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Cervical
spine disorders account for thousands of visits to primary care
physicians each year. The majority of these patients suffer from
acute cervical strain or cervical osteoarthritis. Most sprain
injuries will recover in two to four weeks with a conservative
treatment plan and most cervical arthritis problems respond to
medication and physical treatment measures. However, there are
several red flags signifying potentially serious disorders of
the cervical neck that require diagnostic testing and additional
treatment.
Red
Flags and Initial Treatment
There
are several symptoms that should be considered “red flags”
for patients who are suffering from cervical neck pain. These
include:
- History
of recent fall or trauma to the head or neck
- Unexplained
weight loss
- Unexplained
fever, especially in diabetic patients
- History
of cancer
- Chronic
steroid use
- Evidence
of spinal cord compression, including severe weakness, hand atrophy,
loss of pain and temperature sensation in upper extremities;
gait disturbance; or Babinski’s sign.
These
symptoms may be a sign of a more serious condition, including
infection, tumor, fracture or dislocation. Patients who present
with these symptoms require immediate attention and diagnostic
studies.
Patients
presenting without these red flag symptomss can normally undergo
approximately four weeks of conservative treatment options, including
NSAIDs, muscle relaxants, physical therapy, home heat treatments,
relaxation techniques, and activity modification. If a patient
has not seen relief after four weeks of conservative treatment,
diagnostic studies and a neurosurgical consultation should be
ordered. Patients with pain limited to the neck should undergo
plain x–rays to reveal occult fracture, subluxation, pathological
fracture due to infection or malignancy, or extensive osteoarthritis.
Patients with radiculopathy should have a MRI scan to reveal
disc herniation, cervical spinal stenosis, osteomyelitis or tumor.
Examining
the Cervical Spine
Physically
examining the cervical spine can help reveal tenderness, muscle
spasm and range of motion. There are three steps to examining
the cervical spine:
1) Muscle
spasm/muscle atrophy: The paraspinal muscles can be palpated
to reveal muscle spasm or muscle atrophy in the neck.
2) Flexibility/range
of motion: The flexion, extension, rotation and lateral
bending of the neck can be easily examined. Patients with nerve
root compromise often feel more pain during compression of the
neck by downward pressure on the head and less pain when the
neck is distracted by placing the hands under the chin and occiput
and pulling upward.
3) Radiculopathy/weakness
in the upper extremities: Radicular pain, focal numbness
and isolated muscle weakness in one arm is common in patients
with nerve root compromise. Patients suffering from cervical
spinal stenosis often feel weakness and numbness in both hands
and leg stiffness or unsteadiness of gait without pain.
Common
Disorders of the Cervical Spine
Whiplash: Whiplash injuries
are commonly seen after acceleration/deceleration injuries to
the neck, most commonly a rear–end automobile accident.
Approximately 65 percent of patients make a full recovery, 25
percent have minor residual symptoms and 5 – 10 percent
develop chronic pain syndromes. Unfortunately, treatment for
these patients is limited to pain reduction modalities during
healing phases.
Whiplash
patients commonly present with complaints of neck stiffness,
shoulder or arm pain, mylagias, paresthesias, headache, facial
pain and vertigo. Plain x–rays should be ordered to rule
out fracture or subluxation due to a ligament tear. X–rays
sometimes also reveal a straightening of the natural curve in
the neck because of extensive muscle spasm. The majority of patients
with whiplash injury have normal radiological studies.
Pain from
a whiplash injury can be caused by tears and hemorrhage in the
anterior and posterior musculature that supports the neck, rupture
of the anterior longitudinal ligament, avulsions of the disc
from vertebral bodies, or annular disc injuries. If disc herniation
or nerve root compromise is suggested, a MRI study can help pinpoint
the problem. Treatment for whiplash injuries consists of analgesics,
NSAIDs, muscle relaxants and aggressive physical therapy. Home
cervical traction and manipulation are sometimes helpful.
Cervical
Disc Herniation:
The most common areas for herniation in the cervical spine are
C4–5, C5–6 and C6–7. Which disc is affected may
be diagnosed by where the patient’s tingling/numbness, weakness
and diminished reflexes appear:
|
Disc |
Tingling/Numbness |
Weakness |
Poor
reflex |
|
C5 |
Outer
shoulder, upper arm |
Deltoid |
Not
distinguishable |
|
C6 |
Thumb |
Biceps |
Biceps |
|
C7 |
Middle
finger |
Triceps |
Triceps |
Evidence
of weakness and diminished reflexes in the affected arm should
always be tested against the other arm. Tingling and numbness
in the index finger may indicate either C6 or C7 nerve root while
tingling in the pinky and ring fingers reveals the less common
C8 nerve root compromise (C7–T1 disc herniation).
Disc herniation
is best diagnosed by a MRI scan. If more than one level of herniation
appears, a CT myelogram can help distinguish which disc is irritating
the spinal nerve. An EMG can reveal which nerve is affected,
but it does not confirm disc herniation. This information is
often revealed during the physical exam, making EMG’s most
effective when the MRI shows more than one level of herniation
and there is no definite motor, sensory, or reflex deficit, to
distinguish which nerve root is affected.
If a herniated
disc is suspected, patients can often be treated with two weeks
or more of conservative treatment that includes steroids, muscle
relaxants, and physical therapy before a MRI is ordered. Trigger
point injections, including corticosteroids, can temporarily
relieve pain. Conservative treatment options may continue for
up to six to eight weeks. If there is severe weakness in the
deltoid, biceps, triceps, or intrinsic hand muscles, a more aggressive
timetable may be warranted to try to avoid irreversible atrophy.
However, if pain responds promptly to conservative management,
initial weakness may recover without surgery. Approximately 80
percent of herniated disc patients respond to conservative treatment.
Surgery
consists of either an anterior cervical discectomy, with or without
fusion, or a posterior partial hemilaminectomy and discectomy,
depending on the specific anatomy of the case or individual preference.
Approximately 90 percent of patients gain significant pain relief
after surgery.
Osteoarthritis/Degenerative
Disc Disease:
Osteoarthritis and degenerative disc or joint disease, often
caused by general wear and tear on the spine, are common in the
cervical neck. Patients with a previous history of a whiplash
injury are six times more likely to develop such a condition.
Common presentations include neck pain, headache, numbness, and
tingling in the arms or legs.
Plain
x–rays can sometimes reveal bone spurs at the level of degeneration
that appears to be irritating the spinal nerve root. However,
it should be noted that often an MRI scan will reveal a herniated
disc at, or below, the site of degeneration as shown on plain
X–ray films and this can be the real cause of the symptoms.
Patients
with cervical spondylosis need to be carefully observed for signs
of myelopathy, which may be insidious and progressive. Chronic
and progressive gait and numbness, pain and weakness in the arms
may develop and must be immediately reported. Spinal cord injury
can occur as a result of mechanical compression and ischemic
damage. Referral to a neurosurgeon for a decompression operation
is needed if signs of myelopathy develop.
Conservative
treatment options for patients without signs of myelopathy include
NSAIDs, physical therapy, application of heat, relaxation techniques
and the use of an antidepressant drugs, which in low doses at
night acts as a mild muscle relaxant. Trigger point injections
also may provide temporary relief.
Cervical
Stenosis:
Cervical stenosis occurs when the spinal canal narrows and compresses
the cord as a result of gradual thickening of the ligamentum
flavum, hypertrophy of the facet joints and degenerative disc
disease with protruding bone spurs (osteophytes). Stenosis is
best seen on a MRI. Patients usually present with numbness and
weakness in both hands, unsteady gait, spasticity in the legs,
hyperreflexia, and Babinski signs. Severe stenosis can be identified
by clinical signs of myelopathy and requires referral to a neurosurgeon.
Mild stenosis can be treated conservatively for extended periods
of time as long as the symptoms are restricted to neck pain.
When Surgery
is the Answer
There
are several surgical treatments available to treat cervical spine
disorders. Factors in determining surgical treatment may include
the type of herniation the patient presents, whether there is
pressure on the spinal cord or spinal nerves, and whether the
presence of one or more areas of nerve compression are present
within the cervical spine. Three procedures commonly used include:
Anterior
Cervical Discectomy:
This is the most common surgical procedure used to treat disorders
of the cervical spine. It involves enlarging the nerve root opening
(intervertebral foramen) by removing the intervertebral disc,
as well as the attached bone spurs that cause compression of
the spinal sac and nerve roots. The incision is made in the front
of the neck and the disc is partially or completely removed.
A bone graft may be placed for fusion, but is not always required.
The bone may fuse without placing a bone graft, if all the disc
endplate is removed.
Cervical
Discectomy or Corpectomy With Fusion: In some patients, cervical
spine instability may make it necessary for the neurosurgeon
to perform a spinal fusion by grafting bone and possibly using
metal plates to provide additional spinal support. Fusion is
generally considered in cases where severe neck pain is accompanied
by excessive movement on pre–operative flexion/extension
radiodiographs or where degenerative instability is indicated.
The need for fusion usually will be determined prior to surgery.
The bone graft may be taken from the hip (iliac bone graft),
or a cadaver donor bone graft may be used, avoiding the discomfort
of a second incision. This operation also is done from the front
of the neck.
Posterior
Hemilaminectomy:
In this procedure, the approach is from the back of the neck.
The neurosurgeon will expose the arch of the lamina and remove
the bone, as well as the attached ligaments exerting pressure
on the spinal sac and nerve roots. For a herniated disc with
nerve root compression, the bone removal may be limited to a
small amount over the exiting nerve root, with or without removal
of a disc fragment from in front of the nerve. The spine is not
fused and the movement of the vertebrae is preserved. For spinal
stenosis with myelopathy, the full lamina layer over the back
of the spine is removed, usually at multiple levels, to allow
the spinal cord to expand. The choice of an operation from the
front or back of the neck depends on which side of the spinal
cord the cause of compression lies.
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