Introduction
Neck and back pain are incredibly prevalent complaints encountered across various medical specialties, including orthopedics, pediatrics, emergency medicine, and general practice [1]. Diagnosing the underlying cause of neck and back pain can be challenging due to the extensive range of potential diagnoses. Even experienced clinicians can find it difficult to arrive at a precise diagnosis without a systematic and thorough approach. While common conditions such as cervical radiculopathy due to disc herniation are often readily identifiable through patient history and physical examination, differentiating them from rarer or more complex pathologies requires a broad understanding of potential etiologies. For instance, delayed diagnosis is frequently observed in cases of spinal infections, such as fungal infections, which can significantly impact patient outcomes [2]. Therefore, a comprehensive and efficient method for differential diagnosis is crucial. Such a method should aid clinicians in narrowing down the list of possible diagnoses, minimizing unnecessary diagnostic tests, and expediting the time to a definitive diagnosis.
This article aims to present a practical and systematic approach to classifying the diverse etiologies of neck pain based on key clinical criteria. Our objective is to provide a roadmap that facilitates the navigation through the extensive differential diagnosis of neck pain, guiding clinicians towards appropriate diagnostic tests and imaging studies to confirm or exclude specific conditions. Brief definitions of each disorder will be provided to offer a broad overview, rather than exhaustive descriptions of individual pathologies.
While numerous publications address the diagnostic workup of low back pain, often focusing on acute versus chronic pain and “red flags” for serious conditions [3], the specific approach to cervical neck pain is often extrapolated from the lumbar spine literature. This can be problematic, as focusing solely on one anatomical region might lead to overlooking crucial considerations specific to the cervical spine. This review provides a comprehensive and practically applicable systematic approach specifically tailored for diagnosing patients presenting with neck pain, alongside back pain considerations.
Literature Review
Referred Pain
Referred pain, a crucial consideration in neck pain diagnosis, is characterized by pain perceived in the neck region despite the actual pathology originating elsewhere. Crucially, local signs and tenderness upon palpation and movement of the cervical spine are typically absent [4, 5]. It is paramount to recognize that neck pain can stem from pathological processes outside the spinal column itself [6]. For example, acute myocardial infarction, particularly ischemia of the inferior myocardium, can manifest as neck and jaw pain, often accompanied by chest discomfort, shortness of breath, sweating, and palpitations. Aortic dissection can cause sudden, severe neck and upper back pain. Early signs such as ischemic shock or tachycardia may not always be immediately apparent, and diminished pulses in the upper extremities could be an initial indicator. Pulmonary conditions such as pulmonary embolism, pleuritis, and pneumothorax can also trigger referred neck and upper back pain. Lung cancer, especially tumors extending to the upper posterior thorax, can be a source of thoracic and neck pain.
Intra-abdominal pathologies should also be considered in the differential diagnosis of neck pain. While less common, conditions like esophageal spasm or rupture can refer pain to the neck and upper back. Gallbladder disease and pancreatitis can occasionally present with upper back and referred neck pain. Renal pathologies, such as kidney stones or pyelonephritis, may cause flank pain that radiates upwards, potentially including the neck region, often accompanied by urinary symptoms. Certain gynecological problems, such as endometriosis and pelvic inflammatory disease, although more commonly associated with lower back pain, can, in some instances, contribute to referred pain patterns extending into the neck. Brainstem tumors, although rare, can present with neck pain, potentially accompanied by neurological abnormalities or gait disturbances.
Trauma and Overuse
Trauma and overuse injuries are frequent culprits in neck pain. Traumatic fractures, dislocations, and ligamentous tears of the cervical spine can result from significant impacts. However, a history of trauma may not always be readily apparent, particularly in patients with altered consciousness, cognitive impairment, or in nonverbal children. Conversely, a reported history of trauma doesn’t automatically confirm a traumatic etiology and might be a misleading indicator, diverting attention from the actual underlying cause. Strains and sprains of the cervical spine, representing low-energy injuries, overuse, or excessive stretching of neck muscles, tendons, or ligaments, are common. Whiplash injuries, frequently resulting from motor vehicle accidents, are a well-documented cause of neck pain and associated symptoms [7]. “Clay shoveler’s fracture”, an avulsion fracture of the spinous processes, typically at the cervicothoracic junction, can occur due to sudden forceful neck flexion, either from trauma or repetitive overuse.
SCIWORA (spinal cord injury without radiographic abnormality) is a critical consideration in pediatric neck trauma, referring to spinal cord injury without apparent fracture or dislocation on standard radiographs [8]. MRI is essential for diagnosing SCIWORA, revealing spinal cord contusion or other soft tissue injuries. Central cord syndrome, often resulting from hyperextension injuries to the neck, particularly in older individuals with pre-existing cervical spondylosis, compresses the spinal cord centrally. It manifests with greater weakness in the upper extremities compared to the lower extremities, along with potential urinary retention and sensory disturbances. Pathological fractures of the cervical spine, resulting from osteoporosis, infection, or tumors, can occur with minimal or no trauma. Stress fractures in the cervical spine are less common than in the lumbar spine but can occur in athletes engaging in repetitive neck extension activities.
Apophysitis of the vertebra (Scheuermann’s disease/osteochondrosis) primarily affects the thoracic spine but can also occur in the cervical spine in adolescents. Neck pain may be present, but often the condition is painless, presenting with postural changes. Neurological deficits are uncommon. Brown-Sequard syndrome, resulting from hemicord injury (traumatic or tumor-related), can occur in the cervical spine. It presents with ipsilateral paralysis and loss of proprioception, and contralateral loss of pain and temperature sensation below the lesion level.
Infection
Infections of the cervical spine are serious conditions that can cause significant neck pain. Osteomyelitis and discitis can affect the cervical vertebrae and intervertebral discs, causing gradual or sudden onset of neck pain, potentially accompanied by fever and chills. The pain is typically constant, may worsen at night, and progressively intensifies without treatment. In children, spondylodiscitis can present with neck stiffness, torticollis, or referred pain to the shoulder or arm, sometimes without prominent neck pain itself. Epidural abscess in the cervical spine is a critical emergency, characterized by severe neck pain, fever, chills, and rapidly progressive neurological deficits due to spinal cord compression. Partial treatment with antibiotics can mask the severity of the presentation. Paraspinal abscess, while less common in the cervical region, can cause persistent fever and neck pain that may radiate along nerve pathways.
Fungal infections of the spine, including the cervical region, are more frequent in immunocompromised individuals and can cause neck pain with varying neurological symptoms due to spinal cord or nerve root compression [2]. Tuberculosis of the cervical spine (Pott’s disease) is a chronic infection causing slowly progressive neck pain, stiffness, deformity (kyphosis), and potential neurological complications. Brucellosis can involve the cervical spine, causing fever, systemic symptoms, and neck pain with vertebral microabscesses. Gonorrhea and Syphilis, although rare, can cause spinal infections, including meningitis or gumma formation in the spinal canal, leading to cervical myelopathy or radiculopathy [10]. Herpes zoster (shingles) can cause severe, dermatomal neck pain preceding the characteristic vesicular rash by 2-3 days. In some cases (zoster sine herpete), the rash may not appear at all, making diagnosis challenging. Viral infections, such as influenza and COVID-19, can cause generalized musculoskeletal pain, including neck pain, potentially preceding fever and other systemic symptoms [11]. Acute flaccid myelitis, a rare but serious condition, can present with fever, neck and back pain, and flaccid paralysis of varying severity, with minimal sensory involvement and potential cranial nerve dysfunction [13].
Tumor
Tumors of the cervical spine, both benign and malignant, can manifest as neck pain. Benign tumors, such as osteoid osteoma and osteoblastoma, can cause gradually worsening neck pain, often characterized by night pain unrelated to activity [14]. Eosinophilic granuloma and Langerhans cell histiocytosis can affect cervical vertebrae, causing neck pain and characteristic “vertebra plana” appearance on imaging [15]. Tumors of neural tissue, such as schwannomas and neurofibromas, arising from cervical nerve roots, can cause radicular neck pain and neurological symptoms. Calcifying pseudoneoplasm of the spine (“CAPNON”) is a rare benign tumor that can cause mass effect in the cervical spine, leading to neck pain, weakness, and gait disturbances [16]. Meningiomas, arising from the spinal meninges, can also occur in the cervical region, causing similar symptoms.
Malignant tumors of the cervical spine are less common than metastases. Metastases from distant primary cancers (lung, breast, prostate, kidney, thyroid) are the most frequent malignant tumors in the cervical spine, particularly in older adults. Multiple myeloma and lymphoma, hematologic malignancies, can also involve the cervical spine. Primary bone tumors, such as chondrosarcoma and osteosarcoma, and Ewing’s sarcoma (more common in younger individuals), can occur in the cervical spine, causing neck pain and potential neurological compromise. Chordoma, while most common in the sacrococcygeal region, can rarely affect the cervical spine [17].
Degenerative, Rheumatic, and Autoimmune Conditions
Degenerative conditions are a major cause of chronic neck pain. Intervertebral disc degeneration and herniation in the cervical spine are extremely common, causing neck pain, often radiating into the arm (cervical radiculopathy). Axial neck pain may be present or absent. Nociceptive nerve fibers within the degenerated disc, sensitized by inflammatory cytokines, can cause “discogenic neck pain” [18]. In adolescents, cervical disc herniation can be associated with separation of the apophyseal ring [19]. Cervical spondylosis, encompassing degenerative changes in the cervical discs, facet joints, and ligaments, is a frequent cause of chronic neck pain and stiffness. Cervical spinal stenosis, narrowing of the spinal canal, can compress the spinal cord, leading to cervical myelopathy. Cervical myelopathy manifests with gait ataxia, upper extremity weakness and clumsiness, sensory disturbances, and bowel/bladder dysfunction [22].
Degeneration of the cervical facet joints (cervical osteoarthritis) causes “mechanical” neck pain, worsened by neck extension, rotation, and prolonged postures. Osteophytes (bone spurs) can form at any cervical level, contributing to neck pain and potentially nerve root compression. Spondylolisthesis and cervical instability, although less common than in the lumbar spine, can cause mechanical neck pain and potential neurological symptoms. Costovertebral joint problems in the upper thoracic spine can refer pain to the neck and shoulder region [23]. Diffuse idiopathic skeletal hyperostosis (DISH) can affect the cervical spine, causing neck pain and stiffness [25]. “Crowned dens syndrome”, caused by calcium pyrophosphate crystal deposition around the odontoid process of C2, presents with acute, severe neck pain and stiffness, often mimicking meningitis [26].
Spondyloarthropathies can involve the cervical spine. Ankylosing spondylitis and psoriatic arthritis can cause inflammatory neck pain and stiffness, often associated with sacroiliac joint involvement. Rheumatoid arthritis (RA) frequently affects the upper cervical spine and craniocervical junction, leading to atlantoaxial subluxation, superior odontoid migration, and subaxial subluxation, potentially causing cervical myelopathy and neck pain [27]. Systemic lupus erythematosus (SLE) can also affect the cervical spine, causing myelitis, vasculitis, and atlantoaxial instability [28]. Polymyalgia rheumatica presents with neck, shoulder girdle, and hip pain, particularly in the morning, accompanied by systemic symptoms. Fibromyalgia and myofascial pain syndrome can cause chronic neck pain, often with widespread pain and tenderness in other areas. Transverse myelitis, an inflammation of the spinal cord, most commonly thoracic, can sometimes affect the cervical cord, causing neck pain and rapidly progressive motor and sensory deficits [30]. Arachnoiditis, a chronic inflammation of the spinal arachnoid membrane, can occur in the cervical region, potentially causing chronic neck pain and neurological symptoms [31]. Synovitis, Acne, pustulosis, hyperostosis, and osteitis (SAPHO) syndrome can involve the cervical spine, causing pain and hyperostosis [32]. Gout can rarely affect the cervical spine, causing erosive arthritis and tophi formation [10].
Vascular Disorders
Vascular disorders affecting the cervical spinal cord are rare but can cause neck pain and neurological deficits. Obstruction of the vertebral artery or anterior spinal artery, often due to atherosclerosis or dissection, can cause spinal cord infarction. Cervical spinal cord infarction typically presents with sudden onset of severe neck pain, weakness, and sensory loss [33]. Arteriovenous malformations (AVMs) of the spinal cord can occur in the cervical region, causing radicular neck pain or sudden pain with neurological symptoms due to hemorrhage [34]. Aggressive spinal hemangiomas, although more common in the thoracic and lumbar spine, can rarely occur in the cervical spine, potentially compressing the spinal cord and causing neck pain and myelopathy [35]. Epidural or subdural hematoma of the cervical spine, resulting from trauma, coagulopathy, or procedures, can cause sudden, severe neck pain and neurological deficits due to cord compression [36]. Wegener’s granulomatosis and other vasculitides can rarely affect the cervical spine, causing myelopathy due to spinal cord compression or vasculitis [37].
Congenital and Developmental Conditions
Congenital malformations of the cervical spine, such as hemivertebrae and block vertebrae, can cause spinal deformity, potentially leading to mechanical neck pain due to altered biomechanics and degenerative changes in adjacent segments. Syrinx (syringomyelia), a fluid-filled cavity within the spinal cord, often in the cervical region, is usually caused by Chiari malformation or other conditions obstructing CSF flow [38]. Cervical syrinx can cause neck pain and a characteristic “cape-like” distribution of sensory loss (pain and temperature sensation) in the upper extremities, along with weakness and clumsiness. Chiari malformations, involving herniation of cerebellar tonsils into the foramen magnum, are frequently associated with cervical syrinx and can cause headaches, neck pain, and various neurological symptoms, including myelopathy and cerebellar dysfunction. Klippel-Feil syndrome, characterized by congenital fusion of cervical vertebrae, can cause neck pain, limited neck motion, and scoliosis. Atlantoaxial instability, particularly in individuals with Down syndrome or certain connective tissue disorders, can cause neck pain and potential spinal cord compression. Congenital torticollis (wryneck) presents with neck pain and limited range of motion from birth, often due to sternocleidomastoid muscle contracture [46].
Psychogenic Pain
Psychogenic neck pain, also termed somatoform pain disorder or conversion disorder, is diagnosed after excluding organic causes of neck pain. Complaints of neck pain are common in somatoform disorders, conversion disorders, and malingering [40]. Diagnosis is made by exclusion of other pathologies and requires careful psychological evaluation.
Metabolic and Endocrine Disorders
Metabolic and endocrine disorders can indirectly contribute to neck pain. Paget’s disease of bone can affect the cervical spine, causing bone pain and potential nerve root or spinal cord compression due to vertebral enlargement [41]. Hyperparathyroidism and renal osteodystrophy can cause generalized bone pain, including neck pain, and increased risk of pathological fractures and “brown tumors” in the cervical spine. Osteomalacia can cause diffuse skeletal pain, including neck pain [41]. Ochronosis (alkaptonuria) can cause disc calcification and degeneration throughout the spine, including the cervical region, leading to neck pain and arthritic changes [42].
Iatrogenic Causes
Iatrogenic causes of neck pain include failed neck surgery syndrome, referring to persistent or recurrent neck pain after cervical spine surgery [43]. This can be due to various factors, including recurrent disc herniation, adjacent segment disease, spinal stenosis, instability, epidural fibrosis, arachnoiditis, or infection. Certain medications can also induce musculoskeletal pain, including neck pain, as a side effect. Statins, bisphosphonates (especially risedronate), aromatase inhibitors, and isoretinoin have been implicated in causing musculoskeletal pain [44].
Idiopathic Neck Pain
Idiopathic neck pain refers to neck pain without a clearly identifiable underlying cause after thorough investigation. Sarcoidosis of the spine, although rare, can involve the cervical spine, affecting the bone, meninges, or spinal cord, causing neck pain and neurological symptoms [45]. Torticollis, involuntary muscle contraction in the neck, often involving the sternocleidomastoid muscle, is frequently idiopathic but can also be secondary to trauma, muscle inflammation, infection, medications, or tumors [46].
Neck Pain in Pregnancy
Neck pain during pregnancy can be caused by any of the aforementioned disorders. However, pregnancy-related hormonal and biomechanical changes can also contribute to neck discomfort. While low back and pelvic girdle pain are more common, postural changes and ligamentous laxity during pregnancy can sometimes exacerbate pre-existing neck issues or contribute to new-onset neck pain. Any neck pain during pregnancy that is severe, progressive, or associated with neurological symptoms warrants thorough investigation to exclude serious underlying pathologies.
Method: A Clinical Classification for Cervical Neck Pain
To streamline the diagnostic process for cervical neck pain, we propose a classification system based on readily available clinical, laboratory, and imaging findings. This system aims to guide clinicians, particularly in primary care settings, toward a more focused differential diagnosis and appropriate investigations. This classification divides neck pain etiologies into seven clinical groups, facilitating a systematic approach (Table 1). This categorization is designed to be applicable early in the patient encounter, often based on history and initial physical examination.
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(i) Referred Pain from Cranium, Chest, or Abdomen: Consider pain originating outside the cervical spine. Each potential source (cardiac, vascular, pulmonary, abdominal) has specific associated symptoms and signs. A high index of suspicion is crucial. For example, a patient with risk factors for cardiovascular disease presenting with neck and jaw pain should be evaluated for cardiac ischemia. Diagnostic tools include ECG, chest X-ray, abdominal imaging, etc., depending on the suspected source.
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(ii) Pain with Signs of Infection: Presence of fever, chills, night sweats, malaise, leukocytosis, elevated ESR, CRP, or ferritin strongly suggests infection. Clinical presentation can be subtle in chronic or partially treated infections. Investigations include blood cultures, inflammatory markers, and imaging (CT or MRI). Specific tests for suspected pathogens (Brucella, Tuberculosis, Lyme, etc.) may be indicated.
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(iii) Pain with Signs of Nerve Root Compression (Cervical Radiculopathy): Pain radiating into the arm, following a dermatomal pattern, accompanied by sensory, motor, or reflex deficits in the upper extremity, points to nerve root compression. MRI of the cervical spine is the primary imaging modality. Neurophysiological studies (EMG/NCS) can confirm radiculopathy and assess severity and chronicity.
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(iv) Pain with Signs of Spinal Cord Compression (Cervical Myelopathy): Neck pain accompanied by signs of spinal cord dysfunction, such as gait ataxia, upper extremity weakness and clumsiness, bowel/bladder dysfunction, hyperreflexia, or Babinski sign, necessitates urgent investigation for cervical myelopathy. Gadolinium-enhanced MRI is essential to evaluate for spinal cord compression from various causes (stenosis, tumor, disc herniation, etc.). Tissue diagnosis may be required for suspected tumors.
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(v) Mechanical Neck Pain: Pain related to movement and posture, relieved by rest, is characteristic of mechanical neck pain. Careful history and physical examination are key. Plain radiographs can identify spondylosis, instability, or fractures. CT scans may provide more bony detail if needed.
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(vi) Rheumatic Neck Pain: Neck pain with inflammatory characteristics, including night pain, morning stiffness (>30 minutes), improvement with NSAIDs, and potential involvement of other joints, suggests a rheumatic etiology. Rheumatologic blood tests (rheumatoid factor, anti-CCP, ANA, HLA-B27) and radiographs of hands and cervical spine can aid in diagnosis.
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(vii) Pain with Other Characteristics, with or without Local Tenderness: This category encompasses neck pain that doesn’t fit neatly into the other categories. Thorough history and physical examination are crucial. Consider conditions like fibromyalgia, myofascial pain syndrome, medication-induced pain, metabolic disorders, and psychogenic pain. Further investigations are guided by clinical suspicion, potentially including metabolic blood tests, nerve blocks, or psychological evaluation.
Table 1. Clinical Classification of Cervical Neck Pain for Differential Diagnosis
| 1. Referred Pain (Cranium, Chest, Abdomen) | 2. Pain with Signs of Infection | 3. Pain with Nerve Root Compression (Radiculopathy) | 4. Pain with Spinal Cord Compression (Myelopathy) | 5. Mechanical Neck Pain | 6. Rheumatic Neck Pain | 7. Pain with Other Characteristics |
|---|---|---|---|---|---|---|
| Myocardial Infarction, Aortic Dissection, Pulmonary Embolism, Pleuritis, Pneumothorax, Lung Cancer, Esophageal Spasm, Gallbladder Disease, Pancreatitis, Renal Colic, Brainstem Tumor | Osteomyelitis, Discitis, Epidural Abscess, Paraspinal Abscess, Fungal Infection, Tuberculosis, Brucellosis, Viral Infections (Flu, COVID-19), Bacterial Infections, Post-Surgical Infection | Cervical Disc Herniation, Cervical Spondylosis with Radiculopathy, Foraminal Stenosis, Nerve Root Tumors (Schwannoma, Neurofibroma), Facet Joint Synovitis, Epidural Lipomatosis, Arachnoiditis | Cervical Spinal Stenosis, Cervical Disc Herniation with Myelopathy, Spinal Cord Tumors (Meningioma, Ependymoma, Metastases), Trauma with Cord Injury, Syrinx, Epidural Abscess/Hematoma, Transverse Myelitis, Atlantoaxial Instability, Chiari Malformation, Vascular Malformations | Cervical Spondylosis, Cervical Facet Joint Osteoarthritis, Muscle Strain/Sprain, Whiplash Injury, Ligamentous Injury, Postural Pain, Cervical Instability, DISH, Baastrup Syndrome, Torticollis, Congenital Anomalies | Rheumatoid Arthritis (Cervical Spine), Ankylosing Spondylitis (Cervical Spine), Psoriatic Arthritis (Cervical Spine), Polymyalgia Rheumatica, Crowned Dens Syndrome, SLE (Cervical Spine), Gout (Cervical Spine) | Fibromyalgia, Myofascial Pain Syndrome, Medication-Induced Neck Pain, Psychogenic Neck Pain, Sarcoidosis (Cervical Spine), Metabolic Bone Disease (Osteomalacia, Paget’s), Idiopathic Torticollis, Failed Neck Surgery Syndrome |
| Diagnostic Tools: ECG, Chest X-ray, Abdominal Imaging, Cardiac Enzymes, Vascular Studies as indicated | Diagnostic Tools: CBC, ESR, CRP, Blood Cultures, Imaging (MRI preferred), Specific Infectious Disease Serology | Diagnostic Tools: Cervical Spine MRI, EMG/NCS, Cervical Spine Radiographs/CT | Diagnostic Tools: Cervical Spine MRI (Gadolinium enhanced), CT Myelogram, Neurological Examination | Diagnostic Tools: Cervical Spine Radiographs, Cervical Spine CT (if needed), Physical Examination | Diagnostic Tools: Rheumatoid Factor, Anti-CCP, ANA, HLA-B27, Inflammatory Markers, Cervical Spine Radiographs | Diagnostic Tools: Clinical Evaluation, Psychological Evaluation, Metabolic Blood Tests, Diagnostic Nerve Blocks, Imaging as Clinically Indicated |
DISH, Diffuse Idiopathic Skeletal Hyperostosis; SLE, Systemic Lupus Erythematosus; ECG, Electrocardiogram; CBC, Complete Blood Count; ESR, Erythrocyte Sedimentation Rate; CRP, C-Reactive Protein; MRI, Magnetic Resonance Imaging; EMG/NCS, Electromyography/Nerve Conduction Studies; CT, Computed Tomography; ANA, Antinuclear Antibody; Anti-CCP, Anti-Cyclic Citrullinated Peptide; HLA-B27, Human Leukocyte Antigen B27.
Discussion
A systematic approach to neck pain diagnosis is crucial for effective patient care. While “red flag” approaches for back pain have been questioned for their limited specificity and sensitivity [3, 49], a structured framework remains essential for efficiently evaluating neck pain. Underwood’s suggestion to prioritize early diagnosis of serious conditions like cauda equina syndrome, major abdominal pathology, infections, and fractures in back pain is relevant to cervical neck pain as well, with cervical myelopathy being the cervical spine equivalent of cauda equina syndrome [50]. Singleton and Edlow’s emphasis on risk stratification in emergency department settings for spinal pathology also aligns with our proposed systematic approach for neck pain [1].
Bardin et al.’s “diagnostic triage” for low back pain, starting with excluding non-spinal causes and categorizing spinal pain, provides a useful parallel for neck pain diagnosis [6]. Our proposed classification expands on these approaches by offering a more comprehensive overview of cervical spine pathologies, categorized into seven clinically relevant groups. This expanded classification is particularly valuable in non-emergency settings, enabling a more nuanced differential diagnosis and guiding appropriate investigations.
The strength of this review lies in its inclusive overview of cervical spine conditions, providing a broader perspective on the differential diagnosis of neck pain compared to approaches focusing solely on lumbar pain. By utilizing the proposed seven clinical categories, clinicians can systematically evaluate patients with neck pain, facilitating accurate diagnosis with a minimum of unnecessary investigations and referrals. This systematic approach is intended to enhance diagnostic accuracy and efficiency in managing patients presenting with neck pain across various clinical settings.
Author Contribution
EK: Conceptualization, Methodology, Writing; HS: Methodology, Writing; NS: Methodology, Writing; AT: Methodology, Writing; EB: Methodology, Writing.
Data Availability
Not applicable.
Code Availability
Not applicable.
Declarations
Ethics Approval
Not applicable.
Consent to Participate
Not applicable.
Consent for Publication
Was sent to the corresponding author.
Conflict of Interest
The authors declare no competing interests.
Footnotes
This article is part of the Topical Collection on Surgery
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Elisha Krasin and Haggai Schermann contributed equally to this work.
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Associated Data
Data Availability Statement
Not applicable.
