James C. Farmer
David A. Bomback
Thomas P. Sculco
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 spondylosis ranges from axial neck pain to radiculopathy to frank myelopathy.
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 disease progression.
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.
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 pain 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.
Degeneration of the intervertebral dise 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 including repetitive occupational mechanical strain, and 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.
Acute herniation of the disc material posteriorly may result in impingement of the nerve root and/or spinal cord. The distribution of pain in cervical radiculopathy often fits a dermatomal distribution characteristic for each particular nerve root. When cord compression occurs, the changes within the cord can be caused by acute compression by the disc material, as well as compression of the vascular supply to the cord.
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 ensue, 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.
Prevalence of neck and referred shoulder/brachial pain has been reported to be 9%. In a series of 205 patients who presented with neck pain and were managed nonoperatively, 79% were noted to be asymptomatic or improved at a minimum follow-up of 10 years. Symptoms of 13% were unchanged, 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%.
I. NECK PAIN
Signs and symptoms. Neck pain is a pain that is perceived by the patient as 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 area 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 for patients to localize it. Because the neck can be a prominent area of referred pain from thoracic organs such as the heart or aorta, the physician must be aware of the patient’s comorbid medical issues.
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).
Range of neck motion should include flexion, extension, rotation, and lateral bending. Normal flexion demonstrates the ability 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.
II. CERVICAL RADICULOPATHY
Signs and symptoms. 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.
Physical examination. The shoulder abduction relief sign is characterized by having the patient place the palm of his hand flat onto the top of his skull; this causes symptomatic relief of the radicular pain. Spurling’s test is performed by having the patient extend the neck and rotate and laterally bend the head toward the affected side; an axial compressive force is then applied to the top of the patient’s head. The test is positive when the maneuver reproduces the patient’s typical radicular arm pain.
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