Cervical Spine

• Common causes of neck pain

  • Myofascial pain syndrome
  • Joint dysfunction
  • Sprains/strains
  • Osteoarthritis
  • Intervertebral disc disruption
• RED FLAG = Persistent neck pain can present day and night
• Serious conditions not to be missed

  • Tumours (mets)
  • Infection
  • Fracture/dislocation
  • Vascular lesion
  • Angina or myocardial infarction
• Angina or myocardial infarction can cause neck pain
• Primary tumours in the cervical spine are relatively rare, but metastatic tumours are more common, especially from prostate, breast, and lung cancers
• Common causes of neck pain in under 20 year olds

  • Neuroblastoma
  • Hodgkin's lymphoma
• Transverse Ligament


  The ligament that ruptures in atlanto-axial subluxation
• Inflammatory arthropathies that can affect the neck

  • Rheumatoid arthritis
  • Seronegative spondyloarthropathies
• Polymyalgia Rheumatica


  Affects mainly the shoulder girdle, but neck is part of the symptom complex
• Fibromyalgia Syndrome


  Insidious onset of myelopathy, with involvement of more than one nerve root in the upper limb
• PITFALL = Radiographic evidence of cervical degenerative joint disease does not always correlate with clinical symptoms
• Indications for referral


  • Persisting neck or radicular arm pain despite conservative treatment
  • Evidence of involvement of more than one nerve root
  • Evidence of myelopathy
  • Evidence of cervical instability
  • Fracture/dislocation
  • Tumour
  • Infection
  • suspicion of non-MSK cause
• Radiculopathy


  Radicular pain = isolated pain indicating nerve involvement. True Radiculopathy = pain generated from a nerve root disorder, disease, or injury and has associated neurological signs and symptoms
• It is possible to have neurological symptoms and signs arising from a nerve root disorder without radicular pain
• Many people can have quite advanced foraminal stenosis with no radicular symptoms
• Minor acute axial compression or root traction forces may result in radicular pain in a patient with asymptomatic root compromise
• Mechanisms of nerve root injury

  • Mechanical force (compression, traction, friction)
  • Chemical irritation (nerve root ischemia, vascular stasis, inflammatory 'soup' from tissue injury)
• Grades of nerve injury (Sunderland classification)

  • Neurapraxia (conduction block) - Grade 1
  • Axonotmesis (loss of axon continuity, intact endoneurium) - Grade 2
  • Neurotmesis (loss of axon continuity, disrupted endoneurium, intact perineurium - Grade 3
  • Neurotmesis (Loss of axon continuity, disrupted endoneurium and perineurium, intact epineurium) - Grade 4
  • Neurotmesis (Complete nerve transection) - Grade 5
• Nerve root levels and associated symptoms

  • C5 (motor: deltoid, reflex: biceps tendon, sensation: lateral arm)
  • C6 (motor: wrist extension, reflex: brachioradialis tendon, sensation: radial forearm)
  • C7 (motor: wrist flexion, triceps & finger extensors, reflex: triceps tendon, sensation: middle finger)
  • C8 (motor: finger flexion, reflex: long finger flexors, sensation: medial forearm)
  • T1 (motor: interossei, no reflex, sensation: medial arm)
• Most cervical radiculopathies involve the C6 and C7 nerve root levels
• Nerve root lesions above or below the C5-C7 levels are more likely to have a non-mechanical cause
• Non-mechanical causes of cervical radiculopathy

  • Schwannoma
  • Neurofibroma
  • Meningioma
  • Perineural cyst
  • Metastatic disease
  • Infection
• Radicular and cord pathology can co-exist
• SAFETY DIAGNOSIS - When a patient presents with radicular features, it is important to look for associated spinal cord features such as gait/balance problems or lower limb weakness, as delayed diagnosis of myelopathy can have serious functional consequences
• SAFETY DIAGNOSIS - Multiple or bilateral root level deficits may require imaging
• Neuropathic pain


  Can be myotomal (muscle), dermatomal (skin), or sclerotomal (bone/skeletal)
• Radicular pain


  Usually limited to one specific dermatome, sharp and shooting in nature
• Pain around the superior angle of the scapula is often an early sign of C7 radiculopathy - is often mistaken for Levator scapulae trigger points
• Descriptions of radicular pain

  • Deep intermittent aching in biceps or triceps region
  • Occasional brief sharp pains in lateral forearm
  • Annoying localised burning pain or itch in a small area along medial scapular border
• Acute radicular pain


  Constant, unrelenting, worse at night, may keep patient awake
• Subacute radicular pain


  Shows huge variability, with periods of improvement and exacerbation
• Arm overhead and neck flexion with lateral flexion away can provide short-term relief by reducing neural tension and enlarges IVF
• Patients may not always identify relieving or exacerbating movements for their radicular pain
• Nerve root region


  May exhibit increased mechanosensitivity and ischaemosensitivity, leading to spontaneous pain
• Signs of nerve root involvement

  • Foraminal compression
  • Distraction test
  • Spurling's (Doorbell) sign
  • Increased with upper limb tension tests
  • Brachial plexus tension (Adson's) sign
  • Shoulder depression
  • Valsalva manoeuvre
• Lesions affecting nerve fibres can be motor, sensory, or mixed
• Lower motor neuron lesion


  Weakness, atrophy, flaccidity/hypotonia, diminished/absent muscle stretch reflexes, fasciculations
• Weakness is the most important sign to recognise, as it suggests potential for permanent loss and warrants prompt referral for investigation and surgical opinion
• Weakness is often mild due to bisegmental innervation and incomplete nerve root lesions
• A rapidly progressive radiculopathy with marked lower motor neuron findings that persists for 3-4 weeks is less likely to recover quickly