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For further information, see CMDT Part 41-03: Spine Problems

Key Features

Essentials of Diagnosis

  • Most chronic neck pain is caused by degenerative joint disease and responds to conservative treatment

  • Whiplash is the most common type of traumatic injury to the neck

  • Cervical radiculopathy symptoms can be referred to the shoulder, arm, or upper back

  • Poor posture is often a factor for persistent neck pain

General Considerations

  • Most neck pain, especially in older patients, is due to mechanical degeneration involving the cervical disks, facet joints, and ligamentous structures

  • Many degenerative conditions of the neck result in cervical canal stenosis or neural foraminal stenosis, sometimes affecting underlying neural structures

  • Cervical radiculopathy, usually involving the C5–C7 disks, can cause neurologic symptoms in the upper extremities

  • Other causes of neck pain

    • Rheumatoid arthritis

    • Fibromyalgia

    • Osteomyelitis

    • Neoplasms

    • Polymyalgia rheumatica

    • Compression fractures

    • Pain referred from visceral structures (eg, angina)

    • Functional disorders

  • Amyotrophic lateral sclerosis, multiple sclerosis, syringomyelia, spinal cord tumors, and Parsonage-Turner syndrome (brachial neuritis) can mimic myelopathy from cervical arthritis

Clinical Findings

Symptoms and Signs

  • Neck pain

    • May be limited to the posterior region

    • May radiate segmentally to the occiput, anterior chest, shoulder girdle, arm, forearm, and hand depending on the level of the symptomatic joint

    • May be intensified by active or passive neck motions

  • The general distribution of pain and paresthesias corresponds roughly to the involved dermatome in the upper extremity

  • Patients with discogenic neck pain often complain of pain with flexion, which causes cervical disks to herniate posteriorly

  • Limitation of cervical movements is the most common objective finding


Imaging Studies

  • Radiographs

    • Results are completely normal in many patients who have suffered an acute cervical strain

    • Loss of cervical lordosis is often seen but is nonspecific

    • Comparative reduction in height of the involved disk space and osteophytes are frequent findings when there are degenerative changes in the cervical spine

  • MRI is the best method to assess the cervical spine since the soft tissue structures can be evaluated

  • CT and MRI should be obtained urgently if the patient has signs of cervical radiculopathy with motor weakness

  • CT scanning is the most useful when bony abnormalities, such as fractures, are suspected

Diagnostic Procedures

  • The patient's posture should be assessed, checking for

    • Shoulder rolled forward or head forward posture

    • Scoliosis in the thoracolumbar spine

  • A detailed neurovascular examination of the upper extremities should be performed, including

    • Sensory input to light touch and temperature

    • Motor strength testing, especially the hand intrinsic muscles (thumb extension strength [C6], opponens strength (thumb to pinky) [C7], and finger abductors and adductors strength [C8–T1])

    • Upper extremity reflexes (biceps, triceps, brachioradialis)

  • True cervical radiculopathy symptoms should match an expected dermatomal or myotomal distribution

  • EMG is ...

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