Management

Immobilization. The purpose of neck immobilization is to reduce intervertebral motion which may cause compression, mechanical irritation, or stretching of the cervical nerve roots.76 The soft cervical collar or the more rigid Philadelphia collar both hold the neck in slight flexion. The collar is useful in the acute setting, but prolonged use leads to deconditioning of the paracervical musculature. Therefore, the collar should be prescribed in a time-limited manner, and patients should be instructed to begin isometric neck exercises early in the course of therapy.

Bed Rest. Bed rest is another form of immobilization that modifies the patient's activities and eliminates the axial compression forces of gravity.76 Holding the neck in slight flexion is accomplished by arranging two standard pillows in a V shape with the apex pointed cra-nially, then placing a third pillow across the apex. This arrangement provides mild cervical flexion, and internally rotates the shoulder girdle, thereby relieving traction on the cervical nerve roots.

Medications. Nonsteroidal anti-inflammatory drugs (NSAIDs) are particularly beneficial in relieving acute neck pain. However, side effects are common, and usually two or three medications must be tried before a beneficial result without unacceptable side effects is achieved. Muscle relaxants help relieve muscle spasm in some patients; alternatives include carisoprodol (Soma), methocarbamol (Robaxin), and diazepam (Valium). Narcotics may be useful in the acute setting, but should be prescribed in a strictly time-limited man-ner.76 The physician should be alert to the possibility of addiction or abuse.

Physical Therapy. Moist heat (20 minutes, three times daily), ice packs (15 minutes, four times daily or even hourly), ultrasound therapy, and other modalities also help relieve the symptoms of cervical radiculopathy.76

Surgery. Surgical intervention is reserved for patients with cervical disc herniation confirmed by neuroradiologic imaging and radicular signs and symptoms that persist despite four to six weeks of conservative therapy.71

Cervical Myelopathy

The cause of pain in cervical myelopathy is not clearly understood but is presumed to be multifactorial, including vascular changes, cord hypoxia, changes in spinal canal diameter, and hypertrophic facets. Therefore, patients with cervical myelopathy present with a variable clinical picture. The usual course is one of increasing disability over several months, usually beginning with dysesthesias in the hands, followed by weakness or clumsiness in the hands, and eventually progressing to weakness in the lower extremities.72

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