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ESSENTIALS OF DIAGNOSIS

  • Neck pain, sometimes radiating to arms.

  • Restricted neck movements.

  • Motor, sensory, or reflex changes in arms with root involvement.

  • Neurologic deficit in legs, gait disorder, or sphincter disturbance with cord involvement.

General Considerations

A variety of congenital abnormalities may involve the cervical spine and lead to neck pain; these include hemivertebrae, fused vertebrae, basilar impression, and instability of the atlantoaxial joint. Traumatic, degenerative, infective, and neoplastic disorders may also lead to pain in the neck. When rheumatoid arthritis involves the spine, it tends to affect especially the cervical region, leading to pain, stiffness, and reduced mobility; displacement of vertebrae or atlantoaxial subluxation may lead to cord compression that can be life-threatening if not treated by fixation. Further details are given in Chapter 41-03 and discussion here is restricted to disk disease.

1. ACUTE CERVICAL DISK PROTRUSION

Acute cervical disk protrusion leads to pain in the neck and radicular pain in the arm, exacerbated by head movement. With lateral herniation of the disk, motor, sensory, or reflex changes may be found in a radicular (usually C6 or C7) distribution on the affected side (Figure 24–2); with more centrally directed herniations, the spinal cord may also be involved, leading to spastic paraparesis and sensory disturbances in the legs, sometimes accompanied by impaired sphincter function. The diagnosis is confirmed by MRI or CT myelography. In mild cases, the prognosis is good and complete recovery occurs in a majority of patients with conservative therapy. Evidence does not support any specific intervention, and some combination of bed rest, activity restriction, immobilization of the neck in a collar for several weeks, and physical therapy is generally prescribed. If these measures are unsuccessful or the patient has a significant neurologic deficit, surgical removal of the protruding disk may be necessary.

Figure 24–2.

Cutaneous innervation. The segmental or radicular (root) distribution is shown on the left side of the body and the peripheral nerve distribution on the right side. Segmental maps show differences depending on how they were constructed (single root stimulation or section; local anesthetic injection into single dorsal root ganglia). (Adapted, with permission, from Aminoff MJ, Greenberg DA, Simon RP. Clinical Neurology, 9th ed. McGraw-Hill Education, 2015.)

2. CERVICAL SPONDYLOSIS

Cervical spondylosis results from chronic cervical disk degeneration, with herniation of disk material, secondary calcification, and associated osteophytic outgrowths. One or more of the cervical nerve roots may be compressed, stretched, or angulated; and myelopathy may also develop as a result of compression, vascular insufficiency, or recurrent minor trauma to the cord. Patients present with neck pain and restricted head movement, occipital headaches, radicular pain and other sensory disturbances in the arms, weakness of the arms or legs, ...

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