Approach to imaging the patient with neck pain
From: Journal of Neuroimaging 2003;13:5-16
Neck pain is a common complaint of patients seeking care in the outpatient setting, and the cases seen vary widely in severity and cause. A careful history and physical exam, followed by appropriate imaging studies, are essential for the orderly workup and management of neck pain in the ambulatory patient. Available imaging studies include plain film radiography, computed tomography (CT), magnetic resonance, and CT myelography. The general considerations necessary to select the appropriate imaging study are discussed for a broad spectrum of common disorders.
A careful history is key to placing a patient in a preliminary diagnostic category for further evaluation. A patient’s occupation, postural habits, onset of pain, character of pain, and stress at work and/or home should be discussed. The patient should be questioned regarding the presence of associated symptoms, such as gait or bladder dysfunction. Certain symptom groups are suggestive or even diagnostic of certain disease processes.
Acute pain with limited motion, especially in a younger person, is likely to follow trauma or a persistent new activity. Often, the neck muscles are tender in these patients. Middle-aged patients may present with recurrent or persistent pain, sometimes accompanied by tingling in the arms or fingers and/or pectoral pain from an affected C6 nerve root. Extension or lateral gaze may aggravate the pain. This constellation of symptoms, usually without history of trauma, suggests cervical degenerative arthritis or cervical spondylosis. Rheumatoid arthritis of the cervical spine usually occurs after a decade of peripheral joint disease and is characterized by severe neck pain followed by arm pain and progressive radiculopathy or myelopathy.
Radiculopathy is a constellation of signs or symptoms attributable to a single nerve root. Radiculopathy is most often the result of compression of a nerve root by a ruptured disc or osteophyte but also may be caused by tumor, trauma, infection, or metabolic insult (eg, diabetic neuropathy). Severe persistent pain with arm weakness or radiating pain is the hallmark. Classic radiculopathy includes pain and dysesthesia in the particular root dermatome with an associated reflex abnormality. The dermatomal distribution of pain is consistent with the distribution of involved nerve roots that supply the arm. The involvement of the doral root or ganglion may result in pain, tingling, numbness, sensory impairment, or soreness of the skin. Reflex loss, weakness, atrophy, fascicular twitching, or stasis edema may occur if motor fibers of the anterior root are involved. For example, compression of the fifth cervical root would produce pain and dysesthesia in the shoulder, weakness in the deltoid and bicep muscles, and a decreased biceps reflex. Likewise, sixth root compression causes pain and dysesthesia in the first and second digits, weak wrist extensors, and a reduced brachioradialis reflex.
Myelopathy is the group of signs and symptoms attributable to spinal cord involvement either externally through compression or through intrinsic cord disease. The syndrome generally progresses over time. Upper and lower motor neuron signs may be present, and one commonly sees pathological reflexes. Symptoms include weakness, a feeling of heavy legs, disturbances of gait, and poor hand coordination. Degenerative disease (ie, central spinal stenosis) is the most common cause; however, the differential diagnosis includes infection, noninfectious inflammatory disease, multiple sclerosis, vascular compromise, neoplasm, trauma, and dural arteriovenous fistula.
Myofascial syndromes (localized muscle spasm) often cause pain over the lower scapula and posterior shoulder radiating into the neck and may be associated with stress or poor posture. This is the most common cause of neck pain and usually resolves with lifestyle modifications such as back supports, supportive mattress, and antiinflammatory analgesics.
The gradual onset of pain that worsens even with rest may indicate malignancy or infection. Primary and metastatic tumors present with pain that is worse at night and may worsen quickly with the development of radiculopathy and myelopathy. Discitis and osteomyelitis are most commonly seen in intravenous drug abusers and are characterized by progressive neck pain and rapidly progressing myelopathy.
Whiplash is a hyperextension injury classically occurring as a result of a minor to moderate motor vehicle accident. The onset of stiffness and headache usually occurs 24 to 48 hours after the accident. Chronic pain is most commonly caused by facet joint pain, with C2-C3 joints mainly responsible for headaches.
Headache is an important accompanying symptom to neck pain. Patients with arthritis often complain of an occipital headache. The involvement of the C2-C3 ligaments, nerve roots, articular facets, and joint capsules is often the cause of occipital referred pain. Disc herniation is often accompanied by a suboccipital headache. Tension headaches and migraine headaches often have neck pain as a component that may precede or persist beyond the headache itself. Lesions producing neck and head pain include cervical spondylosis, rheumatoid arthritis, intervertebral disc protrusion, and spinal cord tumors. Vertigo, nystagmus, and tinnitus are other symptoms that may accompany neck pain. This constellation of symptoms suggests vertebrobasilar insufficiency, sometimes caused by cranial settling due to rheumatoid arthritis.
Myofascial syndromes – Localized muscle spasm. Treat empirically if no suggestion of fracture or neurological compromise.
Degenerative disc disease/spondylosis(osteoarthritis) – Protrusion of osteophytes into the foramina or canal, disc dehydration causing narrowing, and compression of nerve roots or spinal cord. Plain films to evaluate disc space narrowing and osteophyte formation; if abnormal neurologic exam, MRI to diagnose nerve root and/or cord compression.
Disc prolapse Eccentric disc bulge or herniation compromises canal or foramina. MRI; perhaps CT/myelography for surgical planning.
Trauma Fracture, subluxation, acute disc herniation, or ligament sprain – Screening plain film series, then CT and/or MRI as indicated for further detail.
Rheumatoid arthritis/inflammatory arthritides – Inflamed synovium, pannus formation, ligamentous distension and rupture, odontoid erosion. MRI to evaluate odontoid, foramen magnum, and cervical spinal cord; plain films in flexion and extension to evaluate for instability.
Infection IV drug abuse or iatrogenic – MRI to evaluate for discitis, osteomyelitis, epidural, or paraspinal abscess.
Tumor Commonly metastasizes from lung, breast, or prostate; lymphoma or multiple myeloma – MRI to delineate canal involvement, cord compression, surgical feasibility; whole body MR or bone scan to locate other metastatic foci.
The patient with neck pain presents the physician with the challenge of narrowing a wide scope of diseases with a number of powerful tools. To diagnose these conditions in an effective and efficient manner with a minimum of waste, an organized approach should begin with a thorough history and physical exam. Following this with imaging studies appropriate to the differential diagnosis will likely produce a definitive diagnosis or, alternatively, rule out severe disease so that the patient and physician can feel satisfied with a thorough investigation.
