Eisenhower Army Medical Center
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NEUROSURGERY SPECIALTY CLINIC REFERRAL GUIDELINE Cervical Spine Disease

Acute symptoms are usually associated with a herniated disc. This typically leads to neck pain associated with upper extremity radicular pain, which may include sensory or motor deficit.

Chronic symptoms are usually from degenerative changes of the cervical spine eventually leading to spinal cord and/or root compression (cervical spondylosis/stenosis). This is frequently associated with arm pain and can be associated with neurological deficits such as radiculopathy or myelopathy. It is usually chronic and progressive.

Initial Diagnosis

With a herniated disc, there is usually an acute or subacute development of neck pain with arm radicular pain. The patient frequently links this with an episode of minor trauma. Usually, no imaging studies are necessary unless the above is associated with a neurological deficit or fails to respond to conservative management (see below).

With cervical spondylosis, the symptoms are mild early in the disease course, and consist mainly of recurring neck pain with restriction of neck motion. Cervical spine x-rays are indicated to exclude problems such as instability or pathological fractures. In more advanced cases when symptoms can include motor deficit, bladder dysfunction, or spasticity and weakness of the legs, an imaging study such as a cervical MRI is indicated.

Initial Management

Initial therapy consists of aggressive use of NSAIDs. Symptoms will improve markedly in 1-2 weeks for the majority of patients. Physical therapy is frequently helpful. However, patients with neurological deficits and cervical spondylosis will not improve with conservative management, and therefore, early specialty referral is indicated.

Ongoing Management

When symptoms are mild, the major consideration is that the pain is decreasing, and the neck mobility is improving. After the acute period, physical therapy may prove helpful, and may be required for several months. At this point, most of these patients will become symptom-free within several months. As stated above, patients with neurological deficits should undergo a cervical MRI and specialty evaluation obtained.

Indications for Neurosurgery Referral

Intractable neck and pain (i.e., failure to respond or worsening during conservative therapy).

Presence of neurological deficit: motor deficit, bladder dysfunction, and evidence of myelopathy (e.g. spasticity).

Diagnostic studies should be obtained for any patients meeting the above criteria and prior to being evaluated in Neurosurgery Clinic. Diagnostic studies should include plain cervical spine x-rays and a cervical MRI. In addition, EMGs of the affected arm are helpful to differentiate between an entrapment peripheral neuropathy and a cervical radiculopathy.