The cervical spine (neck bones) is the most flexible part of the spine. It lets us move our head forward and backward (protraction / retraction), look up and down (extension / flexion), turn side to side (rotation), and tilt our head to the side (lateral flexion).

The cervical spine has seven bones, called vertebrae, labeled C1 to C7. It’s split into two parts: the upper part (C1-C2) and the lower part (C3-C7). Most of these bones look similar to the bones in the upper and lower back. Each one has a main body (vertebral body), a part called the lamina, a central hole where the spinal cord goes through, and side holes (lateral foramen) where nerves come out.

One special feature about the bones in the neck is that they have extra holes on the sides called transverse foramen. These holes let important blood vessels, called vertebral arteries, pass through. These arteries help carry blood to the back part of the brain, through something called the Circle of Willis. These arteries are important to know about when doctors talk about the safety of certain neck treatments, like spinal adjustments.

The upper part of the neck (called the craniovertebral region) includes the first two bones of the spine, C1 (called the atlas) and C2 (called the axis). The atlas connects to the bottom of the skull. It also sits on top of the axis, and its connection with a part of the axis called the dens (or odontoid process) allows the head to turn. This connection is responsible for about half of the neck’s ability to rotate (about 45-50 degrees).

A strong band of tissue called the transverse ligament holds the dens in place. If this ligament is damaged, like from an injury, or in people with Down syndrome or rheumatoid arthritis, it can cause the spine to become unstable or might put pressure on the spinal cord. 

The lower part of the cervical spine includes bones C3 through C7. The most movement happens in the lower bones, especially C5 to C7. One special feature of this lower neck area is the uncovertebral joints, also known as the “Joints of von Luschka.” These small joints are found between the sides of the vertebrae and help stop too much side-to-side movement. They help keep the neck stable while still allowing it to move. But these joints are also where signs of age-related changes (degeneration) often show up first. Over time, stress on these joints can cause bone growths called osteophytes, which might press on nearby nerves as they pass through side openings (lateral foramen) in the spine.

Soft tissues of the neck:

The neck is a very important part of the body because it carries many organ systems through it. In the neck, you’ll find the thyroid gland, the voice box (larynx), the windpipe (trachea), the food pipe (esophagus), lymph nodes that drain the head, and major blood vessels like the carotid and vertebral arteries, and the jugular veins.

There are many ligaments in the cervical spine that help hold the bones together and keep the spine stable. These ligaments continue down into the middle (thoracic) and lower (lumbar) parts of the spine. Some run along the front and back of the bones (the longitudinal ligaments), while others connect the bony points that stick out at the back (spinous processes). 

One ligament that is special to the neck is the nuchal ligament. It goes from the base of the skull to the spinous processes of all the neck bones. Doctors can see this ligament during a pregnancy ultrasound to check for something called nuchal translucency, which can give clues about the baby’s health.

When it comes to movement, exercise, and injury recovery, some important muscles in the neck include the trapezius, sternocleidomastoid, and levator scapula. The trapezius and sternocleidomastoid help keep the neck stable and allow movement from side to side and front to back. They also help with breathing. These surface muscles are supported by deeper muscles like the longus collis, longus capitis, rectus capitis, and splenius, which help keep the head steady and upright during the day.

Causes of neck pain (cervicalgia)

Neck pain can happen for many reasons because the neck moves in different ways and has many types of tissues. These tissues include “hard” ones like bones and “soft” ones like muscles, tendons, ligaments, nerves, and the discs in between the bones. Similar to lower back pain, most neck pain is caused by mechanical stress, which is when unusual or repeated pressure is put on the neck. 

A) Sprains and strains:

Muscle strains and ligament sprains are very common causes of neck pain. These may be sudden (acute) or long-lasting (chronic). A strain happens when muscles or their tendons are stretched too much, often when they are used beyond their strength. This can occur from repeated stress over time (chronic) or from a sudden injury, like twisting or jerking the neck, which can happen during activities such as playing sports or in a car accident (like a whiplash injury).

B) Degenerative changes (spondylosis):

Spondylosis is a general term that refers to changes in the spine that happen as people get older. It includes problems like losing height in the discs, the formation of bony growths called osteophytes, and the wearing down of cartilage in the joints, which is known as osteoarthritis of the facet joints.

As we age, the soft, jelly-like center of the disc can lose its ability to retain water. This leads to a decrease in the height of the disc. Additionally, the ligaments that hold the bones together may become looser because of the reduced space between them. This can cause the bones to move over each other, a condition known as spondylolisthesis.

C) Herniated disc:

Herniated discs in the neck area happen more often in certain age groups and can be found in about 5-10% of people. The big question is whether these herniated discs actually cause symptoms, which determines whether or not treatment is needed. A herniated disc occurs when the soft, jelly-like center of the disc, called the nucleus pulposus, pushes out through a small tear in its tough outer layer, known as the annulus fibrosis. This usually happens at the back of the disc and can press on the spinal nerves that come out of the spinal cord. Sometimes, the jelly center can break through the outer layer completely. Discs can herniate due to injuries, lifting heavy objects, or simply because of aging and wear over time.

D) Posture: 

​The connection between posture and pain is complicated. Research has shown that people who experience pain do not always have a different posture compared to those who don’t feel pain. Sometimes, when people in pain get checked by doctors, their posture may be noted as “poor” just because they are there for an assessment. 

Posture can also change throughout the day. As we get older, our posture can shift, but this doesn’t always mean we will have more pain. However, having poor posture can make us bend forward for a long time, which can put extra stress on certain muscles. This can lead to tired muscles or injuries like sprains and strains.  

E) Stenosis:

​Stenosis is a medical term that means a passage in the body is narrower than normal. This narrowing can happen in the spine, which is made up of different sections: the cervical (neck), thoracic (upper back), and lumbar (lower back) areas. There are two types of stenosis: central stenosis, which affects the spinal cord, and lateral foraminal stenosis, which affects the openings where nerves leave the spine.

The most common reasons for both central and lateral foraminal stenosis are changes that happen to the bones and discs as people age, a condition known as spondylosis. When stenosis occurs in the neck, it can cause symptoms such as pain, numbness, tingling and weakness in the arms.

F) Diffuse idiopathic skeletal hyperostosis (DISH):

​DISH, which is also known as Forestier’s disease, is a condition that affects the spine. In DISH, the ligaments, which are tough bands of tissue that connect bones, become hard and inflexible. This can lead to pain and stiffness in the neck and back. 

DISH mostly impacts the middle (thoracic) and lower (lumbar) parts of the spine, but it can also affect the neck. When the neck is involved, some people may have trouble swallowing, a condition known as dysphagia. They may also feel pain in their shoulders or arms, which is called radicular pain. This occurs when pressure is placed on certain nerve roots.

The exact cause of DISH is not known, but it seems to happen more often in older people, especially men, and in those who have certain health issues like diabetes, high cholesterol, high blood pressure and obesity.

Neck Pain and Treatment Options

1. Therapeutic exercises: See next section.
2. Ergonomic modifications:

Ergonomic modifications are changes made to tools, workspaces, or tasks to make them more comfortable and efficient for people. These adjustments help prevent injuries and improve productivity by ensuring that the setup fits the person using it.

​It’s very important for people who work at desks to change their positions often. If someone sits at a desk for a long time without moving or has an uncomfortable workstation, they can develop problems with their posture, which may lead to strains, sprains, and repetitive stress injuries. To avoid these issues, it is recommended that desk workers change their position every 20 to 30 minutes. Here are some key ergonomic principles to follow:

1. Sitting Position: When you sit, make sure your feet are flat on the floor. Your ankles, knees, hips, and elbows should all bend at a 90-degree angle. You can rest your elbows on a surface if you prefer, but they should help your shoulders stay relaxed and pulled back.
2. Keyboard Use: When typing on the keyboard, your wrists should not bend back (extend) more than 15 degrees. To check this, make a fist with your hand from a neutral position. This is the maximum amount your wrist should extend while typing.
3. Mouse Placement: The mouse should be on the same level as your keyboard. You should be able to reach it without twisting (rotating) your shoulder more than 10 to 15 degrees.
4. Monitor Height: The distance of the monitor from your eyes depends on how well you can see, usually between 30 to 60 centimeters. However, the top of the monitor should be positioned so that your eyes are looking about 2.5 centimeters (or 1 inch) below the top of the monitor.
5. Back Support: No matter how strong your core muscles are, we tend to slouch over time. To prevent this, it is a good idea to use a lumbar roll, which is a small cushion or even a rolled-up towel. This will help support the natural curve of your lower back, ensuring that your spine distributes weight evenly.

A) Use of a cervical (neck) roll:

​Using too many pillows can feel nice, but it may lead to problems with your neck if you sleep on them for a long time. When your neck bends forward too much, it can put stress on the soft tissues in that area and cause pain or injury. To help keep your neck in a good position while you sleep, you can use a cervical roll, which is a small, supportive pillow. You can use it by itself or with a thin pillow. This helps maintain the natural curve of your neck whether you sleep on your back or side. Plus, it can keep your airway open, which is important for breathing well while you rest.

B) Activity modifications: 

To help with neck pain, it is important to limit activities that make the pain worse. Make sure to take breaks from sitting for a long time and try not to hunch forward. Moving regularly and keeping your neck flexible can also help lessen the pain.

C) Over-the-counter (OTC) medications: 

Analgesics: These are medications that help relieve pain. One common analgesic is acetaminophen, which is often sold under the brand name Tylenol. It’s important to take this medication exactly as your doctor directs.

NSAIDs: There are also non-steroidal anti-inflammatory drugs (NSAIDs) that reduce swelling (inflammation) and relieve pain. Ibuprofen (found in Advil or Motrin) and naproxen (sold as Aleve) are two examples. Like acetaminophen, you should take these medications as directed.

If your pain continues, your doctor might suggest other prescription medications. These may include muscle relaxants, medications for nerve pain, or drugs specifically designed for chronic pain management. Always discuss your options with your doctor to find the best solution for you.

D) Transcutaneous Electrical Nerve Stimulation (TENS): 

​TENS, which stands for Transcutaneous Electrical Nerve Stimulation, may be a helpful option for treating neck pain that is not related to cancer. This device works by sending small electrical signals to the skin. These signals help block pain messages from reaching the brain by competing with them in the body’s pain signaling system.

When using TENS for neck pain, the pads, also known as electrodes, are usually placed on the back of the neck. You can use either two or four pads depending on the treatment plan. Before using a TENS unit, it’s important to talk to a doctor or physical therapist. They can help you understand if TENS is right for you and show you the best way to place the electrodes.

E: Manual VS mechanical traction

​Traction, which can be done by a physical therapist or with special machines, is often used for people with spondylosis. Spondylosis is a condition where the spine starts to degenerate or wear down. This can cause the spaces between the discs in the spine to get smaller, which puts pressure on the nerve roots. Using traction helps to relieve that pressure by stretching the spine and making more room for the nerves.

Neck Therapeutic Exercises:

A) Cervical retractions

B) Mulligan Mobilizations With Movement

C) Upper/mid thoracic spine extensions 

D) Trapezius stretch 

E) Levator scapular stretch 

F) Strengthening of deep neck flexors and extensors