Osteoarthritis and osteophytic spur formation of the cervical spine may cause pain that radiates into the back of the head, shoulders, and arm on one or both sides. Coincident compression of nerve roots is manifest by paresthesia, sensory loss, weakness and atrophy, and tendon reflex changes in the arms and hands. Should bony ridges form in the spinal canal, as described in detail in Chap. 42, the spinal cord may be compressed, with resulting spastic weakness, ataxia, and loss of vibratory and position sense in the legs (cervical spondylosis). The bony changes are evident on plain films but are better seen by CT and MRI. There may be difficulty in distinguishing cervical spondylosis with root and spinal cord compression from a disc (see further on) or from a primary neurologic disease (syringomyelia, amyotrophic lateral sclerosis, or tumor) with an unrelated cervical osteoarthritis. Here the MRI is of particular value in revealing compression of the spinal cord, but this study is prone to overinterpretation when a bony ridge barely comes into contact with the cord but does not deform it (see “Cervical Spondylosis with Myelopathy” in Chap. 42).
Spinal rheumatoid arthritis may be restricted to the cervical facet joints and the atlantoaxial articulation. The usual manifestations are pain, stiffness, and limitation of motion in the neck and pain in the back of the head. In contrast to ankylosing spondylitis, rheumatoid arthritis is rarely confined to the spine. Because of evident disease of other joints, the diagnosis is relatively easy to make, but significant involvement of the cervical spine may be overlooked. In the advanced stages, one or several of the vertebrae may become displaced anteriorly, or a synovitis of the atlantoaxial joint may damage the transverse ligament of the atlas, resulting in forward displacement of the atlas on the axis (atlantoaxial subluxation). In either instance, serious and even life-threatening compression of the spinal cord may occur gradually or suddenly. Cautiously performed lateral radiographs in flexion and extension are useful in visualizing atlantoaxial dislocation or subluxation of the lower segments. Occipital headache and neck pain related to degenerative changes in the upper cervical facets is discussed with other cranial pains in “‘Third Occipital Nerve’ Headache” (so-called third occipital nerve pain) in Chap. 9.
Traumatic and whiplash injury Injury to ligaments and muscles as a result of forcible extension and flexion of the neck can create a number of difficult clinical problems. The injury ranges from a minor sprain of muscles and ligaments to severe tearing of these structures, to avulsion of muscle and tendon from vertebral body, and even to vertebral and intervertebral disc damage. The latter lesions can be seen with MRI and, if severe, can result in root or spinal cord compression or, occasionally, in cartilaginous embolization of the spinal cord (see “Fibrocartilaginous Embolism” in Chap. 42). If there is preexisting cervical osteoarthritis, there may be considerable pain, and in extreme cases, cord compression.
However, the more ubiquitous and milder degrees of whiplash injury without the above described structural injuries are so often complicated by psychologic and compensation factors leading to prolonged disability that the syndrome becomes a vexing problem without clear medical definition and occupies a disproportionate amount of time on the part of physicians, compensation boards, and courts (see LaRocca for a review and the book by Malleson for an interesting discussion of the sociology and psychology of this subject). We have no doubt that authentic traumatic neck injuries exist, even at times from minor trauma, but we are in accord with the above-mentioned authors that the high frequency of this putative injury is sustained by societal and legal structures.