Serious Cervical Spine Conditions

Original Editor - Rachael Lowe

Top Contributors - Rachael Lowe  

Introduction

Clinicians must be aware of the key signs and symptoms associated with serious pathological neck conditions (red flags), continually screen for the presence of these conditions, and initiate referral to the appropriate medical practitioner when a potentially serious medical condition is suspected.

Red Flags

In any spinal condition clinicians must be able to identify red flags that suggest the presence serious pathology and the need for medical (infection, cancer, and cardiac involvement). If any of these red flags are identified in the spine, the therapist should first consider if onward referral is appropriate[1]. If serious enough, the therapist may refer onto Accident and Emergency, such as in the case of fractures[2]. Otherwise further specialist medical opinions can be gained from a specialist medical practitioner or in a specialist spinal clinic[3].

Specific to the cervical spine clinicians should screen individuals with neck pain for cervical myelopathy, arterial dysfunction, instability and fracture[4].

Cervical Stenosis and Myelopathy

Cervical myelopathy refers to compression on the cervical spinal cord. Any space occupying lesion within the cervical spine that narrows the spinal canal (spinal stenosis) has the potential to compress the spinal cord can cause cervical myelopathy.[5][6] Spinal stenosis is predominantly caused by cervical spondylosis (degenerative changes in the cervical spine) but can also be the result of traumatic (fractures and instability) and inflammatory conditions or caused by herniated discs or tumours.

Cervical Arterial Dysfunction

Cervical arterial dysfunction (CAD) is an umbrella term covering a broad spectrum of potential vascular pathologies. These range from pre-existing underlying anatomical anomalies, vasospasm, atherosclerosis, through to giant cell arteritis (i.e. temporal arteritis) or arterial dissection. All of these may lead to potential cranio-cerebral ischaemia which may originate and manifest in a variety of ways. Presentations range from pain, through to cranial nerve dysfunctions, sympathetic nerve dysfunction (e.g. Horner’s Syndrome), blindness, stroke, or at worst, death. Care must be taken to differentiate vascular sources of pain from musculoskeletal sources. Urgent medical investigation is indicated if frank vascular pathology is identified.

Cervical Instability

Clinical instability of the cervical spine is defined as the inability of the spine under physiological loads to maintain its normal pattern of displacement so that there is no neurological damage or irritation, no development of deformity, and no incapacitating pain. With cervical instability (particularly in the upper cervical spine) there is potential for serious neurological injury so the cause and extent of instability should be investigated before physiotherapy treatment commences.

Cervical Fractures

When a patient with neck pain reports a history of trauma, the therapist needs to be particularly alert for spinal fracture and the potential for cervical instability and/or spinal cord or brain stem injury. The Canadian C-Spine Rule can be used to determine when to refer for radiography in individuals following trauma where fracture of the cervical spine is a concern.

References

  1. Moffett, J. K., McLean, S. and Roberts, L. Red flags need more evalutation: reply. Rheumatology. 45, pp: 922. 2006
  2. Chau, A. M. T., Xu, L. L., Pelzer, N. R. and Gragnaniello, C. (2013). Timing of surgical intervention in cauda equine syndrome – a systematic critical review. World Neurosurgery. 12
  3. Carvalho, A. Red Alert: How useful are flags for identifying the origins of pain and barriers to rehabilitation? Frontline. 13 (17). 2007
  4. Knew WW. Neck Pain Guidelines: Revision 2017. J Orthop Sports Phys Ther. 2017;47(7):511-2.
  5. Richard K. Root Clinical Infectious Diseases: A Practical Approach, 1999
  6. Kong LD, Meng LC, Wang LF, Shen Y, Wang P and Shang ZK. Evaluation of conservative treatment and timing of surgical intervention for mild forms of cervical spondylotic myelopathy. Exp Ther Med. 2013 Sep;6(3):852-856.