Neck Pain & Cervical Spine Disorders
Separate the stiff neck from the pinched root and the squeezed cord
Mechanical neck pain and red flags
Neck strain and whiplash. Most neck pain is mechanical: paraspinal muscle and ligament strain with spasm and stiffness but no neurologic deficit. Whiplash follows a rear-end acceleration–deceleration injury and behaves the same way. Treatment is reassurance, acetaminophen or NSAIDs, heat, and early return to normal activity with range-of-motion exercise; prolonged soft-collar use delays recovery. Imaging adds nothing unless red flags are present or, after trauma, a decision rule (NEXUS or Canadian C-spine rule) calls for it, in which case CT is the test.
Red flags.
- Fever, IV drug use, immunosuppression, or recent bacteremia: spinal epidural abscess, usually Staphylococcus aureus. Obtain urgent MRI with gadolinium and blood cultures, start antibiotics, and consult for decompression; lumbar puncture is avoided.
- Cancer history, weight loss, or night pain: vertebral metastasis; MRI.
- Progressive neurologic deficit or myelopathic signs at any point: urgent MRI.
Cervical radiculopathy
Mechanism. A nerve root is compressed by a herniated disc in younger patients or by foraminal osteophytes from spondylosis in older ones. Neck pain radiates into the arm in a dermatomal pattern with paresthesias and sometimes weakness or reflex loss. C7 is most often involved, then C6. Because cervical roots exit above the vertebra of the same number, a C5–C6 disc compresses the C6 root.
Exam. The Spurling test (neck extension, rotation, and lateral bending toward the painful side with gentle axial load) reproduces radicular arm pain, and resting the hand on top of the head often relieves it (shoulder abduction relief sign).
| Root | Weakness | Reflex | Sensory loss |
|---|---|---|---|
| C5 | Deltoid, biceps | Biceps | Lateral shoulder and upper arm |
| C6 | Wrist extension, biceps | Brachioradialis (and biceps) | Thumb and index finger |
| C7 | Triceps, finger extension, wrist flexion | Triceps | Middle finger |
| C8 | Finger flexors, hand intrinsics (grip) | None reliable | Ring and little finger, medial forearm |
Management. Most patients improve over weeks to a few months with NSAIDs, activity modification, and physical therapy, and an epidural steroid injection can help persistent pain. MRI is reserved for progressive or significant motor deficit, myelopathic signs, red flags, or symptoms lasting more than 6 weeks despite conservative care, typically when surgery is being considered (anterior cervical discectomy and fusion or foraminotomy). EMG and nerve conduction studies help when a root lesion must be separated from a peripheral entrapment such as carpal tunnel syndrome, a classic C6 mimic.
Cervical spondylotic myelopathy
Pathology. The most common cause of spinal cord dysfunction in older adults, it results from disc–osteophyte bars, ligamentum flavum hypertrophy, or ossification of the posterior longitudinal ligament narrowing the canal.
Presentation. Onset is insidious: clumsy, numb hands (trouble with buttons, handwriting, dropped objects), a broad-based unsteady gait with falls, and later urinary urgency or incontinence. Neck pain may be mild or absent. Upper motor neuron signs appear below the compression: hyperreflexia, Hoffmann sign (flicking the middle fingernail flexes the thumb and index finger), Babinski sign, clonus, and spasticity, often with intrinsic hand wasting at the level. Lhermitte sign, an electric shock down the spine or limbs on neck flexion, points to the cervical cord, though it also occurs in multiple sclerosis and B12 deficiency.
Diagnosis and treatment. MRI shows cord compression and T2 signal change; CT myelography substitutes when MRI is contraindicated. Moderate, severe, or progressive myelopathy is treated with surgical decompression (anterior discectomy or corpectomy with fusion, or posterior laminoplasty or laminectomy) because established deficits often do not fully recover. Spinal manipulation is avoided.
| Feature | Spondylotic myelopathy | ALS | B12 deficiency |
|---|---|---|---|
| Sensation | Numb hands | Normal | Lost vibration and position sense; positive Romberg |
| Motor | UMN signs below the level | Mixed UMN and LMN, widespread fasciculations | Spasticity; ankle reflexes often absent |
| Bulbar or bladder | Bladder later; no bulbar signs | Bulbar signs (tongue fasciculations, brisk jaw jerk); bladder spared | Bladder may be affected |
| Key test | Cervical MRI | EMG: widespread denervation | B12, methylmalonic acid; macrocytosis |
Rheumatoid neck and thoracic outlet syndrome
Atlantoaxial subluxation in RA. Rheumatoid pannus erodes the transverse ligament and odontoid, allowing C1–C2 subluxation that can compress the cord, causing occipital pain, myelopathy, and rarely sudden death with neck hyperextension. Before elective surgery or intubation in long-standing RA, obtain flexion–extension cervical radiographs. Symptomatic or unstable subluxation calls for MRI, neurosurgical fusion, and fiberoptic intubation.
Thoracic outlet syndrome. The brachial plexus (lower trunk, C8–T1) or subclavian vessels are compressed in the scalene triangle, the costoclavicular space, or beneath pectoralis minor by a cervical rib, scalene hypertrophy, trauma, or repetitive overhead work.
- Neurogenic (over 90%): arm pain and paresthesias along the ulnar forearm and hand, sometimes with thenar wasting (Gilliatt–Sumner hand), reproduced by overhead positions such as the elevated arm stress test. Physical therapy and posture correction come first.
- Venous: Paget–Schroetter effort thrombosis of the subclavian vein in a young athlete or weightlifter, with sudden arm swelling, cyanosis, and heaviness. Duplex ultrasound confirms it; treatment is anticoagulation, often with catheter-directed thrombolysis and first-rib resection.
- Arterial (rarest): a cervical rib causes subclavian stenosis or aneurysm with emboli, leaving a pale, cool, pulseless hand that needs surgical decompression and repair.