Installment 2 of the “Neck Owners Manual” (Read installment 1)
What causes neck pain? If you have chronic neck pain, you’ve likely heard many different reasons about why your neck hurts – from tight muscles to bulging discs to neck bones that aren’t aligned. What if I told you that what’s causing the pain is only half the battle, the other half is figuring out why it hurts. Makes sense, right? However, 90% of the alternative or traditional medical care used for neck pain is solely based on getting rid of symptoms, hence they only provide short term relief.
To understand what hurts in your neck, you need to understand it’s different parts. I could spend an entire book going over exactly what’s in your neck and how it works. However, I’m going to do that in one paragraph, so hang on…
You have neck bones that stack on top of one another with discs in between that act as spacers. Your spinal cord carries electrical impulses from your brain and your arms and body and it travels through a hole in these bones. When all of the bones are stacked together these holes create the “spinal canal”. There are also holes between each two stacked neck bones called foramina and this is where the individual spinal nerves exit. There are small joints (about the size of those in your fingers) that articulate in the back of the neck between each two stacked neck bones – these are called facet joints. Finally there are ligaments that act as duct tape to hold the whole thing together and then muscles and fascia to stabilize the neck and to allow you to move your head.
So to understand why your neck may hurt, you have to realize that many of these parts of the neck can be injured or become degenerated due to wear and tear and cause pain. I’ll break these down into their component parts:
1. The disc spacers (a.k.a. intervertebral disc)
2. The spinal cord and nerves
3. The small joints (a.k.a. facet joints)
4. The muscles
Also, to understand why your neck hurts, you also need to know that there are protective systems in the neck that can fail, causing more damage to parts that can cause pain. Here’s that list:
1. The ligaments and muscles that stabilize the neck bones
2. The natural curve and overall alignment of your neck
4. The fascial connections to the rest of the body
So to summarize, there are structures in your neck that as they become injured or degenerated can cause pain (pain generators) and there are protective networks of muscles, ligaments, and fascia that can fail and lead to more damage to the structural parts. In fact, this duality between the simple structural pain generators and the more complex issue of how those parts got injured creates two kinds of medical approaches to the neck. The first “pain generator” approach is usually used by interventional spine physicians and spine surgeons. The focus is to ID the painful area with diagnostic numbing injections or an MRI. The second more complex approach (we’ll call it “Understanding the Biomechanics”) involves detecting the failure of the natural protective mechanisms of the neck and is regrettably less commonly used by physicians.
The “Pain Generator” versus “Understanding the Biomechanics”
As I describe each component part of the neck, I’ll describe what it looks like and how it works. However, before I do that it’s likely best to understand that the main reason a good number patients with neck pain never get any long-term relief is that too much emphasis is placed on the first part of the equation and a lack of understanding of the second part. Meaning an overemphasis on what I call “finding the magic pain generator” with no time or resources spent on figuring out why something got injured or became degenerative (the biomechanics).
I spent the first part of my career focusing on finding pain generators either through injection or imaging. This means injecting parts of the neck that may hurt with numbing agents under sophisticated fluoroscopic guidance to find the one spot that’s causing most of the pain. Another way this is done is to get what I call the “magic” MRI film. This method is often used by surgeons. The approach here is that some structural problem seen on the image will directly correlate with where the patient hurts. While the first approach can be helpful in some patients, relying too heavily on a neck MRI is a sure fire way to misdiagnose patients. Isn’t the MRI film the modern Oracle of Delphi that tells all truths about why the neck hurts? Not even close, as study after study has shown that MRI findings in the spine are often meaningless. In essence, we have many patients with nothing on their MRI with loads of pain and many with horrible MRIs who have no pain.
Both the the injection based way to find the pain (called a diagnostic block) and relying solely on MRI have two problems. The concept is simple – numb out the “pain generator” and if most of the patient’s pain goes away, you have a diagnosis. This is what happens for example when a doctor does facet injections in the neck to find the one or two joints causing neck pain. If the patient reports that most his or her normal pain is numbed out, then those joints are causing pain. Or with an MRI, find what appears to look abnormal on the image and that must be causing the pain. While in theory these simple and elegant approaches make lots of sense, in reality they have two main problems.
The two main issues with the pain generator approach are that it doesn’t help identify why the painful area failed and it produces poor results when multiple parts break and are painful. Since this approach doesn’t fix the problem that caused the pain in the first place, whatever the doctor does to “fix” the painful part, since the cause is still there, the part will just break again. Think about your car for a second, if the tires are wearing too much because of a wheel that’s misaligned or is wobbling too much because of a loose attachment, then replacing the tire is only a “Band-aid” fix. The tire will wear out again. The same holds true for the body, whatever can be done to help the pain in the broken and painful part will be a temporary fix if the cause for why the part failed isn’t also addressed.
The second problem with the pain generator approach is that it produces poor results in patients that have multiple things that are causing pain. For example, doctors trained in this approach are taught to find one thing that’s causing most of the pain. While this works in some patients, in others, numbing out one painful part of many doesn’t ever produce much pain relief. For example, if the facet joints are causing pain and there’s also a pinched nerve in the neck, numbing out just the joints still leaves the nerve painful, so the patient won’t report much relief. Of the if MRI shows a bulging disc pressing on a nerve but the nerve and the facet joints hurt (the later issue is invisible to MRI) than surgically removing the offending bulge only helps part of the pain.
In summary, while most physician specialists who treat neck pain today use the pain generator approach, it ignores the cause of why certain parts of the neck hurt and it can frequently miss problems. Hence, while we occasionally use this approach, we also always focus on the biomechanics. In fact, understanding the protective mechanisms of the neck and how their failure causes the component parts to get more injured or degenerative is so important that we’ll begin our understanding of how the neck works by first learning how these systems protect you. We’ll then give a shout out to each component part and finally we’ll go through each symptom and what can cause that complaint and how to fix it.
Next Up-Understanding How Your Neck Protects Itself…