Cervical spinal disorders: Nonsurgical management strategies

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What etiologies are included in the differential diagnosis of patients who present for initial assessment and management of symptoms attributed to the cervical spine in an outpatient setting?

The most common cervical diagnoses in patients who present for initial evaluation for nonsurgical management in an outpatient clinic or office setting include axial neck pain, radiculopathy, and myelopathy. These conditions may present singly or in combination. Axial neck pain is most often mechanical in nature as it is provoked or relieved by specific activities or postures. Mechanical neck pain is attributed to stimulation of nociceptors located in intervertebral discs, zygapophyseal (facet) joints, ligaments, muscles, and tendons, and arises as a consequence of spinal degeneration or an injury. Radiculopathy and myelopathy occur as a consequence of impingement of neurologic structures from narrowing of the nerve root canals or central spinal canal by pathologies including disc herniation, spondylosis, and congenital stenosis or as a consequence of ischemic injury to neural structures. Specific pathologies that may lead to neck and/or arm pain symptoms include:

• Cervical fractures/dislocations not previously diagnosed

• Cervical spine infections: discitis, osteomyelitis

• Cervical spine tumors: metastatic, primary

• Rheumatologic disorders: rheumatoid arthritis, ankylosing spondylitis, fibromyalgia

• Visceral disorders presenting with referred pain: angina, apical lung tumors (Pancoast tumor)

• Shoulder and elbow pathology: rotator cuff disorders, medial epicondylitis

• Peripheral nerve entrapment syndromes: thoracic outlet syndrome, suprascapular neuropathy; radial, ulnar, or median nerve entrapment

Patients with a cervical spine problem sometimes report neck or upper extremity symptoms in combination with headaches secondary to a source in the cervical spine (cervicogenic headaches). Familiarity with the presentation of primary and secondary headaches is important to avoid misdiagnosis or delayed diagnosis of serious conditions that may manifest with headache symptoms, including vascular disorders (i.e., vertebral artery or aortic aneurysm dissection), intracranial tumors, and meningitis.

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What are the most important initial steps in the assessment of a patient with a cervical pain syndrome?

The medical history and physical examination remain the most important part of the initial assessment of a patient with cervical pain.

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For patients who present with a cervical complaint, what are some important areas to investigate in relation to the patient’s history?

A comprehensive medical history should include the following elements:

• Is this the first episode or a recurrent problem?

• Was there a specific injury (i.e., motor vehicle, work-related, or sport-related injury; a fall)?

• What factors increase and decrease symptoms?

• What is the pattern of pain over a 24-hour period? Is the pain intermittent or constant?

• Is the most intense pain localized to the neck and surrounding areas or to one or both arms?

• Is there focal weakness or numbness in the upper extremities?

• Are there changes in gait including clumsiness and imbalance?

• Are there difficulties with fine-motor tasks such as buttoning a shirt or manipulating small objects?

• Are there new bowel or bladder symptoms?

• Is morning stiffness present?

• Are headaches a major reason for seeking evaluation?

• Is neck pain associated with dizziness, chest pain, or shortness of breath?

• Are any red flag-symptoms present?

• Are any yellow-flag symptoms present?

• Consider use of a validated tool to assess pain and function (Visual Analog Pain Scale, Neck Disability Index).

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What are red flags in the evaluation of cervical pain syndromes?

Red flags are risk factors that suggest significant and/or potentially life-threatening pathologies associated with neck pain. Red flag conditions are rare and are estimated to occur in less than 5% of patients who present for cervical spine evaluation ( Table 13.1 ).

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What are yellow flags in the evaluation of cervical pain syndromes?

Yellow flags are factors used to identify patients at risk of developing chronicity, disability, and poor treatment outcomes. These high-risk patients can potentially benefit from more intensive nonsurgical management with greater emphasis on a return to activity and focus on functional recovery. Some examples of yellow flags include:

• Fear avoidance (avoid activity due to fear of worsening neck pain)

• Catastrophizing (excessively negative thoughts and beliefs about the future)

• Depression

• Lack of motivation to return to work

• High baseline functional impairment

• Medicolegal issues

• Work-related injury

• Presence of nonorganic signs (suggests psychological component to pain)

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What are the key elements to include in the physical examination of a patient referred for initial evaluation of cervical pain with or without arm pain?

• Observation: assess gait, balance, neck posture

• Palpation: assess for cervical tender points, lymphadenopathy

• Range of motion: cervical flexion, extension, rotation, side bending

• Neurologic examination

  • Assess sensory, motor, and reflex function

  • Screen for radiculopathy: Spurling test, shoulder abduction test, cervical compression, and cervical distraction tests

  • Screen for myelopathy: plantar reflex (Babinski sign), Hoffman sign, tandem gait assessment

• Evaluation of related areas as indicated (e.g., shoulder joints)

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When are imaging studies important for evaluation of the cervical spine?

Caution is necessary when deciding to order spinal imaging studies in patients with cervical pain syndromes. Degenerative changes involving the discs and facet joints are commonly observed in asymptomatic patients and may be unrelated to a specific patient’s pain syndrome. In general, imaging studies are used to exclude serious conditions. An initial screening evaluation generally consists of plain radiographs. Patients who present with risk factors for cervical spine fracture or dislocation based on valid screening protocols (i.e., National Emergency X-Radiography Utilization Study [NEXUS] criteria, Canadian C-Spine Rule) should be evaluated with cervical computed tomography (CT). For other patients, magnetic resonance imaging (MRI) is the preferred initial imaging modality because it provides the most diagnostic information regarding a specific spinal region and does not involve ionizing radiation. Reasons to order an MRI include a clinical history and physical examination that suggest a serious spinal condition (i.e., tumors, infection, traumatic injury), positive neurologic signs or symptoms, or if evaluation of the spinal canal and/or nerve root canals is required prior to spinal injections or surgical procedures.

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