Differentials

Whiplash injury (cervical myofascial strain)

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Caused by acceleration/deceleration injuries to the neck, most commonly from rear-end automobile accidents. Approximately 65% of patients make a full recovery, 25% have minor residual symptoms, and 5% to 10% develop chronic pain syndromes. Broad spectrum of symptoms, including neck stiffness, shoulder or arm pain, myalgias, paraesthesias, headache, facial pain, and vertigo.

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Plain x-rays usually ordered to rule out fracture or subluxation due to a ligament tear. X-rays sometimes reveal a straightening of the natural curve in the neck because of extensive muscle spasm. Most patients will have normal radiological studies. If disc herniation or nerve root compromise is suggested, an MRI study can help pinpoint the problem. [5]

Acute disc herniation

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History of repetitive cervical stress or, rarely, from a single traumatic incident. Increased risk may accrue because of vibrational stress, heavy lifting, prolonged sedentary position, whiplash accidents, and frequent acceleration/deceleration.

Cervical radiculopathy can result from nerve root injury in the presence of disc herniation or stenosis, most commonly foraminal stenosis, leading to sensory, motor, or reflex abnormalities in the affected nerve root distribution.

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Best diagnosed by an MRI scan. If >1 level of herniation appears, a CT myelogram can help distinguish which disc is irritating the spinal nerve.

If radiculopathy symptoms are present, an EMG can reveal which nerve is affected, but does not confirm disc herniation. EMG is most effective when the MRI shows >1 level of herniation and there is no definite motor, sensory, or reflex deficit, to distinguish which nerve root is affected.

Metastatic malignancy

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Spontaneous but severe, persistent pain, particularly with bony involvement, which does not resolve with initial treatments.

Bone invasion is common in known malignancy, but can often be the initial sign of an advanced, undiagnosed malignancy.

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Cervical MRI showing mass lesion of bone or soft tissue or multiple lesions suggestive of bony metastases.

Multiple myeloma

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Most common tumour to the spine (along with plasmacytoma). Latter is rare, implies a single lesion with an indolent clinical course, and is seen more commonly in a young person. Multiple myeloma is seen in older patients, is rapidly progressive, and commonly presents with neurological symptoms due to vertebral body collapse. Patients may also have symptoms associated with hypercalcaemia and renal failure.

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X-rays of the cervical spine show ≥1 lytic vertebral bodies.

Multiple myeloma is a plasma cell dyscrasia characterised by infiltration of the bone marrow by plasma cells, and the presence of a monoclonal immunoglobulin or immunoglobulin fragment in the serum and/or urine.

Bone marrow aspirate and biopsy with histopathology shows atypical plasma cell infiltrates.

Osteomyelitis or discitis

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More severe, spontaneous neck pain, often following systemic infection, with marked decreased range of motion, or with progressive neurological changes in upper extremities. Commonly begins as a cervical discitis (i.e., disc space infection) because the disc is highly susceptible to infection. Spreads to adjacent bone, with severe neck pain. Often this entity follows sepsis at some interval, so patient may be over their septic episode by the time the actual neck pain begins.

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Cervical MRI usually shows evidence of bone or disc space infection. Infected areas typically appear with decreased signal intensity on T1-weighted images and increased signal intensity on T2-weighted images.

Epidural abscess

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Commonly an extension of discitis through spinal venous spread, leading to severe neck pain. In advanced cases, leads to compressive myelopathy from spinal cord compression.

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Cervical MRI is the preferred test because both the epidural collection and its effect on the spinal cord are easily discernible, as well as the likely source of the infection. MRI with contrast helps to indicate the spread of the infection.

Cervical bone or joint instability

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More severe spontaneous neck pain or progressive loss of neurological function.

Presence of underlying medical conditions such as rheumatoid arthritis (i.e., C1/2), previous trauma, previous surgery, congenital abnormality (skull base), or spontaneous degenerative spondylolisthesis.

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Cervical radiographs together with cervical MRI helpful to distinguish presence of instability, levels involved, and features of associated condition.

Fibromyalgia

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Presents with widespread body pain persisting for >3 months with multiple tender points; somatic complaints include chronic headaches, sleep disturbance, depression and anxiety, irritable bowel syndrome, genitourinary disturbances, and diffuse sensory disturbances.

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No radiographic or laboratory test; the diagnosis is strictly clinical. However, if the patient does not meet clinical criteria for a diagnosis, tests including FBC, TFT, RF, and ANA may help explain the patient's musculoskeletal pain or fatigue.

Polymyalgia rheumatica (PMR)

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Presents with history of neck, shoulder girdle, and/or hip girdle stiffness and pain, occurring in patients aged >50 years (usually women). Patients complain of difficulty rising from seated or prone positions, varying degrees of muscle tenderness, shoulder/hip bursitis, and/or oligoarthritis.

Rapid improvement is almost invariable within 24 to 48 hours with low-dose prednisolone.

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Diagnosis is made by history and with supportive laboratory tests indicating an elevated ESR or C-reactive protein.

Diagnostic and therapeutic corticosteroid trial.

Giant cell arteritis (GCA) or temporal arteritis

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Associations are new-onset unilateral headache, jaw claudication associated with chewing tough foods, diffuse mandibular discomfort, dental discomfort, sinus pain and pressure, and/or tongue pain. Blindness, diplopia or blurry vision, and an abnormally thickened, tender, erythematous, or nodular temporal artery are also found.

Patients aged >50 years with new-onset headache should be screened for GCA or temporal arteritis. About 15% to 20% of patients with PMR have GCA; 40% to 60% of GCA patients have PMR.

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Elevated ESR or CRP.

A positive temporal artery biopsy showing a granulomatous vasculitis confirms the diagnosis of GCA.

Diagnostic and therapeutic corticosteroid trial.

Ankylosing spondylitis

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A chronic progressive inflammatory arthropathy predominantly affecting the axial spine and sacroiliac joints. Patients present with severe pain and spinal stiffness, which may ultimately lead to spinal fusion (bamboo spine). These patients have extreme disability as a consequence. Peripheral joints, entheses (tendon or ligament attachments to bone), and extra-articular sites such as the eye and bowel are frequently affected.

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There is no diagnostic test. HLA-B27, although not diagnostic, is helpful if it is positive. Inflammatory markers such as ESR and CRP are generally unhelpful in diagnosing or monitoring. Radiographs of the cervical spine may show spinal fusion (bamboo spine).

Rheumatoid arthritis (RA)

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Pain and/or swelling in several joints, significant joint stiffness in the morning or after rest, progressive loss of joint function, symmetrical joint involvement, and good response to NSAIDs, with most patients presenting in their 50s.

Less-common extra-articular features such as rheumatoid nodules over the extensor surfaces of tendons or vasculitic skin involvement may be seen. Clinical signs seen in more severe presentations include pleuritis, pericarditis, and inflammatory eye disease.

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Baseline radiographs of the hands and feet and spine show erosion of cartilage.

RF is positive in about 70% of patients with RA. Anti-cyclic citrullinated peptide antibodies (anti-CCP) are newly described and are found in about 70% to 80% of patients with RA. They can be positive when RF is negative and seem to play more of a pathogenic role in the development of RA.

ESR or CRP levels are usually obtained to reflect the level of inflammation. However, up to 40% of patients with RA may have normal levels.

Cluster headache/chronic headache syndromes

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Diagnosed from the clinical history. The most important historical factors are frequency of headaches, duration of attacks, severity of attacks, whether the headache is constant or intermittent, or unilateral or bilateral, associations (nausea, sensitivity to light or noise), and presence of trigger factors or associations with injury or analgesic overuse.

Headache episodes lasting <2 hours are in keeping with chronic cluster headaches. Episodes lasting >2 hours would be in keeping with either migraine or tension-type headaches.

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Is a clinical diagnosis of exclusion.

Cervical myelogram, CT scan, or MRI will be negative for cervical disc disease or spinal cord disease.

Osteoporosis

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Common in postmenopausal women or older men with maternal history of fragility fractures/osteoporosis, low BMI, and tobacco use. Patients with osteoporosis are asymptomatic until fracture occurs.

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Measurement of BMD using DXA is the definitive test and preferred procedure diagnosis. Use of DXA for screening patients with risk factors will diagnose many cases of osteoporosis.

X-ray can reveal osteopenia and/or fractures (e.g., vertebral fractures), but is not diagnostic of condition.

Quantitative CT or quantitative ultrasound of the heel can be used to measure trabecular bone density if DXA is unavailable.

Spinal compression fracture

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Usually a history of trauma, although the acute event is not always recalled; pain at rest and at night; previous history of fractures; tenderness to palpation over the midline; increased kyphosis; normal neurological examination unless there is retropulsion of bone into the neural elements, such as in burst fractures.

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Plain radiograph shows wedging of the vertebral bodies, typically anteriorly; kyphotic deformity; only the anterior half of the vertebral body is involved in compression fractures.

Polymyositis

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History of symmetrical weakness of shoulder and pelvic girdles.

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Elevated muscle enzyme levels (e.g., CK) often with a positive ANA titre.

Characteristic changes in EMG include increased needle insertional activity, spontaneous fibrillations, low-amplitude short-duration polyphasic motor potentials, and complex repetitive discharges.

Diagnosis is confirmed with muscle biopsy, indicating immune cell infiltration and destruction of muscle fibres.

Thoracic outlet syndrome

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Intermittent unilateral or bilateral upper extremity numbness, often with no objective sensory loss, and weakness noted rarely. Cervical myelopathy is constant, with both upper and lower extremity neurological changes often noted.

Caused by compression of the neurovascular structures just above the first rib and behind the clavicle, involving the lower 2 nerve roots of the brachial plexus (C8 and T1). Less commonly, C5, C6, and C7 involvement leads to symptoms referred to the neck, ear, chest, and outer arm.

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Brachial angiograms may show vascular stenosis and EMG/nerve conduction velocity (NCV) may show proximal brachial plexus changes consistent with thoracic outlet.

Cervical radiology may demonstrate a skeletal abnormality, cervical or first rib, clavicle deformity, pulmonary disease, or Pancoast tumour.

Colour-flow duplex scanning, arteriography, or venography of the arm may demonstrate vascular thoracic outlet syndrome.

Cervical myelogram, CT scan, or MRI will be negative for cervical disc disease or spinal cord disease.

Brachial plexus injury

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Unilateral severe proximal and distal weakness and sensory loss, often following injury, or spontaneous (neuralgic amyotrophy) following viral infection, in a different pattern from cervical radiculopathy or myelopathy.

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EMG/NCV can easily differentiate lower versus upper motor neuron changes.

MRI or cervical myelogram may show root avulsion changes.

Multiple sclerosis

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Spinal manifestations can mimic all signs of cervical compressive myelopathy and overlap. However, in almost all cases there are also brain lesions and neurological findings.

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Brain MRI typically shows changes. On cervical MRI there is no compression but intrinsic spinal cord lesions are usually noted.

Mononeuritis multiplex (MNM)

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Distinctive clinical presentation of progressive motor and sensory deficits in the distribution of specific peripheral nerves.

Involvement of each nerve occurs either sequentially or simultaneously.

Pain is a frequent symptom; usually neuropathic pain within the area of sensory loss and deep pain in the affected extremity.

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Diagnosis is based on clinical picture and characteristic vasculitic changes seen on nerve or muscle biopsy without demyelination.

EMG can distinguish MNM caused by vasculitis, infection, or neoplastic infiltration from multiple entrapment neuropathies.

Cervical myelogram, CT scan, or MRI will be negative for cervical disc disease or spinal cord disease.

Amyotrophic lateral sclerosis

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Can mimic cervical myelopathy, but typically has more severe proximal weakness, fasciculations, brainstem findings (i.e., tongue fasciculations), and no sensory changes.

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Cervical MRI does not show any significant spinal cord compression but may show intrinsic spinal cord lesions.

Complex regional pain syndrome

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Severe, diffuse upper extremity pain (usually unilateral) in a non-radicular distribution, typically following an injury or a surgical procedure on that upper extremity. There are no specific sensory or motor changes beyond limitation by pain.

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Cervical MRI and typically EMG/NCV will both be normal. Sympathetic blocks may help differentiate.

Hereditary muscular dystrophy

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Severe proximal and distal weakness without sensory changes from an early age.

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Cervical MRI and EMG/NCV will show only myopathic changes and no spinal cord compression.

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