Cervical neck conditions

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cervical spine anatomy disc herniation radiculopathy

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Cervical Neck Conditions

The cervical spine (C1-C7) is one of the most clinically active regions in the body, giving rise to a spectrum of conditions ranging from purely axial pain to devastating spinal cord injury. Here is a comprehensive breakdown organized by category.

Anatomy Relevant to Disease

The cervical motion segment involves five key articulations per level: the intervertebral disc, two uncovertebral joints (joints of Luschka), and two facet joints. This interdependence means degeneration at one articulation stresses the others. Cervical nerve roots exit above their corresponding vertebrae - the C6 root exits at the C4-C5 foramen, so a C5-6 disc herniation compresses the C6 root.

Cervical root impingement due to cervical spondylosis - lateral and axial views showing joints of Luschka, facet joints, soft disc herniation, and nerve root compression

1. Cervical Degenerative Disc Disease (Cervical Spondylosis)

The umbrella term for chronic disc degeneration with associated facet arthropathy. It produces four distinct clinical entities:

Entity	Key Feature
Discogenic neck pain	Axial pain only, no neuro compromise
Radiculopathy	Nerve root compression
Myelopathy	Spinal cord compression
Myeloradiculopathy	Combined cord + root involvement

Epidemiology

Peaks between age 40-50 years
Men > women
C5-6 most commonly involved, followed by C6-7
Risk factors: frequent lifting, cigarette smoking, excessive driving

Pathoanatomy (Degenerative Cascade)

Disc dehydration and height loss
Progressive collapse causes loss of normal lordosis and anterior cord compression via chondro-osseous/disc-osteophytic spurs
Facet and uncovertebral joint loading causes foraminal narrowing
Neck extension worsens cord compression (ligamentum flavum infolding posteriorly + spondylotic bar anteriorly); flexion slightly relieves it

Disc Types

"Soft" disc herniation - nucleus pulposus herniation without osteophytes; usually posterolateral; causes acute radiculopathy; rarely anterior (can cause dysphagia)
"Hard" disc herniation - herniation with associated disc-osteophytic spur; similar symptomatology; more chronic
Miller's Review of Orthopaedics 9th Edition, pp. 758-762

2. Discogenic Neck Pain (Axial Pain)

Insidious onset of neck pain without neurologic signs
Exacerbated by excessive vertebral motion
No radicular or myelopathic component
Treatment: NSAIDs, physiotherapy, cervical collar short-term, epidural steroid injections

3. Cervical Radiculopathy

Nerve root compromise from either foraminal narrowing (spondylosis) or disc herniation.

Key clinical features:

Neck pain that evolves into arm pain/paresthesias in a dermatomal distribution
Motor: weakness in the corresponding myotome (less common)
Sensory: numbness/dysesthesias in dermatomal territory (more common)
Reflexes: typically hyporeflexic at the affected level

Dermatomal root map:

Disc Level	Root Affected	Sensation	Reflex Lost	Motor Deficit
C4-5	C5	Lateral arm/shoulder	Biceps (partial)	Deltoid, supraspinatus
C5-6	C6	Lateral forearm, thumb/index	Biceps, brachioradialis	Biceps, wrist extensors
C6-7	C7	Middle finger, dorsal hand	Triceps	Triceps, wrist flexors
C7-T1	C8	Ring/little finger, medial forearm	None reliable	Intrinsics, finger flexors

Special tests:

Spurling's test - ipsilateral rotation + lateral bend + axial compression reproduces radicular symptoms; highly specific for cervical radiculopathy
Shoulder abduction sign (Bakody sign) - relief of radicular pain when hand is placed on top of head; suggests cervical etiology

Sagittal T2 MRI showing C5-C6 disc herniation compressing the C6 nerve root

Treatment:

Conservative (first-line): NSAIDs, cervical epidural steroid injections, isometric exercises, traction, temporary collar immobilization
Surgical indications: progressive motor weakness, persistent disabling pain despite ≥6 weeks conservative treatment
Surgical options: ACDF (anterior cervical discectomy and fusion), cervical total disc replacement (motion-preserving), posterior foraminotomy
Miller's Review of Orthopaedics 9th Edition, pp. 760-763

4. Cervical Spondylotic Myelopathy (CSM)

The most serious consequence of cervical spondylosis - spinal cord compression causing upper motor neuron (UMN) signs. Harrison's 22E calls it a "comprehensive term for degenerative diseases causing symptomatic cervical spine narrowing."

Spinal canal measurements (lateral radiograph):

Normal canal diameter: ≥14 mm
Relative stenosis: 10-13 mm
Absolute stenosis: <10 mm
Pavlov (Torg) ratio (canal/vertebral body width): normal = 1.0; <0.8 = abnormal/risk factor

Clinical features:

Gait disturbance (wide-based, spastic) - often the earliest sign
Bilateral hand clumsiness, loss of fine motor control
Hyperreflexia, clonus, positive Babinski sign (UMN)
Hoffman's sign (finger flexion reflex) - flicking the middle fingernail causes reflex thumb flexion
Lhermitte's sign - electric shock sensation down the spine on neck flexion
Bladder dysfunction (frequency, urgency)
Weakness in lower extremities

Myelopathy scoring: Modified Japanese Orthopaedic Association (mJOA) scale is used to grade severity (0-18; higher = better function).

Treatment:

Surgical decompression is the mainstay for moderate-severe CSM
Anterior options: ACDF, ACCF (anterior cervical corpectomy and fusion)
Posterior options: laminectomy + fusion, laminoplasty (contraindicated in fixed kyphosis)
Combined (circumferential) for complex multilevel disease
Most common postoperative complication: C5 nerve root palsy
Miller's Review of Orthopaedics 9th Edition, p. 761; Goldman-Cecil Medicine

5. Rheumatoid Cervical Spine Disease

Cervical involvement occurs in up to 90% of RA patients, more common with long-standing disease. The occipitoatlantoaxial complex (O-C2) is the primary site.

Three sequential stages:

Atlantoaxial subluxation (AAS) - first and most common; C1 slides on C2 due to transverse ligament erosion
Atlantoaxial invagination (AAI) - dens migrates upward into the foramen magnum (basilar invagination)
Subaxial subluxation (SAS) - step-ladder deformity of lower cervical spine

Symptoms:

Axial neck pain and stiffness
Occipital headaches (C2 nerve compression - pain at base of skull relieved by traction)
Progressive myelopathy/radiculopathy

Imaging: Flexion/extension X-rays mandatory before any elective surgery; MRI to assess cord compression. Anterior atlantodens interval (ADI) and posterior ADI (space available for cord) are key measurements.

Management: Disease-modifying antirheumatic drugs (DMARDs) have reduced the incidence; surgical stabilization (posterior C1-C2 fusion or occiput-to-cervical fusion) for progressive neurologic compromise.

Miller's Review of Orthopaedics 9th Edition, pp. 762-764

6. Whiplash / Cervical Acceleration-Deceleration Injury

Definition: Indirect neck injury from acceleration-deceleration mechanism (typically motor vehicle accidents) causing flexion-extension injury of the cervical spine without direct trauma.

Pathology: Disruption of facet joints, anterior longitudinal ligament, intervertebral discs, and cervical muscles. Radiographs often show flattening of normal cervical lordosis.

Symptoms: Neck pain, stiffness, headache, occipital neuralgia, possible radicular pain. Without treatment, a large proportion improve within 6 months.

Treatment: Analgesia, early mobilization (collars now discouraged long-term), physiotherapy.

Goldman-Cecil Medicine; Swanson's Family Medicine Review

7. Cervical Spinal Stenosis

Narrowing of the cervical canal (congenital or acquired/degenerative)
Congenital short pedicles predispose to early symptomatic stenosis with even minor disc bulging
Presents as myelopathy (see above) or neurogenic claudication of the arms

8. Ossification of the Posterior Longitudinal Ligament (OPLL)

Common in East Asian populations
Calcified OPLL narrows the canal and causes myelopathy
Harrison's 22E classifies it under "degenerative cervical myelopathy" alongside spondylosis
Treatment: surgical decompression (often posterior laminoplasty preferred)

9. Cervical Fractures and Dislocations (Traumatic)

Injury Pattern	Mechanism	Key Concern
Jefferson fracture (C1 burst)	Axial load	Transverse ligament rupture
Odontoid fractures (C2)	Flexion/extension	Atlantoaxial instability
Hangman's fracture (C2 pars)	Hyperextension	C2-3 instability
Bilateral facet dislocation	Flexion-distraction	Complete cord injury
Clay-shoveler's fracture	Sudden flexion	C7/T1 spinous avulsion

Immobilization is essential to prevent further cord injury. Unstable fractures require surgical stabilization.

10. Other Notable Conditions

Condition	Key Points
Thoracic outlet syndrome	Brachial plexus/vascular compression between scalene muscles and 1st rib; vague shoulder pain, ipsilateral 4th-5th digit numbness; cervical rib or scalene hypertrophy
Brachial neuritis (Parsonage-Turner)	Acute onset severe shoulder/arm pain followed by weakness; viral/postviral; EMG confirms; 80% recover in 2 years
Cervical vertigo	Spondylosis-related proprioceptive disruption or vertebrobasilar insufficiency
Cervical lymphadenopathy	Inflammatory, infectious (EBV, CMV, cat-scratch), or malignant (lymphoma, metastases)
Torticollis	Involuntary head tilt; congenital (SCM fibrosis), spasmodic, or dystonic
Ankylosing spondylitis	Can involve cervical spine causing rigid kyphosis and fracture risk

Diagnostic Approach Summary

Plain X-rays - Assess alignment, disc heights, osteophytes, canal diameter, ADI
MRI - Investigation of choice for soft tissue, disc, cord signal change; essential for radiculopathy and myelopathy
CT/CT myelography - Superior for bony detail, OPLL, foraminal osteophytes
EMG/NCS - Differentiate radiculopathy from peripheral neuropathy (e.g., carpal tunnel coexistence)
Flexion/extension films - Assess instability (RA, trauma)

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