Pain in the cervical spine: clinical aspects and approaches to treatment

   Pain in the cervical spine is a widespread and socially significant problem. Its frequency increases with age, and its occurrence is associated with a complex of biological, psychosocial, and occupational risk factors. In most cases, the pain is benign. In unfavourable cases, chronic pain syndrome may develop. The key clinical step is to rule out specific causes of pain. The most common sources of pain in the cervical spine are facet joints, intervertebral discs, nerve roots (radiculopathy) or myofascial structures. The most important principle is to divide non-specific pain into acute and chronic, which determines further tactics. The article analyses current data on the pathogenesis, diagnostic approaches and principles of treatment of pain in the cervical spine. The possibilities of non-drug treatment methods, as well as drug therapy, primarily with non-steroidal anti-inflammatory drugs and centrally acting muscle relaxants, are discussed. The need for a multimodal and individualised approach aimed at pain relief, restoration of functional status and prevention of chronic pain syndrome is emphasised.

1. Fejer R, Kyvik KO, Hartvigsen J. The prevalence of neck pain in the world population : a systematic critical review of the literature. Eur Spine J. 2006 Jun;15(6):834-48. doi: 10.1007/s00586-004-0864-4

2. Vasseljen O, Woodhouse A, Bjorngaard JH, Leivseth L. Natural course of acute neck and low back pain in the general population: the HUNT study. Pain. 2013 Aug;154(8):1237-44. doi: 10.1016/j.pain.2013.03.032

3. Linton SJ. A review of psychological risk factors in back and neck pain. Spine (Phila Pa 1976). 2000 May 1;25(9):1148-56. doi: 10.1097/00007632-200005010-00017

4. Cohen SP, Hooten WM. Advances in the diagnosis and management of neck pain. BMJ. 2017 Aug 14;358:j3221. doi: 10.1136/bmj.j3221

5. Liu R, Kurihara C, Tsai HT, et al. Classification and Treatment of Chronic Neck Pain: A Longitudinal Cohort Study. Reg Anesth Pain Med. 2017 Jan/Feb;42(1):52-61. doi: 10.1097/AAP.0000000000000505

6. Beith ID, Kemp A, Kenyon J, et al. Identifying neuropathic back and leg pain: a cross-sectional study. Pain. 2011 Jul;152(7):1511-6. doi: 10.1016/j.pain.2011.02.033

7. Falco FJ, Datta S, Manchikanti L, et al. An updated review of the diagnostic utility of cervical facet joint injections. Pain Physician. 2012 Nov-Dec;15(6):E807-38.

8. MacVicar J, Borowczyk JM, MacVicar AM, et al. Cervical medial branch radiofrequency neurotomy in New Zealand. Pain Med. 2012 May;13(5):647-54. doi: 10.1111/j.1526-4637.2012.01351.x

9. Nevalainen MT, Foran PJ, Roedl JB, et al. Cervical facet oedema: prevalence, correlation to symptoms, and follow-up imaging. Clin Radiol. 2016 Jun;71(6):570-5. doi: 10.1016/j.crad.2016.02.026

10. Fukui S, Ohseto K, Shiotani M, et al. Referred pain distribution of the cervical zygapophyseal joints and cervical dorsal rami. Pain. 1996 Nov;68(1):79-83. doi: 10.1016/S0304-3959(96)03173-9

11. Barnsley L, Lord S, Wallis B, Bogduk N. False-positive rates of cervical zygapophysial joint blocks. Clin J Pain. 1993 Jun;9(2):124-30. doi: 10.1097/00002508-199306000-00007

12. Van Eerd M, de Meij N, Dortangs E, et al. Long-term follow-up of cervical facet medial branch radiofrequency treatment with the single posterior-lateral approach: an exploratory study. Pain Pract. 2014 Jan;14(1):8-15. doi: 10.1111/papr.12043

13. Okada E, Matsumoto M, Ichihara D, et al. Aging of the cervical spine in healthy volunteers: a 10-year longitudinal magnetic resonance imaging study. Spine (Phila Pa 1976). 2009 Apr 1;34(7):706-12. doi: 10.1097/BRS.0b013e31819c2003

14. Adams MA, Lama P, Zehra U, Dolan P. Why do some intervertebral discs degenerate, when others (in the same spine) do not? Clin Anat. 2015 Mar;28(2):195-204. doi: 10.1002/ca.22404

15. Grubb SA, Kelly CK. Cervical discography: clinical implications from 12 years of experience. Spine (Phila Pa 1976). 2000 Jun 1;25(11):1382-9. doi: 10.1097/00007632-200006010-00010

16. Yin W, Bogduk N. The nature of neck pain in a private pain clinic in the United States. Pain Med. 2008 Mar;9(2):196-203. doi: 10.1111/j.1526-4637.2007.00369.x

17. Onyewu O, Manchikanti L, Falco FJ, et al. An update of the appraisal of the accuracy and utility of cervical discography in chronic neck pain. Pain Physician. 2012 Nov-Dec;15(6):E777-806.

18. Bogduk N, Aprill C. On the nature of neck pain, discography and cervical zygapophysial joint blocks. Pain. 1993 Aug;54(2):213-7. doi: 10.1016/0304-3959(93)90211-7

19. Woods BI, Hilibrand AS. Cervical radiculopathy: epidemiology, etiology, diagnosis, and treatment. J Spinal Disord Tech. 2015 Jun;28(5):E251-9.

20. Matsumoto M, Fujimura Y, Suzuki N, et al. MRI of cervical intervertebral discs in asymptomatic subjects. J Bone Joint Surg Br. 1998 Jan;80(1):19-24. doi: 10.1302/0301-620x.80b1.7929

21. Radhakrishnan K, Litchy WJ, O'Fallon WM, Kurland LT. Epidemiology of cervical radiculopathy. A population-based study from Rochester, Minnesota, 1976 through 1990. Brain. 1994 Apr;117 ( Pt 2):325-35. doi: 10.1093/brain/117.2.325

22. Assmus H, Antoniadis G, Bischoff C. Carpal and cubital tunnel and other, rarer nerve compression syndromes. Dtsch Arztebl Int. 2015 Jan 5;112(1-2):14-25; quiz 26. doi: 10.3238/arztebl.2015.0014

23. Sari H, Akarirmak U, Uludag M. Active myofascial trigger points might be more frequent in patients with cervical radiculopathy. Eur J Phys Rehabil Med. 2012 Jun;48(2):237-44.

24. Rubinstein SM, Pool JJ, van Tulder MW, et al. A systematic review of the diagnostic accuracy of provocative tests of the neck for diagnosing cervical radiculopathy. Eur Spine J. 2007 Mar;16(3):307-19. doi: 10.1007/s00586-006-0225-6

25. Ghasemi M, Golabchi K, Mousavi SA, et al. The value of provocative tests in diagnosis of cervical radiculopathy. J Res Med Sci. 2013 Mar;18(Suppl 1):S35-8.

26. Bono CM, Ghiselli G, Gilbert TJ, et al. An evidence-based clinical guideline for the diagnosis and treatment of cervical radiculopathy from degenerative disorders. Spine J. 2011 Jan;11(1):64-72. doi: 10.1016/j.spinee.2010.10.023

27. Kuijper B, Tans JT, van der Kallen BF, et al. Root compression on MRI compared with clinical findings in patients with recent onset cervical radiculopathy. J Neurol Neurosurg Psychiatry. 2011 May;82(5):561-3. doi: 10.1136/jnnp.2010.217182

28. Wong JJ, Cote P, Quesnele JJ, et al. The course and prognostic factors of symptomatic cervical disc herniation with radiculopathy : a systematic review of the literature. Spine J. 2014 Aug 1;14(8):1781-9. doi: 10.1016/j.spinee.2014.02.032

29. Maigne JY, Deligne L. Computed tomographic follow-up study of 21 cases of nonoperatively treated cervical intervertebral soft disc herniation. Spine (Phila Pa 1976). 1994 Jan 15;19(2):189-91. doi: 10.1097/00007632-199401001-00013

30. Melancia JL, Francisco AF, Antunes JL. Spinal stenosis. Handb Clin Neurol. 2014;119:541-9. doi: 10.1016/B978-0-7020-4086-3.00035-7

31. Nouri A, Tetreault L, Singh A, et al. Degenerative Cervical Myelopathy: Epidemiology, Genetics, and Pathogenesis. Spine (Phila Pa 1976). 2015 Jun 15;40(12):E675-93. doi: 10.1097/BRS.0000000000000913

32. Shimomura T, Sumi M, Nishida K, et al. Prognostic factors for deterioration of patients with cervical spondylotic myelopathy after non-surgical treatment. Spine (Phila Pa 1976). 2007 Oct;32(22):2474-9. doi: 10.1097/BRS.0b013e3181573aee

33. Fehlings MG, Wilson JR, Yoon ST, et al. Symptomatic progression of cervical myelopathy and the role of nonsurgical management: a consensus statement. Spine (Phila Pa 1976). 2013 Oct;38(22 Suppl 1):S19-20. doi: 10.1097/BRS.0b013e3182a7f4de

34. Kuan TS. Current studies on myofascial pain syndrome. Curr Pain Headache Rep. 2009 Oct;13(5):365-9. doi: 10.1007/s11916-009-0059-0

35. Jaeger B. Myofascial trigger point pain. Alpha Omegan. 2013 Spring-Summer;106(1-2):14-22.

36. Chiarotto A, Clijsen R, Fernandez-de-Las-Penas C, Barbero M. Prevalence of Myofascial Trigger Points in Spinal Disorders : A Systematic Review and Meta-Analysis. Arch Phys Med Rehabil. 2016 Feb;97(2):316-37. doi: 10.1016/j.apmr.2015.09.021

37. Audette JF, Wang F, Smith H. Bilateral activation of motor unit potentials with unilateral needle stimulation of active myofascial trigger points. Am J Phys Med Rehabil. 2004 May;83(5):368-74, quiz 375-7, 389. doi: 10.1097/01.phm.0000118037.61143.7c

38. Wytrazek M, Huber J, Lisinski P. Changes in muscle activity determine progression of clinical symptoms in patients with chronic spine-related muscle pain. A complex clinical and neurophysiological approach. Funct Neurol. 2011 Jul-Sep;26(3):141-9.

39. Taheri N, Okhovatian F, Rezasoltani A, et al. Ultrasonography in Diagnosis of Myofascial Pain Syndrome and Reliability of Novel Ultrasonic Indexes of Upper Trapezius Muscle. Ortop Traumatol Rehabil. 2016 Mar 23;18(2):149-54. doi: 10.5604/15093492.1205022

40. Mukhametzyanova AKh, Parfenov VA, Isaikin AI. Management of patients with nonspecific neck pain. Russian Journal of Pain. 2024;22(1):40-6 (In Russ.). doi: 10.17116/pain20242201140

41. Parfenov VA, Yakhno NN, Kukushkin ML, et al. Non-specific neck pain (cervicalgia). Guidelines of the Russian Society for the Study of Pain (RSSP). Nevrologiya, neiropsikhiatriya, psikhosomatika = Neurology, Neuropsychiatry, Psychosomatics. 2023;15(5):4-12 (In Russ.). doi: 10.14412/2074-27112023-5-4-12

42. Expert Panel on Neurological Imaging; McDonald MA, Kirsch CFE, et al. ACR Appropriateness Criteria® Cervical Neck Pain or Cervical Radiculopathy. J Am Coll Radiol. 2019 May;16(5S):S57-S76. doi: 10.1016/j.jacr.2019.02.023

43. Hidalgo B, Hall T, Bossert J, et al. The efficacy of manual therapy and exercise for treating non-specific neck pain : A systematic review. J Back Musculoskelet Rehabil. 2017 Nov 6;30(6):1149-69. doi: 10.3233/BMR-169615

44. Wilhelm M, Cleland J, Carroll A, et al. The combined effects of manual therapy and exercise on pain and related disability for individuals with nonspecific neck pain : A systematic review with meta-analysis. J Man Manip Ther. 2023 Dec;31(6):393-407. doi: 10.1080/10669817.2023.2202895

45. Price J, Rushton A, Tyros I, et al. Effectiveness and optimal dosage of exercise training for chronic non-specific neck pain : A systematic review with a narrative synthesis. PLoS One. 2020 Jun 10;15(6):e0234511. doi: 10.1371/journal.pone.0234511

46. Cote P, Wong JJ, Sutton D, et al. Management of neck pain and associated disorders: A clinical practice guideline from the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration. Eur Spine J. 2016 Jul;25(7):2000-22. doi: 10.1007/s00586-016-4467-7

47. Gross AR, Lee H, Ezzo J, et al. Massage for neck pain. Cochrane Database Syst Rev. 2024 Feb 28;2(2):CD004871. doi: 10.1002/14651858.CD004871.pub5

48. Kuijper B, Tans JT, Beelen A, et al. Cervical collar or physiotherapy versus wait and see policy for recent onset cervical radiculopathy: randomised trial. BMJ. 2009 Oct 7;339:b3883. doi: 10.1136/bmj.b3883

49. Cramer H, Klose P, Brinkhaus B, et al. Effects of yoga on chronic neck pain : a systematic review and meta-analysis. Clin Rehabil. 2017 Nov;31(11):1457-65. doi: 10.1177/0269215517698735

50. Daher A, Carel RS, Tzipi K, et al. The effectiveness of an aerobic exercise training on patients with neck pain during a short- and long-term follow-up: a prospective double-blind randomized controlled trial. Clin Rehabil. 2020 May;34(5):617-29. doi: 10.1177/0269215520912000

51. Bindu S, Mazumder S, Bandyopadhyay U. Non-steroidal anti-inflammatory drugs (NSAIDs) and organ damage: A current perspective. Biochem Pharmacol. 2020 Oct;180:114147. doi: 10.1016/j.bcp.2020.114147

52. Syggelos SA, Giannopoulou E, Gouvousis PA, et al. In vitro effects of non-steroidal anti-inflammatory drugs on cytokine, prostanoid and matrix metalloproteinase production by interface membranes from loose hip or knee endoprostheses. Osteoarthritis Cartilage. 2007 May;15(5):531-42. doi: 10.1016/j.joca.2006.11.003

53. Alvarez-Soria MA, Herrero-Beaumont G, Moreno-Rubio J, et al. Long-term NSAID treatment directly decreases COX-2 and mPGES-1 production in the articular cartilage of patients with osteoarthritis. Osteoarthritis Cartilage. 2008 Dec;16(12):1484-93. doi: 10.1016/j.joca.2008.04.022

54. Gonzalez-Alvaro I, Carmona L, Diaz-Gonzalez F, et al. Aceclofenac, a new nonsteroidal antiinflammatory drug, decreases the expression and function of some adhesion molecules on human neutrophils. J Rheumatol. 1996 Apr;23(4):723-9.

55. Samartsev IN, Zhivolupov SA, Parshin MS, Magomedov KR. Open observational study with a retrospective analysis of the efficacy and tolerability of aceclofenac in patients with acute non-specific low back pain. S.S. Korsakov Journal of Neurology and Psychiatry. 2024;124(12):99-105 (In Russ.). doi: 10.17116/jnevro202412412199

56. Patel PB, Patel TK. Efficacy and safety of aceclofenac in osteoarthritis: A meta-analysis of randomized controlled trials. Eur J Rheumatol. 2017 Mar;4(1):11-8. doi: 10.5152/eurjrheum.2017.160080

57. Ward DE, Veys EM, Bowdler JM, Roma J. Comparison of aceclofenac with diclofenac in the treatment of osteoarthritis. Clin Rheumatol. 1995 Nov;14(6):656-62. doi: 10.1007/BF02207932

58. Jung SY, Jang EJ, Nam SW, et al. Comparative effectiveness of oral pharmacologic interventions for knee osteoarthritis: A network meta-analysis. Mod Rheumatol. 2018 Nov;28(6):1021-8. doi: 10.1080/14397595.2018.1439694

59. Llorente Melero MJ, Tenias Burillo JM, Zaragoza Marcet A. Comparative incidence of upper gastrointestinal bleeding associated with individual non-steroidal anti-inflammatory drugs. Rev Esp Enferm Dig. 2002 Jan;94(1):7-18.

60. Laporte JR, Ibanez L, Vidal X, et al. Upper gastrointestinal bleeding associated with the use of NSAIDs: newer versus older agents. Drug Saf. 2004;27(6):411-20. doi: 10.2165/00002018-200427060-00005

61. Castellsague J, Riera-Guardia N, Calingaert B, et al. Individual NSAIDs and upper gastrointestinal complications : a systematic review and meta-analysis of observational studies (the SOS project). Drug Saf. 2012 Dec 1;35(12):1127-46. doi: 10.2165/11633470-000000000-00000

62. Masclee GMC, Straatman H, Arfe A, et al. Risk of acute myocardial infarction during use of individual NSAIDs: A nested case-control study from the SOS project. PLoS One. 2018 Nov 1;13(11):e0204746. doi: 10.1371/journal.pone.0204746

63. Schink T, Kollhorst B, Varas Lorenzo C, et al. Risk of ischemic stroke and the use of individual non-steroidal anti-inflammatory drugs: A multi-country European database study within the SOS Project. PLoS One. 2018 Sep 19;13(9):e0203362. doi: 10.1371/journal.pone.0203362

64. Samartcev IN, Zhivolupov SA, Parshin MS. An open-label observational study of the efficacy and tolerability of rapidly dissolving forms of aceclofenac and nimesulide for oral use in the treatment of patients with acute non-specific low back pain (ASTRA study). S.S. Korsakov Journal of Neurology and Psychiatry. 2025;125(12):141-7 (In Russ.). doi: 10.17116/jnevro2025125121141

65. Hsieh LF, Hong CZ, Chern SH, Chen CC. Efficacy and side effects of diclofenac patch in treatment of patients with myofascial pain syndrome of the upper trapezius. J Pain Symptom Manage. 2010 Jan;39(1):116-25. doi: 10.1016/j.jpainsymman.2009.05.016

66. Predel HG, Giannetti B, Pabst H, et al. Efficacy and safety of diclofenac diethylamine 1.16 % gel in acute neck pain: a randomized, double-blind, placebo-controlled study. BMC Musculoskelet Disord. 2013 Aug 21;14:250. doi: 10.1186/1471-2474-14-250

67. Haroutiunian S, Drennan DA, Lipman AG. Topical NSAID therapy for musculoskeletal pain. Pain Med. 2010 Apr;11(4):535-49. doi: 10.1111/j.1526-4637.2010.00809.x

68. Cashin AG, Wand BM, O'Connell NE, et al. Pharmacological treatments for low back pain in adults : an overview of Cochrane Reviews. Cochrane Database Syst Rev. 2023 Apr 4;4(4):CD013815. doi: 10.1002/14651858.CD013815.pub2

69. Wewege MA, Bagg MK, Jones MD, et al. Comparative effectiveness and safety of analgesic medicines for adults with acute non-specific low back pain : systematic review and network meta-analysis. BMJ. 2023 Mar 22;380:e072962. doi: 10.1136/bmj-2022-072962

70. Bhattacharjya B, Naser SM, Biswas A. Effectiveness of tolperisone hydrochloride with aceclofenac as combined therapy in acute low back pain. Indian J Phys Med Rehabil. 2012 Jun;23(2):74-8. Available at: https://www.ijopmr.com/doi/pdf/10.5005/ijopmr-23-2-74

71. Titova NV, Putyatin IA. Muscle relaxant selection criteria for musculoskeletal pain. Russian Journal of Pain. 2024;22(4):55-64 (In Russ.). doi: 10.17116/pain20242204155

72. Kohne-Volland R. Клиническое исследование мидокалма (толперизона гидрохлорида). Качественная клиническая практика. 2002;(1):29-39. – Kohne-Volland R. Clinical study of mydocalm (tolperisone hydrochloride). Good Clinical Practice. 2002;(1):29-39 (In Russ.).

73. Scott NA, Guo B, Barton PM, Gerwin RD. Trigger point injections for chronic non-malignant musculoskeletal pain : a systematic review. Pain Med. 2009 Jan;10(1):54-69. doi: 10.1111/j.1526-4637.2008.00526.x

74. Fernandez-Carnero J, Gilarranz-de-Frutos L, Leon-Hernandez JV, et al. Effectiveness of Different Deep Dry Needling Dosages in the Treatment of Patients With Cervical Myofascial Pain: A Pilot RCT. Am J Phys Med Rehabil. 2017 Oct;96(10):726-33. doi: 10.1097/PHM.0000000000000733

75. Kiralp MZ, Ari H, Karabekir I, Dursun H. Comparison of low intensity laser therapy and trigger point injection in the management of myofascial pain syndrome. Pain Clin. 2006 Jan;18(1):63-6. doi: 10.1163/156856906775249794

76. Sterling M, Vicenzino B, Souvlis T, Connelly LB. Dry-needling and exercise for chronic whiplash-associated disorders: a randomized single-blind placebo-controlled trial. Pain. 2015 Apr;156(4):635-43. doi: 10.1097/01.j.pain.0000460359.40116.c1

77. Byrn C, Olsson I, Falkheden L, et al. Subcutaneous sterile water injections for chronic neck and shoulder pain following whiplash injuries. Lancet. 1993 Feb 20;341(8843):449-52. doi: 10.1016/0140-6736(93)90204-t

78. Ghasemi M, Masaeli A, Rezvani M, et al. Oral prednisolone in the treatment of cervical radiculopathy: A randomized placebo controlled trial. J Res Med Sci. 2013 Mar;18(Suppl 1):S43-6.

79. Kwon JW, Lee JW, Kim SH, et al. Cervical interlaminar epidural steroid injection for neck pain and cervical radiculopathy: effect and prognostic factors. Skeletal Radiol. 2007 May;36(5):431-6. doi: 10.1007/s00256-006-0258-2

80. Levin OS, Makotrova TA. Vertebrogenic cervical radiculopathy. RMJ. 2012;(12):621 (In Russ.).