Can cervical spine disease cause tremor?

Can Cervical Spine Disease Cause Tremor?

Yes, cervical spine disease can cause tremor, though this is an uncommon presentation that typically occurs through specific mechanisms: action-induced clonus mimicking tremor in cervical myelopathy, or dystonic tremor secondary to painful radiculopathy.

Mechanisms of Cervical Spine-Related Tremor

Action-Induced Clonus Mimicking Tremor

• Cervical spondylotic myelopathy can produce kinetic or isometric action tremor through hyperexcitability of the stretch-reflex arc due to loss of descending motor control from spinal cord compression 1
• This presents as unilateral upper extremity tremor during voluntary movement, accompanied by motor weakness, spasticity, and exaggerated tendon reflexes on the same limb 1
• The tremor frequency matches the passive clonus frequency, distinguishing it from other tremor types 1
• Cervical myelopathy is the most common cause of spinal cord dysfunction in older persons, resulting from degenerative changes causing cord compression 2

Dystonic Tremor from Radiculopathy

• Cervical disc prolapse with foraminal stenosis can present with dystonic tremor in addition to radicular pain 3
• The mechanism appears to be secondary to painful radiculopathy rather than direct neurological compression 3
• One documented case showed complete resolution of dystonic tremor following anterior cervical discectomy and fusion at C5/6 and C6/7 levels 3
• Diagnostic nerve root blocks (C6 and C7) can provide temporary complete resolution of both brachialgia and tremor, confirming cervical origin 3

Position-Dependent Tremor

• Hirayama disease (juvenile muscular atrophy of distal upper extremity) can cause hand tremor specifically triggered by neck flexion 4
• This occurs due to anterior shift and flattening of the cervical cord with neck flexion, with prominent posterior epidural venous engorgement 4
• MRI in neutral position may be normal; dynamic MRI with neck flexion is required for diagnosis 4

Diagnostic Approach

Clinical Presentation to Recognize

• Look for tremor associated with neck stiffness, arm pain, hand numbness, and progressive weakness 2
• Examine for accompanying signs of myelopathy: motor weakness, spasticity, hyperreflexia, sensory changes, and cerebellar dysfunction 5
• Assess whether tremor is action-induced, position-dependent (neck flexion), or associated with dystonic posturing 4, 3, 1
• Distinguish from essential tremor, cerebellar tremor, or Parkinsonian tremor by presence of radicular or myelopathic signs 1

Imaging Strategy

• MRI is the most sensitive modality for detecting soft tissue abnormalities and spinal cord compression with 90.6% sensitivity and 95.4% specificity 6
• Standard MRI in neutral position may miss dynamic pathology; obtain flexion views if Hirayama disease is suspected 4
• CT scanning is less sensitive for early marrow changes and soft tissue abnormalities but useful for detecting calcification and ossification 5
• Radiographs are inadequate as they require 50-70% bone destruction before detecting pathological changes 6

Diagnostic Confirmation

• Percutaneous nerve blocks serve both diagnostic and therapeutic purposes in confirming cervical origin of tremor 6, 3
• Electromyography can demonstrate neurogenic changes consistent with radiculopathy 3
• Correlation between clinical symptoms, neurological signs, and imaging findings is essential 5

Critical Pitfalls to Avoid

Misdiagnosis Risks

• Cervical vertigo from degenerative spine disease can be mistaken for other vestibular disorders, as proprioceptive abnormalities from cervical dysfunction produce similar symptoms 7
• Symptoms are triggered by head rotation relative to the body (not relative to gravity), distinguishing it from benign paroxysmal positional vertigo 7
• Abnormal imaging findings are common in asymptomatic patients, so correlation with clinical presentation is mandatory 6

Consequences of Delayed Diagnosis

• Missed or delayed diagnosis leads to permanent neurological deficits in up to 29.4% of cases 6
• Lifetime care costs for patients developing tetraplegia from untreated cervical myelopathy reach US$1 million per patient 6
• Progressive myelopathy is characterized by insidious symptom development that may be overlooked initially 2

Management Implications

When Surgery Is Warranted

• Significantly extruded or sequestrated discs causing moderate to marked spinal cord or nerve root compression warrant surgical intervention 5
• Anterior cervical discectomy and fusion can provide immediate and complete resolution of tremor when secondary to radiculopathy 3
• Conservative management with neck collar and physiotherapy may stabilize Hirayama disease 4
• Bulging or protruding discs without significant compression can typically be managed nonsurgically 5

Differential Diagnosis Considerations

• Rule out multiple sclerosis, amyotrophic lateral sclerosis, and spinal cord masses before attributing tremor to cervical spondylosis 2
• Consider vertebrobasilar insufficiency, which produces vertigo lasting less than 30 minutes with gaze-evoked nystagmus that does not fatigue 7
• Medication side effects (carbamazepine, phenytoin, antihypertensives) can produce tremor and dizziness mimicking cervical pathology 7