Clinical Pearls & Morning Reports
In evaluating patients with neck pain, it is useful to recognize that virtually all patients older than 50 years of age have cervical degenerative changes on one or more forms of imaging, and many findings are not specific. Read the NEJM Review Article here.
Q: What are some of the typical presenting features of degenerative cervical spondylosis?
A: Patients with degenerative cervical spondylosis may present with mechanical neck pain, radiculopathy, myelopathy, or a combination of these symptoms. Mechanical neck pain may be isolated to the neck or may radiate broadly, such as to the shoulders, head, chest, and back. The source of the pain is often difficult for patients to pinpoint. This complicates management, since the pain could stem from the degenerated intervertebral disk (pure diskogenic pain), the degenerated facet joints, or the muscular and ligamentous structures. The pain is often worsened by neck motion and relieved by rest and immobilization.
Q: What clinical features are suggestive of degenerative cervical radiculopathy?
A: Cervical radiculopathy from spondylosis is caused by mechanical compression and inflammation of a cervical nerve root, most commonly C6 or C7. The compression may be acute (e.g., caused by an abruptly herniated disk) or chronic (e.g., the result of hypertrophied facet joints). Pain arising from the compressed and inflamed nerve root, mainly radiating from the shoulder or upper back to the proximal arm, is the most common symptom of cervical degenerative radiculopathy. Radicular neck pain may also be accompanied by painful neck spasms. Patients with cervical degenerative radiculopathy may have paresthesia, numbness, or weakness that often — but not always — corresponds to dermatomal distributions of the affected cervical nerve root.
A: Cervical degenerative myelopathy is the least common but most worrisome presentation of degenerative cervical spondylosis. Patients with myelopathy may present with a variety of subtle neurologic findings, which they may attribute to natural loss of function with age. These include loss of manual dexterity; gait and balance disturbances, especially in the absence of visual cues (Romberg’s sign); sensory loss in the hands or feet; arm or hand weakness; and defecatory or urinary frequency, urgency, or hesitancy. There may be upper-motor-neuron signs, including clonus, hyperreflexia, Hoffmann’s sign, and Babinski’s sign. Patients with symptoms of myelopathy almost always have associated neck pain and stiffness and may have pain in the arms or shoulders. Radicular features are also common in the context of cervical degenerative myelopathy.
A: The management of degenerative neck pain in patients who have no neurologic deficit is typically a “tincture of time,” along with analgesics and other conservative options, including physical therapy. Some patients have worsening or chronic pain, even in the absence of signs of nerve-root or spinal cord compression. Many patients benefit from a referral to a specialist in chronic pain management, and many have improvement when coexisting psychiatric disorders, including anxiety and depression, are treated. Most patients with degenerative cervical radiculopathy have reduced pain and improved neurologic function with nonsurgical care, including oral analgesics, epidural glucocorticoid injections, physical therapy, cervical traction or brief immobilization in a cervical orthosis, and other options, such as massage. The severity and rate of progression of neurologic deficits are the main aspects of the evaluation of patients with degenerative cervical radiculopathy, since clinically significant motor weakness or worsening neurologic symptoms usually indicate the need for surgical evaluation. Patients with degenerative cervical myelopathy are also typically referred to a spine surgeon.