If signs of radiculopathy are absent, differential diagnosis includes mechanical shoulder pain (tendinitis, bursitis, rotator cuff tear, dislocation, adhesive capsulitis, and cuff impingement under the acromion) and referred pain (subdiaphragmatic irritation, angina, Pancoast [apical lung] tumor). Mechanical pain is often worse at night, associated with shoulder tenderness, and aggravated by abduction, internal rotation, or extension of the arm.
Treatment: Neck and Shoulder Pain - Indications for cervical disk surgery are similar to those for lumbar disk; however, with cervical disease, an aggressive approach is indicated if spinal cord injury is threatened.
Neck Pain Without Radiculopathy - Spontaneous improvement is expected for most acute neck pain.
- Symptomatic treatment includes analgesic medications.
- If not related to trauma, supervised exercise appears to be effective.
- No valid clinical evidence to support cervical fusion or cervical disk arthroplasty.
- Low-level laser therapy may be effective but additional trials are needed.
- No evidence to support radiofrequency neurotomy or cervical facet injections.
Neck Pain with Radiculopathy - Natural history is favorable and many will improve without specific therapy.
- NSAIDs, acetaminophen, or both with or without muscle relaxants is appropriate initial therapy.
- Soft cervical collars are modestly helpful in limiting movements that exacerbate pain.
- Indications for surgery include a progressive radicular motor deficit, pain that limits function and fails to respond to conservative management, or spinal cord compression.
- Cervical spondylosis with bony, compressive cervical radiculopathy is generally treated with surgical decompression to interrupt the progression of neurologic signs although it is unclear if long-term outcomes are improved over medical therapy.
- Surgical options for cervical herniated disks consist of anterior cervical diskectomy alone, laminectomy with diskectomy, or diskectomy with fusion. The cumulative risk of subsequent radiculopathy or myelopathy at cervical segments adjacent to the fusion is ~3% per year and 26% per decade.
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