Case history

Case history #1

A 60-year-old man presents with diffuse paraspinal neck pain and stiffness, which has slowly worsened over 20 years. He describes significant muscle spasm in the lateral and anterior aspects of his neck, including tender, sore muscles, severe interscapular pain, and occasional headaches. The axial neck pain is worsened by activity and driving, and is improved by a heating pad and nonsteroidal anti-inflammatory drugs (NSAIDs). He describes a grating or popping sound when moving his neck. Physical and neurologic exams reveal decreased range of motion of the neck, paraspinal muscle spasm, and normal sensory and motor function of his upper extremities.

Case history #2

A 57-year-old woman presents with primarily severe and radiating arm pain, which she describes as beginning at the shoulder, and particularly worse pain in the region of the left lateral elbow. This arm pain has been present for >3 months, and she describes it as similar to a lightning bolt coursing through the left arm. No significant neck pain is apparent on the history or exam. She has also noted some weakness of arm extension and grip of the left hand, as well as a tingling sensation in the left index and middle fingers. On exam she has reproduction of her pain on turning her head to the left, significant weakness in the left triceps and absent left triceps reflex, and minimal sensory changes in the index and middle finger.

Other presentations

A less common presentation is degenerative cervical myelopathy. This presentation is more commonly loss of function in the upper limbs (i.e., loss of fine motor function in the hands) rather than the lower limbs (i.e., gait ataxia). This syndrome is epitomized by numb or clumsy hand symptoms where the patient has initial difficulty in fine motor function. This can progress to more diffuse weakness in the upper extremities. Most of these symptoms reflect upper motor neuron pathology directly attributable to pressure on the cervical spinal cord (between the C2 and C7 levels) with resulting hyperreflexia (depending on the level in upper and lower extremities) and, rarely, direct sensory loss. Many patients also have axial neck pain because the compression on the spinal cord is due to severe degenerative changes in the cervical spine. Radicular arm pain is rarely present.

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