Chapter 62: Neck pain

Neck pain is a very common symptom in both sexes at all ages and although most pain is experienced in the posterior aspect of the neck, anterior neck pain can occur from causes that overlap between front and back. The main cause of neck pain is a disorder of the cervical spine, which usually manifests as neck pain but can refer pain to the head, shoulders and chest. Such pain usually originates from the facet (apophyseal) joints but can arise from other musculoskeletal structures, such as the intervertebral discs and the muscles or ligaments (see FIG. 62.1). The other major symptom is limited movement or stiffness.

General causes of neck pain are presented in TABLE 62.1.

A summary of the diagnostic strategy model is presented in TABLE 62.2.

Probability diagnosis

The main causes of neck pain are vertebral dysfunction, especially of the facet joints, and traumatic strains or sprains affecting the musculoligamentous structures of the neck. The so-called myofascial syndrome is mainly a manifestation of dysfunction of the facet joints. Acute wry neck (torticollis), which is quite common, is yet another likely manifestation of apophyseal joint dysfunction. Spondylosis, known also as degenerative osteoarthrosis and osteoarthritis, is also a common cause, especially in the elderly patient.

Intervertebral disc disruption is also a relatively common phenomenon in the cervical spine, especially at the lower levels C5–6 and C6–7.⁴

Serious disorders not to be missed

Conditions causing neck pain and stiffness may be a sign of meningitis or of cerebral haemorrhage, particularly subarachnoid haemorrhage, or of a cerebral tumour or retropharyngeal abscess.

Angina and myocardial infarction should be considered in anterior neck pain. Other visceral disorders can refer pain to the neck.

Arterial dissection of the internal carotid artery or vertebral artery should be kept in mind in patients presenting with acute neck pain, especially without musculoskeletal symptoms or signs.

Tumours are relatively rare in the cervical spine but metastases do occur and should be kept in mind, especially with persistent neck pain present day and night.

Metastasis to the spine occurs in 5–10% of patients with systemic cancer, making it the second most common neurological complication of cancer. The cervical spine accounts for some 15% of spinal metastases.³

The commonest primary tumours are the breast, prostate or lung. Other primaries include the kidney, thyroid and melanoma.

Pitfalls

There are many pitfalls in the clinical assessment of causes of neck pain, many of them related to inflammation.

Rheumatoid arthritis is the prime severe inflammatory arthropathy that involves the neck but the neck can be affected by the seronegative spondyloarthropathies, particularly ankylosing spondylitis, psoriasis and the inflammatory bowel disorders.

While polymyalgia rheumatica affects mainly the shoulder girdle, pain in the lower neck, which is part of the symptom complex, is often overlooked. Diffuse neck pain in myofascial soft tissue with tender trigger areas is part of the uncommon but refractory fibromyalgia syndrome.

General pitfalls

• Failing to appreciate how often the benign problem of facet joint dysfunction occurs in the neck, causing pain and limited movement. This involves failure to appreciate the value of physical therapy, especially exercise programs, in alleviating the problem.

• Failing to adhere to the idiom: one disc—one nerve root. Involvement of more than one nerve root in the upper limb may mean a neoplastic disorder such as metastatic disease, lymphoma in the thoracic outlet and similar serious diseases.

• Missing the insidious onset of myelopathy, especially the spasticity component, caused by rheumatoid arthritis, osteophytic overgrowth or, rarely, a soft disc prolapse.

Seven masquerades checklist

Cervical spinal dysfunction is the obvious outstanding cause. Thyroiditis may cause neck pain, as in the extremely rare cases of acute specific infection in the thyroid (e.g. syphilis, pyogenic infections), which cause severe pain; non-specific thyroiditis (de Quervain thyroiditis) produces painful swelling with dysphagia. The association between depression and neck pain is well documented.

Psychogenic considerations

The neck is one of the commonest areas for psychological fixation following injury. This may involve perpetuation or exaggeration of pain because of factors such as anxiety and depression, conversion reaction and secondary gain.

The psychological sequelae that can follow a whiplash injury and chronic neck problems such as spondylosis serve as a reminder that the state of the patient’s cervical spine can profoundly affect his or her life and that we should always be aware of the whole person. A feeling of depression is a very common sequel to such an injury and these patients demand our dutiful care and understanding.

History

It is important to analyse the pain into its various components, especially the nature of its onset, its site and radiation, and associated features. The diurnal pattern of the pain will provide a lead to the diagnosis (refer to FIG. 38.3: the patterns are similar to low back pain).

Key questions

• Can you point to exactly where in your neck you get the pain?

• Do you wake up with pain in the morning?

• Does the pain come on when you have to look up for a while?

• Do you have trouble reversing your car?

• Can you recall an injury to your head or neck such as hitting your head on an overhead bar?

• Does your neck grate or get stiff?

• Do you get headaches or feel dizzy?

• Is the pain present day and night?

• Do you get pain or pins and needles or numbness in your arms?

• Does the pain come on with activity?

• Does the pain wake you at night?

• Do you feel pain on both sides of your neck and over your shoulders?

• Do your hands or arms feel weak or clumsy?

Examination

It is appropriate to follow the traditional rule for examination of any joint or complex of joints: look, feel, move, measure, test function, look elsewhere and X-ray. Careful examination of the cervical spine is essential for the correct diagnosis and for specific treatment at the painful level.

Three objectives of the examination are to:

• reproduce the patient’s symptoms

• identify the level of lesion or lesions

• determine the cause (if possible)

A neurological examination is essential if radicular pain is present, or weakness or other upper limb symptoms, including any pain or paraesthesia that extends below the elbow.

Inspection

The patient should be examined sitting on a couch, rather than on a chair. The body should be fully supported with the hands resting on the thighs. The following should be noted:

• willingness to move the head and neck

• level of the shoulders

• any lateral flexion

• contour of the neck from the side

In the patient with torticollis the head is held laterally flexed with, perhaps, slight rotation to one side—usually away from the painful side. Patients suffering from whiplash injury and severe spondylosis tend to hold the neck stiff and the head forward, and tend to turn the trunk rather than rotate the neck.

Palpation

For this vital component of the examination it is essential to know the surface anatomy of the neck so that the affected level can be determined.

The patient lies prone on the examination couch with the forehead resting on the hands (palms up). The neck should be flexed forward and the shoulders relaxed.

1. Central digital palpation

   Systematically palpate the first spinous processes of the cervical vertebrae.

   • C2 (axis) is the first spinous process palpable beneath the occiput.

   • C7 is the largest ‘fixed’ and most prominent process—situated at the base of the neck.

   • C6 is also prominent but usually ‘disappears’ under the palpating finger with extension of the neck.

   • The spinous processes of C3, C4 and C5 are difficult to palpate because of cervical lordosis but their level can be estimated (see FIG. 62.2).

     Standing at the patient’s head, place opposed pulps of the thumbs on the spinous processes (starting at C2) and then move down the middle line to C7. Press firmly over each and with arms straight oscillate with moderate firmness three or four times to assess pain, stiffness or muscle spasm.

2. Lateral digital palpation

   The facet joints lie in sequence (called the articular pillar) about 2 to 3 cm from the midline. Press with opposed thumbs against this pillar in a systematic manner on either side of the midline (top to base) to determine any painful area. Palpation should be extended to include the anterior neck, searching for evidence of lymphadenitis, muscle spasm, thyroid disorder and other problems.

Movement

Active movements are observed with the patient sitting on the couch. The movements are as follows with normal range indicated:

• flexion—45°

• extension—50°

• lateral flexion (R and L)—45°

• rotation (R and L)—75°

Lhermitte sign is an electric shock-like pain throughout the body (especially in the legs) upon flexion of the neck. It indicates cervical pathology.

If there is a full range of pain-free movement, apply overpressure slowly at the end range and note any pain.

The range of movements can be plotted on a special grid called a direction of movement (DOM) diagram (see FIG. 62.3). This provides a ready reference for serial assessments.

Neurological examination

A neurological examination for nerve root lesions (C5 to T1) is indicated if the clinical assessment identifies the presence of neurological symptoms and signs such as pain, paraesthesia or anaesthesia in the arm. Nerve root pressure is indicated by:

• pain and paraesthesia along the distribution of the dermatome

• localised sensory loss

• reduced muscular power (weakness or fatigue or both)

• hyporeflexia (reduced amplitude or fatigue or both)

It is necessary to know the sensory distribution for each nerve root and the motor changes. This is summarised in TABLE 62.3. The dermatomes are illustrated in FIGURE 62.4.

Investigations

The investigations are directed to diagnosing the painful condition and determining if suspected or true organic disease is present in the spine. It is inappropriate to perform sophisticated investigations such as CT scans on most patients. Scanning should be reserved where surgery is contemplated and serious disease is suspected but not confirmed by plain X-ray.

Investigations to consider include:

• haemoglobin, film and WCC

• ESR/CRP

• rheumatoid arthritis factor

• HLA-B₂₇ antigen

• radiology:

  • – plain X-ray (not indicated in absence of red flags and major trauma)

  • – CT scan (good for bone definition)

  • – CT scan and myelogram (if cervical disc surgery contemplated)

  • – radionucleide bone scan (for suspected metastatic disease)

  • – MRI: the investigation of choice for cervical radiculopathy, myelopathy, suspected spinal infection and tumour

These should be selected conservatively. CT imaging has high radiation levels.

In children and adolescents, neck pain, often with stiffness, may be a manifestation of infection or inflammation of cervical lymph nodes, usually secondary to an infected throat—for example, tonsillitis or pharyngitis. However, it is vital to consider the possibility of meningitis. Sometimes a high fever associated with a systemic infection or pneumonia can cause meningism. In the presence of fever the rare possibility of poliomyelitis should be kept in mind. In both children and adults the presence of cerebral pathology, such as haemorrhage, abscess or tumour are uncommon possibilities.⁵ Acute torticollis is quite common in this age group and the neck may be involved in chronic juvenile arthritis.

In adults the outstanding causes are dysfunction of the joints and spondylosis, with the acute febrile causes encountered in children being rare. However, cerebral and meningeal disorders may cause pain and stiffness in the neck.⁵

Rheumatoid arthritis is the prime severe inflammatory arthropathy that involves the neck, but the neck can be affected by the spondyloarthropathies (e.g. ankylosing spondylitis). The painful, acute wry neck can affect all ages and is considered to be caused mainly by acute disorders of the apophyseal joints rather than disc prolapse. However, disc lesions do occur and can cause referred pain or radicular pain. In the elderly, radicular pain can also be caused by impingement of the nerve root in the intervertebral foramen that has become narrowed from the degenerative changes of longstanding spondylosis.

Problems with a higher probability with increasing age include:

• cervical spondylosis with radiculopathy or myelopathy

• atlantoaxial subluxation complicating rheumatoid arthritis

• polymyalgia rheumatica

• metastatic cancer

• Pancoast tumour of the lung

• angina and myocardial infarction

• pharyngeal and retropharyngeal infection and tumour

Pain originating from disorders of the cervical spine is usually, although not always, experienced in the neck. The patient may experience headache, or pain around the ear, face, arm, shoulder, upper anterior or posterior chest.⁵

Possible symptoms include:

• neck pain

• neck stiffness

• headache

• migraine-like headache

• facial pain

• arm pain (referred or radicular)

• myelopathy (sensory and motor changes in arms and legs)

• ipsilateral sensory changes of scalp

• ear pain (peri-auricular)

• scapular pain

• anterior chest pain

• torticollis

• dizziness/vertigo

• visual dysfunction

FIGURE 24.1 in CHAPTER 24 indicates typical directions of referred pain from the cervical spine. Pain in the arm (brachialgia) is common and tends to cover the shoulder and upper arm as indicated.

Dysfunction of the 35 intervertebral joints that comprise the cervical spine complex is responsible for most cases of neck pain. The problem can occur at all ages and appears to be caused by disorder (including malalignment) of the many facet joints, which are pain-sensitive. Dysfunction of these joints, which may also be secondary to intervertebral disc disruption, initiates a reflex response of adjacent muscle spasm and myofascial tenderness.

Acute neck pain

Acute neck pain (ANP) is most commonly idiopathic or due to a whiplash accident. Serious causes are rare.⁶ Dysfunction can follow obvious trauma such as a blow to the head or a sharp jerk to the neck, but can be caused by repeated trivial trauma or activity such as painting a ceiling or gentle wrestling. People often wake up with severe neck pain and blame it on a ‘chill’ from a draught on the neck during the night. This is incorrect because it is usually caused by an unusual twist on the flexed neck for a long period during sleep.

Clinical features⁷

• Typical age range 12–50 years

• Dull ache (may be sharp) in neck

• May radiate to occiput, ear, face and temporal area (upper cervical)

• May radiate to shoulder region, especially suprascapular area (lower cervical)

• Rarely refers pain below the level of the shoulder

• Pain aggravated by activity, improved with rest

• Various degrees of stiffness

• Neck tends to lock with specific movements, usually rotation

• Localised unilateral tenderness over affected joints

• Variable restriction of movement but may be normal

• X-rays usually normal: plain X-rays are not indicated for the investigation of ANP in the absence of ‘red flags’ and a history of trauma⁶

Management

The aim of treatment is to reduce pain, maintain function and minimise the risk of chronicity.

• Provide appropriate reassurance, information and support.

• Give advice to the patient about rules of living, including the following:

  Do:

  • – Stay active and resume normal activities.

  • – Keep your neck upright in a vertical position for reading, typing and so on.

  • – Keep a good posture—keep the chin tucked in.

  • – Sleep on a low, firm pillow or a special conforming pillow.

  • – Sleep with your painful side on the pillow.

  • – Use heat and massage: massage your neck firmly three times a day using an analgesic ointment.

  Don’t:

  • – Look up in a strained position for long periods.

  • – Twist your head often towards the painful side (e.g. when reversing a car).

  • – Lift or tug with your neck bent forwards.

  • – Work, read or study with your neck bent for long periods.

  • – Become too dependent on ‘collars’.

  • – Sleep on too many pillows.

• Monitor the patient’s progress without overtreatment.

• Analgesia:⁷

  • – first line: paracetamol 1 g (o) qid or 1.33 g (o) 8-hourly

  • – consider tricyclic antidepressant for night pain or resistant pain

• Prescribe an exercise program as early as possible; start with gentle exercises and maintain them at home. Suitable exercises are shown in FIGURE 62.5.

• Refer to an appropriate therapist for cervical mobilisation for persisting pain. Mobilisation combined with exercises can be an effective treatment. Occasionally, manipulation may help with a stubborn ‘locked’ neck but should be left to an expert. If manipulation, which carries the rare but real risk of vertebral artery dissection and stroke, is to be performed, informed consent and an experienced therapist are required.⁸

Approximately 40% of patients recover fully from acute idiopathic ANP, about 30% continue to have mild symptoms, while 30% continue to have moderate or severe symptoms.⁶

Chronic non-specific pain (lasting more than 3 months)⁷

Continue normal activities and exercises.

Additional treatment modalities to consider include:

• a course of antidepressants

• TENS, especially when drugs are not tolerated

• hydrotherapy

• acupuncture (may provide short-term relief)

• corticosteroid facet injections (ideally under image intensification)

• facet joint denervation with percutaneous radiofrequency (if nerve block provides relief)

• multidisciplinary rehabilitation program

Cervical spondylosis⁷

Cervical spondylosis following disc degeneration and apophyseal joint degeneration is far more common than lumbar spondylosis and mainly involves the C5–6 and C6–7 segments. The consequence is narrowing of the intervertebral foramen with the nerve roots of C6 and C7 being at risk of compression.

Cervical spondylosis is generally a chronic problem but it may be asymptomatic. In some patients the pain may lessen with age, while stiffness increases.

Clinical features

• Dull, aching suboccipital neck pain (see FIG. 62.6)

• Stiffness

• Worse in morning on arising and lifting head

• Improves with gentle activity and warmth (e.g. warm showers)

• Deteriorates with heavy activity (e.g. working under car, painting ceiling)

• Usually unilateral pain—may be bilateral

• Pain may be referred to head, arms and scapulae

• May wake patient at night with paraesthesia in arms

• C6 nerve root most commonly involved

• Acute attacks on chronic background

• Aggravated by flexion (reading) and extension

• Associated vertigo or unsteadiness

• Restricted tender movements, especially rotation/lateral flexion

• Joints tender to palpation

• X-ray changes invariable

Treatment

• Provide appropriate reassurance, information and support.

• Refer for physiotherapy, including warm hydrotherapy.

• Use regular mild analgesics (e.g. paracetamol).

• Use NSAIDs: a trial for 2 weeks and then review.

• Prescribe gentle mobilising exercises as early as possible.

• Give passive mobilising techniques.

• Outline general rules to live by, including advice regarding sleeping and pillows, and day-to-day activities.

• Radiculopathy (unilateral or bilateral)

• Myelopathy—pressure on spinal cord

• Spinal canal stenosis

Acute torticollis

Torticollis (acute wry neck) means a lateral deformity of the neck. This is usually a transient self-limiting acutely painful disorder with associated muscle spasm of variable intensity.

Clinical features

• Age of patient between 12 and 30 years

• Patient usually awakes with the problem

• Pain usually confined to neck but may radiate

• Deformity of lateral flexion and slight flexion/rotation

• Deformity usually away from the painful side

• Loss of extension

• Mid-cervical spine (C2–3, C3–4, C4–5)

• Any segment between C2 and C7 can cause torticollis

• Usually no neurological symptoms or signs

The exact cause of this condition is uncertain, but both an acute disc lesion and apophyseal joint lesion are implicated, with the latter the more likely cause. Acute torticollis is usually a transient and self-limiting condition that can recover within 48 hours. Sometimes it can last for about a week. Encourage heat massage and early mobility. Avoid cervical collars. Management by mobilisation and muscle energy therapy is very effective.

Muscle energy therapy

This amazingly effective therapy relies on the basic physiological principle that the contracting and stretching of muscles leads to automatic relaxation of agonist and antagonist muscles.^9,10 Lateral flexion or rotation or a combination of movements can be used, but treatment in rotation is preferred. The direction of contraction can be away from the painful side (preferred) or towards the painful side, whichever is most comfortable for the patient.

1. Explain the method to the patient, with reassurance that it is not painful.

2. Rotate the patient’s head passively and gently towards the painful side to the limit of pain (the motion barrier).

3. Place your hand against the head on the side opposite the painful one. The other (free) hand can be used to steady the painful level—usually C3–4.

4. Request the patient to push the head (in rotation) as firmly as possible against the resistance of your hand. The patient should therefore be producing a strong isometric contraction of the neck in rotation away from the painful side (see FIG. 62.7A). Your counterforce (towards the painful side) should be firm and moderate (never forceful) and should not ‘break’ through the patient’s resistance.

5. After 5–10 seconds (average 7 seconds) ask the patient to relax; then passively stretch the neck gently towards the patient’s painful side (see FIG. 62.7B).

6. The patient will now be able to turn the head a little further towards the painful side.

7. This sequence is repeated at the new improved motion barrier. Repeat three to five times until the full range of movement returns.

8. Ask the patient to return the following day for treatment, although the neck may be almost normal.

The patient can be taught self-treatment at home using this method.

Acceleration hyperextension (whiplash) injury

Patients with the whiplash syndrome, preferably referred to as an acceleration hyperextension injury, typically present with varying degrees of pain-related loss of mobility of the cervical spine, headache and emotional disturbance in the form of anxiety and depression. The problem can vary from mild temporary disability to a severe and protracted course.

The injury occurs as a consequence of hyperextension of the neck followed by recoil hyperflexion, typically following a rear-end collision between motor vehicles. There is a reversal of the sequence of these movements in a head-on collision. In addition to hyperextension, there is prolongation or anterior stretching plus longitudinal extension of the neck.⁸ It can also occur with other vehicle accidents and in contact sports such as football.

Whiplash causes injury to soft tissue structures, including muscle, nerve roots, the cervical sympathetic chain, ligaments, apophyseal joints and their synovial capsules and intervertebral discs. Damage to the apophyseal joints appears to be severe, with possible microfractures (not detectable on plain X-ray) and long-term dysfunction.

Pain and stiffness of the neck are the most common symptoms. The pain is usually experienced in the neck and upper shoulders but may radiate to the suboccipital region, the interscapular region and down the arms. The stiffness felt initially in the anterior neck muscles shifts to the posterior neck.

Headache is a common and disabling symptom that may persist for many months. It is typically occipital but can be referred to the temporal region and the eyes.

Nerve root pain can be caused by a traction injury of the cervical nerve roots or by inflammatory changes or direct pressure subsequent to herniation of a disc.

Paraesthesia of the ulnar border of the hand, nausea and dizziness are all relatively common symptoms.

Delayed symptoms are common. A patient may feel no pain until 24 (sometimes up to 96) hours later; most experience symptoms within 6 hours. Complications of whiplash are summarised in TABLE 62.4.

The Canadian guidelines (1995) for whiplash are:

• Grade I—neck pain, stiffness or tenderness

• Grade II—neck symptoms + musculoskeletal signs (e.g. decreased range of motion, point tenderness)

• Grade III—neck symptoms + neurological signs

• Grade IV—neck symptoms + fracture or dislocation

Management principles

The objective of treatment is to obtain a full range of free movement of the neck without pain by attending to both the physical and the psychological components of the problem. Other objectives include an early return to work and discouragement of unnecessary and excessive reliance on cervical collars and legal action.

Treatment

• Establish an appropriate empathy and instil patient confidence with a positive, professional approach. Discourage multiple therapists.

• Provide appropriate reassurance and patient education.

• Encourage normalisation of activities as soon as possible.

• Compare the problem with a sprained ankle, which is a similar injury.

• Inform that an emotional reaction of anger, frustration and temporary depression is common (lasts about 2 weeks). Offer psychotherapy, e.g. CBT for evidence of post-traumatic stress.

• X-ray is required for ‘red flags’.

• Prescribe rest only for grades II and III (max. 4 days).

• Use a cervical collar (limit to 2 days) for grades II and III. Provide collar and refer for grade IV.

• Use analgesics (e.g. paracetamol)—avoid narcotics.

• Use a trial of NSAIDs for 14 days (poor evidence).

• Use tranquillisers, mild—up to 2 weeks.

• Refer for physiotherapy.

• Provide neck exercises (as early as possible).

• Use heat and massage—‘spray and stretch’—or ice.

• Give passive mobilisation (not manipulation).⁹

Recovery can take any time from 1–2 weeks up to about 3 months. A valuable reference is Update Quebec Task Force Guidelines for the Management of Whiplash—Associated Disorder at <www.nhmrc.gov.au/guidelines/>.

Cervical disc disruption

Disruption of a cervical disc can result in several different syndromes.

1. Referred pain over a widespread area due to pressure on adjacent dura mater.

   Note: A disc disruption is capable of referring pain over such a diffuse area (see FIG. 62.8) that the patient is sometimes diagnosed as functional (e.g. hysterical).

2. Nerve root or radicular pain (radiculopathy). The pain follows the dermatomal distribution of the nerve root in the arm.

3. Spinal cord compression (myelopathy).

Radiculopathy

Apart from protrusion from an intervertebral disc, nerve root pressure or irritation causing arm pain can be caused by osteophytes associated with cervical spondylosis. Uncommon causes include various tumours involving the vertebral segment, the meninges and nerves or their sheaths. The pain follows neurological patterns down the arm, being easier to localise with lower cervical roots, especially C6, C7 and C8.

1. The cervical roots exit above their respective vertebral bodies. For example, the C6 root exits between C5 and C6 so that a prolapse of C5–6 intervertebral disc or spondylosis of the C5–6 junction affects primarily the C6 root (see FIG. 62.4).

2. One disc—one nerve root is the rule.

3. Spondylosis and tumours tend to cause bilateral pain (i.e. more than one nerve root).

Clinical features

• A sharp aching pain in the neck, radiating down one or both arms

• Onset of pain may be abrupt, often precipitated by a sudden neck movement on awakening

• Paraesthesia in the forearm and hand (in particular)—in 90% with proven disc prolapse⁹

• Stiffness of neck with limitation of movement

• Nocturnal pain, waking patient during night

• Pain localised to upper trapezius and possible muscle spasm

Investigations

• Plain X-ray (AP, lateral extension and flexion, oblique views to visualise foramina); not required before 6–8 weeks unless red flags present; not useful for diagnosis or for surgery

• Plain CT scan

• CT scan and myelogram—excellent visualisation of structures but invasive

• MRI—excellent but expensive, sometimes difficult to distinguish soft disc from osteophytes

• Electromyography—may help delineate lesions requiring surgery

Treatment

Many patients respond to conservative treatment, especially from a disc prolapse. It is basically a self-limiting disorder—about 10% remain severely disabled:¹⁰

• bed rest

• soft cervical collar

• analgesics (according to severity—see CHAPTER 38)

• consider a course of corticosteroids for severe neck radicular pain, e.g. prednisone 30 mg (o) daily for 5–10 days then taper off to 3 weeks (limited evidence)⁸

• tranquillisers, especially at night

• traction (with care)

• careful mobilisation (manipulation is contraindicated)

Sometimes the presence of large or multiple osteophytes or in the presence of a narrowed spinal canal symptoms of spinal cord involvement may develop.^11,12 The common cause is a hard mass of material projecting from the posterior aspect of the vertebral body to indent the spinal cord and possibly the nerve roots at the exit foramina. This resultant spinal cord compression may result in several different clinical presentations, notably myelopathy in particular, but also central cord and anterior cord syndrome. A full neurological assessment is necessary.

Clinical features

• Older patients, typically men >50 years

• Insidious onset—symptoms over 1–2 years

• Numbness and tingling in fingers

• Leg stiffness

• Gait disturbance

• Numb, clumsy hands, especially with a high cervical lesion

• Signs of UMN: spastic weakness, increased tone and hyper-reflexia (arms > legs) ± clonus

• Neurological deficit, which predicts the level with reasonable accuracy

• Bowel and bladder function usually spared

Note: LMN signs occur at the level of the lesion, and UMN signs and sensory changes occur below this level.

Causes

• Cervical spondylosis

• Atlantoaxial subluxation: rheumatoid arthritis, Down syndrome

• Primary spinal cord tumours (e.g. meningiomas)

• Metastasis to cervical spine → epidural spinal cord compression

Investigations

• MRI scan

• CT scan with myelogram (most accurate)

Central cord syndrome¹²

This rather bizarre condition occurs classically in a patient with a degenerative cervical spine following a hyperextension injury that causes osteophytes to compress the cord anteriorly and posteriorly simultaneously.

The maximum damage occurs in the central part of the cord, leading to sensory and motor changes in the upper limbs with relative sparing of the lower limbs due to the arrangements of the long tracts in the cord.

Fortunately, the prognosis is good, with most patients achieving a good neurological recovery.

Anterior cord syndrome

Anterior cord syndrome occurs with hyperflexion injuries that produce ‘teardrop’ fractures of the vertebral bodies or extrusion of disc material. The syndrome can also be produced by comminuted vertebral body fractures.

It is characterised by complete motor loss and the loss of pain and temperature discrimination below the level of the injury, but deep touch, position, two-point discrimination and vibration sensation remain intact.

Because it is probably associated with obstruction of the anterior spinal artery, early surgical intervention to relieve pressure on the front of the cord may enhance recovery. Otherwise the prognosis for recovery is poor.

Down syndrome

One of the more sinister problems with trisomy 21 syndrome is hypoplasia of the odontoid process, leading to C1–2 subluxation and dislocation. If unrecognised in the early stages, sudden death can occur in these children. If suspected, flexion–extension lateral views of the cervical spine will highlight the developing instability and the need for early specialist opinion.

Rheumatoid arthritis^7,15

Involvement of the cervical spine is usually a late manifestation of rheumatoid arthritis (RA). It is important to be aware of the potentially lethal problem of C1–2 instability due to erosion of the major odontoid ligaments in the rheumatoid patient. These patients are especially vulnerable to disasters when under general anaesthesia and when involved in motor vehicle accidents. Early cervical fusion can prevent tragedies, especially with inappropriate procedures such as cervical manipulation. It is imperative to perform imaging of the cervical spine of all patients with severe RA before major surgery to search for C1–2 instability. Lateral plain X-rays in flexion and extension may reveal increased distance in the atlanto–dens interval. This can be assessed further with MRI or CT scanning in a specialist clinic.

Treatment of spondylitic myelopathy

Conservative (may help up to 50%):²

• soft cervical collar

• physiotherapy for muscle weakness

• analgesics and/or NSAIDs

Surgery is indicated when the myelopathy interferes with daily activities. One procedure is the Cloward method, which is anterior decompression with discectomy and fusion. The aim of surgery is to halt deterioration.

• Persisting radicular pain in an arm despite conservative treatment

• Evidence of involvement of more than one nerve root lesion in the arm

• Severe symptoms with motor weakness

• Evidence of myelopathy, such as weakness, numbness or clumsiness of the upper limbs

• Evidence, clinical or radiological, of cervical instability in post-accident victims, or people with Down syndrome or rheumatoid arthritis

Hand-out sheets from Murtagh’s Patient Education 7th edition:

• Exercises for your neck

• Neck: painful neck

• Whiplash

• Wry neck (torticollis)