Pain in the neck is a common complaint. It is the product of a fast, mechanical life full of tension, lack of exercise and bad posture, use of cushy pillows and a soft bed. It may also be due to an injury. No specific cause can be pin-pointed. Some patients develop a stiff neck due to the incorrect positioning of the head in bed, especially while lying on the tummy with the head turned to one side. Sometimes the pain in the neck lasts for a few days and wears off on its own. But when it persists for a long time, it presents greater problems.

The cervical vertebrae have many peculiarities. They protect the spinal chord which carries practically all the nerves to the whole body. A disease of the cervical spine can have much wider effect than a similar disturbance in the dorsal or lumbar spine. The neck has to be mobile and yet it has no support like the ribs in the dorsal spine or the pelvis in the lumbar spine. It has to support the head and a considerable strain is borne by the neck when the arm muscles are put to vigorous use. It carries its own blood supply through the vertebral arteries and veins. These vessels are well protected in transverse processes, but they still experience mechanical problems.

Limitation of movement is one of three main problems. It may occur due to osteoarthritis of the cervical spine, which is called spondylosis. As a person grows old, there is always some generalised wear and tear of bones, including the cervical spine. The most common complaints mentioned are those of pain and stiffness in the neck. These generally occur in the three lowest cervical vertebrae. Patients are not able to turn their necks and look behind. This pain may radiate to the posterior part of the head or upper back between the two shoulder blades and to both shoulders. It is likely that only referred pain is prominent – that is, the patient may not complain of pain in the neck but pain between his shoulder blades only. These patients, especially women, often have swelling in the lower part of the neck. As the swelling subsides there is improvement of mobility and the pain is also reduced or relieved.

In this condition, there is degeneration of the disc between the vertebral bodies. A few osteophytes can be seen at the joint margins in an X-ray. These osteophytes may encroach upon the intervertebral foramen (the passages between the vertebrae) and reduce their size. This causes pressure on the cervical nerves. There may be numbness, tingling and a feeling of pins and needles in the hands. There is a tenderness over the muscles of the neck. Occasionally creaking sounds can be heard while moving the neck.

The therapeutic result of manipulation cannot be judged by changes seen in the X-ray. In advanced osteoarthritis excellent results are achieved with the spine recovering its normal range of movement and the pain completely subsiding. On other occasions, minor changes may take much longer to respond. When osteoarthritis involves facet joints, the results of manipulation are less satisfactory. In such cases manipulation which is too brisk should not be used; the technique must be gentle with a steady progress.

The patient should not be manipulated in an acute phase. A clear cut distinction must be made as to whether the problem is mechanical or inflammatory. In an inflammatory condition movement in al directions is painful. Cases of rheumatoid arthritis should not be manipulated. A preliminary test and examination of the patient will provide enough indication about the therapeutic success of manipulative treatment. In a majority of cases treatment is possible and induces immediate beneficial results upon the mobility of the spine. The pain and other complaints start getting better. Manipulative treatment of cervical spondylosis is therefore helpful. A few select exercises after the cure diminish any chance of recurrence.

Brachial Neuralgia

Sometimes the arm becomes painful. The pain shoots down one of the arms, accompanied by numbness and a tingling sensation in one or more fingers. This is due to irritation in the nerve roots emerging between the fourth cervical and the second thoracic vertebrae.

There are two factors which cause this pain:

First, pressure of the disc on the nerve root;

Second , inflammation of the nerve sheath or tissue contained in the intervertebral foramen. The pain may be in the entire upper arm or in a localised area depending upon the site of pressure. It may be a severe pain or a dull pain. It may increase during certain movements of the neck or on laughing. It usually increases when the patient is in bed and is relieved by certain movements, for example, placing one’s hand behind one’s head.

The patient usually complains of stiffness of the neck and pain between the shoulder blades for years before the disc begins to protrude. When the pain becomes acute, spreading over the upper limb, and the movements get restricted, it is then that the diagnosis of a disc prolapse can be made. A couple of more clinical tests confirm the diagnosis:

1. When the lower part of the neck is involved, movement in the painful side of the neck increases the pain, leading to a numbness in the arm.
   
   
   
2. When traction of the neck provides relief, it confirms the diagnosis.

A symptom frequently accompanying the pain may be in the form of weakness of the neck muscles. Sometimes the pain may be so severe that the patient has to hold his head while sitting. Even while turning his head in bed he may have to support it. If the pain has started following an injury, the patient may complain of pain several hours after the injury.

The site of pain, numbness, tingling, a feeling of pins and needles, weakening of the neck muscles, decrease in the muscle power and altered reflexes – all depend upon the level of the disc lesion. Clinical and neurological examination can determine the approximate site of the level of disc protrusion.

Treatment

In many cases of brachial neuralgia manipulation is quite effective. When there is acute pain and almost no movement of the neck is possible, manipulation should not be attempted. Prior to manipulation, immobilisation of the neck in a collar, rest and shortwave diathermy may be tried. In some cases where only a little movement is possible, manoeuvres to relax the muscles and gradual mobilisation are helpful. Manipulative manoeuvres should only be attempted when considerable movement in the neck is achieved.

Sometimes manipulation of the upper dorsal spine is also necessary along with cervical manipulation. In moderate cases manipulation can be immediately. The treatment must be conducted gently. This is more important in the region of the neck that in any other region.

Selective and gentle treatment is more effective. Thus treatment is given in the following order:

1. Relaxation of the cervical region, shoulders, muscles and upper back.
   
   
   
2. Mobilisation prior to manipulation.

Before manipulation, traction can be utilised, but in cases where traction has failed, manipulation must be given a fair trial. Following the reduction of disc herniation by manipulation, the patient can use the collar as a protection against strain.

Once the muscle spasm has subsided, the collar can be removed. Other physiotherapy methods may also be used. Patients should sleep on a hard bed without a pillow. Neck exercises should be started when the pain has completely subsided.

Case Histories

• A bankman aged forty-two years suffered for one and a half months from pain in the neck, which radiated to the right arm. He also felt numbness and a tingling sensation in the right arm. He experienced relief by raising his arm but felt more pain when the right arm was hanging down. He had a similar attack six years before but then the pain used to radiate to the left arm and subside with cervical traction. The pain, at that time, had lasted for one month. A similar pain had occurred six months ago, which had subsided in fifteen days with the same treatment.This time the pain was radiating in the right arm and nothing seemed to work in spite of medication and cervical traction. Manipulative treatment was started. He experienced considerable relief and the numbness and tingling completely subsided. By the third session of the treatment, he was ninety percent better. In six weeks he had no pain at all and has had no attack since.
  
  
  
• A cloth merchant aged forty-eight years complained of neck pain for six months. The pain radiated to the right arm. It was severe for three months. It started without any injury and went on increasing, being present all the time. He felt more pain during the evening after working the whole day. He felt stiffness in the neck when he got up in the morning. Medication and traction of the neck did not help. The X-ray showed no abnormality in the cervical spine. The laboratory tests were all normal. He felt a lot of relief for 2-3 days after the first manipulative treatment. The treatment was repeated again after one week and the improvement was remarkable. After four weeks he was free of pain. Now two years have passed and he has had no repetition of pain.
  
  
  
• A young housewife from kanpur, aged twenty-four, had been suffering from pain in the neck for four years. It started without any apparent cause and went on increasing, radiating to both arms, especially when she worked without wearing a collar. She consulted an orthopaedic surgeon and was advised medication and traction, and then given a collar which she used for three years. When she came to me, an X-ray of her cervical spine was taken again and it showed no change from the previous X-ray. Her laboratory tests were all normal. Manipulative treatment was started for her cervical and upper dorsal spine. Her pain started getting less from the very first day of treatment. She was advised to use the collar for shorter periods, and that too only when she felt the pain. Within a month, she stopped using the collar. The pain was seventy-five per cent better. She obtained complete relief in two months. A year later I received greetings from her giving me the good news that she no longer suffered from any pain.