Neck pain resulting from trauma should be managed with particular caution to avoid causing or exacerbating damage to the cervical spine. When injury to the spinal column is suspected, immediate cervical immobilization is critical. Neurologic examination should be performed immediately to determine if there are neurologic deficits referable to a spinal level or vascular injury. Computed tomography (CT) of the cervical region is the imaging study of choice to examine the bony structure of spinal column. Magnetic resonance imaging (MRI) can provide more information regarding the spinal cord and the surrounding soft tissues and is recommended for patients with altered consciousness who cannot participate fully in the neurologic examination. Vascular imaging either with CT or MRI should be performed if there is suspicion for a vascular injury (see section B).
Dissection of the carotid or vertebral arteries should be considered in any patient with neck pain and symptoms or signs suggesting cerebral ischemia. While trauma is a significant risk factor for dissection, ~ 50% of dissections occur spontaneously without obvious antecedent trauma. Fibromuscular dysplasia, Marfan or Ehlers-Danlos syndrome, and a variety of other rare disorders of connective tissue predispose to dissection. An important diagnostic clue to carotid dissection is the presence of an ipsilateral Horner syndrome (anisocoria with an ipsilateral small pupil and ptosis) due to injury to the third-order sympathetic neurons ascending with the carotid artery.
If a patient has neck pain with difficulty walking or leg weakness, suspect cervical myelopathy. This requires emergent neuroimaging if acute and urgent neuroimaging if subacute or chronic to evaluate for the need for surgical decompression. If an intrinsic spinal cord lesion not related to compression is identified in a patient with acute or subacute onset of symptoms, refer to the evaluation of transverse myelitis in Chapter 113 .
Pain radiating into and down the arm (radicular pain) suggests cervical radiculopathy. However, radicular pain is not always present and cervical radiculopathy must still be considered if there is arm weakness.
The absence of arm weakness in the setting of radicular pain suggests a mild or sensory-predominant cervical radiculopathy, although a pure musculoskeletal process without nerve compression cannot be entirely excluded. In either case, patients are treated with conservative symptomatic management with nonsteroidal antiinflammatory drugs (NSAIDs) and physical therapy. If pain is severe or persistent, medications for neuropathic pain (tricyclic antidepressants) may be used. Time-limited trials of opioids or benzodiazepines can be considered for severe, disabling pain but, given the potential for abuse and addiction should not be used as initial treatment for mild–moderate pain. Although frequently used, gabapentin, systemic steroids, or epidural steroid injections have not demonstrated clear long-term benefit. Failure to respond to conservative treatment should prompt reevaluation for progressive neurologic deficits.
Weakness of shoulder abduction along with neck pain radiating into the shoulder is most consistent with a C5 radiculopathy. Weakness of external rotation may also be present due to involvement of the muscles of rotator cuff.
Weakness of elbow flexion or a reduced biceps and brachioradialis reflex along with neck pain radiating into the anterior arm or lateral forearm is most consistent with a C6 radiculopathy.
Weakness of elbow and wrist extension or a reduced triceps reflex along with neck pain radiating into the posterior arm or forearm is most consistent with a C7 radiculopathy. For further localization of wrist drop, see Chapter 26 .
Weakness of finger extension and abduction along with neck pain radiating into the posterior arm or forearm is most consistent with a C8/T1 radiculopathy. For further localization of hand weakness, see Chapter 27 .
The presence of arm weakness in a presumed cervical radiculopathy indicates the loss of motor axons with the potential for further axonal loss if the underlying cause is not addressed. MRI of the cervical spine (with contrast if there is clinical suspicion for infection or malignancy) should be performed to evaluate for the need for surgical decompression. Be aware that degenerative cervical spine changes, such as disc herniation or osteophytes, are very common in older patients and may represent an incidental finding unrelated to symptoms. If there is clinical uncertainty regarding whether the degenerative changes seen on MRI are causing the patient’s symptoms, nerve conduction studies/electromyography (NCS/EMG) should be performed. NCS/EMG can confirm the localization of the lesion in the peripheral nervous system, assess the severity of motor axon loss, and provide information on the acuity of the injury.
The absence of arm weakness or radicular pain suggests a musculoskeletal source of pain. In the acute phase, these patients may benefit from NSAIDs. With more chronic pain, an interdisciplinary approach including physical therapy, massage, yoga, and cognitive-behavioral therapy may be helpful. Patients should be instructed to resume normal activities and limit themselves to 1–2 hours of rest daily when the pain is most severe.
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