Chapter 016. Back and Neck Pain (Part 14)

Trauma to the Cervical SpineTrauma to the cervical spine (fractures, subluxation) places the spinal cord at risk for compression. Motor vehicle accidents, violent crimes, or falls account for 87% of spinal cord injuries (Chap. 372). Immediate immobilization of the neck is essential to minimize further spinal cord injury from movement of unstable cervical spine segments. A CT scan is the diagnostic procedure of choice for detection of acute fractures. Following major trauma to the cervical spine, injury to the vertebral arteries is common; most lesions are asymptomatic and can be visualized by MRI and angiography.Whiplash injury is due to...
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Chapter 016. Back and Neck Pain (Part 14) Chapter 016. Back and Neck Pain (Part 14) Trauma to the Cervical Spine Trauma to the cervical spine (fractures, subluxation) places the spinal cordat risk for compression. Motor vehicle accidents, violent crimes, or falls accountfor 87% of spinal cord injuries (Chap. 372). Immediate immobilization of the neckis essential to minimize further spinal cord injury from movement of unstablecervical spine segments. A CT scan is the diagnostic procedure of choice fordetection of acute fractures. Following major trauma to the cervical spine, injuryto the vertebral arteries is common; most lesions are asymptomatic and can bevisualized by MRI and angiography. Whiplash injury is due to trauma (usually automobile accidents) causingcervical musculoligamental sprain or strain due to hyperflexion or hyperextension.This diagnosis should not be applied to patients with fractures, disk herniation,head injury, focal neurologic findings, or altered consciousness. Imaging of thecervical spine is not cost-effective acutely but is useful to detect disk herniationswhen symptoms persist for >6 weeks following the injury. Severe initialsymptoms have been associated with a poor long-term outcome. Cervical Disk Disease Herniation of a lower cervical disk is a common cause of neck, shoulder,arm, or hand pain or tingling. Neck pain, stiffness, and a range of motion limitedby pain are the usual manifestations. A herniated cervical disk is responsible for~25% of cervical radiculopathies. Extension and lateral rotation of the necknarrows the ipsilateral intervertebral foramen and may reproduce radicularsymptoms (Spurlings sign). In young persons, acute nerve root compression froma ruptured cervical disk is often due to trauma. Cervical disk herniations areusually posterolateral near the lateral recess and intervertebral foramen. Typicalpatterns of reflex, sensory, and motor changes that accompany specific cervicalnerve root lesions are summarized in Table 16-4; however, (1) overlap in functionbetween adjacent nerve roots is common, (2) symptoms and signs may be evidentin only part of the injured nerve root territory, and (3) the location of pain is themost variable of the clinical features. Cervical Spondylosis Osteoarthritis of the cervical spine may produce neck pain that radiates intothe back of the head, shoulders, or arms, or may be the source of headaches in theposterior occipital region (supplied by the C2-C4 nerve roots). Osteophytes, diskprotrusions, and hypertrophic facet or uncovertebral joints may compress one orseveral nerve roots at the intervertebral foramina (Fig. 16-7); this compressionaccounts for 75% of cervical radiculopathies. The roots most commonly affectedare C7 and C6. Narrowing of the spinal canal by osteophytes, ossification of theposterior longitudinal ligament (OPLL), or a large central disk may compress thecervical spinal cord. Combinations of radiculopathy and myelopathy may also bepresent. Spinal cord involvement is suggested by Lhermitts symptom, an electricalsensation elicited by neck flexion and radiating down the spine from the neck.When little or no neck pain accompanies cord compression, the diagnosis may beconfused with amyotrophic lateral sclerosis (Chap. 369), multiple sclerosis (Chap.375), spinal cord tumors, or syringomyelia (Chap. 372). The possibility of cervicalspondylosis should be considered even when the patient presents with symptomsor signs in the legs only. MRI is the study of choice to define the anatomicabnormalities, but plain CT is adequate to assess bony spurs, foraminal narrowing,or OPLL. EMG and nerve conduction studies can localize and assess the severityof the nerve root injury. Figure 16-7 Cervical spondylosis; left C6 radiculopathy. A. Sagittal T2 fast spin echomagnetic resonance imaging reveals a hypointense osteophyte that protrudes fromthe C5-C6 level into the thecal sac, displacing the spinal cord posteriorly (whitearrow). B. Axial 2-mm section from a 3-D volume gradient echo sequence of thecervical spine. The high signal of the right C5-C6 intervertebral foramen contrastswith the narrow high signal of the left C5-C6 intervertebral foramen produced byosteophytic spurring (arrows).