Cervicalgia (radiculopathy)

Cervicalgia Definition

Cervicalgia is the term for neck pain which does not radiate outward and is derived from the Greek ‘algos’ meaning pain, and the Latin ‘cervic’ meaning neck. It is, therefore, distinguished from neck pain and radiculopathy and is most likely due to causes other than nerve compression in the neck. The muscles in the neck are under continual pressure to maintain posture and hold up the considerable weight of the skull and brain which averages around 10lbs. For every inch that the head projects forwards the forces on the neck double; effectively, an inch of forward projection means 20lbs of weight on the neck. It is easy to see how the strain on the cervical spinal muscles can take its toll over time, leading to fatigue in the muscles, spasms, cramps, stiffness, and cervicalgia. The muscles of the neck may become tight and inflexible, which can lead to tearing upon sharp movement and acute neck pain.

How Cervicalgia Develops

Cervicalgia may develop through chronic wear and tear, an inflammatory joint disorder such as rheumatoid arthritis, persistent stress and tension causing muscles in the neck to become tight, and acute injuries from sports, or whiplash. Fibromyalgia is another cause of cervicalgia for many patients, with tender points between the shoulders and in the neck causing constant pain. A large number of those suffering cervicalgia will only do so temporarily as it is often caused by simply sleeping at an awkward angle, slouching over a desk, or standing or sitting in a draught for a period of time. In some cases there may be a physical abnormality causing the neck pain, such as ligaments calcification, cervical arthritis, spinal curvature, or torticollis (wry neck) which causes the head to tilt to one side due to shortened muscles in the neck.

Symptoms of Cervicalgia

Cervicalgia symptoms include both sharp neck pain and chronic pain in the neck, along with aching, tenderness, tension, pain upon rotating the head, stiffness of the neck, and even headaches. In some cases the neck pain associated with cervicalgia may be short-lived and improve with rest if symptomatic of an acute neck muscle strain. However, cervicalgia may remain constant, or even progress leading to degeneration of the cervical spine and the development of other symptoms such as radiculopathy or myelopathy. Chronic problems with the neck muscles also increase the likelihood of conditions such as osteoarthritis as the cervical spine may try to compensate for instability by growing osteophytes and causing cervical spinal stenosis.

Cervicalgia Treatment

Treatment for cervicalgia are usually conservative and include methods of relieving inflammation where it is evident. Applying ice to the area is a good way of relieving pain and swelling and is often advised where a muscle tear is suspected. Heat is contraindicated in such a situation as this is likely to make the problem worse by increasing blood flow to the area. If the cervicalgia is due to muscle tension rather than an injury then thermotherapy can be effective in aiding relaxation of the muscle and relieving neck pain. Adequate rest and the temporary use of a supportive neck collar is also helpful in some cases of cervicalgia although it is inadvisable to use a collar long-term as this may itself lead to muscle weakness in the neck. Many patients also make use of anti-inflammatory medications, including prescribed drugs, over-the-counter remedies, and natural supplements to lower inflammation and pain. Physical therapy, including neck stretches and strengthening exercises, is a good idea for anyone who suffers from chronic neck pain, and intractable cases may require more invasive surgical intervention to address some causes of cervicalgia.

Cervicalgia is extremely prevalent with around a third of people suffering some degree of neck pain at least once a year and more than 10% of people thought to have had neck pain lasting longer than six months. Common cervicalgia causes include poor posture, such as working at a desk for long periods of time without a break and with a poor ergonomic set up. Ideally a computer screen should be placed so that the head or neck does not have to tilt or strain to see it comfortably. An un-supportive chair and elevated keyboard position, or writing position, will also cause strains in the lower back, wrists, and arms, which can then create imbalances further up in the neck and shoulders.

Causes of cervicalgia are often multi-factorial with a combination of poor posture increasing muscle tension and strain and predisposing a person to acute injury during sporting or recreational activity. Conversely, an acute injury to the neck, such as a stinger or burner in football, or whiplash, can then cause alterations in the posture which, if not addressed, may develop into chronic cervicalgia.

Physical symptoms of pain can also be connected to anxiety and depression and many people carry a lot of tension in their neck and shoulders; almost like they are carrying the weight of the world on their shoulders like Atlas. Where stress and tension are the underlying cause of cervicalgia it can help to combine thermotherapy with relaxation techniques as both the immediate symptoms and the underlying problem will need addressing to provide effective relief. Patients who are depressed are also increasingly sensitized to pain and even small aches and strains in the neck can be felt more profoundly. Where there are no clear reasons for neck pain and other symptoms such as fatigue, listlessness, and prolonged and/or profound sadness are evident it may be that depression is responsible for the neck pain. Conversely, the ongoing experience of neck pain, particularly when unable to be attributed to any particular cause, can actually lead to stress, tension, and depression, further exacerbating the symptoms. It is, therefore, clearly extremely important to determine the timeline for such symptoms to appear in order to try to establish cause and effect.

Musculoskeletal Problems

Cervicalgia can also be an aspect of generalized musculoskeletal issues, such as rheumatoid arthritis, fibromyalgia, osteoarthritis, ankylosing spondylitis, or osteoporosis. Disc herniation and spinal stenosis can be at the root of cervicalgia although these often also lead to radicular pain in the shoulders, arms, and hands. In rare cases the cause of neck pain may be an infection in the spine, with osteomyelitis sometimes occurring after back surgery for instance, or following trauma of some kind. Tumor growth in the spine is another infrequent cause of cervicalgia.

Cardiovascular Problems

Cervicalgia causes for some patients is sometimes not connected to the spine at all, and is, instead, linked to cardiovascular problems, or respiratory and upper gastrointestinal issues. Acid reflux may make itself known as a burning pain in the neck rather than lower in the chest and, if this is chronic, the acid can cause damage to the oesophagus leading to precancerous changes (Barrett’s Oesophagus). Blood vessel compression, or abnormalities in the vasculature of the neck can lead to ischaemia in the cervical spinal muscles, causing neck pain. Swelling, congestion, and oedema from upper respiratory tract infections may also lead to neck pain, as can a constant cough which strains the neck muscles and puts pressure on the intervertebral discs.

Cervicalgia symptoms cover non-specific neck pain which can be either acute or chronic and may vary according to particular activities engaged in by the sufferer, such as sleeping awkwardly, maintaining poor posture whilst working at a desk, recreational and exercise activities such as jogging, and even therapies like massage when applied inappropriately. Specific movements may also exacerbate cervicalgia symptoms, such as raising the arm, turning the head to one side, or extending the neck. Conversely, patients may notice that certain movements and activities can reduce their neck pain, with exercise of benefit to a number of patients with cervicalgia (particularly those with fibromyalgia), and that rest may also be helpful to some sufferers.

Coexisting Symptoms

Neck pain is the main symptom of cervicalgia but this pain may coexist with visual disturbances, dizziness, headaches, stiffness of the neck, and spasm of the neck muscles. Radiating pain is not a symptom of cervicalgia as this indicates a specific neurological problem creating pain outside of the neck area, despite it originating in many cases in the cervical spine. The loss of sensation and development of muscle weakness is, again, not a sign of cervicalgia with other cervical radiculopathy (see image below) or myelopathy the usual diagnosis in such cases. On rare occasions the patient may also experience dysphagia, syncope, chest pain, and/or migraine along with cervicalgia.

Signs of cervicalgia that may be observed during physical examination include wry neck (torticollis) as a result of asymmetry in the neck muscles. Patients may also develop restricted movement in the neck and asymmetric range of motion, which is quite common in those who are elderly or have incurred significant wear and tear due to their professional or recreational activities. Tender points in the neck or between the shoulders can also be symptoms of cervicalgia, although these may indicate fibromyalgia or an acute muscular injury in some cases.

Herniated Disc and Cervicalgia

Where patients also complain of a sore throat or problems swallowing, along with tiredness and a slight fever, this may indicate the presence of tonsillitis or a retropharyngeal abscess. Jaw and neck pain can be a sign of a tooth infection or crowding of the teeth which would require dental work in some cases rather than suggesting a problem with the neck itself. Cervicalgia can also present itself in cases where the true pathology at work is a herniated disc in the neck, cervical lymphadenopathy, osteomyelitis, spinal fracture, or even a stroke. Encephalitis, adverse drug reactions, and tumor growth can also present as cervicalgia symptoms with a physician then applying an alternative diagnosis after examination and tests.

Patients with cervicalgia will usually undergo a thorough examination of the spine, along with a neurological examination of the upper limbs, and the doctor will normally take a neurological history to assess any signs of nerve issues. Lower limbs may also be affected if there is spinal cord compression in the neck and the doctor will take any signs of an abnormal gait, as well as bowel or bladder problems into consideration.

Tender points in the neck muscles, intervertebral joints, and between the shoulders may be observed during a physical examination, and localized nodules or tight musculature may be evident. Signs of heat in the muscles or joints can demonstrate an underlying inflammatory problem, which may be due to an acute injury or a condition such as rheumatoid arthritis. Where excruciating pain is felt upon light pressure being placed on a tender point in the neck or between the shoulders this may lead the physician to suspect fibromyalgia if other symptoms such as fatigue and constant full-body pain exist.

Lhermitte’s sign

The doctor performing a physical examination may check for Lhermitte’s sign which indicates a neurological problem. This is an electric-shock-type sensation that occurs upon flexion of the neck with the sensation radiating down the spine and into the limbs. Upper spinal cord compression and altered motor neuron function in the lower limbs will be checked including any incidence of up-going plantar reflex (Babinski’s sign), or Hoffman’s reflex in the thumb. Changes in sensation of vibration and problems with joint position, coordination, and other reflexes can all offer insight into the cause or pathological development of cervicalgia.

Diagnostic Tests for Cervicalgia

In cases where evidence of neurological deficit is found during initial physical examination the patient will usually be referred for further testing by a neurologist, including an electromyelogram in many cases. Diagnostic imaging tests such as MRI and CT scans, along with X-Rays, and ultrasound, are also used to observe degenerative problems in the cervical spine, the presence of tumors pressing on the spinal cord or causing blood vessel or nerve compression, and numerous other issues not outwardly observable. Such imaging techniques are not always required, especially in cases where a clear cause and effect seems to be evident, such as an awkward sleeping posture, exposure to a prolonged cold draught, or tension and lack of stretching or exercise in the normal daily routine of a person presenting with cervicalgia.

In some cases circulation in the neck may be monitored, particularly where a patient is suffering migraines, visual disturbances, and dizziness alongside the cervicalgia. Malaise, unexplained weight loss, and fever are not symptoms of cervicalgia and should be investigated thoroughly as these are suggestive of infection, an inflammatory disease such as rheumatoid arthritis, or the presence of cancer. Specific ‘red flags’ exist for those presenting with cervicalgia, with patients showing new symptoms before the age of twenty, or after fifty-five, more likely to have a serious underlying problem. Changes in sensation, or weakness developing in more than one dermatome or myotome also increase the likelihood of a serious issue being at work.

Cervicalgia ICD 9 Diagnosis Code

723.1 is a billable ICD-9-CM medical code that can be used to specify a diagnosis on a reimbursement claim.

Cervicalgia treatment may consist of simple rest initially, with the application of heat or ice, as appropriate, and the possible use of a supportive neck device, such as a neck collar for a short period of time. Strengthening and stretching exercises for the neck are also a common treatment for cervicalgia as these may release muscle tension and improve posture so as to prevent future occurrences of neck pain. Patients may be referred to a physical therapist to devise such a regime and they may also be given tips on preventing neck pain, including the establishment of correct posture during their daily routine, the importance of carrying heavy weights safely, and lighter goods in a more evenly distributed fashion (such as in a backpack rather than a shoulder bag).

Massage Therapy for Cervicalgia

Massage and mobilization therapy may be suggested for some patients with cervicalgia where the problem appears to be related to tension or tightness in the muscles of the neck and shoulders. Where pain the neck is an aspect of a larger pain profile then alternative strategies for pain management may be required, such as analgesics, psychosocial therapy such as cognitive behavioural therapy, or even the prescribing of antidepressants, anxiolytics, or antispasmodics.

Cervicalgia with no Pathology

In the majority of cases of cervicalgia with no underlying pathology, the neck pain will likely resolve within three to four weeks. Patients are usually reassured that this is quite a common experience and that cervicalgia rarely indicates a serious problem requiring invasive treatment. Normal activities are to be encouraged, with care taken to avoid the suspected cause of neck pain such as sleeping in a draught or adopting poor posture at work. Specific help with this may be required, such

as engagement in sessions with an Alexander Technique practitioner, or consultation with an ergonomist for the office or work environment. Supportive devices to help with posture may be useful in the short-term but are usually discouraged as they can lead to muscle weakening and invite future problems with hypermobility of the neck. Cervical collars should not usually be work for more than two to four days unless otherwise advised. Neck pain pillows may be helpful in addressing cervicalgia connected to the patient’s sleeping position.

Some patients may be advised against driving in the short-term, particularly where they have limited range of motion. Unsafe driving with restricted neck movement may lead to accidents and whiplash which would further compromise the neck, along with the possibility of more serious consequences for both the driver and other road users. Painkillers such as NSAIDs may be used for cervicalgia treatment but are inadvisable over the longer term. Symptoms of cervicalgia that persist after four weeks require referral to a physiotherapist in many cases, and specific exercises for neck pain, along with manual therapy may be helpful at this stage. Many patients find that acupuncture relieves neck pain and can also aid relaxation to relieve any tension that is contributing to the cervicalgia.

Finding the Right Treatment for Cervicalgia

Referral to a psychologist or therapist may be appropriate if the patient’s neck pain appears to be connected to anxiety, fear, or avoidance beliefs. Where the patient has an unrelated chronic medical condition, it may be that helping to manage this more effectively can lead to the reduction or relief of neck pain. Persistent pain after twelve weeks is deemed chronic and the patient will often be referred to a specific pain clinic to develop coping strategies for their condition. Physiotherapy may be discontinued unless it displays benefits for the patient, and massage and other passive therapies are often to be avoided as they are unlikely to provide much pain relief for the majority of cervicalgia patients at this stage. Low-dose antidepressants may be prescribed as a cervicalgia treatment, and those with chronic pain, especially where it appears to be worsening will likely undergo further assessment to test for mechanical problems such as spinal stenosis which was too subtle to be observed in initial investigations. Back or neck surgery may then become appropriate to relieve a specific obstruction in the spine that is causing cervical nerve or blood vessel compression and cervicalgia.