What are the causes and treatments of numbness in the neck?

Numbness in the Neck: Causes and Treatment

Immediate Assessment Priority

Numbness in the neck requires urgent evaluation for serious underlying pathology, particularly neurological deficits, malignancy, infection, or vascular causes, before considering benign mechanical etiologies. 1, 2

Red Flag Assessment

You must immediately screen for the following serious conditions:

• Neurological deficits - Assess for cranial neuropathy, myelopathy, or radiculopathy that could indicate spinal cord compression or nerve root involvement 1, 2, 3
• Malignancy indicators - Unexplained weight loss, history of cancer, constitutional symptoms, or progressive symptoms warrant immediate investigation 2, 4
• Infection signs - Fever, elevated inflammatory markers (CRP/ESR), immunosuppression, or IV drug use history 2, 4
• Vascular pathology - Pulsatile masses, bruits, or symptoms suggesting arteriovenous malformation 1
• Trauma history - Recent injury with risk factors for fracture or ligamentous injury 2, 5
• Inflammatory arthritis - Morning stiffness, systemic symptoms, elevated inflammatory markers 2, 4

Physical Examination Specifics

Perform a targeted neurological examination focusing on:

• Cranial nerve testing - Numbness may indicate involvement of CN V (trigeminal), CN VII (facial), or CN IX-XII depending on distribution 1
• Sensory mapping - Document exact distribution of numbness to localize lesion from nucleus to peripheral nerve 1
• Motor examination - Weakness, atrophy, or fasciculations suggest nerve root or cord involvement 3, 6
• Neck palpation - Assess for masses, lymphadenopathy, or tenderness that could indicate structural pathology 1, 2
• Range of motion - Limitation with neurological symptoms suggests mechanical compression 2, 7

Diagnostic Approach Based on Findings

If Red Flags Present:

MRI of the cervical spine without contrast is the imaging modality of choice when red flags are identified, as it provides superior soft tissue evaluation for infection, malignancy, cord compression, or inflammatory processes. 2, 4, 7

• CT with contrast may be added if bony detail is needed or MRI is contraindicated 1
• Do NOT delay imaging when red flags are present 2, 4
• Consider extending imaging to include the skull base if cranial neuropathy is suspected 1

If No Red Flags Present:

• Imaging is NOT recommended initially - Most neck symptoms resolve with conservative management 2, 5, 7
• MRI has high rates of abnormal findings in asymptomatic individuals that do not correlate with symptoms 2, 7
• Reserve imaging for symptoms refractory to 6-8 weeks of conservative treatment 2, 7

Common Causes by Clinical Pattern

Cervical Radiculopathy:

• Nerve root compression from herniated disc or bone spurs produces radiating arm numbness, not isolated neck numbness 3, 6
• Typically includes dermatomal sensory loss and may have motor weakness 6

Cervical Myelopathy:

• Spinal cord compression causes bilateral symptoms, gait disturbance, and upper motor neuron signs 3
• This is a surgical emergency requiring prompt decompression 3

Cranial Neuropathy:

• Isolated numbness in specific nerve distributions (e.g., jaw/chin numbness in CN V) may indicate malignancy, particularly if progressive 1, 8
• Requires complete evaluation from brainstem nuclei to peripheral nerve distribution 1

Cervical Proprioception Impairment:

• Chronic neck pain can cause altered sensation through muscle dysfunction and mechanoreceptor changes 9
• This is a benign cause but requires specific sensorimotor retraining 9

Treatment Algorithm

Conservative Management (No Red Flags):

• Exercise therapy - Most effective evidence-based treatment for mechanical neck pain 7
• NSAIDs - For pain control in acute presentations 5, 7
• Physical therapy - Focus on cervical proprioception retraining if sensory disturbance persists 9
• Avoid cervical collars - No benefit and potential complications; use only briefly if needed 5, 6
• Reassess in 6-8 weeks - If no improvement, proceed to MRI 2, 7

When Imaging Reveals Pathology:

• Radiculopathy - Multimodal approach including physical therapy, medications for neuropathic pain, and selective nerve blocks if refractory 6
• Myelopathy - Surgical decompression indicated as natural history shows stepwise deterioration 3
• Mass lesions - Fine needle aspiration is the initial diagnostic test for neck masses 1
• Malignancy - Urgent referral to oncology or appropriate surgical specialist 1, 4

Critical Pitfalls to Avoid

• Do not assume cystic masses are benign - High rate of malignancy in cystic neck masses requires continued evaluation until diagnosis confirmed 1
• Do not order imaging without red flags - Leads to overdiagnosis of incidental findings that don't correlate with symptoms 2, 7
• Do not miss "numb chin syndrome" - Isolated jaw/chin numbness can be the presenting symptom of malignancy 8
• Do not delay MRI when red flags present - Elevated inflammatory markers, constitutional symptoms, or progressive neurological deficits require urgent imaging 2, 4
• Do not perform open biopsy before FNA - Fine needle aspiration should always be attempted first for neck masses 1

Prognosis

• Most acute neck pain resolves within 7-8 weeks with conservative treatment 5, 7
• Approximately 50% may have persistent mild symptoms at one year 5, 7
• Myelopathy has poor natural history and requires surgical intervention 3
• Radiculopathy has favorable prognosis with most improving nonoperatively 6