary and may be described as sharp, shooting, stabbing, throbbing, tender, burning, cramping, aching, dull, heavy, or a sensation of pressure. 
• Stiffness in the neck that makes it difficult to move and hurts at the end of your range of motion.
• Burning or aching pain between the shoulder blades.
• Pain that radiates to the back of the head.
• Headaches.
• Numbness, tingling, or pain in the arms and hands.

Some body positions will make the pain worse, and others can make it better. For example, you may find that the pain gets worse when you look down – we call this flexion-sensitive pain. Alternatively, looking up to reach objects on high shelves or turning and bending your neck to look over your shoulder may cause pain – we call this extension-sensitive pain. Understanding which type of pain you have can enable us to identify which structure in your neck is irritated or injured and guide our recommendations for the most effective treatment. 

When to contact us

Although neck and back pain does not usually indicate a serious medical condition, if you have any of the following signs or symptoms, please call our 24/7 Appointment and Advice line immediately:

• Loss of bladder or bowel control or difficulty starting or stopping urination
• Weakness in the arms and/or legs
• Balance problems
• New or increased neck pain with unexplained fever or recent infection
• New or increased neck pain with a history of cancer, immune system problems, or use of the drug prednisone
• Pain that is intolerable and/or not relieved by rest, or a loss of sensation or strength

Diagnosis

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The most important tools we use to help diagnose the cause of your pain are your medical history, including the information that you tell us about your neck symptoms, and a physical examination. 

Medical history

We will ask you a number of questions including:

• Where does it hurt?
• Does the pain travel anywhere else?
• How did the pain start?
• What does the pain feel like?
• What makes it feel better and/or worse?
• Does it stop you from going to work, pursuing your hobbies, or exercising?

Physical examination

We will perform a physical examination of your neck to evaluate the following:

• The condition of your muscles and joints
• The alignment of your neck and shoulders
• Your posture
• Your range of motion
• The location of your pain
• The function of your nerves
• Specific body positions that provoke your pain

The results of your medical history and physical examination will help us confirm your diagnosis and develop a treatment plan. We can also determine if we need to order any further tests such as imaging studies.

Imaging Studies

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We rarely need an imaging study to determine what is causing your neck pain. Imaging studies do not show pain. However, if we suspect that a more unusual condition may be the source of your neck pain, we may refer you for an X-ray, MRI, CT scan, or bone scan.

X-rays

X-rays show bones. We usually order X-rays before ordering other more specialized tests. X-rays can give us a lot of information about your neck, including:

• The alignment of the vertebrae
• Wear and tear-type changes in the joints
• Bone loss caused by tumors or infection
• The amount of space in the discs
• Narrowing of the holes where the spinal nerves exit the spine (neuroforamen)

Magnetic resonance imaging (MRI)

MRI lets us see soft-tissue structures such as discs, muscles, and nerves. It also enables us to look at bones such as the vertebrae and facet joints. We may order an MRI if an X-ray does not give enough information to explain your problem. Remember, MRIs do not tell us where pain is located; they only show us the status of different structures in the spine.

Computed tomography (CT)

A CT scan is an advanced form of X-ray that helps us to get more specific information about problems with the bones. We typically order CT scans for patients who have had spinal surgery with implanted hardware that may blur the image of an MRI.
  
We may also recommend a myelogram at the same time as the CT scan. During this procedure, dye is injected into the spinal canal to make specific structures in the spinal canal show up more clearly. Pictures are taken before and after the dye is injected. 

Bone scan

A bone scan is a test that looks for abnormal activity within the bones. We inject a radioactive dye into the blood and then take X-ray-type pictures several hours after the dye has circulated through your body. The pictures can help us find subtle fractures, areas of infection, or tumors.

Additional Tests

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Blood tests

We may order laboratory blood tests. These may help to identify:

• Other causes of neck pain not related to general degenerative conditions
• Certain types of arthritis or infections that may be causing neck pain
• Problems with internal organs that may be referring pain to your neck or arm

Diagnostic spinal injections

In certain situations, we may use diagnostic spinal injection procedures to help identify the cause of your neck pain. These include nerve or joint blocks that are performed with the use of fluoroscopy (real-time X-ray). We use two types of diagnostic spinal injection procedures:

• Intra-articular injections. We inject anesthetic into the facet joints that we suspect may be causing your pain. This allows us to verify if the pain is coming from inside that specific joint.  
• Medial branch block. During this procedure, we inject anesthetic around the nerves in the area of your spine that we suspect may be causing your pain. These nerves carry pain information from the facet joint and surrounding tissue to the brain. The anesthesia temporarily prevents the nerves from sending pain information from that joint and/or tissue to the brain. If your pain goes away while the anesthetic is working, that can help confirm that the pain is coming from the joint or tissue that we blocked. 

Causes and Risk Factors

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You can develop neck pain as the result of an injury; for example, a whiplash injury during a car crash. However, most neck pain is caused by wear and tear damage that develops over time. We describe this process as a degenerative cascade that involves multiple structures within the cervical spine.  

Degenerative changes occur in all of us as we get older; however, in some individuals, they can occur more quickly and cause more pain. A number of factors can accelerate the damage caused by normal wear and tear. These include:

• Advanced age
• Activity levels
• Acute or repeated trauma or injury 
• Poor posture
• Weak muscles around the spine

The degenerative cascade

Over time, normal everyday stress and external trauma begin to affect the structures in your spine. Problems often begin with the discs, and, unless you begin exercises to strengthen the muscles that support your neck, they go on to affect the entire spine. Here’s how:

• Discs tear and rupture. Small tears develop in the tough outer part of your discs. Eventually, the inside of the disc (the nucleus) can begin to push through the small tears in the outer portion of the disc (annulus). This is called a herniation, also known as a ruptured or slipped disc. This process causes inflammation, which can irritate the spinal nerves, causing numbness, tingling, or pain in the shoulders, arms, or hands.
• Ligaments get weaker. Wear and tear also puts strain on the ligaments that support the spine and neck and causes protective cartilage in the facet joints to degenerate. As the ligaments get weaker, they can no longer keep the structures of the spine stable.
• The spine becomes unstable. Without strong ligaments to keep them in place, the structures in the spine begin to move slightly. This places even more force on the disc and the joints. Instability causes motion at the discs, facet joints, and surrounding muscles and ligaments. This may cause pain. Instability can also pinch the spinal nerves as they travel out of the spinal canal, causing nerve pain.
• The discs shrink and ligaments buckle. More and more small tears weaken the discs, reducing their capacity to  bear weight and cushion the bones. Eventually, the disc shrinks significantly, causing the surrounding ligaments to buckle and the joint bones to rub against each other. This may cause pain.  
• Bone spurs develop. Movement causes pulling on the ligaments, which leads to the formation of bone spurs. These can narrow the holes where the spinal nerves exit. This may squeeze and irritate the nerves, causing numbness, tingling, or nerve pain in the shoulders, arms, or hands.
  

Prevention

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Many people who suffer a first-time episode of neck pain will still have some symptoms at least a year later. Even if the pain and other symptoms go away, you may still experience another episode in the future. It is important to recognize that an initial episode of pain is a warning sign that you are putting too much stress on your neck. There are a number of things you can do to prevent neck pain from occurring in the first place or from coming back after you have recovered from the initial episode.

Postural stabilization exercises

Wear and tear affects all of us as we age. Poor posture makes things worse and is becoming increasingly common as we expand our use of computers for everyday tasks.
 
We can show you specific exercises that strengthen and coordinate the muscles in the back of your neck and shoulders, stretch out the muscles in the chest and front of the neck, and help you prevent wear and tear from causing pain and inflammation.

Good posture and ergonomics

Rounding the shoulders while sitting at a computer or standing can overuse the neck and shoulder muscles. Constantly remind yourself to lift your chest, pull your shoulders back, and tuck in your chin.

Make sure when you are working at a computer to keep the monitor at eye level and the keyboard close to your body and at a level where your shoulders are relaxed and pulled back.

If you work at a computer, we can talk to you about ergonomic changes you can make to your workstation to prevent overuse injuries to your neck and back. If you work in an office, you should consider asking your employer to conduct an ergonomic evaluation of your workstation.

Weight loss

If you are overweight, you may be putting more load on your spine than it is able to tolerate. Losing weight and engaging in aerobic exercise and postural stabilization exercises are critical to prevent neck pain and to help heal your neck after an injury or flare-up of pain and inflammation.

Home Treatment

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Most people feel significantly better within 6 weeks of an initial episode of neck pain. However, many people still note some discomfort 1 year later. Almost everyone who has a first-time episode of neck pain will suffer another episode in the future. Usually, you can treat your symptoms effectively at home. We recommend a combination of approaches that include the following:  

Relative rest

In the acute phase of neck pain, we recommend “relative rest” for a few days. Try to continue with your normal daily activities and let your pain levels tell you when you need to slow down.

Studies show that prolonged bed rest (more than 3 days) is actually bad for your spine because the tissues in your spine need to be exposed to normal movements in order to heal correctly. Pace yourself by planning your activities ahead of time and taking frequent breaks.

Over-the-counter anti-inflammatory pain medications

Medications can help control your symptoms while your irritated or injured tissues heal. We may recommend pain medication, such as over-the-counter (OTC) acetaminophen (Tylenol), or OTC nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen or naproxen, to reduce pain, inflammation, and muscle spasms and help you sleep. When using these medications, follow these guidelines: 

• Over-the-counter NSAIDs, such as ibuprofen or naproxen, can help manage your pain or discomfort. Even though you do not need a prescription for OTC NSAIDs, you should still be careful to consult the package so that you take the correct dosage.
• Also, please be aware that OTC NSAIDs can interact with other medicines you may be taking and cause problems for people with various medical conditions. If you have a complex medical condition, are pregnant or trying to get pregnant, or have been taking OTC NSAIDs and they do not relieve your symptoms, please let us know so that we can recommend an alternative.

Exercise and weight management

• Exercise is medicine for your neck pain. We cannot stress this enough. During aerobic exercise, your body releases endorphins that can help improve your mood and reduce your pain. We can help you choose the exercise that feels good and does not exacerbate your pain. Good choices generally include bicycling and walking.
• If you have worked with a physical therapist before, after a previous neck issue, but have not been consistent with your postural stabilization exercises, please start them again. Start with the exercises that do not make your pain worse, then progress back into your entire home exercise program. Remember, you need to do these exercises throughout your lifetime to prevent reinjury. 
• Excess weight can put more load on your spine than it is able to tolerate. Working on weight loss, aerobic exercise, and postural strengthening exercises is critical to your healing. 

Sleep

Lack of sleep is closely related to the amount of pain that people feel. It is important to get plenty of sleep to help you manage your pain. If you find yourself waking up frequently during the night and you do not feel well rested during the day, discuss this with us. Follow our guidelines for sleeping well.
 

Medications

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If OTC acetaminophen and NSAIDs are not controlling your neck pain sufficiently, we may prescribe additional pain medications. These may include opioid pain medications, such as Vicodin or Tylenol with codeine. We reserve opioids for very severe pain flare-ups, and they should generally not be taken for more than 2 weeks. Opioids are not always effective for nerve type pain.

Interventional Spine Procedures

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Spinal injections have a limited role in the treatment of neck pain.

There are two types of procedures that can help treat pain originating from the facet joints. They are:

• Facet joint intra-articular injection. If you are experiencing a new episode of inflammatory pain originating from a facet joint, then we may recommend a steroid injection into the joint to reduce inflammation and pain.

• Radiofrequency neurotomy (RFN) of the medial branch nerves. If a diagnostic spinal procedure has already confirmed which joint your pain is coming from, we may refer you for RFN. During this procedure, we use heat-generating radio waves to destroy the nerves that surround the joint that is causing your pain. This prevents them from transmitting pain signals from the joint to the brain. The radio waves are sent to the nerves through needles in your skin. It is important to note that, in some cases, the nerves grow back and your pain may return. 

Epidural steroid injection

In rare cases, we may use an epidural steroid injection (ESI) to treat irritated nerves. We usually do not recommend epidural steroid injections for isolated neck pain. We may use this approach to treat irritated spinal nerves that are causing pain radiating down your arms on into the hands. Excessive amounts of corticosteroids (the medication used in ESI) can increase the risk of developing osteoporosis, glaucoma, and cataracts and can have other side effects as well. 

In special circumstances, there are other interventional spine procedures that may help reduce pain. If you are a candidate for any of these procedures, we will discuss the details with you.

Surgery

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For most cases of uncomplicated neck pain, there is little evidence to suggest that surgery is an appropriate or helpful treatment. Surgery may be a treatment option in rare situations if you have any of the following conditions:

• Tumors
• Fractures
• An unstable spine
• Severe degenerative changes that have not responded to all other treatment approaches

If any of these conditions apply to you, we may discuss surgical options that are available.

Lifestyle Changes and Management

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There are a number of steps you can take to manage your neck pain and prevent future recurrences.

Back and neck exercises. It is important to strengthen and stabilize the structures in your neck to prevent pain and inflammation from developing again. We will teach you to do postural stabilization exercises that you should integrate into your regular stretching and exercise routine. You can review these exercises in the Spine Care Exercise videos. You can also ask us about a referral to our WebCare program for back pain.

Manage your weight. Your weight can contribute to neck problems. Reaching and maintaining a healthy weight can reduce the load on your spine. 

Get enough sleep. Tiredness and fatigue can make pain feel worse. If you have trouble sleeping for any reason, discuss this with us.

Exercise. Regular aerobic exercise makes you feel good and reduces pain. We can work with you to choose activities, such as cycling and walking, that do not exacerbate your neck pain.

Your Care with Me

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If you are having symptoms that concern you, your first contact will typically be with your personal physician, who will evaluate your health and symptoms.
 
If specialty care is needed, your personal physician will arrange an appointment for you in my department. If appropriate, she or he might call me or one of my colleagues while you are in the office so we can all discuss your care together. If we decide you need an appointment with me after that discussion, we can often schedule it the same day or soon thereafter. 

During your office visit, we will discuss your medical and family history and I will perform a physical exam. If we ordered X-rays to be taken before your visit, I will review those with you as well. I will explain the findings of your exam and answer any questions or concerns you may have. We will discuss treatment options, and together we will create a treatment plan that is right for you.

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If you need to talk with me after your visit or procedure, please call my office. You can also e-mail me with nonurgent issues from this website whenever it is convenient for you.

For general medical advice, our Appointment and Advice line is available 24 hours a day, 7 days a week.

If you have urgent concerns or issues while my office is closed, you can call the Appointment and Advice line. You will be connected with a nurse who can give you immediate advice.

If you are experiencing a serious problem or an emergency, call 911 or go to the nearest Emergency Room when the clinic is not open.

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Coordinating Your Care

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Having all of our Kaiser Permanente departments located together or nearby, including pharmacy, laboratory, radiology, and health education, makes getting your care easier for you.

Another major benefit is our comprehensive electronic medical record system, which allows all of the doctors and clinicians involved in your care to stay connected on your health status and collaborate with each other as appropriate.

When every member of the health care team is aware of all aspects of your condition, care is safer and more effective.

If you come to an office visit

• At the beginning of your visit, you will receive information about when you are due for your next test, screening, or immunization. We can discuss and schedule any preventive tests that you need. 
• At the end of your visit, you may receive a document called the “After Visit Summary” that will summarize the issues we discussed during your visit. You can refer to it if you forget what we discussed, or if you just want to recheck your vital signs and weight. You can also view it online under Past Visits.
• To help you prepare for your visit, please see additional details under Office Visit. 

If I prescribe medications

We will work together to monitor and assess how your medications are working and make adjustments over time. Prescriptions can be filled at any Kaiser Permanente pharmacy. Just let me know which pharmacy works best for you, and I will send the prescription electronically in advance of your arrival at the pharmacy.

If refills are needed in the future, you can:

• Order them online or by phone. Order future refills from my home page or by phone using the pharmacy refill number on your prescription label.
• Have them delivered to you by mail at no extra cost. Or you can pick up your medications at the pharmacy. If no refills remain when you place your order, the pharmacy will contact me regarding your prescription.

If lab testing or imaging is needed

For lab tests, I will use our electronic medical record system to send the requisition to the Kaiser Permanente laboratory of your choice. For imaging procedures, we will schedule an appointment with the Radiology department. When the results are ready, I will contact you with your results by letter, secure e-mail message, or phone. In addition, you can view most of your laboratory results online, along with any comments that I have attached to explain them.

If I refer you to another specialty colleague

If we decide together that your condition would also benefit from the care of other types of specialists, our staff will help arrange the appointment(s) with one or more of my specialty colleagues.

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If Surgery or a Procedure is a Treatment Option

I will recommend that you review educational information and tools to help you prepare for your procedure or surgery. The information will often help you decide whether surgery is right for you. If you decide to have a surgery or procedure, the information will provide details about how to prepare and what to expect.

Convenient Resources for You

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As your specialist, I have a goal to provide high-quality care and to offer you choices that make your health care convenient. I recommend that you become familiar with the many resources we offer so that you can choose the services that work best for you.

My Doctor Online is available at any time that is most convenient for you. From my home page you can:

Manage your care securely

• View and compose secure e-mail messages.
• Manage your prescriptions.
• View your past visits and test results.
• View your Preventive Services to see whether you are due for a routine screening or updated immunization.

Learn more about your condition

• Read about causes, symptoms, treatments, and procedures.
• Find interactive health tools, videos, and podcasts to help you manage your condition.
• View programs to help you decide on or prepare for a surgery or procedure.

Stay healthy

• Locate health education classes and support groups offered at every medical center.
• Explore interactive programs, videos, and podcasts that focus on helping you stay healthy.
• View your Preventive Services to see whether you are due for a routine screening or updated immunization.

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