Degenerative Spinal Disease (Cervical)

Evaluation

The diagnosis of degenerative cervical spine conditions comes from proper evaluation. The initial step is obtaining a thorough history of the chief complaint. Characterizing the pain (eg, location, duration, quality, aggravating or alleviating factors), motion abnormality, or neurologic deficits is essential for formulating a differential. The patient may exhibit a pattern of symptoms that will help point toward a particular diagnosis.

After obtaining the history, a thorough neurologic exam is imperative; dermatomes, myotomes, and upper motor neuron signs (hyperreflexia, Hoffman and Babinski signs) must be evaluated. Occasionally, a patient will describe problems in the neck that are actually derived from the shoulder, thus shoulder pathology must be ruled out. Palpation and assessing range of motion are also crucial and may elicit signs of nerve impingement. Further, clinical suspicion should aid in determining whether symptoms are due to systemic diseases that are not localized to the cervical spine (eg, multiple sclerosis, sarcoidosis, amyotrophic lateral sclerosis).

Determining whether the patient is suffering from myelopathy or radiculopathy is challenging, as myelopathy and radiculopathy may present similarly, particularly in the early stages of disease. Clinical features that suggest myelopathy are hyperreflexia, Hoffman sign, increased tone or spasticity, Babinski sign, and gait abnormalities. The physical presentation of radiculopathy, which is often due to foramen encroachment of the spinal nerve, depends on which root is compressed. For example, compression of the C5 root may present with diminishment of the supinator reflex; sensory loss in the lateral upper arm; weakness of the deltoid, supraspinatus, and infraspinatus; and pain in the medial scapular border and lateral upper arm. Typically, neck pain—with or without radiating arm pain—and diminished muscle stretch reflexes, sensory loss, and motor weakness point toward radiculopathy. Patients can present with signs of both myelopathy and radiculopathy, complicating the diagnosis. Specific tests (eg, the Spurling maneuver, L'hermitte sign, signs of clonus, or a Hoffman test) typically help to focus the differential.

Depending on the physical examination findings, further testing is required to make a more definitive diagnosis. Electromyography may help to rule out peripheral nerve etiologies. More commonly, radiographic studies are the next test of choice. An anterior-posterior or lateral radiograph is often used to formulate an initial impression, though radiographs typically have limited usefulness due to the low sensitivity of certain pathologies. Unless contraindicated, magnetic resonance imaging (MRI) is the best option for visualizing cervical architecture, neural elements, and intervertebral disks, as well as the primary tool for evaluating patients with myelopathy or radiculopathy. Computed tomography (CT) is a cheaper, faster alternative to MRI, but it often has considerable limitations in investigating both myelopathy and radiculopathy. Nevertheless, CT or CT myelogram is an option for patients either unable to undergo MRI or with significant MRI artifact due to previous instrumentation. Lastly, the results of any study should be interpreted within the context of the symptoms, as many patients can have abnormal cervical spine MRI studies but be asymptomatic and thus do not require treatment.