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Osteoarthritis of the cervical spine may produce neck pain that radiates into the back of the head, shoulders, or arms. Arthritic or other pathologic conditions of the upper cervical spine may be the source of headaches in the posterior occipital region (supplied by the C2-C4 nerve roots). Cervical spondylosis with osteophyte formation in the lateral recess or hypertrophic facet joints may produce a monoradiculopathy (Fig. 16-7). Narrowing of the spinal canal by osteophytes, ossification of the posterior longitudinal ligament, or a large central disk may compress the cervical spinal cord. In some patients, a combination of radiculopathy and myelopathy occur. An electrical sensation elicited by neck flexion and radiating down the spine from the neck (Lhermitte's symptom) usually indicates cervical or upper thoracic (T1-T2) spinal cord involvement. When little or no neck pain accompanies the cord compression, the diagnosis may be confused with amyotrophic lateral sclerosis (Chap. 365), multiple sclerosis (Chap. 371), spinal cord tumors (Chap. 368), or syringomyelia (Chap. 368). The possibility of this treatable cervical spinal cord disease must be considered even when the patient presents with leg complaints only. Furthermore, lumbar radiculopathy or polyneuropathy may mask an associated cervical myelopathy. MRI or CT-myelography can define the anatomic abnormalities, and EMG and nerve conduction studies can quantify the severity and localize the levels of motor nerve root injury. Other Causes of Neck Pain Rheumatoid arthritis (RA) (Chap. 312) of the cervical apophyseal joints results in neck pain, stiffness, and limitation of motion. In typical cases with symmetric inflammatory polyarthritis, the diagnosis of RA is straightforward. In advanced RA, synovitis of the atlantoaxial joint (C1-C2; Fig. 16-2) may damage the transverse ligament of the atlas, producing forward displacement of the atlas on the axis (atlantoaxial subluxation). Radiologic evidence of atlantoaxial subluxation occurs in 30% of patients with RA. Not surprisingly, the degree of subluxation correlates with the severity of erosive disease. When subluxation is present, careful neurologic assessment is important to identify early signs of myelopathy. Occasional patients develop high spinal cord compression leading to quadriparesis, respiratory insufficiency, and death. Although low back pain is common among RA patients, the frequency of facet disease, fracture, and spondylolisthesis is no greater than among age- and sex-matched controls with mechanical low back pain.
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Cervical Spondylosis
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