NECK PAİN

KEY POINTS
• Degenerative disease of the cervical
spine, or cervical spondylosis, is an age-
related process that affects many
components of the cervical spinal column.
• The spectrum of cervical spondylosis
ranges from axial neck pain to
radiculopathy to frank myelopathy.
 KEY POINTS
• The clinical manifestations of neck disorders range from
midline posterior neck pain to the neurologic sequelae of
cervical nerve root or spinal cord compression.
• Axial neck pain may radiate from the base of the skull
down to the upper trapezius region.
• Cervical radiculopathy involves compression of a nerve
root, with pain radiating down the arm in an anatomic
distribution.
• Cervical myelopathy is characterized by dysfunction of
the spinal cord. This may be caused by cord
compression, vascular abnormalities, or a combination of
both.
 ETIOPATHOGENESIS
• Degeneration of the intervertebral disc
• Cervical spondylosis
• Acute herniation of the disc material
 PRVALENCE
Prevalence of neck and referred shoulder/brachial pain has
been reported to be 9%.
In a series of 205 patients who present with neck pan and
were managed nonoperatively, 79% were noted to be
asymptomatic or improved at a minimum follow-up of 10
years.
Symptoms of 13% were unchanged, and only 8% had
worsening of their symptoms.
Radiographically, 25% of patients in their fifth decade have
been shown to have degenerative changes in one or
more discs.
By the seventh decade, this number increases to over
75%.
 CLINICAL MANIFESTATIONS
I-NECK PAIN
– A. Signs and symptoms
• existing primarily within the axial portion of the spine
• Night pain is common because the neck becomes a weight-bearing area
– B. Physical examination
• noting the position in which the neck is held
• muscle spasm can often be visualized
• inspection of the symmetry of the paraspinal muscles as well as the
trapezius and shoulder musculature
– C. Range of neck motion
• normal neck extension allows the occiput to approach the prominent C7
spinous process.
• rotation is normally 70 degrees bilaterally and
• lateral bending is 50 to 60 degrees bilaterally
II- RADICULOPATHY
• A. Signs and symptoms
– pain traveling on the basis of an anatomic distribution to the
shoulder or down the arm.
– There may be sensory or motor loss corresponding to the
involved nerve root, and reflex activity may be diminished.
• B. Physical examination
– The shoulder abduction relief sign
– Spurling’s test
• C. Herniation or degeneration of an intervertebral disc
– spesific radicular patterns, depending on the level of involvement
– Weakness
– The reflex is often decreased or absent.
• The shoulder abduction relief sign is
characterized by having the patients place the
palm of his hand flat onto the top of his skull; this
causes symptomatic relief of the radicular pain

• Spurling’s test is performed by having the patient

extend the neck and rotate and laterlly bend the
head toward the affected side; an axial
compressiv forc is then applied to the top of the
patient’ head. The test is positive when the
maneuver reproduces the patients typical
radicular arm pain.
III- MYELOPATHY
• A. Signs and symptoms
– gait disturbances with balance difficulty
– fine motor dysfunction in the hands and motor weakness.
– Bowel and bladder dysfunction is found late in the progression of
cervical myelopathy.
– Physical findings often include difficulty with tandem gait,
dysdiadochokinesia, hyperreflexia, and various sensory and
motor changes.
• B. Physical examination
– Hoffmann’s reflex is often present
– positive Babinski’s reflex
– Upper and lower extremity strength needs to be tested
 DIAGNOSTIC EVALUATION
I- LABORATORY STUDIES.
routine blood workup:
A complete blood count with differential, an
erythrocyte sedimentation rate (ESR) and
C-reactive protein(CRP).
These results will most commonly be
abnormal when an infectious or malignant
process is involved.
 DIAGNOSTIC EVALUATION
II- ELRCTROPHYSIOLOGICAL TESTING
An electrogram (EMG) may be helpful in defining a
spesific anatomic level when nerve compression
is present.
Such a study may also be helpful in rulling out
other neurlogic disorders including peripheral
neuropathy.
At times, a double-crush syndrome may exist
when cervical radiculopathy can coexist with
carpal tunnal syndrome.
 IMAGING STUDIES
I- PLAIN X-RAYS.
A plain x-ray series should include an
anterior/posterior view, a lateralview, and oblique
views.
Degeneration can often be noted within the disc
spaces and the facet joints.
There are often osteophytes noted along the area of
the disc space, and foraminal narrowing can be
noted on oblique views.
Clinical correlation with patient symptoms is often poor
in those older than 40.
Instability has been define as greater than 3,5 mm of
translation or 11 degrees of angulation betweem
adjacent vertebral segments.
 IMAGING STUDIES
II- MYELOGRAPHY.
Myelography can be used to help evaluate nerve root
compression as well as compression of the spinal
cord.
Root compression is manifested by an extradural filling
defect with obliteration of the nerve root sleeve.
Flattening of the spinal cord can be appreciated on the
lateral view.
In cases of severe compression, there will be complete
obstruction of flow of the myelogram dye.
 IMAGING STUDIES
III- COMPUTED TOMOGRAPHY
Computed tomography (CT) is helpful in evaluating the
degee of foraminal stenosis caused by bony
osteophytes.
In combination with myelographyi it provides superior
imaging compared to myelography alone.
It permits the visualizaton the spesific levels (e.g, C6-7)
and locaton (e.g., lateral recess and foraminal) of nerve
root compression; filling defects allow or the
determination of the extent of spinal cord compression.
In addition, patients with a cord-compression ratio
(anteroposterior cord diameter divided by transverse cor
diameter) less than 0.40 tend to have worse neurologic
function.
 IMAGING STUDIES
IV- MRI
MRI perhaps the primary imaging modality
overall for cervical spine disorders.
It provides excellent visualization of the
spinal cord and soft tissues.
Measurements of sagittal and axial canal
diameters as well as cord-compression
ratios can be calculated from an MRI.
 TREATMENT
• Conservative care
• Surgery
 TREATMENT
I- Conservative care
Is the primary treatment of patients with
neck pain, with or without radicular
symptoms.
Lifestyle modifications should be
instituted to avoid activities that tend
to create or aggravate neck and arm
symptoms.
 TREATMENT
Typical activities to modify:
athletic activities,
sitting at a desk with neck flexion
(e.g.,reading and typing) for extended
periods of time, and driving.
An ergonomic assessment of the
modern computerized offices often
helpful in decreasing day-long stresses
to the neck.
• A soft cervical collar can be used to limit motion
and allow the spasm to settle down.
• The use of two or three pillows at night, in order
to decrease reflux symptoms or breathing
problems, exacerbate cervical spine problems
and should be avoided. Therefore, use of a
cervical pillow under the nape of the neck at
night help decrease spasms and pain, as it
tends to optimize the position of the neck during
sleep.
• Other modalities such as moist hate and light
massage may prove beneficial
 TREATMENT
I- Conservative care
B- Use of medications including anti-
inflammatory medications help decrease the
amount of inflammation and prvide pain relief.
In cases of severe pain, mild narcotics may
be useful.
Muscle relaxants may also help decrease the
amount of spasm and allow or more
comfortable periods of rest.
Short courses of steroids are sometimes
needed to control the inflammatory process.
 TREATMENT
I- Conservative care
C- Physical therapy is often useful in the treatment of
neck and radicular arm pain, once the phase of severe
pain and radicular problems resolve.
Modalities including traction, ultrasound, or diathermy can
give pain relief.
Once the patient’s symptoms have begun to decrease, an
exercise regimen can be added taking note that this
does not exacerbate the neck or arm pain symptomsç
Active ROM exercises along with some isometric
exercises can help regain the strength of the neck.
 TREATMENT
II- Surgery is indicated in cases of significant radicular pain
that has failed to respond to conservative treatment, or in
the presence of significant neurologic deficits.
Only a small percentage of patients with cervical spine
problems eventually require surgery.
However, if considered necessary the surgical procedure is
either an anterior cervical discectomy and fusion or a
posterior laminoforaminotomy.
For cases of melopathy with significant disability, surgery
can be a reasonable alternative. The goal of surgery with
myelopathy is to prevent progression of the disease.
 PROGNOSIS
I- The prognosis for patients with axial neck pain
is, in general, good.
In a folow-u of a seies of 205 patients with neck pain
and treated nonoperatively, 79% were noted to be
either asymptomatic or improved at 10-year follow-
up,13% were noted to be unchanged, and 8% were
felt to have worsening symptoms.
Surgery for axial neck pain by itself is rarely indicated,
except perhaps in the setting of instability.
 PROGNOSIS
II- The prognosis for patients with cervical radiculopathy is also, in
general, favorable.
A significant number of patients tend to respond to nonoperative
measures and show significant improvement 2 to 3 months after the
onset of symptoms.
A series of 26 patients with cervical disc herniation and radiculopathy
were managed nonoperatively with traction, medications and
education.
A1 year follow-up show succesful nonoperative management 24 of
the26 patients.

For patients who have radicular symptoms despite 2 to 3 months of

nonsurgical treatment, or who have significant weakness, surgery is
a reasonable option.
The prognosis for improvement with surgery is generally favorable.
Most patients experience significant improvement in their radicular
painç
 PROGNOSIS
III- Cervical myelopathy with early myelopathy and no
significant neurologic deficits can initially be followed in an
outpatient setting.
The prognosis for cervical myelopathy in general shows that a
high percentage of these patients slowly deteriorate over time.
The deteioration is often slow and occurs over years; a small
percent of cases may display signs and symptoms of rapid
progression.
In patients with gross findings of myelopathy with significant cord
compression and impairment, surgery is a reasonable option.
The goal of surgery is to prevent deterioration and potentially
promote improvement in their overall neurologic status. In a
series of patients treated surgically for cervical myelopathy,
90% of patients had significant neurologic improvement and
80% has significant pain relief.
 ETIOPATHOGENESIS
I- Degeneration of the intervertebral disc can lead to
pain referred to the neck, posterior skull, and/or upper
shoulders. This occurs as a natural consequence of the
normal aging process with a resulting decrease in the
water content of the disc. Disc degeneration can be
affected by many external factors ncluding repetitive
occupational mechanical straind a history of diving or
heavy weight lifting. The structures affected within the
neck include the intervertebral disc, zygapophyseal joint
with associated facet capsules, ligaments, musculature,
and the neural elements. Changes can be acute (e.g.,
traumatic), chronic, or acute on chronic.
 ETIOPATHOGENESIS
II- Acute herniation of the disc material
posteriorly may result inimpingement of the
nerve root and/or spinal cord. The distribution of
pain in cervical radiculopathy often fits a
dermatomal distribution charateristic for each
particular nerve root. When cors compression
occurs, the changes within the cord can e
caused by acute compression by the disc
material, as well as compression of the vascular
supply to the cord.
 ETIOPATHOGENESIS
III- Cervical spondylosis involves loss of
disc space height. As a result of the
degeneration within the disc and the
decreased intervertebral height, altered
spinal biomechanics ensu, with
osteophytes forming along the area of the
disc space as well as posteriorly along the
facet joints. This can be associated with
nerve root and spinal cord compression.
 DIFFERENTIAL DIAGNOSIS
I- Differential diagnoses to consider with cervical disc
disease are numerous. When a history of trauma is
present, cervical sprain, traumatic injury to the brachial
plexus, fracture, dislocation, or post-traumatic instability
need to be considered.
II- Inflammatory conditions including rheumatoid arthritis
and ankylosing spondylitis can also present with cervical
pathplogy. An infectious process including discitis,
osteomyeltis, or soft tissue abscess (especially in light of
a clinical history that includes fever or chills) must be
ruled out.
 DIFFERENTIAL DIAGNOSIS
III- Tumors can be a cause of neck and upper extremity
symptoms. These may include metastatic tumors,
primary bone tumors, and tumors within the spinal cord.
Additonally, tumors involving the upper lung (Pancoast’
tumor) may cause symptoms consistent with a C8
radiculopathy and/or a Horner’s syndrome. The
presence of a history of weight loss, night pain, and
present or past malignancy should increase the
physician’s sensitivity to the possibility of a malignant
tumor.
IV- Shoulder disorders including rotator cuff disease,
instability, and impingement may cause pain referred to
the neck and can be confused with a C5 radiculopathy.
More cmmonly, the neck refers pain to the soulder and
may actually be associated with the development of
frank shoulder pathology.
 DIFFERENTIAL DIAGNOSIS
V- Neurologic disorders such as the demyelinating
disease, multipl sclerosis, as well as disease nvolving
the anterior horn cells must be considered in the
differential diagnosis.
VI- Finally, many other conditions such as peripheral
nerve entrapment syndromes, reflex sympathetic
dystroph, thoracic outlet syndrome, as well as coronary
artery disease with angina pectoris may stimulate
radicular type symptoms. Pathology in the neck or
shoulder may take those areas more likely sites to which
visceral pain refers.
 TREATMENT
II- Surgery Postoperatively, some patients show
improveent from their preoperative neurologic status. For
myelopathy, surgery cnsists of either multipl anterior
cervical discectomies/corporectomies and fusion versus
posterior procedures such aslaminectomy alone,
lamioplasty, or laminectomy and fusion. A small
percentage of patients with significant multilevel disease
or poor bone quality are good candidates for a combined
anterior/posterior procedureç Surgery should be done
emergently in the setting of anepidural abscess.
 PROGNOSIS
I- The prognosis for patients with axial neck
pain is, in general, good. In a folow-u of a seies
of 205 patients with neck pain and treated
nonoperatively, 79% were noted to be either
asymptomatic or improved at 10-year follow-
up,13% were noted to be unchanged, and 8%
were felt to have worsening symptoms. Surgery
for axial neck pain by itself is rarely indicated,
except perhaps in the setting of instability.
 PROGNOSIS
II- The prognosis for patients with cervical
radiculopathy is also, in general, favorable. A significant
number of patients tendto respond to nonoperative
measures and show significant improvement 2 to 3
months after the onset of symptoms. A series of 26
patients with cervical disc herniation and radiculopathy
were managed nonoperatively with traction, medications
and education. A1 year follow-up show succesful
nonoperative management 24 of the26 patients. For
patients who have radicular symptoms despite 2 to 3
months of nonsurgical treatment, or who have significant
weakness, surgery is a reasonable option. The
prognosis for improvement with surgery is generally
favorable. Most patients experience significant
improvement in their radicular painç
 PROGNOSIS
III- Cervical myelopathy with early myelopathy and no
significant neurologic deficits can initially be followed in
an outpatient setting. The prognosis for cervical
myelopathy in general shows that a high percentage of
these patients slowly deteriorate over time. The
deteioration is often slow and occurs over years; a small
percent of cases may display signs and symptoms of
rapid progression. In patients with gross findings of
myelopathy with significant cord compression and
impairment, surgery is a reasonable option. The goal of
surgery is to prevent deterioration and potentially
promote improvement in their overall neurologic status.
In a series of patients treated surgically for cervical
myelopathy, 90% of patients had significant neurologic
improvement and 80% has significant pain relief.
 KEY POINTS
• Physical examination findings correlated with
diagnostic imaging studies can aid in diagnostic
evaluation.
• Almost all patients with symptomatic cervical
degenerative disease without neurologic
involvement can be managed nonoperatively.
• Surgery for patients with myelopathy is a
reasonable option to prevent diease
progression.
 KEY POINTS
Neck pain is a common complaint and
tends to occur with increasing frequency
after the age of 30. Most episodes of neck
pain are short-lived and tend to respond to
nonoperative management.
 CLINICAL MANIFESTATIONS
I-NECK PAIN
A. Signs and symptoms. Neck pain is a pain that is
perceived by the patients an existing primarily within the
axial portion of the spine. Pain may radiate to the base of
the skull or to the midupper periscapular region. The
pain may involve the posterior trapezius muscles or the
posterior deltoids. The pain itself may be limited to a
focal ara or may involve a more global region. Night pain
is common because the neck becomes a weight-bearing
area. The longer the pain exists the more difficult it is
pain from thoracic organs such as the heart or aorta, the
physician must be aware of the patient’s comorbid
medical issues.
 CLINICAL MANIFESTATIONS
I-NECK PAIN
B- Physical examination. Examination of the patient with
neck pain should include noting the position in which the
neck is held. When there is severe neck spasm, the
head may be flexed laterally to that side or even rotated.
Muscle spasm can often be visualized and can be
palpated posteriorly along the paraspinal musculature.
Examination should include inspection of the symmetry
of the paraspinal muscles as well as the trapezius and
shoulder musculature. Any signs of atrophy must be
noted. Strength and range of motion of the shoulder
should be tested, as well as examination for focal
tenderness within the shoulder(to help rule out the
shoulder as a source of potential pain or to define
coexistent shoulder disease.)
 CLINICAL MANIFESTATIONS
I-NECK PAIN
C- Range of neck motion should include flexion,
extension, rotation, and lateral bending. Normal
flexion demonstrates the abillity to touch the chin
to the chest. Normal neck extension allows the
occiput to approach the prominent C7 spinous
process. Rotation is normally 70 degrees
bilaterally and lateral bending is 50 to 60
degrees bilaterally. Palpation for carotid artery
pulses as well as for the presence or absence of
supraclavicular adenopathy should be
performed.
 CLINICAL MANIFESTATIONS

II- CERVICAL RADICULOPATHY

C- Herniation or degeneration of an
intervertebral disc
2. C6-7 (C7 nerve root affected). The pain
distribution is similar to that of a C7
radiculopathy. Anesthesia and parestheias,
when present, involve the ndex and log
fingers. Weakness, if present, is noted in the
ticeps, wrist flexors, and finger extensors. The
triseps reflex may be reduced.
 CLINICAL MANIFESTATIONS
II- CERVICAL RADICULOPATHY
C- Herniation or degeneration of an
intervertebral disc
3. C7-T1 (C8 nerve root affected). Pain may
occur along the medial aspect of the upper arm
and forearm. Anesthesia and paresthesias
involve the ring and small fingers. Weakness, if
present, is notes in the finger flexors and
intrinsic musculature of the hand. The triceps
reflex may be reduced.
 CLINICAL MANIFESTATIONS
III- CERVICAL MYELOPATHY
A. Signs and symptoms. Cervical myelopathy alone (e.g.,
in the absence of radiculopathy) is painless. This is due
to the fact that there is spinal cord compression only.
The pain becomes apparent only when compression of
the spinal cord is accompanied by compression of the
nerve root (myeloradiculopathy). Symptoms associated
with spinal cord compression include gait disturbances
with balance difficulty, fine motor dysfunction in the
hands, and motor weakness. Bowel and bladder
dysfunction is found late in the progression of cervical
myelopathy. Physical findings often include difficulty with
tandem gait, dysdiadochokinesia, hyperreflexia, and
various sensory and motor changes.
 CLINICAL MANIFESTATIONS
III- CERVICAL MYELOPATHY
B- Physical examination. Hoffmann’s reflex is often
present, which is elicited by flicking the middle finger of
the patient and observing forced finger and thumb
interphalangeal joint flexion. There can be upgoing toes
(e.g.,positive Babinski’s reflex) as well as associated
clonus at the ankles. Myelopathy-related hand
abnormalities include atrophy of the thenar musculature
and an inability to maintain the ring and small fingers is
an extended and adducted position (e.g., finger escape
sign)Lhermitte’s sign involves flexion of the neck with an
electric-shocklike sensation extending down the axial
spine and/or extremities.In addition to the physical
examination for neck pain, a thorough neurologic
evaluation is necessary.This includes motor testing of all
pertinent motor groups including the deltoid, biceps,
tricepswrist flexors/extensors, finger flexors/extensors
 CLINICAL MANIFESTATIONS
III- CERVICAL MYELOPATHY
B- Physical examination. Additionally, lower extremity
strength needs to be tested including hip flexors, nee
extensors and flexors, hip abductors and adductors,
ankle dorsiflexors and plantar fleksors as well as the
function of the function of the extensor hallucis longus,
and peroneals. Sensory examination should include light
touch, pinprick, and vibration sense using a tuning fork.
Reflex examination should include the triceps, biceps
and brachioradialis, quadriceps, and the Achilles tendon
Another abnormal finding is the inverted radial reflex,
characterized by spontaneous fnger flexion whenthe
examiner attempts to elicit a brachioradialis reflex. Gait
should be tested during normal gait as well as with toe to
heel walking.
 CLINICAL MANIFESTATIONS
II- CERVICAL RADICULOPATHY
A. Signs and symptom. Cervical radiculopathy
implies pain traveling on the basis of an
anatomic distribution to the shoulder or down the
arm. Patients describe sharp pain and tingling or
burning sensations in the involved area. There
may be sensory or motor loss corresponding to
the involved nerve root, and reflex activity may
be diminished.
 CLINICAL MANIFESTATIONS
II- CERVICAL RADICULOPATHY
B- Physical examination The shoulder abduction relief
sign is characterized by having the patients place the
palm of his hand flat onto the top of his skull; this causes
symptomatic relief of the radicular pain Spurling’s test is
performed by having the patient extend the neck and
rotate and laterlly bend the head toward the affected
side; an axial compressiv forc is then applied to the top
of the patient’ head. The test is positive when the
maneuver reproduces the patients typical radicular arm
pain.
 CLINICAL MANIFESTATIONS
II- CERVICAL RADICULOPATHY
C- Herniation or degeneration of an
intervertebral disc may produce spesific
radicular patterns, depending on the level
of involvement. Considerable overlap exist
among the patterns outlined in the
subsequent text. C5-6 and C6-7 are far
more commonly involved tha C7-T1 or C4-
5.
 CLINICAL MANIFESTATIONS
II- CERVICAL RADICULOPATHY
C- Herniation or degeneration of an
intervertebral disc
1. C5-6 (C6 nerve root affected). Pain will radiate
to the shoulder or lateral arm and dorsal
forearm. Anesthesia and paresthesias may be
present in the thumb and index finger.
Weakness, if present, will involve the biceps and
wrist extensors. The brachioradialis or biceps
reflex is often decreased or absent.