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a. Ligamentous injury to the neck results in pain and cervical instability.

b. Acute muscular spasm can produce acute pain and torticollis ("wry neck"). Wry neck may arise after trauma (e.g., whiplash), prolonged exposure to cold, prolonged period in an awkward position, or other activities that strain and require considerable neck rotation or positioning.

c. Polymyalgia rheumatica may lead to neck and shoulder pain in an elderly patient with systemic complaints or headache.

d. Tension and anxiety can produce severe paracervical muscle spasm.

5. Surrounding structures. Neck pain may be referred from the shoulder or periscapular structures. Cervical lymphadenopathy, if painful, can produce severe restriction in neck motion. Occipital headaches may produce secondary neck pain and muscle spasm. In addition, trigeminal and glossopharyngeal neuralgias have been described to cause neck pain.

B. Neck pain with radiculopathy. Objective neurologic deficit may or may not be present.

1. Vertebrae. Tumors or infections may produce radicular signs and symptoms.

2. Intervertebral disk. Herniation or degeneration of an intervertebral disk may produce specific radicular patterns, depending on the level of involvement. Considerable overlap exists among the patterns outlined below. C5-6 and C6-7 are far more commonly involved than C7-T1 or C4-5.

a. C5-6 (C-6 nerve root). Pain will radiate to the shoulder or lateral arm and dorsal forearm. Anesthesia and paresthesias may be present in the thumb and index finger. Weakness, if present, will involve the biceps and wrist extensors. The biceps reflex is often decreased or absent.

b. C6-7 (C-7 nerve root). The pain distribution is similar to that of a C-6 radiculopathy. Anesthesia and paresthesias, when present, involve the index and long fingers. Weakness, if present, is noted in the triceps, wrist flexors, and finger extensors. The triceps reflex is often decreased or absent.

c. C7-T1 (C-8 nerve root). Pain may occur along the medial aspect of the upper arm and forearm. Anesthesia and paresthesias involve the ring and small fingers. Weakness, if present, is noted in the finger flexors and intrinsic musculature of the hand. The triceps reflex may be reduced.

3. Apophyseal and uncovertebral joints. Degenerative arthritis affecting these joints in the cervical area can lead to secondary encroachment of the cervical intervertebral foramina with nerve root irritation.

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