What Is Neck Pain?
Neck pain (cervicalgia) is the medical term for pain in the cervical region of the spine, that is, in the neck. It encompasses any pain located between the base of the skull (occiput) and the first thoracic vertebra, and may radiate to the shoulders, upper limbs, or interscapular region.
Like low back pain, neck pain can be acute (up to 6 weeks), subacute (6 to 12 weeks), or chronic (more than 12 weeks). The majority of cases are nonspecific, without a clearly identifiable structural cause.
Over the past decades, the prevalence of neck pain has increased significantly, largely due to prolonged use of electronic devices and sedentary work in front of computers — a phenomenon that has become known as "text neck".
Work-Related
Professionals who work at computers for more than 6 hours daily have a 2 to 3 times greater risk of developing neck pain.
Text Neck
Sustained cervical flexion when using smartphones significantly increases the biomechanical load on the cervical spine, especially at greater angles of forward head tilt.
Rising Prevalence
The prevalence of neck pain in young adults aged 18 to 25 has doubled in the last decade, associated with mobile device use.
Epidemiology
Neck pain is the fourth leading cause of disability worldwide. It is estimated that between 30% and 50% of the adult population will experience significant neck pain at some point in the year, and the lifetime prevalence exceeds 70%.
Women are more affected than men, with a prevalence ratio of approximately 2:1 to 3:1. Risk factors include age (peak between 35-49 years), sedentary work, psychological stress, smoking, previous history of neck pain, and cervical trauma (including whiplash).
Pathophysiology
The cervical spine is composed of seven vertebrae (C1-C7), interconnected by intervertebral discs, ligaments, muscles, and facet joints. This region is remarkably mobile, allowing a wide range of head motion, but this also makes it vulnerable to injury.
Structures Involved in Pain
The facet joints (zygapophyseal) are one of the most common sources of cervical pain, frequently implicated in case series of patients with chronic neck pain. These joints are richly innervated and can undergo degenerative, inflammatory, or traumatic processes.
The cervical intervertebral discs progressively lose hydration with age, reducing their cushioning capacity. Fissures in the annulus fibrosus allow penetration of nerve endings, making the disc a source of pain — so-called discogenic pain.
The cervical musculature, especially the deep flexor muscles (longus colli and longus capitis), frequently shows inhibition and atrophy in patients with chronic neck pain. This creates a vicious cycle: weak muscles lead to overload of other structures, perpetuating pain.
Symptoms
The symptoms of neck pain range from mild and localized pain to disabling syndromes with radiation to the upper limbs. Precise identification of symptoms helps differentiate mechanical from neuropathic causes.
Common Symptoms of Neck Pain
- 01
Pain in the neck and nape
Localized pain that may be constant or intermittent, usually aggravated by movement and sustained positions.
- 02
Cervical stiffness
Limitation of range of motion, especially rotation and lateral inclination, with a sensation of "locking".
- 03
Cervicogenic headache
Headache that originates in the cervical spine, usually unilateral, beginning at the nape and radiating to the frontal region.
- 04
Radiated pain to shoulders and arms
May indicate involvement of a cervical nerve root (radiculopathy) or referred muscular pain.
- 05
Tingling in the hands
Paresthesias in specific dermatomes suggest nerve root compression — C6 (thumb) or C7 (middle finger).
- 06
Dizziness and instability
Dysfunction of cervical proprioceptors can cause cervicogenic dizziness.
- 07
Crepitus on movement
Popping or joint noises are common and generally benign, associated with normal degenerative changes.
- 08
Interscapular pain
Pain between the shoulder blades frequently originates from cervical, not thoracic, dysfunction.
Diagnosis
The diagnosis of neck pain is predominantly clinical, based on a detailed history and physical examination. Specific tests such as the Spurling test (foraminal compression) and the cervical distraction test help identify radiculopathy.
Imaging studies are indicated only in the presence of red flags or when symptoms persist beyond 6 weeks without response to conservative treatment.
🏥Red Flags in Neck Pain
Fonte: Bone and Joint Decade Task Force / NICE Guidelines
Cervical Myelopathy (Urgent)
Refer for neurosurgical evaluation- 1.Progressive weakness in upper and/or lower limbs
- 2.Gait abnormality (spastic gait)
- 3.Difficulty performing fine motor movements with the hands
- 4.Positive Lhermitte sign (electric shock with neck flexion)
- 5.Hyperreflexia and Babinski sign
Suspected Serious Cause
- 1.Significant recent trauma (fall, accident)
- 2.History of cancer or unexplained weight loss
- 3.Fever or signs of systemic infection
- 4.Severe nighttime pain that does not improve with rest
- 5.Prolonged use of corticosteroids or immunosuppression
Vertebrobasilar Insufficiency
Cervical manipulation contraindicated- 1.Severe dizziness on neck rotation
- 2.Dysarthria, dysphagia, or diplopia
- 3.Drop attacks (sudden falls without loss of consciousness)
- 4.Nystagmus provoked by cervical rotation
Vertebral Artery Dissection (VAD)
Cervical manipulation CONTRAINDICATED; deep cervical needling should be deferred until investigation with CT angiography or MR angiography- 1.Sudden occipital/cervical headache, "the worst of life"
- 2.Ipsilateral Horner syndrome (ptosis + miosis + anhidrosis)
- 3.Vertebrobasilar signs: vertigo, ataxia, diplopia, dysarthria, dysphagia
- 4.History of recent cervical trauma, manipulation, or extreme exertion
Meningitis (Infectious Emergency)
Infectious emergency — immediate referral for lumbar puncture and empirical antibiotic therapy- 1.Fever + neck stiffness + headache
- 2.Altered level of consciousness, photophobia
- 3.Positive Kernig or Brudzinski sign
- 4.Petechiae or purpuric rash (meningococcemia)
Complementary Tests
INDICATION OF TESTS IN NECK PAIN
| TEST | WHEN TO ORDER | WHAT IT ASSESSES |
|---|---|---|
| Cervical radiograph | Trauma, deformity, suspected instability | Vertebral alignment, fractures, spondylosis |
| MRI | Persistent radicular symptoms, myelopathy | Discs, spinal cord, nerve roots |
| CT | Bone detail, complex fractures | Detailed bone anatomy |
| Electroneuromyography | Define level and severity of radiculopathy | Peripheral nerve function |
DIAGNÓSTICO DIFERENCIAL
Diagnóstico Diferencial
Cervical Disc Herniation
- Pain radiating to the arm
- Paresthesia in dermatome
- Positive Spurling sign
- Cervical myelopathy: clonus, hyperreflexia
Testes Diagnósticos
- Cervical MRI
- Electroneuromyography
Cervicobrachialgia
- Cervical pain + radiation to upper limb
- Follows dermatome
- May have sensory/motor deficit
Testes Diagnósticos
- Spurling test
- Cervical MRI
Cervical Myofascial Pain
Leia mais →- Trigger points in trapezius/SCM
- Associated tension-type headache
- No neurological abnormality
High efficacy of acupuncture for cervical trigger points
Cervical Spondylosis
Leia mais →- Discovertebral degeneration
- Progressive stiffness
- Radiology with osteophytes
Testes Diagnósticos
- Cervical radiograph
- MRI
Cervicogenic Headache
- Unilateral pain originating in the neck
- Worsens with cervical movements
- May mimic migraine
Testes Diagnósticos
- Diagnostic anesthetic block
Cervical Disc Herniation
Cervical disc herniation causes radiculopathy when disc material compresses a foraminal or central nerve root. The clinical picture differs from nonspecific neck pain by the presence of radiating pain to the upper limb following a specific dermatome (C6: thumb and index finger; C7: middle finger), accompanied by paresthesias and, in more severe cases, muscle weakness. The Spurling test — foraminal compression with ipsilateral inclination — is considered highly specific for cervical radiculopathy in diagnostic accuracy studies.
Cervical myelopathy is the most severe presentation, resulting from compression of the spinal cord. It manifests with difficulty performing fine motor tasks with the hands, spastic gait, hyperreflexia, and eventually sphincter dysfunction. Any sign of myelopathy demands urgent referral for neurosurgical evaluation, regardless of imaging findings.
Cervicobrachialgia
Cervicobrachialgia describes the combination of cervical pain with radiation to the upper limb, which may be of radicular origin (nerve root compression) or referred (myofascial or facet pain projected to the shoulder and arm). The distinction is clinically important: in true radicular origin, the pain follows a precise dermatome with possible neurological deficit; in referred pain, the pattern is more diffuse and without objective deficit.
The cervical traction test — which relieves pain by decoapting the facets and widening the foramina — distinguishes radicular from myofascial origin. Electroneuromyography is essential to confirm the level and severity of nerve injury when there is motor or sensory deficit, guiding the therapeutic decision between conservative treatment and surgical intervention.
Cervical Myofascial Pain
Cervical myofascial pain syndrome is extremely prevalent in clinical practice, especially in workers who use computers or maintain prolonged static posture. The most common trigger points are located in the upper trapezius, sternocleidomastoid (SCM), levator scapulae, and suboccipital muscles. Pressure on these points reproduces the characteristic referred pain — occipital headache in the case of suboccipitals, or pain in the shoulder and lateral aspect of the neck for the trapezius.
Medical acupuncture with dry needling of cervical trigger points is one of the most effective and rapid treatments available, producing immediate pain relief and lasting muscular relaxation. The medical acupuncturist can precisely identify trigger points and treat them in a single session, combining with postural guidance and strengthening exercises for the deep cervical flexors to prevent recurrence.
Cervical Spondylosis
Cervical spondylosis represents the natural degenerative process of the cervical spine — degeneration of intervertebral discs with loss of height, formation of osteophytes, hypertrophy of the uncovertebral and facet joints — and is practically universal above age 60. Radiographically, it presents narrowing of the disc spaces, osteophytes, and sclerosis of the vertebral endplates. The clinical problem is that these findings are frequent in asymptomatic patients.
Spondylosis can be completely asymptomatic or manifest as chronic neck pain with progressive stiffness and audible crepitus. The pain tends to be of mechanical character, worsens with movement, and improves with rest. When accompanied by osteophytes that narrow the foramina or vertebral canal, it can progress to radiculopathy or myelopathy, requiring investigation with MRI even in the absence of overt neurological deficit.
Cervicogenic Headache
Cervicogenic headache is a secondary headache originating in upper cervical structures (C0-C1, C1-C2, C2-C3 joints, occipital nerves), capable of mimicking migraine or tension-type headache. The classic clinical pattern includes unilateral pain that begins in the occipital region and radiates to the frontal and temporal area, worsens with cervical movements or compression of the upper cervical joints, and is frequently associated with ipsilateral cervical stiffness.
Differentiation from migraine is not always simple, since both can present with nausea and photophobia. Elements that favor cervicogenic headache include: onset with cervical movement, absence of aura, strictly unilateral pain without alternation of side, and pain on pressing the upper cervical joints. Diagnostic anesthetic block of the greater occipital nerve or of the C2-C3 joints with relief greater than 50% is confirmatory.
Treatments
Treatment of neck pain follows a stepwise approach, prioritizing conservative interventions. The combination of active and passive therapies demonstrates better results than any isolated intervention.
Therapeutic Approaches
TREATMENT OPTIONS FOR NECK PAIN
| TREATMENT | MECHANISM | EVIDENCE | RECOMMENDATION |
|---|---|---|---|
| Cervical strengthening exercises | Activation of deep flexors and stabilizers | Strong (level A) | First line — all patients |
| Mobilization/manipulation | Restores joint mobility and inhibits pain | Moderate (level B) | Combined with exercises |
| NSAIDs (short-term) | Reduction of inflammation and pain | Moderate (level B) | Acute phase, maximum 7-10 days |
| Acupuncture | Neuroendocrine pain modulation | Moderate (level B) | Adjuvant in chronic neck pain |
| Ergonomics and postural education | Reduction of biomechanical overload | Moderate (level B) | Prevention and maintenance |
| Cognitive-behavioral therapy | Management of catastrophizing and kinesiophobia | Moderate (level B) | When psychosocial factors present |
Cervical Exercises
Craniocervical flexion training is the exercise with the strongest evidence for chronic neck pain. It consists of selectively activating the deep flexor muscles of the neck (longus colli and longus capitis), which are typically inhibited in these patients.
Exercises for strengthening of the scapular musculature (lower and middle trapezius, serratus anterior) complement the program, since scapulothoracic stability is fundamental to cervical health.
Stretches of the upper trapezius, scalenes, and sternocleidomastoid help reduce excessive muscle tension but should be performed gently and never in isolation — always combined with strengthening.
Cervical Collar
The use of a cervical collar is strongly discouraged in nonspecific neck pain. Evidence shows that prolonged immobilization leads to muscle atrophy, loss of proprioception, and delay in recovery. The only clear indication is after trauma with documented instability.
Acupuncture as Treatment
Acupuncture is one of the most studied complementary therapies for neck pain. A Cochrane review concluded that acupuncture provides short-term pain relief superior to placebo in chronic neck pain, although long-term effects require further investigation.
Proposed mechanisms include modulation of descending inhibitory pain pathways, release of endorphins, and reduction of activity at cervical myofascial trigger points, which are extremely prevalent in this region.
The integration of acupuncture with cervical strengthening exercises and postural education is the approach with the best clinical results. Acupuncture can facilitate adherence to the exercise program by reducing pain in the early phases of treatment.
Prognosis
The prognosis of acute neck pain is generally good, with most patients showing significant improvement in 2 to 6 weeks. However, neck pain tends to recur more frequently than low back pain, and between 15-20% of cases become chronic.
Typical Course and Rehabilitation
Phase 1
0-2 weeksPain Control
Pain management with medication if necessary, ergonomic guidance, and initiation of gentle movement.
Phase 2
2-4 weeksMobility and Activation
Activation exercises for deep cervical flexors, light stretches, and progressive mobility.
Phase 3
4-8 weeksStrengthening
Progressive strengthening of cervical and scapulothoracic musculature, isometric and concentric resistance.
Phase 4
OngoingPrevention and Maintenance
Maintenance exercise program, workplace ergonomics, and self-management strategies.
Myths and Facts
Myth vs. Fact
Cracking the neck causes cervical osteoarthritis.
There is no evidence that cracking the joints causes osteoarthritis. The sound is produced by cavitation of synovial fluid and is generally harmless.
Neck pain is always caused by a herniated disc.
The vast majority (85-90%) of cases of neck pain are nonspecific, without disc herniation. Muscular and facet causes are much more common.
Wearing a cervical collar helps improve neck pain.
Except after trauma, the cervical collar is contraindicated. Immobilization weakens the musculature and delays recovery.
Orthopedic pillows cure neck pain.
Adequate pillows can improve comfort but do not treat the cause of neck pain. Exercises and postural correction are more effective.
Neck pain is something that only affects older adults.
Neck pain affects all age groups. Prevalence in young people has increased significantly with smartphone use.
When to Seek Medical Help
Most episodes of neck pain are benign and self-limited. However, some signs indicate serious conditions that require urgent medical evaluation.
Frequently Asked Questions about Neck Pain
Neck pain is pain localized in the cervical region of the spine, between the base of the skull and the first thoracic vertebra. The vast majority of cases (85-90%) are nonspecific, without an identifiable structural lesion, associated with inadequate posture, muscle tension, and sedentary lifestyle. Other causes include cervical spondylosis, disc herniation, myofascial pain syndrome, and, more rarely, serious causes such as fractures, tumors, or myelopathy. Excessive smartphone use and computer work are growing risk factors.
The most common symptoms include pain in the neck and nape, cervical stiffness with limitation of movement, headache that originates in the nape (cervicogenic), and referred pain to the shoulders and interscapular region. When there is nerve involvement, tingling and numbness in the arms following a specific dermatome may occur. Cervicogenic dizziness, crepitus on neck movement, and pain that worsens with prolonged screen use are frequent presentations in clinical practice.
The diagnosis is predominantly clinical, based on detailed history and physical examination. Specific tests such as the Spurling test (for radiculopathy) and the cervical traction test help identify nerve root compression. Imaging tests are only indicated in the presence of red flags (signs of myelopathy, trauma, suspected neoplasia) or when symptoms persist beyond 6 weeks without response to treatment. MRI is the test of choice when spinal cord compression is suspected.
First-line treatment includes strengthening exercises for the deep cervical flexors (greatest evidence), ergonomic correction, and postural education. NSAIDs may be used short-term in the acute phase. The cervical collar is strongly discouraged in nonspecific neck pain, as it causes muscle atrophy and delays recovery. Joint mobilization combined with exercises is effective for the subacute phase. Cognitive-behavioral therapy benefits patients with psychosocial factors present.
Acupuncture is recognized by the WHO and the Neck Pain Task Force as a therapeutic option for chronic neck pain. It acts by reducing the activity of cervical myofascial trigger points (extremely prevalent in this region), modulating descending inhibitory pain pathways, and releasing endorphins. Acupuncture facilitates adherence to the exercise program by reducing pain in the early phases, being especially effective when combined with cervical strengthening and postural guidance.
For chronic neck pain, a typical cycle consists of 8 to 10 sessions, performed 1-2 times per week. Many patients report improvement within the first 3-4 sessions. The medical acupuncturist evaluates the response to treatment and may recommend monthly maintenance sessions, especially in patients with persistent occupational factors (computer work, forced posture). For acute neck pain, 4-6 sessions are usually sufficient.
Medical acupuncture is very safe for neck pain when performed by a trained medical acupuncturist. Mild hematomas at the puncture site are the most common adverse effect. Contraindications include coagulation disorders, local infection, and, specifically for the cervical region, vertebrobasilar insufficiency (severe dizziness on neck rotation), which contraindicates any cervical manipulation. The physician always performs red-flag screening before initiating treatment.
Yes, the combination is the most effective approach. Acupuncture is enhanced when associated with cervical strengthening exercises, which constitutes the combination with the strongest scientific evidence. It can be integrated with ergonomic guidance, NSAIDs (when necessary), and physical therapy according to medical indication. The medical acupuncturist coordinates the therapeutic plan, ensuring that the interventions are complementary and safe.
Acute neck pain has an excellent prognosis, with improvement in 2 to 6 weeks in most cases. Neck pain tends to recur more frequently than low back pain — 15-20% of cases become chronic. Prognosis improves significantly with a maintenance exercise program, ergonomic correction of the work environment, and control of psychosocial factors. The presence of catastrophizing and fear of movement are the main predictors of chronification and should be addressed in treatment.
Seek the emergency department immediately if you have progressive weakness in the arms or legs, difficulty walking or loss of balance, difficulty performing fine motor movements with the hands, loss of bladder or bowel control, or severe neck pain after trauma (fall, accident). These signs may indicate cervical myelopathy or cervical instability — conditions that require urgent neurosurgical evaluation to prevent irreversible neurological damage.
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