Cervical Angina

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Jacobs B. Cervical Angina. NY State J Med 1990;90:8-11.

A.A. Cervical angina, resembling true angina pectoris, but resulting from cervical spondylosis and nerve root compression, is also known as pseudoangina. This report describes 164 patients treated over a 22-year period. Patients included 103 men and 61 women, with ages ranging from 45-68 years and averaging 54 years of age. The duration of symptoms prior to definitive diagnosis averaged 10 months and ranged from 10-18 months. Most patients had consulted at least two cardiologists prior to diagnosis. The results of stress testing were abnormal in 10 patients, but none underwent angiography. Symptoms common to all patients, in varying severity, included neck pain and stiffness, occipital headache, arm pain with sensory symptoms. Neurologic deficit was found in only three instances. The majority of patients responded satisfactorily to a standard nonsurgical regimen, employed for at least 3 months, involving the use of a hard collar, intermittent traction, isometric exercise, and a combination of anti-inflammatory and muscle relaxant medications. In cases where disability persisted, myelography was usually employed and when confirming nerve root compression, anterior disc excision and spine fusion were performed. Such treatment was required in only 38 cases and resulted in complete relief of complaints in all but five instances in which fusion failure required reoperation with ultimate success. Fusion usually was completed in three months, during which time the patient was required to wear a hard collar.

E.S. Cervical angina is a well-documented clinical entity. Symptoms frequently include pain in the neck, arm, head and parasternal region; however, crushing chest pain, diaphoresis, nausea and other evidence of autonomic dysfunction have been reported. Pain responsive to nitroglycerin also has been documented. Several factors contribute to the confusing presentation of cervical angina: a) degenerative changes causing root compression in which C4-C8 nerve roots contribute to the sensory and motor innervation of the anterior chest wall; b) referred pain arising from facet joints, ligaments and degenerated discs (without herniation); and c) sympathetic nervous system irritation mediating autonomic symptoms. This broad spectrum of signs and symptoms underscores the requirement for a thorough cardiac evaluation before entertaining a diagnosis of cervical angina. The patients in this study had undergone EKG evaluation; however, the results were not noted. Thirty-six underwent stress testing with 10 abnormal responses. Coronary angiography studies were not performed.

The author concluded that the presence of parasternal tenderness, neck and arm pain provoked by movement and relieved by traction and abnormal radiographs provide enough information to formulate a diagnosis of cervical angina. He does not address the significance of positive stress testing in 10 subjects, and further states that angiography is optional when considering this diagnosis.

This contradicts a 1985 study by Brodsky, who argued that only coronary angiography studies are reliable in differentiating cervical angina from true angina. Conventional criteria such as response to nitrites, resting and stress EKGs, or the character of pain cannot be used to exclude true angina. His study also raised the possibility that organic coronary artery disease may coexist with cervical angina, an issue this author did not address. Both studies demonstrated that conservative care is an effective means of managing cervical angina. Although not addressed in these studies, spinal manipulation may alleviate pain in spondylotic patients with cervical angina.

Additional References

1. Brodsky AE. Cervical angina: a correlative study with emphasis on the use of coronary arteriography. Spine 1985;10:700-709

The National College of Chiropractic.

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