Neck pain is a common complaint in clinical practice, but determining when it warrants surgical evaluation is not always straightforward. Most patients improve with conservative measures such as physical therapy, anti-inflammatory medication or lifestyle modifications. However, for a subset of patients, particularly those with neurological deficits or progressive functional decline, early recognition and timely referral to a spine specialist are critical.
The decision to escalate care should be guided by the presence and persistence of neurologic symptoms, imaging findings and the patient’s response to nonoperative treatment. Delayed referral can prolong suffering and, in cases of spinal cord involvement, increase the risk of permanent impairment. Conversely, referring too early may expose patients to unnecessary surgical consideration when conservative measures could still provide relief.
In this article, Nebraska Medicine orthopaedic surgeon Scott Vincent, MD, discusses the evaluation process, clinical indicators for surgical referral and current surgical options for patients with refractory or progressive neck pain.
Diagnosis and evaluation of neck pain
In most patients, neck pain is related to degenerative changes or everyday wear and tear. Initial evaluation typically begins with a physical exam and a plain x-ray, assuming there are no concerning symptoms such as weakness, numbness or other neurological signs. When initial imaging is unremarkable, conservative management, including physical therapy and anti-inflammatory medications, is appropriate.
“If symptoms persist or worsen, advanced imaging such as MRI is often ordered to evaluate the spinal cord and nerve roots,” says Dr. Vincent. “MRI provides critical detail for identifying nerve compression and determining the next steps in management.”
Patients referred to Nebraska Medicine’s Spine Center are evaluated by spine surgeons or advanced practice providers. Advanced imaging is not required for referral. If indicated, it will be obtained during the evaluation. When surgical intervention is a possibility, patients meet with a surgeon to review imaging findings, treatment options and expected outcomes.
Determining when surgery is appropriate
Neck pain alone is rarely an indication for surgery. However, persistent or progressive neurological symptoms – such as arm pain, numbness, tingling or weakness in the extremities – signal the need for further evaluation if conservative care fails.
Dr. Vincent explained that a critical distinction in determining surgical necessity is whether the patient is experiencing cervical radiculopathy or cervical myelopathy.
- Cervical radiculopathy results from nerve root compression. It often produces unilateral symptoms, including arm pain, numbness, tingling or weakness. Most patients improve with nonoperative management.
- Cervical myelopathy involves spinal cord compression and typically presents with more diffuse symptoms such as numbness or tingling in the arms or legs, impaired balance, leg heaviness or difficulty with fine motor tasks like buttoning a shirt. Because myelopathy can progress and cause irreversible deficits, timely surgical referral is essential.
Surgical options for relieving neck pain
The surgical approach for neck pain depends on the underlying pathology and the number of levels involved. In general, radiculopathy is more often managed with an anterior approach, while myelopathy may require a posterior approach when multiple levels are affected.
- Anterior cervical discectomy and fusion (ACDF): The gold standard for decades, ACDF involves removing the damaged disc, placing a bone graft and securing the vertebrae with a plate to promote fusion. This approach has high success rates but sacrifices motion at the treated level.
- Disc replacement (disc arthroplasty): An alternative to fusion, this procedure decompresses the nerves and implants an artificial disc to preserve motion. Evidence suggests it may reduce the risk of adjacent segment disease and future surgery.
- Motion-sparing procedures (disc replacement, laminoplasty): These preserve range of motion and may reduce long-term stress on adjacent levels, often allowing faster recovery than fusion.
“Fusion remains a highly reliable surgery for neck pain,” says Dr. Vincent. “However, it’s limitations, including reduced motion and potential for adjacent level degeneration, make motion-preserving options increasingly attractive for select patients.”
Recovery and follow-up
Most anterior procedures, including ACDF and disc replacement, are performed on an outpatient basis. Many patients return home the same day. Recovery typically takes about six weeks. During that time, patients should avoid heavy lifting and strenuous activity. With appropriate healing, most patients resume normal activities without long-term restriction.
“Our patients receive structured follow-up after surgery,” says Dr. Vincent. “Routine follow-up extends for at least one year, and often up to two or three years, depending on patient progress and outcomes. This long-term partnership ensures sustained recovery and optimal functional improvement.”
For more information about surgical options for neck pain, or to refer a patient, call 800.922.0000 or visit NebraskaMed.com/Spine/Surgery.