The Evaluation of Patients With Neck Pain

Donald R. Gore, MD

Disclosures

Medscape Orthopaedics & Sports Medicine eJourn. 2001;5(4) 

In This Article

What's the Diagnosis?

The diagnosis is made using the patient's history and clinical evaluation. A gait abnormality characterized by poor coordination should alert the examiner to the possibility of cervical cord involvement. The most common cause of a cervical myelopathy is spondylosis causing spinal stenosis.

Herpes zoster is a viral infection of the dorsal root ganglion and peripheral nerve caused by the chicken pox virus (Figure 13). It occurs in adults and may involve any peripheral nerve. The condition is characterized by severe pain in the distribution of the involved nerve or nerves, and this pain usually precedes the rash, so it can be easily confused with a cervical radiculopathy.

Figure 13.

Erythematous vesicular rash with early crusting located in the back of the neck of a 72-year-old woman with radicular pain caused by herpes zoster.

A short, obviously stiff neck is characteristic of Klippel-Feil syndrome, which is a congenital fusion of the cervical vertebrae. This, of itself, is not a painful condition but may be associated with degenerative changes above or below the levels of fusion. (Figure 14). Another clinical finding of this syndrome is a low posterior hair line.

Figure 14.

Congenital fusion of lower cervical vertebrae (arrow) with severe degenerative changes at the level above.

Drooping of the eyelid, a constricted pupil, absence of sweating, and a red flush to 1 side of the face caused by vasodilatation is indicative of Horner's syndrome caused by damage to the cervical sympathetic chain. (Figure 15).

Figure 15.

Horner's syndrome, in which the eyelid of the patient's left eye droops, and the pupil is contracted.

Involuntary movements of the face, neck, or extremities have a variety of causes that include Parkinson's disease or various forms of chorea that may be inherited or acquired and habitual tics such as in Tourette syndrome. None of these originate from neck pathology.

Muscle atrophy may be caused by primary muscle or neurologic disease, but in the context of patients with neck pain, it is more likely to be due to cervical nerve root damage. Fasciculations are a brief contraction of a group of fibers that can be seen through the skin caused by destruction of the anterior horn cell. The combination of atrophy and fasciculations is characteristic of amyotrophic lateral sclerosis.

A decreased pin-prick sensation in the distribution of a cervical nerve root along with neck pain strongly suggests a compressive lesion of the cervical nerve root (Figure 12, Table 4 ). The cervical nerves all have a sensory component; however, only nerve roots of C5-T1 have identifiable motor components. When the nerves above C5 are involved, the pattern of sensory deficit is the only positive physical finding that allows localization.

Neck motion may be limited by congenital anomalies such as Klippel-Feil syndrome or as a result of degenerative changes and not accompanied by pain (Figure 16). In the normal cervical spine in a young person, the cervical nerve root occupies about one third of the neural foramen.[5] Degenerative changes of the uncovertebral and zygapophyseal joints, hypertrophy of ligamentous supportive structures, and intervertebral disc protrusions decrease the available space of the nerve (Figure 17). When the patient extends his/her neck, the neural foramen decreases in size, which accentuates nerve root compression. If neck extension is not painful, it is unlikely that the pain is caused by nerve root compression in the neural foramen.

Figure 16.

Sixty-year-old male with limitation of neck motion and degenerative changes but no pain.

Figure 17.

Osteophytes originating from the zygapophyseal joint (A) and the uncovertebral joint (B), causing a decrease in the size of the neural foramen.

As with atrophy, identification of muscle weakness helps in localizing nerve root lesions in the lower cervical nerves. The amount of weakness indicates the degree of damage to the motor component of the nerve. In nerve root compressive lesions, it is not uncommon to discover weakness that the patient may not be aware of. Feigned weakness can be identified by a distribution that lacks an anatomic pattern.

Resistance to free passive motion may occur with pain, intra-articular diseases such as arthritis, abnormalities of muscles, and central neurologic diseases. Cervical cord lesions may produce a flaccid paralysis of the muscles innervated by the nerve root at the level of the lesion and spasticity below. Other forms of resistance to motion such as contractures or muscle rigidity are not of neck origin.

In most patients with neck pain, an absent or depressed deep-tendon reflex is the result of nerve root compression. When the reflexes are hyperactive, the lesion is centrally located either in the spinal cord or brain involving the pyramidal system. The activity of deep-tendon reflexes is variable between normal individuals; however, asymmetry in reflex response usually indicates pathology. Clonus is a rapid repetitive alternating muscle contraction brought on by the stretch reflex. As with hyperactive reflexes, this is found in upper motor neuron disease with pyramidal tract involvement. The most common location to observe this phenomenon is when eliciting the ankle-jerk reflex.

Babinski's and Hoffmann's signs have the same significance as the hyperactive deep-tendon reflexes in that they indicate involvement of the pyramidal tracts but Hoffmann's sign is occasionally present in normal people, so as an isolated finding, it is of doubtful significance.

The inverted radial reflex and the finger escape sign are indications of cervical myelopathy. However, their physiologic mechanism is not fully understood. Lhermitte's sign was originally described in multiple sclerosis but can also be found with cervical myelopathy.

The arm-abduction sign is usually positive in cervical nerve root compression. Theoretically, tension on the nerve is decreased by arm abduction. This may be the only position of comfort for patients with large lateral disc herniations (Figure 7). Extending the neck, as in Spurling's test, not only stretches the nerve but also narrows the neuroforamen, exacerbating radicular pain (Figure 17); whereas neck flexion and cervical traction increase the size of the neuroforamen, thereby relieving nerve root pain.

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