Neck pain is a common reason for seeing a veterinarian, whether as a routine appointment, on an emergency basis and/or as an appointment to see a specialist. Cervical hyperesthesia, regardless of cause, can be subtle or debilitating, with varying degrees of severity between these two extremes. Such a clinical sign can be peracute, acute or chronic, with each of these historical aspects just as clinically relevant as another.
Neck pain can be a substantial contributor to overall quality of life. What makes cervical hyperesthesia seemingly more emergent to owners, when compared to hyperesthesia originating from, for example, the back, might be the accompanying clinical signs. Hunched posture, low head carriage, reluctance to walk or take stairs (notably, descending generally more problematic than ascending), inappetance, vocalizing, limping and/or holding a thoracic limb off the ground, gastrointestinal signs (likely due to the accompanying distress/anxiety, occasionally from an offending pharmaceutical within a medical regimen) and lethargy are common presenting complaints in dogs with neck pain and can be quite difficult to watch at home.
A general physical examination is invaluable in establishing the presence of neck pain. Vital parameters may demonstrate an elevated body temperature, whether hyperthermia or pyrexia, tachycardia and/or tachypnea. Often, it does not take much to elicit neck pain upon cervical palpation. One can generally start applying gentle, bilateral, medially-directed pressure on each pair of transverse processes within the cervical spine. Starting with a minimal amount of force often helps to establish a comfort zone with the patient. The most common behaviors shown by dogs with neck pain are vocalization, muscle spasms (often palpated and not directly seen), lower head carriage during and/or immediately after palpation and/or ear pinnae shifting caudally. Once discomfort is appreciated, further examination may only seek to disrupt the positive relationship between the veterinarian and patient, although further head and neck movements in a vertical/horizontal direction may further contribute to being more specific than the finding of generalized neck pain.
Neck pain can occasionally be misinterpreted as back pain, possibly from the head and neck movements during thoracolumbar palpation. Making the clinical diagnosis of neck pain can often be the greatest hurdle to jump over, especially in situations where the clinical signs are vague and/or the pain is difficult to elicit on examination whether due to severity or breed variability in stoicism.
Neck pain can originate from either one or multiple anatomic locations. Skin, sub-cutaneous tissues, vertebrae, articular facets, intervertebral disc, meninges and/or spinal cord are most commonly thought of as potential primary sources for neck pain. Thinking of these anatomic structures during examination can help the clinician when formulating a list of differential diagnoses incorporating a comprehensive list of disease categories.
Patient signalment is critical in helping to formulate a list of differential diagnoses. Although differential diagnoses are typically ordered from most common to least, it remains beneficial to have a comprehensive list of differential diagnoses to keep all possibilities open, as those more uncommon diseases will appear every now and then, depending on how many cases of neck pain are seen in any given veterinary clinic or hospital.
Once neck pain is established with an ordered list of differential diagnoses, a minimum database is often an excellent set of tests to start with. A CBC, chemistry, urinalysis and 4Dx might suggest systemic inflammation and/or systemic abnormalities, which, in keeping with clinical abnormalities found in addition to neck pain, such as pyrexia, joint pain, multifocal paraspinal hyperesthesia, will help order the differential diagnoses further.
Cervical orthogonal radiographs with the patient taken under sedation are not only important for establishing presence of lytic bone and/or endplate disease, intervertebral disc disease (mineralized intervertebral discs, narrowed intervertebral disc spaces, sclerotic end plates, opacification of intervertebral foramina), degenerative joint disease and spondylosis deformans, but they importantly serve as the only imaging modality taken in situations where the clinician feels conservative management is needed prior to considering further advanced testing modalities, most of which require general anesthesia.
Third tier testing, including MRI, CT, cerebrospinal fluid analysis, pathology review, joint aspirate and cytology, infectious disease titers and cerebrospinal fluid culture and sensitivity should be considered from the outset of initiating care, with clinical judgement and informed consent guiding the decision to start conservative management or pursue timely testing towards a definitive diagnosis. If conservative management is elected for prior to considering further testing, the importance of a means for follow-up within a week, either by email or phone, on behalf of the client to the veterinarian, cannot be overstated.
When considering conservative management in a dog with neck pain, (likely because the clinician feels with an otherwise normal general physical examination and given signalment there is a higher likelihood for intervertebral disc-related injury), rest and physical activity restrictions are advised in order to reduce the risks of either exacerbation and/or making the clinical situation worse. Minimizing free access to stairs, avoiding neck collars and rough play are typically recommended for a given period of time, usually on the order of weeks.
Conservative management usually involves some type of drug regimen in most cases. The benefits of a medical regimen, such as improved comfort, mobility and/or appetite, should be weighed against the potential risks, such as artificially causing a situation where a dog may feel better than it should and inadvertently set the stage to make a bad situation worse, directly contributing to gastrointestinal upset and/or delaying potential further tier testing in a situation where such testing is indicated.
Pharmaceuticals often employed in medical regimens for a conservative approach to neck pain include NSAIDs, gabapentin, tramadol, amantadine, opioid patch, methocarbamol and corticosteroids. An NSAID +/- amantadine is usually effective in situations of neck pain (i.e. soft-tissue injury, intervertebral disc related injury) that are going to respond to time, rest and medical management, although gabapentin and tramadol are additional considerations. A proposed timeframe for such a medical regimen is ~10-21 days, tapering the medication during this time. If the neck pain persists during/after this time period and/or further clinical signs become evident (additional body system involvement, lethargy, inappetance, progression of neck pain to include signs of myelopathy), prompt referral to a specialty hospital is recommended.
It is advisable to hold on recommending corticosteroids in this time of conservative management, as such therapy may falsely give the client and/or clinician the impression that the pet is improving and/or may make further diagnostic test results more challenging to interpret towards making a definitive diagnosis.
Adjunctive therapy, such as massage, acupuncture, and physical rehabilitation are excellent modalities to consider, but might be better considered once the cause of neck pain has been established and/or a degree of chronicity has been established for which a conservative regimen has been effective.