Cervical Spine

Charles De Mesa, DO, MPH

Omar Dyara, DO

FAST FACTS

Neck pain is the third most common pain condition reported nationally and a frequent reason for seeking medical attention.
Most episodes of acute neck pain are self-limited, but nearly 50% of individuals will continue to experience some level of pain or frequent occurrences.
Excluding red flags is essential for early identification and management of more serious diagnoses of neck pain.
Success of therapeutic procedures and surgeries relies heavily on appropriate patient identification/selection.

INTRODUCTION

Neck pain is the third most common pain condition reported nationally and a frequent reason patients visit their primary care physician.¹ Pathology in the cervical spine can radiate to the head, shoulder, arm, or hand. When a severe injury to the neck occurs, the spinal cord can be affected, which may lead to impaired function of all extremities. For this reason, identifying the specific pain generator and accompanying symptoms is essential in creating a differential diagnosis of neck pain.

Significant uncertainty surrounds the pathophysiology of chronic neck pain, and in many cases, the chance of accurately identifying a specific cause is low.² The most critical task is to evaluate patients with neck pain for myelopathy, radiculopathy, and dangerous underlying causes such as cancer, fractures, and osteomyelitis.

To be more specific when referring to cervical pain, it is described as the region bounded superiorly by the superior nuchal line and inferiorly by an imaginary transverse line through the T1 spinous process. Few diagnoses cause neck pain alone and referred pain is common. A clinician’s role is to determine the most likely pain generator that can be difficult but not impossible (Table 15-1).

HISTORY

In addition to determining pain onset, location, duration, character, aggravating/alleviating factors, radiating features, and timing, a careful determination of recent trauma and mechanism of injury is imperative. Although the majority of patients presenting to primary care physicians with a chief complaint of neck pain will not have a serious condition, it is important to exclude serious causes. Symptoms that may suggest significant pathology include fever, chills, extremity weakness or clumsiness, gait disturbance, and bowel or bladder dysfunction.

A pertinent history of past cancer, unexplained weight loss, and pain lasting more than 1 month are key features suggesting cancer-related cervical spine pain.³ Immunosuppression, chronic steroid use, and IV drug use are antecedent factors that may predispose a patient to conditions such as osteomyelitis or fractures with associated myelopathy.⁴ A diagnosis of vertebral artery dissection should always be considered in a patient with neck pain following relatively minor trauma because it can be life-threatening.⁵ In elderly individuals with severe osteoarthritis of the neck, the development of neurologic injury may occur from minor trauma or strenuous lifting—a condition known as cervical spondylotic myelopathy.⁶

TABLE 15-1 Differential Diagnosis of Neck Pain

DIAGNOSIS	PHYSICAL EXAMINATION	WORKUP	TREATMENT	WHEN TO REFER
Cervical strain/sprain	Decreased cervical range of motion (ROM) Tender to palpation of neck, upper trapezius, and sternocleidomastoid muscles Neurologic examination normal	Imaging or electrodiagnostic examination not indicated unless neurologic impairment If considering X-rays, assess for alignment and fractures	Physical therapy (PT) functional restoration Nonsteroidal anti-inflammatory drugs (NSAIDs) acetaminophen Osteopathic manipulative treatment (OMT) Massage Heat Transcutaneous electrical nerve stimulation (TENS) Soft collar (kinesthetic reminder, limit use to 3 d)	If no improvement after 1-2 mo, consider additional imaging (X-ray, MRI) and referral to pain medicine or physical medicine and rehabilitation
Cervical radicular pain (cervical radiculitis)	Upper limb pain Neurologic examination normal. Special tests: Spurling examination Perform shoulder examination to rule out rotator cuff pathology	X-rays (anterior-posterior and lateral) Flexion and extension X-rays if concern for instability or before prescribing PT rehabilitation MRI-C spine	PT—cervicothoracic stabilization Scapulothoracic kinetic efficiency NSAIDs, acetaminophen Neuropathic drugs (Neurontin, TCA) Muscle relaxants (tizanidine)	If no clinical improvement after conservative management, referral to pain medicine
Cervical radiculopathy	Any combination of neurologic deficits:↓ sensory, ↓ motor, and/or ↓ reflex	MRI EMG	Activity modification, PT (as above in radiculitis), analgesics	If no improvement or if concern of neurologic compromise, referral to orthopedic or neurosurgery
Cervical zygapophyseal (facet) joint disease (e.g., arthritis)	Pain in distinct pain referral distribution (Dwyer et al.) ↓ ROM	X-ray AP and lateral CT if still concern for fracture or to delineate joint fracture (note: ↑ radiation exposure with this examination, so weigh risks/benefits in pursuing this study)	PT (cervicothoracic stabilization exercises, analgesics, cervical collar)	If no improvement with conservative therapy, refer to pain medicine for diagnostic facet joint blocks (medial branch blocks) Referral to orthopedic or neurosurgery for fractures or concern for neurologic compromise
Cervical spondylolisthesis		X-ray cervical A/P, lateral, flexion, and extension films (assess for instability)		Neurosurgical referral when signs of myelopathy and/or instability
Cervical intervertebral disk disruption	Tenderness to palpation affected cervical region, head, neck, trapezius, and interscapular pain, which is nonradicular Trauma worse with sitting and Valsalva (coughing, sneezing)	X-ray A/P and lateral concomitant spondylosis likely to be present MRI shows ↓ signal on T2-weighted sequence	PT (functional restoration), analgesics	Failure of conservative treatment, then refer to pain medicine for consideration of injection therapies Refer to orthopedic or neurosurgery surgery for severe axial pain discogenic in origin which has failed injection therapy, such as epidural steroid injection Surgeries may include anterior cervical discectomy and fusion or posterior fusion
Cervical myelopathy (also myeloradiculopathy)	(males > females) Numbness and paresthesia of the distal limbs and extremities Δ in pain/temp sensory testing Lower limb > upper limb involvement Atrophy hand intrinsics +Hoffman and/or Babinski signs	X-ray A/P and lateral (central canal diameter less than 10 mm indicates myelopathy if patient has + physical exam findings) MRI may demonstrate cervical spondylosis, myelomalacia, ↓ CSF flow EMG to establish nerve root injury	PT, occupational therapy (OT) for manual dexterity and activities of daily living (ADLs); cervical orthosis for mild or static symptoms without evidence of gait disturbance	Refer to orthopedic or neurosurgery for severe and progressive symptoms
Cervical stenosis	Spurling may be positive for cervical radicular pain to shoulder and relieved by holding hand overhead. Assess for upper motor signs including Hoffman sign and wrist clonus (which indicate myelopathy). Assess for sensory ataxia due to posterior column dysfunction via Romberg test. Wide-based gait and loss of dexterity may be observed all point to progression due to cervical spondylotic myelopathy	X-ray cervical A/P, lateral, flexion, and extension films Torg-Pavlov ratio (i.e., sagittal diameter of the cervical canal: width of a mid-cervical vertebral body Cervical MRI EMG (in some cases)	Early cervical stenosis with mild-to-moderate cord compression without edema is usually treated nonoperatively Physical therapy Serial neurologic examinations every 6 mo to ensure early myelopathic symptoms are not missed	Neurosurgic referral when signs of myelopathy are present, cord compression is severe, or edema is seen on MRI

Assessing demographic information and past diagnoses will aid the management plan. For instance, an elderly, osteoporotic individual with a recent fall may be more likely to suffer a fracture and/or develop cervical myelopathy. A 45-year-old nurse who lifts patients and engages in repetitive computer charting for employment may have a postural disorder leading to cervical strain. This may be accompanied by symptoms of neck pain, soreness, triggered by neck movement in a nondermatomal radiation pattern. If she experiences focal point tenderness and reproduction of pain upon palpation, it may be consistent with myofascial trigger points.⁷ These have a fairly consistent distribution (Figure 15-1).

MECHANISM OF INJURY

The mechanism of injury for neck pain can help discern a diagnostic hypothesis. For example, did the painful symptoms appear over time and as a result of poor posture while performing computer work or use of heavy attire? Or did the pain develop after a motor vehicle collision?

These would suggest distinct etiologies including neck strain and cervical zygapophyseal joint (Z-joint)-mediated pain, respectively.

Establishing the sequence and time course of each of the symptoms will lead to more accurate assessment. For example, acute pain from sharply turning one’s head may result in an acute cervical strain. This is common because cervical muscles attach to bone through myofascial tissue. On the other hand, a rear-end collision with resulting whiplash injury may lead to chronic, painful symptoms from biomechanical stress on cervical Z-joints. This is a leading source of chronic neck pain with a consistent distribution (Figure 15-2). Z-joints are also known as facet joints.