Chronic neck pain: when to see a pain specialist

Why the neck hurts: mechanisms of neck pain

The cervical spine is a highly mobile structure that supports a heavy head all day long. That necessary mobility also makes it especially prone to wear and tear. Each cervical vertebra articulates with the next through an intervertebral disc and two facet joints, and running inside the spinal canal are the spinal cord and the nerve roots that provide sensation and movement to the arms and hands.

When we talk about chronic neck pain, we mean pain that persists for more than three months. At that point we are no longer dealing with a simple muscle strain: what predominates is a combination of joint changes, secondary muscle tightness, sensitization of the nervous system and, in many cases, irritation of nerve roots that travel toward the shoulders and arms.

That is why chronic neck pain presents in different ways depending on which structure is the main generator of the problem, and why it is worth identifying the source before continuing to try treatments at random.

One nuance I repeat often in the office: cervical imaging in adults very frequently shows degenerative findings — disc disease, facet joint osteoarthritis, the occasional small herniation — that may or may not be related to the current pain. So finding a cervical herniated disc on an MRI is not enough to conclude that it is the cause: the symptoms have to match the affected nerve root. In the neck, moreover, there are pain generators that MRI does not show well — the facet joints, for example — which can only be diagnosed clinically and, when appropriate, with specific diagnostic blocks.

Most common causes of chronic neck pain

Cervical facet joint syndrome

The cervical facet joints wear down over time and are a very common cause of neck pain, especially after age 45. The pain is usually localized and gets worse when holding the neck in one position (working at a computer, for example), looking upward, or rotating the head. It tends to respond very well to cervical facet joint blocks and, in selected cases, to medial branch radiofrequency ablation.

Cervical herniated disc

When a cervical intervertebral disc herniates, it can compress a nerve root and produce pain that radiates into the shoulder, arm and fingers, often with tingling, numbness or loss of strength. Most cervical herniated discs improve with medical treatment, targeted physical therapy and, when indicated, image-guided epidural or nerve root injections.

Cervicogenic headache

Many patients seek care for "headaches" without knowing the source is in the neck. The first three cervical vertebrae contain structures that can produce pain referred to the scalp, the back of the head, the temples and the area behind the eyes. Greater occipital nerve blocks and procedures targeting the C2-C3 joint are highly effective when this pattern is identified.

Cervical myelopathy

When degenerative changes compress the spinal cord and not just the nerve roots, different symptoms appear: difficulty coordinating the hands, a feeling of unsteadiness when walking, weakness in the legs. This situation requires immediate evaluation by neurosurgery.

Cervical myofascial pain

Deep muscle tightness in the trapezius, the scalenes or the suboccipital muscles can produce trigger points that are painful and refer pain elsewhere. It is a very common cause in people who spend many hours in front of a screen. Treatment combines physical therapy, trigger point injections and postural correction.

When anti-inflammatories stop being enough

It is a situation I see all the time: a patient takes ibuprofen or diclofenac every day, at first it helps somewhat, then less and less, and finally "it doesn't do anything anymore". That progression has a clear clinical explanation.

Non-steroidal anti-inflammatory drugs are useful in the first weeks of acute pain, when inflammation predominates. But once the pain becomes chronic, other mechanisms take over: sensitization of the nervous system, facet joint pain, neuropathic pain from nerve root irritation, myofascial pain. None of these responds to anti-inflammatories.

Increasing the dose only increases the risks: gastritis, stomach ulcers, kidney failure, high blood pressure, cardiovascular events. If you have been taking NSAIDs every day for more than a month, that is a clear signal to seek evaluation.

Treatment options without surgery

The approach to chronic neck pain is stepwise and always aims to start with the least invasive option. At the visit we determine the main pain generator and design a personalized plan that usually combines several of these tools:

• Medication adjustment: often the problem is not a lack of anti-inflammatories but a lack of the right medication. For cervical neuropathic pain, gabapentinoids and certain low-dose antidepressants are usually far more effective than NSAIDs.
• Targeted physical therapy: not all physical therapy is the same. Deep cervical stabilization work, postural correction and well-applied myofascial release techniques can change the picture.
• Image-guided cervical facet joint blocks: under ultrasound or fluoroscopy, we deliver medication directly into the affected facet joints. They usually relieve pain for weeks to months.
• Cervical radiofrequency ablation: when blocks confirm a facet joint origin, medial branch radiofrequency ablation extends the relief for 9 to 18 months in selected patients.
• Cervical epidural injections: for herniated discs with intense radicular pain, they are an alternative to surgery in many cases.
• Regenerative medicine: platelet-rich plasma can be useful in some associated facet or tendon conditions.

Cervical surgery is reserved for cases with a clear indication: myelopathy, herniation with progressive motor deficit, instability. Most patients with chronic neck pain benefit from non-surgical treatments.

My criteria for deciding that neck pain warrants evaluation by a pain specialist are similar to those for low back pain: more than 6 to 12 weeks without response to initial conservative treatment, pain radiating into the arm that persists beyond a month, recurrent episodes affecting sleep or quality of life, or any presentation associated with neurological deficit. Red flags — progressive weakness in the arms or legs, gait disturbance, loss of bladder or bowel control, a history of cancer — require immediate evaluation, without waiting out any timeline. The rest can initially be managed at a primary level, but if it doesn't improve within that window, there is no point in continuing to try the same thing.

When to see a specialist

There is no single rule, but these situations usually indicate that a specific evaluation is worthwhile:

• Neck pain persisting more than three months despite initial treatment.
• Pain that does not respond to common painkillers or that requires progressively stronger medication.
• Pain radiating to the shoulder or arm with tingling, numbness or loss of strength.
• Recurrent headaches you suspect may originate in the neck.
• Neck pain that limits your work, your rest or your daily activities.
• If you have been told you need neck surgery and want a second opinion on minimally invasive alternatives.

To me, successful treatment of chronic neck pain doesn't end when the patient stops hurting, but when they build habits that keep it from coming back: active strengthening of the neck and shoulder-blade muscles, stress management when there is a significant tension component, workstation adjustments and active breaks during the day. Relapses in chronic neck pain are common when treatment is limited to putting out the acute episode without addressing the causes that sustain it. When a patient understands how their neck works and what triggers it, the frequency and intensity of flare-ups drop considerably — and that is what defines long-term success.

Dr. Mauricio Casarsa

Anesthesiologist, specialist in Pain Medicine and Interventional Pain Management. Postgraduate training at UBA (Fundación Dolor) and UNLP (CAIDBA). Staff physician at Hospital Alemán, Buenos Aires.

MN 137756 · San Isidro · Villa Urquiza