Cervical Angina: A Literature Review on Its Diagnosis, Mechanism, and Management

[A case of T1 radiculopathy caused by intervertebral disc herniation with cervical angina]

A 65-year-old man presented to the emergency department with the complaints of left anterior chest and back pain, numbness in the left medial arm, and weakness in the left hand grip. Myocardial infarction was suspected, but later ruled out, and the patient was subsequently referred to our department. Among the intrinsic muscles, the left abductor pollicis brevis was the most severely weakened, and there was a sensory disturbance in the left T1 region and left Horner's sign. An MRI T2-weighted image of the cervical spine showed a herniated disc on the left lateral side at the T1/2 level, suggesting compression of the T1 nerve root. Cervical angina is a rare, angina-like anterior chest pain due to cervical spine diseases. It is often reported in patients with C6 and C7 radiculopathy. The most severe weakness in the abductor pollicis brevis muscle in T1 radiculopathy is important to distinguish it from C8 radiculopathy.

Diagnosis and Management of Thoracolumbar Spinal Disorders Presenting as Cardiac, Gastrointestinal, and Other False Pain Syndromes

SUMMARY OF BACKGROUND DATA

Although pseudoangina is most commonly caused by cervical disc herniation, several cases have been described where thoracic herniation produced symptoms of pseudoangina. If thoracic herniation can produce angina-like pain, then it is important to consider whether pathology of the thoracolumbar spine, in general, can trigger false pain syndromes distinct from pseudoangina.

OBJECTIVE

We seek to provide the most comprehensive study regarding the diagnosis and treatment of spinal conditions causing false pain syndromes.

STUDY DESIGN

Systematic review of the current literature using PRISMA 2020 recommendations.

METHODS

We queried the literature and systematically selected relevant studies according to PRISMA guidelines.

RESULTS

Across 22 selected studies, the sample size was 30 patients, and a total of 26 met the criteria for statistical analysis. Seven (26.9%) of these patients presented with a chief complaint of pseudoangina resulting from thoracic disc herniation. 73.1% (19/26) of patients exhibited pain mimicking visceral origin. Overall, 13/19 (68.4%) patients exhibited thoracic spine disease only and 4/19 (21.1%) patients were affected at lumbar levels only, while 2 (10.5%) patients exhibited thoracolumbar herniation. Presentations included abdominal pain (11/19) mimicking appendicitis or pancreatitis, flank pain mimicking renal colic (8/19), and 2 cases of scrotal pain/orchalgia. Symptom durations ranged from acute (<24 h) to 7 years. Treatments were reported for 18/19 patients and all treated patients reported alleviated pain. Seven out of 18 patients were managed conservatively while 11/18 were treated surgically. Misdiagnosis resulted in unnecessary surgery (pancreaticojejunostomy) or other invasive procedures.

CONCLUSIONS

In spinal disorders manifesting with atypical pain syndromes, delay in proper diagnosis and unnecessary treatments can, unfortunately, cause prolonged patient suffering and increased cost of health care. As a result, some have proposed that spinal screening should be incorporated into clinical examinations involving false pain syndromes.

Coexisting Lower Back Pain in Patients With Cervical Myelopathy

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

The aim of the present study is to investigate the coexisting lower back pain (LBP) in patients with cervical myelopathy and to evaluate changes in LBP after cervical spine surgery.

SUMMARY OF BACKGROUND DATA

Only a few studies with a small number of participants have evaluated the association between cervical myelopathy surgery and postoperative improvement in LBP.

METHODS

Patients who underwent primary cervical decompression surgery with or without fusion for myelopathy and completed preoperative and 1-year postoperative questionnaires were reviewed using a prospectively collected database involving 9 tertiary referral hospitals. The questionnaires included the patient-reported Japanese Orthopaedic Association (PRO-JOA) score and Numerical Rating Scales (NRS). The minimum clinically important difference (MCID) for NRS-LBP was defined as >30% improvement from baseline. Patient demographics, characteristics, and PRO-JOA score were compared between patients with and without concurrent LBP, and the contributor to achieving the MCID for LBP was analyzed using logistic regression analysis.

RESULTS

A total of 786 consecutive patients with cervical myelopathy were included, of which 525 (67%) presented with concurrent LBP. LBP was associated with a higher body mass index ( P <0.001) and worse preoperative PRO-JOA score ( P <0.001). Among the 525 patients with concurrent LBP, the mean postoperative NRS-LBP significantly improved from 4.5±2.4 to 3.4±2.7 ( P <0.01) postoperatively, with 248 (47%) patients reaching the MCID cutoff. Patients with a PRO-JOA recovery rate >50% were more likely to achieve MCID compared with those with a recovery rate <0% (adjusted odd ratio 4.02, P <0.001).

CONCLUSIONS

More than 50% of patients with myelopathy reported improvement in LBP after cervical spine surgery, and 47% achieved the MCID for LBP, which was positively correlated with a better PRO-JOA recovery rate. Treating cervical myelopathy in patients with concomitant LBP may be sufficient to mitigate concomitant LBP.

LEVEL OF EVIDENCE

Level III.

The Positive Side Effect of Anterior Cervical Decompression and Fusion on Axial Neck Pain

STUDY DESIGN

Observational Cohort Study.

OBJECTIVES

This study aims to comprehensively assess the outcomes of anterior cervical spine surgery in patients who have undergone surgical intervention for radiculopathy or myelopathy, with a specific focus on the surgery's impact on axial neck pain.

METHODS

Data from an institutional spine surgery registry were analyzed for patients who underwent anterior cervical spine surgery between January 2016 and March 2022. Patient demographics, clinical variables, and outcome measures, including the Neck Disability Index (NDI), numeric rating scales for neck and arm pain (NRS-Neck and NRS-Arm), and 36-Item Short Form Health Survey (SF-36) scores, were collected. Statistical analysis included paired t-tests, chi-squared tests, and multivariate linear regression.

RESULTS

Of 257 patients, 156 met the inclusion criteria. Patients showed significant improvement in NDI, NRS-Neck, NRS-Arm, SF-36 (Physical and Mental components), and all changes exceeded the minimum clinically important difference. Multivariate regression revealed that lower preoperative physical and mental component scores and higher preoperative NRS-Neck predicted worse NDI scores at follow-up.

CONCLUSIONS

This study underscores that anterior cervical fusion not only effectively alleviates arm pain and disability but also has a positive impact on axial neck pain, which may not be the primary target of surgery. Our findings emphasize the potential benefits of surgical intervention when neck pain coexists with neurologic compression. This contribution adds to the growing body of evidence emphasizing the importance of precise diagnosis and patient selection. Future research, ideally focusing on patients with isolated neck pain, should further explore alternative surgical approaches to enhance treatment options.

Is neck pain treatable with surgery?

INTRODUCTION

Neck pain is one of the most common complaints in clinical practice and can be caused by a wide variety of conditions. While cervical spine surgery is a well-accepted option for radicular pain and myelopathy, surgery for isolated neck pain is controversial. The identification of the source of pain is challenging and subtle, and misdiagnosis can lead to inappropriate treatment. MATERIALS AND METHODS AND RESULTS: We conducted a thorough literature review to discuss and compare different causes of neck pain. We then supplemented the literature with our senior author's expert analysis of treating cervical spine pathology.

CONCLUSIONS

This study provides an in-depth discussion of neck pain and its various presentations, as well as providing insight into treatment strategies and diagnostic pearls that may prevent mistreatment of cervical spine pathology.

Cervicogenic Angina and Dyspnea Secondary to Cervical Radiculopathy

Cervicogenic angina and dyspnea are conditions characterized by chest discomfort and breathing difficulties that resemble angina pectoris and dyspnea of cardiac origin. However, this condition is caused by cervical spine pathology, cervical spondylosis, and radiculopathy. This case study reports a 66-year-old man who presented with cervicogenic angina and dyspnea due to cervical radiculopathy to a chiropractic clinic. The patient underwent a comprehensive diagnostic evaluation, including taking the patient's history, a physical examination, and radiological investigations, which demonstrated cervical spine involvement consistent with a cervicogenic origin of the pain. The patient's angina-like symptoms and dyspnea improved significantly after chiropractic manipulation of the spine, soft tissue mobilization, and other manual therapies. Accurate diagnosis is essential to minimize unnecessary cardiac interventions and ensure proper therapy for underlying cervical spine problems. This case demonstrates the necessity of conservative management, such as chiropractic care, for patients presenting with cervicogenic angina and dyspnea, particularly when a diagnostic assessment reveals cervical spinal involvement.

Cervical Angina as a Cause of Non-Cardiac Chest Pain: A Case Report

Cervical angina is a form of non-cardiac chest pain that originates in the cervical spine or cervical cord; it is an under-recognized and easily underdiagnosed condition. Patients with cervical angina often report delayed diagnosis. Here, we report the case of a 62-year-old woman with a history of cervical spondylosis and undiagnosed recurrent chest pain who presented with numbness in the left upper arm and was diagnosed with cervical angina. Although most cases of cervical angina involve uncommon self-limited diseases that improve with conservative treatment, timely diagnosis can reduce patient anxiety and unnecessary office visits and tests. The critical aspect of chest pain evaluation is to rule out fatal disease. Once fatal disease is ruled out, cervical angina should be considered in differential diagnosis if there is a history of cervical spine disease, if the pain radiates to the arm, if it is elicited by cervical spine range of motion or upper extremity movement, or if the chest pain lasts less than a few seconds.

Cervical Radiculopathy as a Hidden Cause of Angina: Cervicogenic Angina

Patients presenting with chest pain to the emergency department constitute a diagnostic challenge as 77% of the patients' symptoms are not cardiac. Diagnostic uncertainty is a pervasive issue in primary care. A 56-year-old man presented with non-traumatic chest pain and chronic neck pain for 2 years, as well as numbness in his right third and fourth fingers for 6 months. It was not associated with palpitation, orthopnea or pedal edema. Except for hyperglycemia, no abnormal findings were found in diagnostic tests. At that time, he was being treated for type 2 diabetes using glucose-lowering drugs in order to lower his blood glucose and lessen his risk of heart disease. The cause of his chest pain remained unknown. Following a second opinion from an orthopedist, the patient was diagnosed with cervical radiculopathy and was treated with analgesics and physical therapy. Because the treatments had only provided temporary pain relief for the previous 6 months, he sought chiropractic care for pain relief. The patient's vital signs were stable and within normal limits during the assessment. A restricted neck movement, a positive Spurling test, and hypoesthesia in the right C7 dermatome were seen. Cervical radiographs revealed degenerative spondylosis with right C5/C6 neuroforaminal stenoses and bilateral C6/C7 neuroforaminal stenoses. A provisional diagnosis of cervical spondylotic radiculopathy associated with cervicogenic angina (CA) was made. Chiropractic procedures, including cervical manipulation, instrumented soft tissue mobilization, and motorized intermittent neck traction, were performed two to three times per week. After 3 months, the patient reported that the chest pain, neck pain, and radicular symptoms had completely resolved. Repeated radiographs taken during the 11th month follow-up revealed a comparable improvement in the increased spacing of the restricted neuroforamina, which could signify a beneficial alteration related to cervical function retrieval. CA is an angina-like chest pain caused by cervical spine disorders. This study adds to our understanding of the biomechanical impact of cervical radiculopathy on chest pain, which has largely been overlooked during diagnostic workups. Once cervical radiculopathy has been identified, CA symptoms can be eased by alleviating the noxious input stemming from the pinched nerve roots.