Suspected cervical myelopathy and neck pain in the setting of systemic disease require urgent evaluation in the form of imaging studies, laboratory investigation, and often, referral to the appropriate specialist.
- Symptoms of weakness in upper and lower extremities; urinary or rectal incontinence.
- Upper motor neuron signs on examination of the lower extremities.
Cervical myelopathy occurs secondary to compression of the neural elements (spinal cord or nerve roots) in the cervical spinal canal. Cervical spondylitic myelopathy is the most common cause of spinal cord dysfunction in persons older than 55 years. The cause of the compression is usually a combination of osteophytes and degenerative disk disease that leads to a decrease in the volume of the spinal canal. The distribution and severity of symptoms depend on the location, duration, and size of the lesion.
The most frequent presentation of myelopathy is a combination of arm and leg dysfunction. Patients with cervical myelopathy may have symptoms in four limbs, difficulty walking, and urinary or rectal incontinence. Only one-third of patients with cervical myelopathy mention neck pain. Older patients may describe leg stiffness, foot shuffling, and a fear of falling. Physical examination reveals weakness of the appendages in association with spasticity; hyperreflexia, clonus, and a positive Babinski sign are findings in the lower extremities.
MRI detects the extent of spinal cord compression and is the imaging test of choice for most cases. CT myelogram helps distinguish between osteophytes and protruding disks. Plain radiographs reveal advanced degenerative disease with narrowed disk spaces, facet joint sclerosis, and osteophytes but do not image neural compression.
The natural history of cervical spondylitic myelopathy is gradual progression. Although some patients improve with conservative therapy, progressive myelopathy requires surgery to prevent further cord compression, vascular compromise, and myelomalacia. Outcomes are best when surgery is performed before severe neurologic deficits appear.
Neck Pain Associated with Systemic Medical Illness
- The history and physical examination help identify patients whose neck pain is not due to a mechanical disorder.
- The differential diagnosis and clinical context of each case determine the urgency and nature of the evaluation.
Patients with neck pain require urgent evaluation if they have constitutional symptoms, symptoms that suggest either a focal process or referred pain, a history of cancer, or a condition that predisposes to infection (see Table 9–1). If present, signs or symptoms of radiculopathy or spinal cord compression add to the urgency of the situation. The differential diagnosis, clinical setting, and findings of the individual case dictate the use of imaging, laboratory investigations, and need for consultations.
Neck pain in the presence of fever, night sweats, weight loss, or a predisposing condition (such as injection drug use, AIDS, or diabetes) raises the possibility of infection. MRI and CT are indicated in cases of suspected vertebral osteomyelitis, diskitis, and epidural abscess. In these conditions, radiographs of the cervical spine may demonstrate alterations of bone integrity but are often unrevealing, especially early in the disease course.
Spinal cord infiltrative processes and vertebral column tumors tend to produce pain that is greatest at night or with recumbency. Patients with these symptoms and neurologic signs should undergo MRI of the central nervous system. Patients with nocturnal pain and with normal neurologic examinations may have a bone tumor. Benign bone tumors affect the posterior elements of vertebral bodies, while malignant lesions affect the vertebral bodies. If plain radiographs are unable to detect alterations in bone architecture, bone scan is a sensitive means to detect lesions over the entire axial skeleton. CT scan clarifies the nature of abnormalities seen on bone scan.
Pain localized directly over the bony structures of the cervical spine is usually associated with either fracture or expansion of bone. Any condition that replaces bone with abnormal cells or increases mineral loss from trabeculae causes fractures that occur spontaneously or with minimal trauma. Fractures cause pain in the area of the lesion. Physical examination identifies the maximum point of tenderness. A bone scan may identify the area of fracture if the radiograph is normal. MRI can identify the presence of malignancies, such as myeloma, that do not stimulate osteoblast activity and thus are not detected by bone scan.
The spondyloarthropathies and rheumatoid arthritis can cause early morning stiffness of the cervical spine lasting for hours. Patients with neck symptoms due to these diseases usually have extensive disease of other joints, but women with ankylosing spondylitis may have neck disease without low back pain. Flexion-extension views of the cervical spine can reveal the presence of C1–C2 subluxation in either the spondyloarthropathies or rheumatoid arthritis. MRI is an important technique to identify synovitis affecting the C1–C2 articulation in rheumatoid arthritis. MRI can also visualize the presence of bone marrow inflammation and edema in vertebral structures affected by ankylosing spondylitis.
Patients with viscerogenic pain (ie, neck pain secondary to cardiovascular, gastrointestinal, or neurologic disorders) have symptoms that recur in a regular pattern in structures that extend beyond the cervical spine. Pain with exertion raises the possibility of myocardial ischemia. Carotidynia is pain and tenderness over the carotid arteries. Esophageal disorders should be considered if neck pain occurs in association with eating. Posterior esophageal lesions, in particular, may affect the prevertebral space, causing neck pain. Disorders of the cranial nerves can cause cervical spine and facial pain.
Patients with polymyalgia rheumatica are over 50 years of age and have severe early morning muscle stiffness. Pain is localized to the proximal muscles of the shoulders and thighs. The erythrocyte sedimentation rate is elevated in most cases.