Evaluation of the Cervical Spine

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Chapter Synopsis

This chapter describes a methodical approach to the patient with suspected cervical spine disease. Characteristic aspects of the history and physical examination are discussed and warning flags for musculoskeletal and neurologic diseases which mimic spinal disease are discussed. Relevant diagnostic tests are described. The chapter concludes with a brief discussion of disability and workers’ compensation assessments and how these evaluations differ from a standard patient evaluation.

Important Points

Careful selection of patients is critical and relies heavily on the history and physical examination.
Developing a knowledge of the characteristic natural history and symptomatology of myelopathy, radiculopathy, and axial neck pain is important as these clinical entities have some shared features.
Different types of musculoskeletal, psychiatric, and neurologic disease states can mimic cervical spine disease and must be distinguished by clinical history and physical examination.
Electrodiagnostic testing may help make or confirm the diagnoses and are a valuable adjunct to clinical judgment.

Achieving a successful outcome after spinal surgery relies as heavily on careful selection of appropriate operative indications as it does on the technical aspects of the operative procedure. Degenerative changes within the spine are ubiquitous in asymptomatic individuals. Therefore, the history and physical examination make up the key components of establishing a diagnosis. Imaging studies are confirmatory but can be interpreted only in light of knowledge gained from a careful history and physical examination.

Interpreting a patient’s symptoms and establishing a diagnosis are skills that can be honed with knowledge of the natural history of common and uncommon disease entities and a careful physical examination. Fortunately, diseases of the cervical spine generally manifest with reproducible physical findings that offer substantial clues to the underlying diagnosis. Imaging modalities and laboratory tests provide useful confirmatory data to substantiate and quantify the clinical impression gained from the history and physical examination.

History

The diagnostic process begins with the taking of a thorough medical history. The history of the condition, as obtained from the patient, is the most important portion of the diagnostic process. It is not possible to evaluate findings on the physical examination or imaging studies accurately without knowledge gained from the history. Thus, this portion of the workup should come first in sequence and should provide early clinical impressions about the probable diagnosis. These impressions are then confirmed or refuted, based on the physical examination, imaging studies, and any other ancillary medical tests. During the history, the physician must understand the presenting symptoms in terms of location, character, onset, severity, exacerbating and alleviating factors, neurologic deficits, prior treatments and their effects, and the course of the symptoms since onset. The physician must also understand the medical history of the patient including health, medications, prior surgical interventions, habits, and family history.

Natural History of Common Cervical Conditions

When formulating a diagnostic impression, the physician must understand the natural history of common cervical conditions. Cervical radiculopathy generally manifests with pain along a dermatomal distribution as the primary symptom and may be associated with sensory or motor complaints related to the involved nerve root. Patients commonly complain of associated sharp parascapular pain. The onset of cervical radiculopathy may be insidious or acute. It may be associated with a particular inciting event, or the disorder may manifest with an acute-on-chronic history of rapid worsening of symptoms that were already present in a less severe form. Although the symptoms may regress spontaneously, they have the potential to erupt again in an unpredictable fashion. Cervical radiculopathy is relatively common and is the most frequent indication for cervical spinal surgery.

Myelopathy, conversely, typically manifests with a slowly progressive process that may be subtle enough initially that the patient may not be aware of early neurologic deficits or may believe that the symptoms are simply part of aging. Common complaints include a loss of fine dexterity in hand function (inability to fasten buttons), nondermatomal finger numbness, changes in balance, urgency with bladder control, and increasing muscle atrophy (particularly involving the hand intrinsics). Myelopathy may be painless or may be associated with symptoms of neck or arm pain, depending on the specific neural tissues involved. As the disease progresses, the neurologic symptoms generally worsen, although this occurs classically in a slow, stepwise fashion with long periods of stability between changes in neurologic functioning. Rarely, a patient may have a more rapid neurologic decline, particularly in the setting of trauma.

Axial neck pain is relatively common, although the severity of the condition varies widely. In most cases, the symptoms are self-limited. The symptoms are usually described as having a deep, aching character and are located along the posterior neck. The pain may be described as radiating across the shoulders (along the trapezius muscle distribution) or to the posterior occipital region (where it may be associated with occipital region headaches). The symptoms often wax and wane in severity and may be aggravated by repetitive function, prolonged positions, or an awkward sleeping position.

Symptoms

Radiculopathy usually manifests with classic, well-defined symptoms of nerve root irritation secondary to compression in the neural foramen ( Table 8-1 ). Arm pain is the classic symptom and is generally more severe than neck pain (which may or may not be an associated symptom). Patients often note that the pain is worse with neck flexion, extension, or rotation. They may report relief when abducting the ipsilateral arm and placing their hand behind their head (shoulder abduction relief sign). Although nerve roots have stereotypic patterns of associated motor, sensory, and reflex functions, the examiner must keep in mind that overlap between adjacent root distributions is common. Although pain is usually the predominant symptom, discrete neurologic symptoms may be noted. In some cases, the pain may subside, leaving the affected individual with residual persistent numbness or weakness, or both. The surgeon should be aware of the possibility of a less classic presentation of radicular pain such as isolated parascapular pain or atypical chest pain. For patients presenting with atypical symptoms, the physician must be careful to characterize the symptoms fully, to rule out potential disease in an alternative organ system (e.g., cardiac angina).

Table 8-1

Stereotypic Nerve Root Functions

Nerve Root	Sensory Distribution	Motor Distribution	Skeletal Reflex
C5	Lateral arm	Deltoid, biceps	Biceps
C6	Thumb and index finger	Biceps, wrist extensors	Brachioradialis
C7	Middle finger	Triceps, wrist flexors	Triceps
C8	Small finger	Hand intrinsics	None

Myelopathy has a wide variety of presenting symptoms and is classically associated with hand or finger numbness, increasing clumsiness or difficulty holding objects with one or both hands, and a shuffling and unsteady gait. Patients may complain of difficulty walking at night when they have fewer visual clues or may note problems navigating uneven terrain. Generally, the changes in coordination and weakness are symmetric, although this is not always the case. Patients may also complain of aching pain in the neck and upper back or radicular pain radiating to the arms. Myeloradiculopathy is relatively common and may have the clinical features of both conditions. Although complete bladder or bowel incontinence is rare, more subtle symptoms of urgency are seen more commonly.

Axial neck pain, by definition, consists of pain without associated pain down the extremity or neurologic findings. The pain is usually described as deep seated, along the posterior aspect of the neck and upper shoulders. Patients with axial neck symptoms may complain of associated posterior headaches or constitutional symptoms. The physician must distinguish axial neck pain from radicular pain related to the upper cervical radiculopathy, which is less likely to have a waxing-waning course and is generally localized to one side. Additionally, radicular pain is generally affected by maneuvers that narrow or widen the neural foramina.

Warning Signs of Mimetics of Cervical Spine Disorders

Because many nonspinal sources of pain and disability can have a presentation similar to that of cervical spine disease, the spinal surgeon must always be attentive for features of the patient’s history that suggest an alternative diagnosis. Other musculoskeletal disorders that can masquerade as cervical spine disease include shoulder disorders, especially rotator cuff disease, which may manifest with shoulder pain radiating to the upper arm and is not relieved by shoulder elevation. Suprascapular nerve entrapment can cause aching shoulder or periscapular pain that may be noted on physical examination to be associated with atrophy of either the supraspinatus or infraspinatus muscles and confirmed by electromyography (EMG). Peripheral nerve entrapment commonly creates sensory deficits (with or without associated pain) that may be similar in distribution to patterns of radiculopathy. In particular, carpal tunnel syndrome (similar to C6 radiculopathy) and cubital tunnel syndrome (C8 radiculopathy) should be considered and ruled out when patterns of sensory disturbance suggest their inclusion in the differential diagnosis ( Fig. 8-1 ). Again, EMG can be helpful in excluding these conditions.