Neck - Cervical Pain

Many different pathologies and processes may cause neck pain and arm pain. The list includes the following :

  • a congenitally narrow spinal canal
  • musculoskeletal or mechanical neck pain
  • shoulder disease, which can cause referred neck pain
  • a degenerative disease
  • trauma and injury, including fractures, ligamental injuries, and whiplash
  • instabilities and subluxations
  • spondylosis
  • deformities, including alteration of normal curvature (lordosis)
  • post-operative problem
  • inflammation and inflammatory conditions, such as arthritis or ankylosing spondylitis
  • infection
  • vascular malformations
  • tumours, both benign and malignant (cancerous)

This list is not exhaustive.

Cervical disc herniation is often without any symptoms and may not cause any problems. However. When compression affects a nerve root or multiple roots, the pathology is called cervical radiculopathy. Compression of the spinal cord can cause weakness; poor control of arms and/or legs; loss of ability to use hands appropriately, e.g., inability to use cutlery, close buttons when dressing, or tie shoelaces; poor balance; frequent falls; urinary incontinence and abnormal reflexes. This pathological process is called cervical myelopathy. Sometimes these two pathologies can coexist.

Spinal disc herniation, difference beetween normal and herniated disc

Cervical disc herniation can cause compression of the spinal cord and nerve root. This process can lead to sensory changes, such as pain, numbness, loss of sensation, and tingling. It can also cause weakness and loss of muscle bulk, or atrophy, in specific muscles or muscle groups.

Spinal cord, spinal nerve with median fissure

Cervical myelopathy requires medical attention at the earliest convenience. It may need surgery.

Cervical radiculopathy in acute presentation tends to get better without surgery in more than 9 out of 10 cases. The period of recovery varies. During this period, it is necessary to have adequate pain control and avoid activities that would make pain and discomfort worse; this may require some adjustments at home and in the work-place. Surgery is an option for those cases that fail to improve with conservative management and those that get worse and develop a neurological deficit.

Spinal cord under pressure

Spinal cord under pressure

Cervical pain, normal sagital MRI

Normal sagital MRI

Cervical disc herniation can affect one or multiple levels.

Cervical Myelopathy

Compression of the cervical spinal cord can cause cervical myelopathy. Many possible pathological processes result in compression of the spinal cord in the neck:

  • Some individuals are predisposed to this condition as a result of the congenitally narrow spinal canal. Degenerated spinal discs in the neck can protrude and cause spinal cord compression.
  • Degenerative processes can lead to hypertrophy of facet joints, laminas and ligaments; all of these can compress the spinal cord.
  • Subluxation, abnormal mobility of the vertebras, and instability can lead to the spinal cord becoming compressed or "pinched."
  • In some individuals, a structure known as the posterior longitudinal ligament becomes ossified and hard. That can also cause spinal cord compression.
  • Severe neck trauma can lead to cervical spinal cord compression. A cervical spinal cord injury may result in paralysis and loss of sensation below the level of cord damage.
  • Various tumours (or neoplasms) can cause cervical spinal cord compression.

Cervical myelopathy, compression of nerve root in the neck

Cervical myelopathy is frequently related to neck pain. Sometimes, it can be associated with the compression of nerve roots in the neck. This is known as cervical radiculopathy and manifests as pain, loss of sensation and weakness in the distribution of that particular nerve.

When cervical myelopathy and radiculopathy are present together, this condition is called cervical myeloradiculopathy.

Cervical myelopathy may manifest in the following ways:

  • Loss of sensation
  • Numbness
  • Weakness in arms and legs
  • Loss of dexterity
  • Muscle atrophy
  • Brisk reflexes
  • Abnormal reflexes "Hoffman and Babinski"
  • Increased muscle tone and rigidity
  • Unsteady gait, poor balance, and difficulty walking
  • Loss of ability to control sphincters ("water-work" in particular)

Cervical myelopathy,C5 compression MRI

In the number of cases with cervical myelopathy, it may be necessary to perform a surgical intervention and decompress the spinal cord. The operation aims to stop the progression of the disorder. Any improvement in function and symptoms should be considered as a bonus. In some cases, the decompression must be accompanied with a fusion procedure to prevent any instability, thus preventing further injury and damage to the spinal cord.

The operation can be done from the back or the front of the neck. The procedure of choice depends on the individual patient and her or his presentation. Common surgical procedures include:

  • Laminectomy and decompression (approach from the back)
  • Anterior cervical discectomy and fusion (approach from the front).

Less commonly, it may be necessary to remove the whole cervical vertebra. The name of this procedure is corpectomy.

Treatment options, surgical and nonsurgical, must be discussed with a spinal specialist.

Cervical spine canal, severe stenosis, MRI axial plane image

Cervical spine canal severe stenosis, axial plane image

Cervical spine canal, severe stenosis at C3-C4 level, associated with spinal cord compression

Severe cervical spinal canal stenosis at C3 - C4 level associated with spinal cord compression and cervical myelopathy, MRI saggital image

Cervical spine canal, severe stenosis at C4-C5 level, MRI sagittal view

Cervical spine canal stenosis at C4 - C5 level, sagittal MRI image

Cervical Radiculopathy

Cervical radiculopathy manifests as pain, change (loss) of sensation and weakness in one or both arms. It frequently goes hand in hand with neck pain, and sometimes it is challenging to distinguish between the two.

Cervical radiculpathy pointing at men shoulder and arm, from the back

The distribution of pain, sensory change, numbness and muscle weakness depends on the nerve roots involved. Symptoms may be mild in some cases and can settle spontaneously with some simple painkillers and exercise. However, in some other cases, pain, loss of sensation, and weakness can be severe. In those cases, surgical intervention may be necessary.

Cervical radiculpathy pointing at men shoulder and arm

In some cases, this narrowing of the spinal canal may lead to compression on the spinal cord - it appears "pinched ". This condition is called cervical myelopathy. It can coexist with cervical radiculopathy.

The underlying pathological process can be described as a degenerative spinal disease affecting the neck. Structures involved in the degenerative process include discs, facet joints and ligaments. Physiological neck spinal curvature is frequently lost, and the spinal canal may become narrow.

Damage to the intervertebral discs and intervertebral hernia pinched
Facet joints parts - healthy condition

Surgery for cervical radiculopathy aims to decompress the nerve roots. If there is associated compression of the spinal cord, then this may need to be decompressed as well. Surgical interventions include foraminotomy, laminectomy, arthroplasty procedures, and if there is neck instability, cervical fusion procedures. These procedures vary in their technical aspects, possible results, benefits and risks. It is essential to discuss these procedures with a spinal specialist if you are taking any of these operations.

In some cases, pain in the distribution of the particular nerve root can be treated with injections. These injections often contain a cocktail of local anaesthetics and steroids. Sometimes, the injection can work very well. However, the effect usually does not last long. Fortunately, the injection therapy can be repeated.

It is essential to be aware that shoulder pathology can present with neck pain as well. Shoulder problems require the attention of an orthopaedic surgeon and shoulder specialist.

Equally, loss of sensation, pain and weakness can be the result of compression on one of the peripheral nerves. The most commonly affected is the median nerve. If compressed at the wrist, the condition is called carpal tunnel syndrome. This may be treated by decompressing the nerve at the wrist level. Compression of the ulnar nerve is less frequent. This nerve is mostly compressed at the level of the elbow. This is called cubital tunnel syndrome. All possible treatment options, including surgical decompression, must be discussed with a specialist.

Cervical spine-degenerative disease, MRI image

Cervical spine - degenerative disease