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D ONALD C. FERLIC
EDITOR, VOL. 52
C OMMITTEE
D AVID L. H ELFET
CHAIRMAN
J AMES H. B EATY
D ONALD C. FERLIC
TERR Y R. L IGHT
VINCENT D. PELLEGRINI J R.
E X -O FFICIO
D EMPSEY S. S PRINGFIELD
DEPUTY EDITOR OF THE JOURNAL OF BONE AND JOINT SURGERY
COURSE LECTURES
FOR INSTRUCTIONAL
J AMES D. HECKMAN
EDITOR-IN-CHIEF,
THE JOURNAL OF BONE AND JOINT SURGERY
THE JOUR NAL OF BONE & JOINT SURGER Y JBJS.ORG
VO L U M E 84-A N U M B E R 10 O C T O B E R 2002
N E C K P A I N , C E R V I C A L R A D I C U L O P A T HY,
A N D C E R V I C A L M YE L O P A T HY
AND
CLINICAL EVALUATION
BY RAJ RAO, MD
An Instructional Course Lecture, American Academy of Orthopaedic Surgeons
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VO L U M E 84-A N U M B E R 10 O C T O B E R 2002
N E C K P A I N , C E R V I C A L R A D I C U L O P A T HY,
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Fig. 1
Cross-sectional view showing the cervical nerve root, dorsal and ventral primary rami, recurrent
meningeal or sinuvertebral nerve, and sympathetic plexus. Note the proximity of the disc space,
vertebral artery, and facet joints. (Reprinted, with permission, from: Cramer GD, Darby SA,
editors. Basic and clinical anatomy of the spine, spinal cord and ANS. St. Louis: Mosby YearBook; 1995. p 141.)
Cervical Radiculopathy
and Myelopathy
Neurologic symptoms in cervical
spondylosis are the result of a cascade of
degenerative changes that most likely
begin at the cervical disc. Age-related
changes in the chemical composition of
the nucleus pulposus and annulus fibrosus result in a progressive loss of
their viscoelastic properties. The disc
loses height and bulges posteriorly into
the canal. With this loss of height, the
vertebral bodies drift toward one another. Posteriorly, there is infolding of
the ligamentum flavum and facet joint
capsule, causing a decrease in canal and
foraminal dimensions. Osteophytes
form around the disc margins and at
the uncovertebral and facet joints. The
posteriorly protruded disc material, osteophytes, or thickened soft tissue
within the canal or foramen results in
extrinsic pressure on the nerve root or
spinal cord.
Mechanical distortion of the
nerve root may lead to motor weakness
or sensory deficits. The exact pathogenesis of radicular pain is unclear, but it is
generally thought that, in addition to
the compression, an inflammatory response of some kind is necessary for
pain to develop. Within the compressed nerve root intrinsic blood vessels show increased permeability, which
secondarily results in edema of the
nerve root. Chronic edema and fibrosis
within the nerve root can alter the re-
Non-Neurogenic
Substance P
Somatostatin
Bradykinin
Serotonin
Cholecystokinin-like substance
Histamine
Acetylcholine
Prostaglandin E1
Gastrin-releasing peptide
Prostaglandin E2
Dynorphin
Leukotrienes
Enkephalin
DiHETE
Gelanin
Neurotensin
Angiotensin II
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VO L U M E 84-A N U M B E R 10 O C T O B E R 2002
N E C K P A I N , C E R V I C A L R A D I C U L O P A T HY,
A N D C E R V I C A L M YE L O P A T HY
Fig. 2
Axial pain patterns provoked during discography at each cervical level. A = level
between second and third cervical vertebrae, B = level between third and fourth
cervical vertebrae, C = level between
fourth and fifth cervical vertebrae, D =
level between fifth and sixth cervical vertebrae, and E = level between sixth and
seventh cervical vertebrae. (Reprinted,
with permission, from: Grubb SA, Kelly
CK, Bogduk N. Cervical discography: clinical implications from 12 years of experience. Spine. 2000; 25:1382-9.)
sponse threshold and increase the sensitivity of the nerve root to pain10.
Neurogenic chemical mediators of pain
released from the cell bodies of the
sensory neurons and non-neurogenic
mediators released from disc tissue may
play a role in initiating and perpetuating this inflammatory response11 (Table
I). The dorsal root ganglion has been
implicated in the pathogenesis of radicular pain. Prolonged discharges originate from the cell bodies of the dorsal
root ganglion as a result of brief pressure. In addition to the chemicals produced by the cell bodies of the dorsal
root ganglion, the membrane surrounding the dorsal root ganglion is
more permeable than that around the
nerve root, allowing a more florid local
inflammatory response.
Certain positions of the arm may
decrease stress within the nerve root
and relieve radicular pain. Davidson et
al. described the shoulder abduction
signi.e., relief of severe radicular pain
when the patient rests the hand on the
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Fig. 4
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Fig. 6
Dynamic compression of the spinal cord with flexion and extension of the spinal column. (Reprinted from: Bernhardt M, Hynes RA, Blume HW, White AA. Current concepts review: cervical
spondylotic myelopathy. J Bone Joint Surg Am. 1993;75:119-28.)
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these areas, known as trigger points, results in reproducible patterns of referred pain.
In the absence of radicular symptoms or findings, determining the
source of neck pain can be a diagnostic
challenge. Identifying a position of
maximal discomfort may provide a clue
to the underlying pathology. Anterior
neck pain along the sternocleidomastoid muscle belly that is aggravated by
rotation to the contralateral side is most
often a result of muscular strain. Pain in
the posterior neck muscles that is worsened by flexion of the head suggests a
myofascial etiology. Pain in the posterior aspect of the neck that is aggravated
by extension, especially with rotation of
the head to one side, suggests the possibility of a discogenic component. Patients who present with severe pain in
the suboccipital region often have
pathological changes in the upper cervical spine. The pain in these patients
may radiate to the back of the ear or the
caudad part of the neck. Rotation of the
neck is often markedly restricted.
Pain in the neck and shoulder girdle can develop as a result of adaptations stemming from an initial source
of pain. The initial source of pain may
resolve, but postural adaptations and
compensatory overuse of normal tissues in the neck and shoulder girdle can
result in new pain patterns. It is important to obtain an accurate history regarding how the pain initially presented
and how it might have changed with
time.
Pathological changes in the
shoulder can present with localized
pain or pain referred to the neck. The
pain may radiate down the anterior or
lateral aspect of the arm. Careful examination of the shoulder will help to differentiate this cause from pathological
changes in the neck. Pain in the neck
and shoulder girdle can also be referred
from the heart, lungs, viscera, and temporomandibular joint. A detailed and
accurate history and examination will
help to rule out the possibility that pain
in the neck is being referred from another region. Morning stiffness, polyarticular involvement, rigidity, or
cutaneous manifestations suggest an in-
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No difficulty in walking
Grade II
Grade III
Grade IV
Grade V
Chairbound or bedridden
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VO L U M E 84-A N U M B E R 10 O C T O B E R 2002
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