History
Obtaining an accurate history is essential when evaluating patients with neck pain.
Identifying specific red flags that are indicators of potentially serious spinal or nonspinal pathology or conditions that may interfere with treatment is extremely important. The absence of red flags diminishes the need for special studies during the first 4 weeks of symptoms, a time in which spontaneous recovery is common. Serious spinal and nonspinal conditions associated with red flags include the following:
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Cancer/malignancy
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Infection
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Trauma with possible underlying fracture
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Osteoporosis with possible underlying fracture
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Conditions associated with spine instability (eg, rheumatoid arthritis, Down syndrome)
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Significant or progressive neurologic deficit (eg, profound muscle weakness and/or reflex loss, bowel and/or bladder incontinence or retention)
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Vertebral basilar artery insufficiency
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Pregnancy
Obtain an accurate description of the characterization of the pain, including location, onset, duration, frequency, description, distribution, and aggravating and relieving factors. Note the following:
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Differentiating between referred and radicular pain is important. Referred pain is more diffuse, whereas radicular pain is more specifically along the course of a dermatome.
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Patients with disc degeneration could have chronic low-grade pain that is periodically exacerbated for several weeks.
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Cervical discogenic pain may be localized pain, referred pain, or radicular pain.
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Mechanical pain can be constant or intermittent, whereas chemical pain is more likely to be constant.
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Cervicogenic pain is usually worse in positions that involve prolonged sitting, especially in sitting positions with a protruded head posture or prolonged flexion. Bending positions also provoke cervicogenic pain. Frequent changes of position provide relief. However, in cases of severe acute pain, a still position may be most comfortable. Pain worse upon awakening is probably related to using an unsuitable pillow or having adopted an inappropriate posture while sleeping. [2, 31]
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In 1959, Ralph B. Cloward, MD, published referral patterns of the cervical spine discs using cervical discography. [32]
He found that stimulating the anterolateral aspect of the cervical discs produced pain at the ipsilateral scapula. Stimulation in the midline of the anterior aspect of the disc produced pain between the shoulders in the middle of the back. Cloward described that pain from the C6-7 disc was felt in the inferior angle of the scapula. Pain from the C5-6 disc was felt in the center of the medial scapular border. Pain from C4-5 disc was experienced in the region of the spine and superior angle. Pain from the C3-4 disc was referred to the C7 spinous process and the posterior border of the trapezius muscle.
Cloward also found that when stimulating patients with posterolateral disc protrusions, the referral patterns were found to be more intense than when stimulating the anterior aspect of the disc and were found to spread from the vertebral border of the scapula out to the shoulder and upper arm as far as the elbow. Midline posterior disc protrusions were found to refer pain to a confined area overlying the fifth cervical to the second thoracic spinous processes near the midline, with upper discs more cephalad and lower discs more caudad. When extensive disc rupture and degeneration were present, a combination of the posterolateral and midline posterior referral patterns was found. [32]
Risk factors for malignancy include age older than 50 years, history of cancer, unexplained weight loss, pain with bed rest, and failure to improve with conservative therapy. [33, 34]
Ask questions related to potential infection (eg, history of recent surgery, including dental surgery; history of fever or chills; history of intravenous drug abuse). [34]
Obtain information regarding the patient's past medical history, including previous neck pain, surgeries, trauma, motor vehicle accidents, and work-related or sports-related injuries.
Obtain information regarding a history of alcohol, tobacco, or drug use or abuse; osteoporosis; rheumatologic conditions; diabetes; or other conditions associated with neuropathy (eg, vitamin deficiencies, thyroid disease).
Obtain information regarding previous diagnostic studies and treatment interventions.
Evaluation of Cervical Athletic Injuries
The initial evaluation of cervical spine injuries starts with the basic history and physical examination done on the field. Following this initial evaluation, a more comprehensive evaluation may include plain radiographs; serial examinations; neurologic or orthopaedic consultation; and computed tomography (CT) scanning, MRI, or CT myelogram, or dynamic studies.
Physical Examination
Physical examination of the patient with cervical discogenic pain includes the assessment for neurologic deficits suggestive of myelopathy.
While assessing the patient, look for altered balance, stooped and wide-base gait, weakness, decreased sensation of the upper extremities, lower motor neuron findings in the upper extremities, and upper motor neuron findings in the lower extremities.
Patients with a herniated nucleus pulposus (HNP) without radiculopathy can present with limited ROM and referred pain, which may be elicited with the cervical compression test (see image below). Patients with an HNP with radiculopathy may present with limited ROM and radicular pain, dermatomal sensory loss, diminished strength in a myotomal distribution, and loss of muscle stretch reflexes.
Manual muscle testing has greater specificity than either reflex or sensory changes. [19, 35] The Spurling test can elicit radicular pain and is performed by having the patient actively extend the neck, laterally flex, and rotate toward the side of the pain. Then, careful downward compression is applied on the head. The Spurling test is helpful in the diagnosis of cervical radiculopathy, because of its high specificity. However, its absence does not preclude the diagnosis of radiculopathy because of its low sensitivity. [19]
The Lhermitte test is performed by flexing the neck with the patient in the sitting position. This test may produce an electriclike sensation down the spine and occasionally the extremities. This electriclike sensation has been reported in patients with cervical spondylosis, cervical myelopathy, cervical cord involvement secondary to tumor, and multiple sclerosis. [19]
Another helpful clinical sign is pain relief upon arm abduction in cases of a ruptured cervical disc. No changes in pain occur with arm position when the disease process is spondylosis with foraminal stenosis. [36]
The neck compression test (Spurling test), axial manual traction, and the shoulder abduction test have high specificity but low sensitivity for the diagnosis of root compression in cervical disc disease. Despite the low sensitivity, these tests are valuable in the clinical examination of a patient with neck and arm pain. [37]
The Arm Squeeze Test may be used to differentiate shoulder pain caused by cervical nerve root compression from that caused by shoulder disease. [38] The test involves squeezing the middle third of the upper arm; if pain is elicited from this maneuver, the etiology of the should pain may be cervical in origin. [38]
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Appearance of torticollis as a result of sternomastoid fibrosis in a young child.
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Lateral cervical spine plain radiograph illustrating the Torg/Pavlov ratio.
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Axial computed tomography scan of cervical herniated nucleus pulposus.
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T1-weighted magnetic resonance image of a cervical disk herniation.
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T2-weighted magnetic resonance image of a cervical disk herniation.
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Myelogram of cervical herniated disk. A filling defect is shown.
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Three-dimensional computed tomography scan of C1.
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Lateral view of a C2 fracture dislocation.
