Can Cervical Radiculopathy Present as Chest Pain?
Yes, cervical radiculopathy can present as chest pain through a phenomenon known as "cervical angina," though this is an atypical presentation that requires careful diagnostic evaluation to exclude cardiac causes first. 1
Understanding Cervical Angina
Cervical angina is chest pain that mimics cardiac angina but originates from cervical spine disorders rather than cardiac pathology. 1 The mechanisms underlying this pain production remain incompletely understood but are attributed to:
- Cervical nerve root compression 1
- Involvement of cervical sympathetic afferent fibers 1
- Referred pain patterns from cervical structures 1
- Lesions affecting the posterior horn of the spinal cord 1
Typical vs. Atypical Presentations
Classic Cervical Radiculopathy Presentation
The standard presentation of cervical radiculopathy includes:
- Neck pain radiating into the arm in a dermatomal distribution 2, 3
- Upper extremity sensory deficits or motor dysfunction 2, 4
- Reflex changes corresponding to the affected nerve root 3, 4
- Pain with an "electric" neuropathic quality 5
Atypical Presentation with Chest Pain
When cervical radiculopathy presents as chest pain, this represents an unusual manifestation that deviates from the typical upper extremity dermatomal pattern. 1 This presentation is particularly important to recognize because it can be mistaken for cardiac disease.
Diagnostic Algorithm
Step 1: Exclude Cardiac Pathology First
Before attributing chest pain to cervical spine pathology, cardiac workup must be negative. 1 This is a critical safety step given the life-threatening nature of true cardiac angina.
Step 2: Look for Neurologic Signs
When neurologic signs and symptoms are present alongside chest pain, maintain strong suspicion for cervical angina. 1 Key examination findings include:
- Painful neck movements and muscle spasm 4
- Diminished deep tendon reflexes, particularly triceps 4
- Positive provocative tests: Spurling test, shoulder abduction test, or upper limb tension test 4
Step 3: Obtain Cervical Imaging
Cervical angina can be diagnosed based on:
- Negative cardiac workups 1
- Positive neurologic examination findings 1
- Cervical radiographic findings showing herniated disk, spinal cord compression, or foraminal encroachment 1
MRI of the cervical spine without contrast is the appropriate imaging modality for evaluating suspected cervical radiculopathy with atypical presentations. 2, 6 MRI provides superior soft tissue visualization for detecting disc herniations and nerve root compression compared to other modalities. 2, 6
Management Approach
Initial Conservative Treatment
Most cases of cervical radiculopathy, even with atypical presentations, respond to conservative management (75-90% success rate). 2, 6
Conservative treatments for cervical angina include:
- Cervical collar immobilization 1
- Head traction 1
- Nonsteroidal anti-inflammatory drugs 1
- Physical therapy with strengthening and stretching 4
When to Consider Surgery
Surgical intervention becomes appropriate when:
- Conservative treatment fails after 4-6 weeks 4
- Intractable or persistent pain despite adequate conservative management 3
- Severe or progressive neurological deficits develop 3
Anterior cervical surgery with complete decompression of the spinal cord and/or nerve root effectively relieves cervical angina symptoms when conservative treatment fails. 1 Surgical outcomes for arm pain relief range from 80-90% with either anterior or posterior approaches. 7
Critical Red Flags Requiring Urgent Evaluation
Watch for development of:
- Progressive motor weakness or neurological deficits 6
- Bilateral symptoms suggesting myelopathy 6
- New bladder or bowel dysfunction 6
- Loss of perineal sensation 6
- Symptoms affecting both upper and lower extremities 6
Common Pitfalls to Avoid
Do not attribute chest pain to cervical spine pathology without first completing a thorough cardiac evaluation. 1 The consequences of missing true cardiac angina are potentially fatal.
Do not order MRI in the acute phase (<6 weeks) without red flags or after adequate cardiac workup. 8 This leads to identification of incidental degenerative findings that are common in asymptomatic individuals over age 30 and may drive unnecessary interventions. 2, 8
Do not assume all chest pain with cervical spine findings is cervical angina. The diagnosis requires the triad of negative cardiac workup, positive neurologic examination, and confirmatory cervical imaging findings. 1