History and exam

Key diagnostic factors

More likely to be associated with cervical spondylosis, particularly if multiple episodes over time. If the neck pain is acute and associated with an event, cervical myofascial strain or trauma may be considered, particularly if neck pain is more severe. Neck pain following an infection or with a history of systemic neoplasia may suggest more serious conditions.[19]

Axial neck pain can exist in any axial neck muscle, including scalenes (anterior scalene syndrome), trapezius and interscapular muscles, and paraspinal muscles extending from the occiput to the lumbar region, where axial muscle spasm can spread.[20]

Referred components include occipital pain and cluster or tension headaches.[25]

Subjective presence focuses the differential on either neurologic complications of cervical spondylosis or some other neurologic problem with similar complaints.[13][27]

Pain distal to the shoulder triggers a concern for radiculopathy; radiating pain is rarely present in cervical myelopathy.[19]

Decreased reflexes are a sign of radiculopathy, whereas increased reflexes may signal cervical myelopathy, possibly in the upper extremity but particularly in the lower extremity.[27]

Can occur with C5 radiculopathy, but is uncommon with cervical myelopathy, suggesting a wider differential in many cases.[27]

Particularly in the intrinsic hand muscles (e.g., interossei, abductor pollicis brevis), suggests cervical myelopathy.[27]

Difficulty walking in a straight line. Can indicate cervical myelopathy, through compression of white matter tracts descending to the lower spinal cord.[13][19]

Other diagnostic factors

A common secondary symptom associated with cervical spondylosis.[25]

Commonly caused by degenerative changes, similar to osteoarthritis at any joint.[19]

Common and often less helpful in diagnosis unless a specific root (radiculopathy) or peripheral nerve pattern suggests a different diagnosis (e.g., carpal tunnel syndrome with median nerve hypalgesia).[27]

Risk factors

Population-based MRI studies show nearly 100% of adults aged >40 years have severe degeneration of at least 1 cervical level (commonly C5/6).[1][2][3][4][5][6] However, only a subset of patients present with axial neck pain, and patients are commonly asymptomatic.[4][25][8]

May accelerate the disk and facet degeneration process, particularly if there has been a fracture of an aspect of the joint (i.e., a facet fracture).

May predispose adjacent joints to accelerated degenerative changes, particularly after a cervical fusion.[16] This has been difficult to prove because these joints also spontaneously degenerate, and the rate of change shows little difference with or without previous surgery. However, particularly posterior cervical surgery (i.e., a laminectomy) may enhance the paraspinal muscle spasm symptoms seen with cervical spondylosis-related axial neck pain.[26]

A previous soft-tissue injury to the neck may have resulted in a cervical myofascial strain (including whiplash injury), which can predispose to the same types of axial cervical pain symptoms as seen from degenerative changes alone.

Some forms of severe, accelerated degenerative changes, including diffuse idiopathic skeletal hyperostosis, ankylosing spondylitis, and ossification of the posterior longitudinal ligament, are more prone to occur in some populations.[16] These less-common forms of severe degenerative changes may also lead to markedly decreased neck motion due to calcification around the joints and ligaments. Both cervical degenerative changes and degenerative cervical myelopathy show a tendency for genetic predisposition.[17][18]

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