As I mentioned previously, the pain associated with cervical degenerative disc disease (DDD) and cervical spondylosis (which I will refer to here, generically, as neck pain) is often self-limited. Upwards of 75% of patients will get better with conservative treatments alone and will avoid surgery. In the next two posts we’ll look at some examples of conservative treatments of neck pain that you should try before considering surgery. We’ll also discuss the strength of the evidence found in the literature regarding the efficacy of these treatments in treating neck pain.
Non-steroidal anti-inflammatory medications (NSAIDs) have long been an initial medical therapy for neck pain. It is believed that these medications are beneficial because of their anti-inflammatory properties (it is believed that the pain associated with cervical DDD and spondylosis is secondary to inflammatory mediators secreted from degenerating discs and facet joints.) Unfortunately, no data on their efficacy in treating neck pain exists. We do know that NSAIDs are beneficial versus placebo for acute low back pain (but not chronic pain) and we often extrapolate this data to neck pain. Thus, despite the paucity of data on their efficacy, NSAIDs are often a first-line treatment for neck pain. This may be hazardous, particularly in older patients, given that they can cause kidney damage and gastric ulcers.
Very limited evidence exists on the efficacy of oral narcotics in treating neck pain. There is some evidence that oxycodone (active ingredient in Percocet) is beneficial in patients with acute neck pain. These medications are also beneficial in older patients who may not be able to tolerate the toxicity of NSAIDs. Of course there is always fear of the addictive nature of these medications so one has to be careful in situations where these they are required longer than a few weeks.
Much of the pain associated with cervical spondylosis is actually muscle pain from spasm in the paraspinal muscles and trapezius. Thus, muscle relaxants are often prescribed in cases of acute neck pain. Again, these medications can be habit forming and shouldn’t be used for longer than a few weeks (i.e. they should not be used the in the treatment of chronic neck pain.)
Physical Therapy, Chiropractic Manipulation, and Accupuncture
Exercise, physical therapy and chiropractic manipulation (including cervical traction) have all been shown, with weak to moderate strength data, to be beneficial in patients with chronic neck pain. There is no data to suggest that one is any better than the other and they seem to work best as part of a holistic treatment program. Unlike exercise and physical therapy, chiropractic manipulation may have some benefit in patients with acute neck pain. In my opinion, though, chiropractic treatments in the neck should be limited to low-velocity, high amplitude maneuvers as high velocity, low-amplitude maneuvers are associated with higher risk of injury to the vertebral artery (which can cause stroke and death). Finally, there is moderate evidence that acupuncture is better than placebo for treatment of neck pain in the short-term.
In the next post we’ll look at the use of interventional pain management in the treatment of neck and arm pain.
J. Alex Thomas, M.D.