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Neck Pain¶

Chapter 19 | Part 2: Cardinal Manifestations and Presentation of Diseases · Part 2 – Cardinal Manifestations & Presentation · Chapter 19

Key Clinical Points¶

Neck pain is a high-prevalence condition (nearly 50% lifetime prevalence) and the 4th leading cause of disability in the US.
Distinguish between nociceptive (e.g., discogenic, myofascial) and neuropathic (radiculopathy/myelopathy) pain.
Red flags (cancer, infection, cord compression) require immediate investigation.
Degenerative cervical myelopathy (DCM) can have a diagnosis delay of up to 2 years; early signs are often subtle (clumsiness, paresthesia).
Spurling's maneuver is specific for radiculopathy; Lhermitte's sign and Hoffmann's test indicate spinal cord involvement.
MRI is the gold standard for soft tissue, radiculopathy, myelopathy, malignancy, and infection.
CT is preferred for evaluating fractures or hardware complications.
Surgery is indicated for progressive motor deficits, cord compression, or refractory pain.
Adjacent segment disease risk after fusion: ~3% per year; 26% per decade.
Radiculopathy involves specific nerve roots (C5, C7, T1) with distinct sensory and motor findings.

DEFINITION & OVERVIEW¶

• Overview: High-prevalence global problem; 4th leading cause of disability in the US. • Demographics: Affects all ages, genders, and professions; women at higher risk than men; incidence peaks in late middle life. • Prevalence: Nearly 50% lifetime prevalence. • Pain Characteristics: ◦ Nociceptive: e.g., discogenic (due to inflammatory mediators/cytokines), myofascial, or from facet overgrowth. ◦ Neuropathic: Originates from identifiable nerves; caused by compression/irritation of cervical spinal nerves due to disk herniation, ligamentous hypertrophy, or facet overgrowth. • Clinical Assessment: Patients should be specifically asked about: ◦ Numbness or tingling in extremities ◦ Clumsiness in hands ◦ Change in handwriting ◦ Difficulty with buttons ◦ Unsteady gait ◦ Saddle anesthesia ◦ Bladder or bowel incontinence.

EPIDEMIOLOGY¶

• Prevalence: Nearly 50% lifetime prevalence. • Risk Factors: ◦ Genetics, history of neck pain, and back pain. ◦ Lifestyle: Smoking, obesity, sedentary lifestyle. ◦ Clinical: Headaches, sleep disorders, and poor overall physical/mental health. ◦ Other: Secondary gain, trauma, and work-related injuries.

ETIOLOGY & PATHOPHYSIOLOGY¶

Degenerative Cervical Myelopathy (DCM)¶

• Definition: Comprehensive term for various degenerative diseases causing symptomatic cervical spine narrowing. ◦ Components: Cervical spondylosis, ossification of the posterior longitudinal ligament (OPLL), degenerative disk disease, and ossification of the ligamentum flavum. ◦ Clinical Course: - Symptoms often vague/misleading → diagnosis can be delayed up to 2 years. - Progression: Slow and stepwise. - Early signs: Paresthesia, minor loss of hand dexterity, feelings of clumsiness. - Late signs: Gait disturbance, quadriparesis, bladder/bowel incontinence. ◦ Management: Prompt diagnosis and early surgical intervention lead to better outcomes.

Neoplastic Causes¶

• Metastases: Most common extrardural spinal tumors; involve cervical spine in <20% of patients; pain is typically unrelieved by rest and worse at night. ◦ Primary Spinal Cord Tumors: Schwannomas, meningiomas (neuropathic), and intramedullary tumors. ◦ Primary Spinal Bone Tumors: Hemangiomas or chordomas (nociceptive).

Infectious Causes¶

• Osteomyelitis/Diskitis: Can cause constant neck pain; fever may be absent in many patients. - Clinical Alert: High suspicion in patients with IV drug abuse, immunocompromised status, or diabetes. • Epidural Abscess: Causes severe neck pain and progressive neurologic deterioration → often requires urgent surgery. • Meningitis: Accompanied by fever and headache.

Vascular Causes¶

• Dissections: Vertebral and carotid artery dissections (sudden neck pain + headache). • Acute Coronary Syndromes: May present as referred neck pain. • Other: Cervical arteriovenous malformations (bleeding) and cervical epidural hematomas (may be misdiagnosed as stroke; look for pain aggravated by spinous process palpation).

Congenital & Autoimmune Causes¶

• Chiari type 1: Headache/neck pain aggravated by cough. • Rheumatoid Arthritis: Often causes neck pain due to cervical instability; ≈50% have atlantoaxial subluxation. • Polymyalgia Rheumatica: Pain and stiffness in the neck, shoulder, and pelvic girdle. • Ankylosing Spondylitis: Pain worsens with rest or inactivity. • Crowned Dens Syndrome: Periodontoid calcium pyrophosphate dihydrate crystal deposition disease; severe pain/stiffness. • Paget's Disease: Less common in cervical spine but can cause pain worse at rest. • Metabolic Bone Disease: Osteoporosis (from hyperparathyroidism or glucocorticoids) and osteomalacia (vitamin D deficiency) can cause pathological fractures.

Traumatic Causes¶

• Fracture/Dislocation: Life-threatening if spinal cord is involved. • Whiplash: Often from motor vehicle collisions; involves facet joint injury; ≈50% of patients have persistent pain for ≥1 year. • Myofascial Pain: Common; involves trigger points (palpable nodules in taut muscle bands); often caused by restricted cervical motion.

CLINICAL FEATURES¶

Neurologic Examination Findings¶

• Physical Exam: Assess for deformity, mass, skin changes, and signs of trauma. • Range of Motion: 50% of cervical motion (flexion, extension, rotation) originates from C1-C2; 50% from subaxial (C3-C7). • Specific Maneuvers: - Spurling's maneuver: Rotation/flexion + axial compression → positive if it triggers upper extremity radiculopathy. - Lhermitte's sign: Neck flexion → positive if it reproduces electric pain down spine/extremities (indicates cervical spinal pathology). - Hoffmann's test: Sign of hyperflexia indicating cervical spinal cord pathology (upper motor neuron).

Radiculopathy Neurologic Features¶

• C5 Nerve Root: - Reflex: Biceps. - Sensory: Lateral arm, medial scapula. - Motor: Deltoid, Rhomboid (elbow extended back), Infraspinatus (arm rotated externally), Deltoid (arm raised laterally 30-45^{\circ}), Biceps (arm flexed at elbow in supination), Pronator teres. • C7 Nerve Root: - Reflex: Triceps. - Sensory: Posterior arm, dorsal forearm, dorsal hand. - Motor: Triceps (forearm extension), Wrist/finger extensors, Finger flexors, Abductor pollicis brevis, First dorsal interosseous, Abductor digiti minimi. • T1 Nerve Root: - Reflex: Finger flexors. - Sensory: Axilla, medial arm, anteromedial forearm. - Motor: Abductor pollicis brevis, First dorsal interosseous, Abductor digiti minimi.

DIFFERENTIAL DIAGNOSIS¶

Red Flags (Table 19-2)¶

• History: - Congenital disorders - Cancer - Substance abuse - Inflammatory arthritis - Recent trauma to head/neck - Family history of spinal conditions - Unexplained weight loss - Progressive neurologic deficits • Physical Exam: - Fever - Severe neck pain and tenderness - Motor weakness in upper or lower extremities - Upper motor neuron signs (Hoffmann, clonus, Babinski) - Unsteady gait - Bladder or bowel incontinence

Non-Muscular Causes¶

• Critical Goal: Identify infection, malignancy, or spinal cord involvement.

INVESTIGATIONS & DIAGNOSIS¶

Initial Imaging (X-ray):
Used to assess for instability and osteoarthritis.
Performed in AP, lateral, and flexion-extension views.
Advanced Imaging (CT):
Preferred for evaluating fractures or hardware complications.
Gold Standard (MRI):
Primary modality for soft tissue, radiculopathy, myelopathy, malignancy, and infection.
Electrophysiology (EMG/NCS):
Used to evaluate patients with neck pain and associated neuropathic symptoms.

MANAGEMENT & TREATMENT¶

Acute & Chronic Management¶

Pharmacologic Management:
Analgesics: NSAIDs, acetaminophen.
Muscle Relaxants: Cyclobenzaprine (5–10 mg at night).
Physical Therapy: Supervised exercise.
Supportive Care: Soft collar (modestly helpful by limiting movements that exacerbate pain; hard collars are poorly tolerated).

Surgical Management¶

Indications for Surgery:
Progressive motor deficit.
Functionally limiting pain refractory to conservative management.
Spinal cord compression.

PROGNOSIS & COMPLICATIONS¶

Adjacent Segment Disease¶

• Risk after fusion: ≈ 3% per year; 26% per decade. • Note: This may reflect the natural history of degenerative cervical disk disease.

Delay in Diagnosis¶

• Degenerative Cervical Myelopathy: Diagnosis can be delayed up to 2 years; early recognition is critical for better outcomes.

KEY PEARLS & CLINICAL TRAPS¶

• Radiculopathy Identification: Use Table 19-1 to differentiate C5, C7, and T1 involvement. • Surgical Timing: Prompt surgery at the initial phase of myelopathy leads to better clinical outcomes. • Imaging Selection: MRI is gold standard for soft tissue/cord; CT is preferred for bone/hardware.

Reference Tables¶

TABLE 19-1 Cervical Radiculopathy: Neurologic Features¶

Harrison's 22e, p.129

CERVICAL NERVE ROOT	EXAMINATION FINDINGS			PAIN DISTRIBUTION
	REFLEX	SENSORY	MOTOR
C5	Biceps	Lateral deltoid	Rhomboidsa (elbow extends backward with hand on hip)	Lateral arm, medial scapula
			Infraspinatusa (arm rotates externally with elbow flexed at the side)
			Deltoida (arm raised laterally 30°–45° from the side)
	Biceps	Palmar thumb/index finger Dorsal hand/lateral forearm	Bicepsa (arm flexed at the elbow in supination) Pronator teres (forearm pronated)
C7	Triceps	Middle finger	Tricepsa (forearm extension, flexed at elbow)	Posterior arm, dorsal forearm, dorsal hand
		Dorsal forearm	Wrist/finger extensorsa
	Finger flexors	Palmar surface of little finger Medial hand and forearm	Abductor pollicis brevis (abduction of thumb) First dorsal interosseous (abduction of index finger) Abductor digiti minimi (abduction of little finger)
T1	Finger flexors	Axilla, medial arm, anteromedial forearm	Abductor pollicis brevis (abduction of thumb)	Medial arm, axilla
			First dorsal interosseous (abduction of index finger)
			Abductor digiti minimi (abduction of little finger)

TABLE 19-2 Clinical Features Suggesting a Need for Further Investigation in Patients With Neck Pain HISTORY History of…¶

Harrison's 22e, p.130

HISTORY	PHYSICAL EXAM
History of congenital disorders	Fever
History of substance abuse	Severe neck pain and tenderness
Recent trauma to the head and neck	Motor weakness in upper or lower extremities
Family history of spinal conditions	Upper motor neuron signs: Hoffman, clonus, Babinski
Progressive neurologic deficits	Unsteady gait
Bladder or bowel incontinence