non-traumatic upper neck pain

Introduction

upper cervical pain is a relatively common condition in adults and is a common cause of cervicogenic headaches
there is usually focal tenderness and possibly trigger points and there may be worsening of the pain on ROM testing of the cervical spine
they may cause referred pain through involvement of:
- greater occipital nerve
- lesser occipital nerve
- and rarely, via the trigeminal nerve
  - C1-3 rorsal rami converge with trigeminal afferents via trigemino-cervical nucleus and may cause referred pain to maxillary V2 pre-auricular region
the cervicogenic headaches may be associated with blurred vision, nausea, tinnitus
atlanto-occipital and atlanto-axial arthropathies are generally clinical diagnoses as radiologic investigations including MRI are usually non-diagnostic but may be indicated to exclude other pathologies
- management of these is generally conservative with:
  - non-steroidal anti-inflammatory drugs (NSAIDs), physical therapies such as hot packs, ROM exercises, etc
  - some may benefit from short courses of corticosteroids
  - those with severe chronic unreponsive pain may benefit from intracaspular radiologic guided injections of steroid

atlanto-occipital facet joint arthropathy
- this joint normally has a ROM of 25 degrees of extension and 10 degrees of flexion
- osteoarthritis
- rheumatoid arthritis
- ankylosing spondylitis (AS)
atlanto-axial joint arthropathy
- this joint normally allows 70deg of lateral rotation on each side as well as 5 degrees of flexion and 10 degrees of extension
- osteoarthritis - (lateral AAOA - see below)
- rheumatoid arthritis
- ankylosing spondylitis (AS)
C2-3 facet joint arthropathy
C2-3 disc degeneration and herniation
muscular or ligamentous injury or myofascial cervical pain
C1-3 nerve root irritation / true occipital neuralgia
- nerve entrapment by a hypertrophic atlanto-epistrophic ligament
- neoplasm
- mechanical compression from a severely congested C2 venous plexus or ectatic vertebral artery
- atlanto-axial instability due to rheumatoid arthritis or following trauma
- osteophytes due to lateral AAOA (see below)
vertebral artery dissection may present with tinnitus, bruit, TIA, stroke or as subarachnoid haemorrhage (SAH)
vertebral artery aneurysm
basilar artery spasm / migraine
rarely, tumour, AV malformation, Arnold-Chiari malformation

affects 5% of 50-60 yr olds and 18% of 80-90 yr olds ¹⁾ but only a minority develop severe ongoing pain
~75% are female and it is usually unilateral
aetiology
- instability of the AA joint following trauma or surgery
- instability of the AA joint due to rheumatoid arthritis
characterised by:
- occipital pain
- occipital trigger points
- crepitus in the occipital region
- unilateral neck pain occurring with the slightest head rotation which may be markedly reduced
- a rotational head tilt deformity may be present and is usually associated with either or both:
  - collapse of the C1 lateral mass
  - subluxation of C1-2 facet joint (lateral shift of C1 lateral mass)
diagnosis can be made on a standard transoral atlas view or CT scan, showing the narrowing of the C1–C2 joint space
origin of pain was confirmed by diagnostic C1–C2 facet blocks
those with unresponsive severe pain may have excellent short and long term pain relief from C1–C2 transarticular screw fixation and Gallie type fusion ²⁾

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