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The radiographic findings depend on the cause of the pain; many plain radiographs are completely normal in patients who have suffered an acute cervical strain Loss of cervical lordosis is often seen but is nonspecific In osteoarthritis, comparative reduction in height of the involved disk space is a frequent finding The most common late radiographic finding is osteophyte formation anteriorly, adjacent to the disk; other chronic abnormalities occur around the apophysial joint clefts, chiefly in the lower cervical spine Use of advanced imaging techniques is indicated in the patient who has severe pain of unknown cause that fails to respond to conservative therapy or in the patient who has evidence of myelopathy MRI is more sensitive than CT in detecting disk disease, extradural compression, and intramedullary cord disease CT is preferable for demonstration of fractures
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Most chronic neck pain is caused by degenerative joint disease and responds to conservative approaches Whiplash, the most common type of traumatic injury to the neck, responds to early mobilization Serious erosive disease of joints in the neck that may lead to neurologic complications sometimes occurs in rheumatoid arthritis and occasionally in ankylosing spondylitis; the usual joint involved in these disorders is the atlantoaxial joint (C1 2)
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The causes of neck pain include acute and chronic cervical strain or sprains, herniated nucleus pulposus, osteoarthritis, ankylosing spondylitis, rheumatoid arthritis, fibromyalgia, osteomyelitis, neoplasms, polymyalgia rheumatica, compression fractures, and functional disorders
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A Nonspecific Neck Pain
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In the absence of trauma or evidence of infection, malignancy, neurologic findings, or systemic inflammation, the patient can be treated conservatively Conservative therapy can include rest, analgesics, or physical therapy
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At any point in time, about 15% of adults are experiencing neck pain The prevalence of neck pain peaks at age 50 and develops more commonly in women than in men A large group of articular and extra-articular disorders are characterized by pain that may involve simultaneously the neck, shoulder girdle, and upper extremity Diagnostic differentiation may be difficult Some represent primary disorders of the cervicobrachial region; others are local manifestations of systemic disease It is frequently not possible to make a specific diagnosis
B Acute Cervical Musculotendinous Strain
Cervical strain is generally caused by mechanical postural disorders, overexertion, or injury (eg, whiplash) Acute episodes are associated with pain, decreased cervical spine motion, and paraspinal muscle spasm, resulting in stiffness of the neck and loss of motion Muscle trigger points can often be localized After whiplash injury, patients often experience not only neck pain but also shoulder girdle discomfort and headache Management includes administration of analgesics Soft cervical collars are commonly recommended, but evidence suggests they may delay recovery Acupuncture, manipulation, or physical therapy can help some patients, but the precise role of these treatments is not well established Corticosteroid injection into cervical facet joints is ineffective Gradual return to full activity is encouraged
Clinical Findings
A Symptoms and Signs
Neck pain may be limited to the posterior region or, depending on the level of the symptomatic joint, may radiate segmentally to the occiput, anterior chest, shoulder girdle, arm, forearm, and hand It 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 Radiating pain in the upper extremity is often intensified by hyperextension of the neck and deviation of the head to the involved side Limitation of cervical movements is the most common
C Herniated Nucleus Pulposus
Rupture or prolapse of the nucleus pulposus of the cervical disks into the spinal canal causes pain radiating at a C6 7 level When intra-abdominal pressure is increased by coughing, sneezing, or other movements, symptoms are aggravated, and cervical muscle spasm may occur Neuro-
Arthritis & Musculoskeletal Disorders
logic abnormalities include decreased reflexes of the deep tendons of the biceps and triceps and decreased sensation and muscle atrophy or weakness in the forearm or hand Cervical traction, bed rest, and other conservative measures are usually successful Radicular symptoms usually respond to conservative therapy, including NSAIDs, activity modification, intermittent cervical traction, and neck immobilization Cervical epidural corticosteroid injections may help those who fail conservative therapy Surgery is indicated for unremitting pain and progressive weakness despite a full trial of conservative therapy and if a surgically correctable abnormality is identified by MRI or CT myelography Surgical decompression achieves excellent results in 70 80% of such patients
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