Evaluation of the patient with neck pain and cervical spine disorders
- Zacharia Isaac, MD
Zacharia Isaac, MD
- Section Editor — Soft Tissue Rheumatic Disease
- Assistant Professor in Physical Medicine and Rehabilitation
- Harvard Medical School
- Section Editor
- Steven J Atlas, MD, MPH
Steven J Atlas, MD, MPH
- Section Editor — Spinal disease and back pain
- Associate Professor of Medicine
- Harvard Medical School
Approximately 10 percent of the adult population has neck pain at any one time . This prevalence is similar to low back pain, but few patients with neck pain lose time from work and less than 1 percent develop neurologic deficits.
Clinical disorders affecting the cervical spine can be categorized as those that predominantly cause neck pain and those that most often cause extremity pain and/or neurologic dysfunction. Disorders that cause neck pain include cervical strain, internal disc disruption syndrome/discogenic pain, cervical facet-mediated pain, cervical "whiplash" syndrome, and myofascial pain. Disorders that predominantly cause extremity symptoms and/or neurologic dysfunction include cervical radiculopathy and cervical spondylotic myelopathy.
The evaluation of the patient with cervical spine disease is reviewed here. The management of disorders of the neck is discussed separately (see "Treatment of neck pain"). Evaluation of a patient with acute neck trauma is also discussed separately (see "Evaluation and acute management of cervical spinal column injuries in adults"). Diagnosis and clinical features of cervical radiculopathy are discussed separately. (See "Clinical features and diagnosis of cervical radiculopathy".)
The cervical spine is comprised of seven vertebrae. The articulation between the occiput and the first cervical vertebra (the atlantooccipital joint) allows for approximately one-third of flexion and extension and one-half of lateral bending of the neck . The articulation between the first and second cervical vertebrae (the atlantoaxial joint) allows for 50 percent of rotational range of motion. The articulations between the second and seventh cervical vertebrae allow for approximately two-thirds of flexion and extension, 50 percent of rotation, and 50 percent of lateral bending.
The most severe injuries and greatest wear and tear occur between C4 and C7 ; the nerve roots passing through the intervertebral foraminal in these areas are C5, C6, and C7. Uncovertebral articulations (also known as joints of Luschka) are present in the C3-7 spinal segments, located on the posterolateral border of the intervertebral disc, and in the anteromedial portion of the intervertebral foramen. These articulations are not true synovial joints, but can hypertrophy, associated with disc degeneration, and result in narrowing of the intervertebral foramen. This foraminal narrowing is a common cause of cervical radiculopathy .
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- CLINICAL CLASSIFICATION
- FACTORS SUGGESTING SIGNIFICANT DISEASE
- FACTORS SUGGESTING PERSISTENT SYMPTOMS
- AXIAL NECK PAIN SYNDROMES
- Cervical strain
- Cervical spondylosis
- Cervical discogenic pain
- Cervical facet syndrome
- - Whiplash injury
- Cervical myofascial pain
- Diffuse skeletal hyperostosis
- EXTREMITY PAIN AND/OR NEUROLOGIC DEFICIT
- Cervical spondylotic myelopathy
- Cervical radiculopathy
- NON-SPINAL CAUSES OF NECK PAIN
- Thoracic outlet syndrome
- Herpes zoster
- Diabetic neuropathy
- Other causes
- PHYSICAL EXAMINATION
- General observation
- Range of motion
- Muscle palpation
- Neurologic examination
- - Muscle strength
- - Reflex testing
- - Cervical level correlates to findings
- Provocative maneuvers
- CONFIRMATORY TESTS
- - Indications
- - Plain films
- - MRI or CT scan
- Other studies
- - Electrodiagnostic testing
- - Blood tests
- EVALUATION OF THE TRAUMA PATIENT
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS