NECK PAN

KEY POINTS
Degenerative disease of the cervical
spine, or cervical spondylosis, is an age-
related process that affects many
components of the cervical spinal column.
The spectrum of cervical sppondylosis
ranges from axial neck pain to
radiculopathy to frank myelopathy.
 KEY POINTS
Physical examination findings correlated with
diagnostic imaging studies can aid in diagnostic
evaluation.
Almost all patients with symptomatic cervical
degenerative disease without neurologic
involvement can be managed nonoperatively.
Surgery for patients with myelopathy is a
reasonable option to prevent diease
progression.
 KEY POINTS
Neck pain is a common complaint and
tends to occur with increasing frequency
after the age of 30. Most episodes of neck
pain are short-lived and tend to respond to
nonoperative management.
 KEY POINTS
The clinical manifestations of neck disorders range from
midline posterior neck pain to the neurologic sequelae of
cervical nerve root or spinal cord compression. Axial
neck pan may radiate from the base of the skull down to
the upper trapezius region. Cervical radiculopathy
involves compression of a nerve root, with pain radiating
down the arm in an anatomic distribution. Cervical
myelopathy is characterized by dysfunction of the spinal
cord. This may be caused by cord compression, vascular
abnormalities, or a combination of both.
 ETIOPATHOGENESIS
I- Degeneration of the intervertebral disc can lead to
pain referred to the neck, posterior skull, and/or upper
shoulders. This occurs as a natural consequence of the
normal aging process with a resulting decrease in the
water content of the disc. Disc degeneration can be
affected by many external factors ncluding repetitive
occupational mechanical straind a history of diving or
heavy weight lifting. The structures affected within the
neck include the intervertebral disc, zygapophyseal joint
with associated facet capsules, ligaments, musculature,
and the neural elements. Changes can be acute (e.g.,
traumatic), chronic, or acute on chronic.
 ETIOPATHOGENESIS
II- Acute herniation of the disc material
posteriorly may result inimpingement of the
nerve root and/or spinal cord. The distribution of
pain in cervical radiculopathy often fits a
dermatomal distribution charateristic for each
particular nerve root. When cors compression
occurs, the changes within the cord can e
caused by acute compression by the disc
material, as well as compression of the vascular
supply to the cord.
 ETIOPATHOGENESIS
III- Cervical spondylosis involves loss of
disc space height. As a result of the
degeneration within the disc and the
decreased intervertebral height, altered
spinal biomechanics ensu, with
osteophytes forming along the area of the
disc space as well as posteriorly along the
facet joints. This can be associated with
nerve root and spinal cord compression.
 PRVALENCE
Prevalence of neck and referred shoulder/brachial
pain has been reported to be 9%. In a series of 205
patients who present with neck pan and were managed
nonoperatively, 79% were noted to be asymptomatic or
improved at a minimum follow-up of 10 years. Symptoms
of 13% were uncanged, and only 8% had worsening of
their symptoms. Radiographically, 25% of patients in
their fifth decade have been shown to have degenerative
changes in one or more discs. By the seventh decade,
this number increases to over 75%.
 CLINICAL MANIFESTATIONS
I-NECK PAIN
A. Signs and symptoms. Neck pain is a pain that is
perceived by the patients an existing primarily within the
axial portion of the spine. Pain may radiate to the base of
the skull or to the midupper periscapular region. The
pain may involve the posterior trapezius muscles or the
posterior deltoids. The pain itself may be limited to a
focal ara or may involve a more global region. Night pain
is common because the neck becomes a weight-bearing
area. The longer the pain exists the more difficult it is
pain from thoracic organs such as the heart or aorta, the
physician must be aware of the patients comorbid
medical issues.
 CLINICAL MANIFESTATIONS
I-NECK PAIN
B- Physical examination. Examination of the patient with
neck pain should include noting the position in which the
neck is held. When there is severe neck spasm, the
head may be flexed laterally to that side or even rotated.
Muscle spasm can often be visualized and can be
palpated posteriorly along the paraspinal musculature.
Examination should include inspection of the symmetry
of the paraspinal muscles as well as the trapezius and
shoulder musculature. Any signs of atrophy must be
noted. Strength and range of motion of the shoulder
should be tested, as well as examination for focal
tenderness within the shoulder(to help rule out the
shoulder as a source of potential pain or to define
coexistent shoulder disease.)
 CLINICAL MANIFESTATIONS
I-NECK PAIN
C- Range of neck motion should include flexion,
extension, rotation, and lateral bending. Normal
flexion demonstrates the abillity to touch the chin
to the chest. Normal neck extension allows the
occiput to approach the prominent C7 spinous
process. Rotation is normally 70 degrees
bilaterally and lateral bending is 50 to 60
degrees bilaterally. Palpation for carotid artery
pulses as well as for the presence or absence of
supraclavicular adenopathy should be
performed.
 CLINICAL MANIFESTATIONS
II- CERVICAL RADICULOPATHY
A. Signs and symptom. Cervical radiculopathy
implies pain traveling on the basis of an
anatomic distribution to the shoulder or down the
arm. Patients describe sharp pain and tingling or
burning sensations in the involved area. There
may be sensory or motor loss corresponding to
the involved nerve root, and reflex activity may
be diminished.
 CLINICAL MANIFESTATIONS
II- CERVICAL RADICULOPATHY
B- Physical examination The shoulder abduction relief
sign is characterized by having the patients place the
palm ofhis hand flat onto the top of his skull; this causes
symptomatic relief of the radicular pain Spurlings test is
performed by having the patient extnd the neck and
rotate and laterlly bend the head toward the affected
side; an axial compressiv forc is then applied to the top
of the patient head. The test is positive when the
maneuver reproduces the patients typical radicular arm
pain.
 CLINICAL MANIFESTATIONS
II- CERVICAL RADICULOPATHY
C- Herniation or degeneration of an
intervertebral disc may produce spesific
radicular patterns, depending on the level
of involvement. Considerable overlap exist
among the patterns outlined in the
subsequent text. C5-6 and C6-7 are far
more commonly involved tha C7-T1 or C4-
5.
 CLINICAL MANIFESTATIONS
II- CERVICAL RADICULOPATHY
C- Herniation or degeneration of an
intervertebral disc
1. C5-6 (C6 nerve root affected). Pain will radiate
to the shoulder or lateral arm and dorsal
forearm. Anesthesia and paresthesias may be
present in the thumb and index finger.
Weakness, if present, will involve the biceps and
wrist extensors. The brachioradialis or biceps
reflex is often decreased or absent.
 CLINICAL MANIFESTATIONS

II- CERVICAL RADICULOPATHY

C- Herniation or degeneration of an
intervertebral disc
2. C6-7 (C7 nerve root affected). The pain
distribution is similar to that of a C7
radiculopathy. Anesthesia and parestheias,
when present, involve the ndex and log
fingers. Weakness, if present, is noted in the
ticeps, wrist flexors, and finger extensors. The
triseps reflex may be reduced.
 CLINICAL MANIFESTATIONS
II- CERVICAL RADICULOPATHY
C- Herniation or degeneration of an
intervertebral disc
3. C7-T1 (C8 nerve root affected). Pain may
occur along the medial aspect of the upper arm
and forearm. Anesthesia and paresthesias
involve the ring and small fingers. Weakness, if
present, is notes in the finger flexors and
intrinsic musculature of the hand. The triceps
reflex may be reduced.
 CLINICAL MANIFESTATIONS
III- CERVICAL MYELOPATHY
A. Signs and symptoms. Cervical myelopathy alone (e.g.,
in the absence of radiculopathy) is painless. This is due
to the fact that there is spinal cord compression only.
The pain becomes apparent only when compression of
the spinal cord is accompanied by compression of the
nerve root (myeloradiculopathy). Symptoms associated
with spinal cord compression include gait disturbances
with balance difficulty, fine motor dysfunction in the
hands, and motor weakness. Bowel and bladder
dysfunction is found late in the progression of cervical
myelopathy. Physical findings often include difficulty with
tandem gait, dysdiadochokinesia, hyperreflexia, and
various sensory and motor changes.
 CLINICAL MANIFESTATIONS
III- CERVICAL MYELOPATHY
B- Physical examination. Hoffmanns reflex is often
present, which is elicited by flicking the middle finger of
the patient and observing forced finger and thumb
interphalangeal joint flexion. There can be upgoing toes
(e.g.,positive Babinskis reflex) as well as associated
clonus at the ankles. Myelopathy-related hand
abnormalities include atrophy of the thenar musculature
and an inability to maintain the ring and small fingers is
an extended and adducted position (e.g., finger escape
sign)Lhermittes sign involves flexion of the neck with an
electric-shocklike sensation extending down the axial
spine and/or extremities.In addition to the physical
examination for neck pain, a thorough neurologic
evaluation is necessary.This includes motor testing of all
pertinent motor groups including the deltoid, biceps,
tricepswrist flexors/extensors, finger flexors/extensors
 CLINICAL MANIFESTATIONS
III- CERVICAL MYELOPATHY
B- Physical examination. Additionally, lower extremity
strength needs to be tested including hip flexors, nee
extensors and flexors, hip abductors and adductors,
ankle dorsiflexors and plantar fleksors as well as the
function of the function of the extensor hallucis longus,
and peroneals. Sensory examination should include light
touch, pinprick, and vibration sense using a tuning fork.
Reflex examination should include the triceps, biceps
and brachioradialis, quadriceps, and the Achilles tendon
Another abnormal finding is the inverted radial reflex,
characterized by spontaneous fnger flexion whenthe
examiner attempts to elicit a brachioradialis reflex. Gait
should be tested during normal gait as well as with toe to
heel walking.
 DIAGNOSTIC EVALUATION
I- LABORATORY STUDIES. Laboratory
studies should include routine blood
workup; a complete blood count with
differential, an erythrocyte sedimentation
rate (ESR) and C-reactive protein(CRP).
These results will most commonly be
abnormal when an infectious or malignant
process is involved.
 DIAGNOSTIC EVALUATION
II- ELRCTROPHYSIOLOGICAL TESTING An
electrogram (EMG) may be helpful in defining a
spesific anatomic level when nerve compression
is present. Such a study may also be helpful in
ruling out other neurlogic disorders including
peripheral neuropathy. At times, a double-crush
syndrome may exist when cervical radiculopathy
can coexist with carpal tunnal syndrome.
 IMAGING STUDIES
I- PLAIN X-RAYS. A plain x-ray series should
include an anterior/posterior view, a lateralview,
and oblique views. Degeneration can often be
noted within the disc spaces and the facet joints.
There are often osteophytes noted along the
area of the disc space, and foraminal narrowing
can be noted on oblique views. Clinical
correlation with patient symptoms is often poor
in those older than 40. Instability has been
define as greater than 35 mm of translation or
11 degrees of angulation betweem adjacent
vertebral segments.
 IMAGING STUDIES
II- MYELOGRAPHY. Myelography can be used to
help evaluate nerve root compression as well as
compression of the spinal cord. Root
compression is manifested by an extradural
filling defect with obliteration of the nerve root
sleeve. Flattening of the spinal cord can be
appreciated on the lateral view. In cases of
severe compression, there will be complete
obstruction of flow of the myelogram dye. In
most clinical situations, this test has given way
to the magnetic resonance imaging (MRI)
 IMAGING STUDIES
III- COMPUTED TOMOGRAPHY Computed tomography
(CT) is helpful in evaluating the degee of foraminal
stenosis caused by bony osteophytes. In combination
with myelographyi it provides superior imaging compared
to myelography alone. It permits the visualizaton the
spesific levels (e.g, C6-7) and locaton (e.g., lateral
recess and foraminal) of nerve root compression; filling
defects allow or the determination of the extent of spinal
cord compression. Measurement of the diameter of the
spinal canal can be made to help define pre-existing
stenosis. Individuals with an anteroposteior spinal canal
diameter less than 13 mm are considered to have
congenital cervical stenosis. In addition, patients with a
cord-compression ratio (anteroposterior cord diameter
divided by transverse cor diameter) less than 0.40 tend
to have worse neurologic function.
 IMAGING STUDIES
IV- MRI MRI perhaps the primary imaging
modality overall for cervical spine
disorders. It provides excellent
visualization of the spinal cord and soft
tissues. Measurements of sagittal and
axial canal diameters as well as cord-
compression ratios can be calculated from
an MRI.
 DIFFERENTIAL DIAGNOSIS
I- Differential diagnoses to consider with cervical disc
disease are numerous. When a history of trauma is
present, cervical sprain, traumatic injury to the brachial
plexus, fracture, dislocation, or post-traumatic instability
need to be considered.
II- Inflammatory conditions including rheumatoid arthritis
and ankylosing spondylitis can also present with cervical
pathplogy. An infectious process including discitis,
osteomyeltis, or soft tissue abscess (especially in light of
a clinical history that includes fever or chills) must be
ruled out.
 DIFFERENTIAL DIAGNOSIS
III- Tumors can be a cause of neck and upper extremity
symptoms. These may include metastatic tumors,
primary bone tumors, and tumors within the spinal cord.
Additonally, tumors involving the upper lung (Pancoast
tumor) may cause symptoms consistent with a C8
radiculopathy and/or a Horners syndrome. The
presence of a history of weight loss, night pain, and
present or past malignancy should increase the
physicians sensitivity to the possibility of a malignant
tumor.
IV- Shoulder disorders including rotator cuff disease,
instability, and impingement may cause pain referred to
the neck and can be confused with a C5 radiculopathy.
More cmmonly, the neck refers pain to the soulder and
may actually be associated with the development of
frank shoulder pathology.
 DIFFERENTIAL DIAGNOSIS
V- Neurologic disorders such as the demyelinating
disease, multipl sclerosis, as well as disease nvolving
the anterior horn cells must be considered in the
differential diagnosis.
VI- Finally, many other conditions such as peripheral
nerve entrapment syndromes, reflex sympathetic
dystroph, thoracic outlet syndrome, as well as coronary
artery disease with angina pectoris may stimulate
radicular type symptoms. Pathology in the neck or
shoulder may take those areas more likely sites to which
visceral pain refers.
 TREATMENT
I- Conservative care isthe primary
treatment of patients with neck pain, with
or without radicular symptoms. Lifestyle
modifications should be instituted to avoid
activities that tend to create or aggravate
neck and arm symptoms.
 TREATMENT
I- Conservative care
A. Typical activities to modify include athletic activities,
sitting at a desk with neck flexion (e.g.,reading and
typing) for extended periods of time, and driving. An
ergonomic assessment of the modern computerized
office s often helpful in decreasing day-long stresses to
the neck. A soft cervical collar can be used to limit
motion and allow the spasm to settle down. The use of
two or three pillows at night, in order to decrease reflux
symptoms or breathing problems, exacerbate cervical
spine problems and should be avoided. Therefore, use
of a cervical pillow under the nape of the neck at night
help decrease spasms and pain, as it tends to optimize
the position of the neck during sleep. Other modalities
such as moist hate and light massage may prove
beneficial
 TREATMENT

I- Conservative care
B- Use of medications including anti-
inflammatory medications help
decrease the amount of inflammation
and prvide pain relief. In cases of
severe pain, mild narcotics may be
useful. Muscle relaxants may also help
decrease the amount of spasm and
allow or more comfortable periods of
rest. Short courses of steroids are
sometimes needed to control the
 TREATMENT
I- Conservative care
C- Physical therapy is often useful in the
treatment of neck and radicular arm pain, once
the phase of severe pain and radicular problems
resolve. Modalities including traction, ultrasound,
or diathermy can give pain relief. Once the
patients symptoms have begun to decrease, an
exercise regimen can be added taking note that
this does not exacerbate the neck or arm pain
symptoms Active ROM exercises along with
some isometric exercises can help regain the
strength of the neck.
 TREATMENT
II- Surgery is indicated in cases of significant radicular pain
that has failed to respond to conservative treatment, or in
the presence of significant neurologic deficits. Only a
small percentage of patients with cervical spine
problems eventually require surgery. However, if
considered necessaryi the surgical procedure is either
an anterior cervical discectomy and fusion or a posterior
laminoforaminotomy. For cases of melopathy with
significant disability, surgery can be a reasonable
alternative. The goal of surgery with myelopathy is to
prevent progression of the disease.
 TREATMENT
II- Surgery Postoperatively, some patients show
improveent from their preoperative neurologic status. For
myelopathy, surgery cnsists of either multipl anterior
cervical discectomies/corporectomies and fusion versus
posterior procedures such aslaminectomy alone,
lamioplasty, or laminectomy and fusion. A small
percentage of patients with significant multilevel disease
or poor bone quality are good candidates for a combined
anterior/posterior procedure Surgery should be done
emergently in the setting of anepidural abscess.
 PROGNOSIS
I- The prognosis for patients with axial neck
pain is, in general, good. In a folow-u of a seies
of 205 patients with neck pain and treated
nonoperatively, 79% were noted to be either
asymptomatic or improved at 10-year follow-
up,13% were noted to be unchanged, and 8%
were felt to have worsening symptoms. Surgery
for axial neck pain by itself is rarely indicated,
except perhaps in the setting of instability.
 PROGNOSIS
II- The prognosis for patients with cervical
radiculopathy is also, in general, favorable. A significant
number of patients tendto respond to nonoperative
measures and show significant improvement 2 to 3
months after the onset of symptoms. A series of 26
patients with cervical disc herniation and radiculopathy
were managed nonoperatively with traction, medications
and education. A1 year follow-up show succesful
nonoperative management 24 of the26 patients. For
patients who have radicular symptoms despite 2 to 3
months of nonsurgical treatment, or who have significant
weakness, surgery is a reasonable option. The
prognosis for improvement with surgery is generally
favorable. Most patients experience significant
improvement in their radicular pain
 PROGNOSIS
III- Cervical myelopathy with early myelopathy and no
significant neurologic deficits can initially be followed in
an outpatient setting. The prognosis for cervical
myelopathy in general shows that a high percentage of
these patients slowly deteriorate over time. The
deteioration is often slow and occurs over years; a small
percent of cases may display signs and symptoms of
rapid progression. In patients with gross findings of
myelopathy with significant cord compression and
impairment, surgery is a reasonable option. The goal of
surgery is to prevent deterioration and potentially
promote improvement in their overall neurologic status.
In a series of patients treated surgically for cervical
myelopathy, 90% of patients had significant neurologic
improvement and 80% has significant pain relief.