History and exam

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Aspecifieke nekpijn: diagnose en behandelingPublished by: KCELast published: 2013Douleurs cervicales aspécifiques : diagnostic et traitementPublished by: KCELast published: 2013

Key diagnostic factors

common

spontaneous onset of neck pain

Patients typically present with axial neck pain. Most commonly the degeneration is asymptomatic, even though cervical radiographs and magnetic resonance imaging (MRI) may show severe, spontaneous degenerative disease.[20]

For patients with cervical neck pain there are several symptoms that should be considered red flags and that indicate the need for urgent further investigation to exclude important differential diagnoses, they include history of recent fall or trauma to the head or neck; unexplained weight loss; severe, intractable pain or severe local tenderness, cervical lymphadenopathy; unexplained fever (especially in diabetic patients); history of cancer or chronic corticosteroid use.[1][13][30]​​

cervical muscle pain and spasm

Axial neck pain can exist in any axial neck muscle, including scalenes (anterior scalene syndrome), trapezius and interscapular muscles, and paraspinal muscles extending from the occiput to the lumbar region, where axial muscle spasm can spread.[3][21]​ On exam, there may be more restricted motion toward the end ranges of motion and pain along the articular pillars. Besides the aforementioned regions, axial based cervical pain may also radiate to the lateral shoulder if the main pain generators are the cervical facet joints. Cervical facet-mediated pain is generally reproduced with extension and rotation-based movement.[31] Clinicians should keep in mind the different pain referral patterns arising from the cervical facet joints, which sometimes may be reproduced with motion, depending on the level(s) affected or suspected.

headaches or occipital pain

Referred components of axial neck pain include occipital pain and cluster or tension headaches.[12]​​

weakness or numbness

Subjective presence focuses the differential on either neurologic complications of cervical spondylosis or some other neurologic problem with similar complaints.[27][30]

presence of radiating shoulder and upper extremity pain

Pain distal to the shoulder triggers a concern for radiculopathy; radiating pain is rarely present in cervical myelopathy.[1]

reflex changes

Decreased reflexes are a sign of radiculopathy, whereas increased reflexes may signal cervical myelopathy, possibly in the upper extremity but particularly in the lower extremity.[30]

uncommon

proximal arm weakness

Can occur with C5 radiculopathy, but is uncommon with cervical myelopathy, suggesting a wider differential in many cases.[30]

distal hand weakness

Particularly in the intrinsic hand muscles (e.g., interossei, abductor pollicis brevis), suggests cervical myelopathy.[30]

gait ataxia

Difficulty walking in a straight line or difficulty with tandem walking can indicate cervical myelopathy, through compression of white matter tracts descending to the lower spinal cord.[1][27]​​[30]

Other diagnostic factors

common

cervical muscle spasm

A common secondary symptom associated with cervical spondylosis.[12]​​

decreased cervical range of motion

Commonly caused by degenerative changes, similar to osteoarthritis at any joint.[1]

sensory changes

Common and often less helpful in diagnosis unless a specific root (radiculopathy) or peripheral nerve pattern suggests a different diagnosis (e.g., carpal tunnel syndrome with median nerve hypalgesia).[30]

Risk factors

strong

age >50 years

Population-based studies show approximately 80% to 90% of people to have disk degeneration on magnetic resonance imaging (MRI) by the age of 50 years.[6][7]

weak

head or neck trauma

May accelerate the disk and facet degeneration process, particularly if there has been a fracture of an aspect of the joint (i.e., a facet fracture).[1]​ A previous soft-tissue injury to the neck may have resulted in a cervical myofascial strain (including whiplash injury), which can predispose to the same types of axial cervical pain symptoms as seen from degenerative changes alone.[19]

previous cervical spine surgery

May predispose adjacent joints to accelerated degenerative changes, particularly after a cervical fusion.[13][18]​ This has been difficult to prove because these joints also spontaneously degenerate, and the rate of change shows little difference with or without previous surgery. However, particularly posterior cervical surgery (i.e., a laminectomy) may enhance the paraspinal muscle spasm symptoms seen with cervical spondylosis-related axial neck pain.[28]

genetic predisposition

Some forms of severe, accelerated degenerative changes, including diffuse idiopathic skeletal hyperostosis, ankylosing spondylitis, and ossification of the posterior longitudinal ligament, are more prone to occur in some populations.[13] These less-common forms of severe degenerative changes may also lead to markedly decreased neck motion due to calcification around the joints and ligaments. Both cervical degenerative changes and degenerative cervical myelopathy show a tendency for genetic predisposition.[14][15]

smoking

It has been reported that smoking is associated with an increased risk of degenerative cervical spine disease, and cervical myelopathy.[16][17][18]

participation in contact sports

Some evidence suggests that participation in contact sports may increase the risk of degenerative cervical spine disease.[16]

occupation

Some evidence suggests that occupation, such as being an astronaut, may increase the risk of degenerative cervical spine disease.[16]

heavy load bearing

Some evidence suggests that regularly carrying a heavy load on the head may increase the risk of degenerative cervical spine disease.[16]

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