Kristin B. Gendron

Neck pain and torticollis (or “wry neck”) can be a result of disease of the musculoskeletal system or multiple other organ systems and may occur separately or concurrently. Degenerative disease of the cervical spine, disk herniation, and muscular strain are common causes of neck pain, but it is important to keep in mind that infectious, rheumatologic, and neoplastic etiologies among others can cause similar symptoms. Important factors in distinguishing the origin and type of neck pain include history pertaining to the onset of the pain, severity, timing (daytime vs nocturnal), and associated symptoms (fevers, chills, neurological symptoms, throat pain).

Torticollis in adults is often due to abnormalities of the atlantoaxial (C1–C2) joint or adjacent tissues, in which case it is usually accompanied by neck pain. However, torticollis may also be due to a generalized or focal dystonia, pharmacological effects, or other causes.

Neck pain that is aching in quality, worse with activity, and associated with decreased range of motion can be caused by the following:

Cervical spondylosis (cervical osteoarthritis): May present as neck pain alone, with radiculopathy (arm pain due to nerve root compression, often relieved by placing the affected hand on the head), or with cervical myelopathy (loss of manual dexterity, palmar paresthesias, subtle gait disturbance, possible urinary incontinence)

Cervical disk herniation: Presents in younger patients and may cause cervical radiculopathy

Cervical strain (muscular or ligamentous): Presents with nonradicular, non-focal neck pain anywhere from the skull base to the cervicothoracic junction. It may be associated with muscle spasms, occipital headaches, fatigue, irritability, and sleep disturbance.

Flexion-extension injury (“whiplash”). Most commonly after car accident. Symptoms may present minutes to hours after injury.

Cervical spine fracture: May be posttraumatic or secondary to tumors. Injuries causing fractures usually involve axial compression, hyperextension, or flexion-type trauma. It is important to consider malignancies that can metastasize to bone (breast, prostate, lung, kidney, stomach).

Atlantoaxial subluxation with or without basilar invagination (brainstem compression). This may be seen with trisomy 21 (Down syndrome), rheumatoid arthritis, and congenital odontoid anomalies. May present as untoward amount of flexion, posterior skull pain, torticollis, and numbness and paresthesias in the ulnar distribution.

Neck pain with morning stiffness that improves with activity can be caused by the following:

Fibromyalgia: Pain tends to be more diffuse, though patients often have multiple tender points throughout their body.

Polymyalgia rheumatica (neck, shoulder girdle, and pelvic girdle pain and stiffness): Important to keep in mind because up to 15% of cases are associated with temporal arteritis (eg, giant cell arteritis), which warrants aggressive therapy with high-dose steroids due to the risk of blindness.

Spondyloarthropathies (ankylosing spondylitis, Reiter syndrome/reactive arthritis, psoriatic arthritis, enteropathic arthritis): Cervical spine involvement is uncommon and is generally preceded by lumbar and thoracic disease, though early involvement may be seen in women.

Crowned dens syndrome (microcrystalline deposition in the cruciform ligament): Causes acute and chronic cervical pain and morning stiffness. Should be in the differential diagnosis for polymyalgia rheumatica. Computed tomographic findings are subtle, so high-resolution imaging of C1–C2 is recommended.

Neck pain in association with dysphagia, sore throat can arise from the following: