Serious cervical spine conditions

Patient recourses
NHS Inform Cervical Myelopathy  

Definition

Cervical Myelopathy (also known as Degenerative Cervical Myelopathy) is the most common atraumatic spinal cord condition in adults. It occurs when degenerative changes cause spinal cord compression and is characterised by loss of fine motor control and coordination, gait dysfunction, and genitourinary disturbance.

A diagnosis of cervical myelopathy is made when an individual presents with clinical symptoms and corresponding MRI evidence of myelopathic cord compression.

Prognosis

Cervical myelopathy symptoms exist on a spectrum of severity.  The natural history is relatively unknown. However, there is moderate evidence that 20%-62% of patients with symptomatic cervical myelopathy deteriorate by ≥1 point on the modified Japanese Orthopaedic Assessment (mJOA) scale within 3-6 years.

There is moderate evidence that patients with cervical myelopathy worsen in performing activities of daily living with non-operative treatment at 1year (6%), 2year (21%), 3year (28%), and 10year (56%) follow-up.

Typical Signs & Symptoms

The onset is usually insidious, and diagnosis is based on history, physical examination, and imaging findings.

Common symptoms include:

• Stiff neck or legs
• Altered sensation in the legs
• Altered balance and staggering when walking
• Bilateral hand numbness
• Loss of dexterity (difficulty doing up buttons/holding a pen)
• Clumsiness in the hands.

Signs include:

• Hyper-reflexia
• Abnormal pathological reflexes (e.g. positive Hoffman, plantar response, ankle clonus)
• Increased tone
• Motor deficits
• Atrophy of intrinsic hand muscles
• A broad-based unstable, ataxic gait
• Bowel and bladder dysfunction

Risk factors for poor outcome

It is suggested that the severity and length of time patients have symptoms prior to treatment results in a poorer outcome.

Other considerations

mJOA scale is the most widely used outcome scale to measure the severity of cervical myelopathy. It has moderate internal consistency.  The reliability of the mJOA has not been established.

Differential Diagnosis

Differential diagnoses include intracranial, demyelinating, motor neuron, infectious, inflammatory, and metabolic diseases. In a recent narrative review, it was suggested that vitamin B₁₂ deficiency, Multiple sclerosis (MS), and peripheral nerve entrapment are differential diagnoses of cervical myelopathy. 

Red flags include

• Sudden onset of severe central spinal pain which is relieved by lying down
• There may be a history of trauma (such as road traffic collision or fall from height), minor trauma, or even just strenuous lifting in people with osteoporosis or those who use corticosteroids
• Structural deformity of the spine (such as a step from one vertebra to an adjacent vertebra) may be present
• There may be point tenderness over a vertebral body.

Key risk factors

• Older age (>50 years for women and >65 years for men)
• Previous fragility fracture
• Long term glucocorticoids
• History of falls
• Family history of hip fracture
• Other causes of secondary osteoporosis, e.g., RA & problems with malabsorption
• Low body mass (<18.5kg/m2)
• Smoking
• Alcohol intake >3.5 units /day

History

• Sudden pain in thoracic or lumbar spine
• Minimal trauma
• Pain that gets worse when sitting (esp. a straight-backed chair) & leaning backwards or standing leaning forwards.

Physical Examination

• No clinical signs specific for VFF
• In acute phase may have: Local tenderness / pain on percussion over spine level
• Potential for: Height loss of person > 2.5cm
• Thoracic kyphosis.

Why is it important to identify a VFF

• A vertebral fracture is a powerful predictor of another vertebral fracture (5x more likely) & of future hip fracture (3x more likely) without treatment (ROS, 2021).
• There are high rates of mortality within the first year after fragility fractures such as the hip (The Vertebral Fractures Study, 2022).
• All patients with a VFF should be considered for fracture risk assessment to reduce fracture risk and prevent further fractures (ROS, 2022).

Relevant Resources

SIGN Guideline 142 - Management of Osteoporosis and the prevention of vertebral fragility fractures.

Suspected inflammatory spinal conditions include a range of pathologies. Conditions such as Giant Cell Arteritis or Temporal Arteritis may require emergency management.

See here for further information on other Inflammatory Spinal Conditions 

Red flags include:

• Localised neck pain with a current diagnosis of cancer (particularly: breast, lung, prostate, kidney, thyroid)
• Fatigue
• History of weight loss
• Bone pain
• Severe intractable vertebral pain (especially thoracic)
• New spinal nerve root pain (burning, numb, shooting)
• New difficulty walking
• Reduced power/ altered sensation in limbs
• Bowel/ bladder disturbance

Red flags include:

• Fever in a patient with new neck pain
• Recent infection (especially skin or urinary tract)
  • Cervical osteomyelitis and cervical epidural abscesses arise from haematogenous spread in most cases
  • About one third of cases of cervical epidural abscesses arise from contiguous spread from the skin
• Tuberculosis
• Diabetes
• History of IV drug use
• HIV infection, use of immunosuppressants, or the person is otherwise immune-compromised

Red flags include:

• Aged over 50 years
• Gradual onset of symptoms
• Severe unremitting pain that remains when the person is supine
• Aching night pain that prevents or disturbs sleep
• Pain aggravated by straining (e.g. bowel movements, coughing, sneezing) and thoracic pain
• Localised spinal tenderness
• No symptomatic improvement after 4-6 weeks of conservative therapy
• Unexplained weight loss
• Currently has or has a history of cancer (breast, lung, gastrointestinal, prostate, renal, thyroid cancers are more likely to metastasize to the spine)

Definition

There are a range of potential vascular pathologies of the neck which have the potential to mimic musculoskeletal problems (vascular masqueraders).

Typical signs and symptoms

Typically in addition to neck pain clinical features such as headache, facial pain, cranial nerve deficits, TIA/ wider neurological symptoms will form part of the clinical picture.

Prevalence and risk factors

Vascular pathologies of the neck are rare, but are an important consideration in patients presenting with neck and head pain. 

Occurrences of vascular pathologies of the neck are complex and multifactorial. Rarely is an event associated with a single causal factor.

It is important to note that there is a different risk profile for dissection and non-dissection events.

• Dissection events most commonly present with a history of trauma, with cardiovascular factors being less common
• Non-dissection events most commonly occur in the presence of cardiovascular factors

An absence of risk factors does not necessarily rule out the risk of serious neuro-vascular event.

Guidance

Relevant Resources

Headaches:  Headache – RefHelp Page (includes guide to differentiating primary headache disorders, headache as a new complaint including adult assessment

Facial pain: Facial Pain-Neurology – RefHelp Page

Transient ischaemic attack (TIA) and stroke: Transient Ischaemic Attack (TIA) And Stroke – RefHelp Page

Vertigo and dizziness: Vertigo and dizziness – RefHelp Page

Definition

• Central neck pain
• Loss of sensation or paralysis in the body, arms, and/or legs
• Pain that radiates from the neck into the arms and/or shoulders

Prevalence

Risk Factors

• Age 18-25 (80%) or >65 years (especially if they have risk factors for osteoporosis)
• A fall from a height >1 metre or 5 steps
• An axial load to the head (e.g., diving, high-speed motor vehicle collision, rollover motor accident, ejection from a motor vehicle, accident involving motorised recreational vehicles, bicycle collision, horse riding accident)
• Approximately one third of patients with cervical spine and/or spinal cord injuries have an associated head injury

Prognosis

Most patients with acute neck pain or whiplash will recover completely in a matter of days to weeks. Approximately one third of patients will experience persistent symptoms.

Risk factors for poor outcome

• High intensity initial pain is associated with persistent neck pain and disability
• There is a positive association between post-traumatic stress symptoms and outcome
• Negative expectations of recovery are associated with ongoing neck pain and disability
• Self-rated collision severity may be predictive of poor recovery
• Decreased initial neck range of motion and initial cold hyperalgesia are predictive of ongoing disability

Other considerations

Canadian C Spine rule

Patients with traumatic neck pain are typically managed through A&E. However, prior to completing a physical examination, it is important to apply the Canadian C Spine Rule if appropriate. 

Patients with known vertebral disease (i.e. ankylosing spondylitis, rheumatoid arthritis, spinal stenosis, previous cervical spine surgery), hypermobile patients (inc. Ehlers Danlos syndrome and Marfan's), Down’s syndrome, and gymnasts should have a higher level of suspicion of cervical spine injury.

Whiplash Associated Disorder (WAD)

Whiplash is subcategory of traumatic neck pain, some specific WAD information is below.

WAD Patient Resources

• BMJ – Best Practice – Whiplash Patient Leaflet
• NHS Inform - Whiplash

Whiplash Classification - Quebec Task Force Classification of whiplash-associated disorders

1. neck pain and associated symptoms in the absence of objective physical signs.
2. neck pain and associated symptoms in the presence of objective physical signs and without evidence of neurological involvement.
3. neck pain and associated symptoms with evidence of neurological involvement including decreased or absent reflexes, decreased or limited sensation, or muscular weakness.
4. neck pain and associated symptoms with evidence of fracture or dislocation.

Differential diagnosis