What is the appropriate management and treatment for a patient with cervical angina, considering potential underlying cardiac disease?

Cervical Angina: Diagnosis and Management

Cervical angina is chest pain originating from cervical spine pathology—most commonly C7 nerve root compression from disc herniation—that mimics cardiac angina but requires fundamentally different management focused on spinal decompression rather than cardiac intervention. 1, 2

Critical First Step: Rule Out Cardiac Disease

Before diagnosing cervical angina, you must definitively exclude true coronary artery disease through appropriate cardiac workup, as the two conditions can coexist and misdiagnosis can be fatal. 1, 2, 3

• Obtain 12-lead ECG, cardiac biomarkers (troponin), and consider stress testing or coronary angiography based on cardiovascular risk factors 4
• A 77-year-old woman with presumed cervical angina developed 99% right coronary artery stenosis requiring emergency stenting immediately after cervical spine surgery, illustrating the danger of missed cardiac disease 3
• Coexisting coronary artery disease must always be ruled out before attributing chest pain solely to cervical pathology 1

Diagnostic Features of Cervical Angina

Once cardiac causes are excluded, cervical angina should be suspected when chest pain has these specific characteristics:

Pain characteristics that distinguish cervical from cardiac angina:

• Pain radiates to the arm (particularly left upper extremity) with associated numbness or motor weakness 1, 2, 5
• Pain is elicited or worsened by cervical spine range of motion or upper extremity movement 5
• Pain episodes last only seconds to minutes (typically briefer than cardiac angina) 5
• Pain is accompanied by neurologic signs (numbness, weakness, paresthesias in dermatomal distribution) 2, 5

Physical examination findings:

• Positive Spurling's test (cervical compression with rotation reproduces radicular symptoms) 1
• Dermatomal sensory deficits, particularly C7 distribution 1
• Motor weakness in affected nerve root distribution 2, 3
• Reduced or absent deep tendon reflexes 1

Confirmatory imaging:

• MRI of cervical spine showing herniated disc, spinal cord compression, or foraminal encroachment at the symptomatic level 1, 2
• Cervical disc herniation accounts for 72.6% of cervical angina cases 6
• Discography can confirm the pain-generating disc level if MRI findings are equivocal 1

Conservative Management (First-Line Treatment)

Conservative treatment successfully resolves symptoms in most patients with cervical angina and should be attempted for 6-12 weeks before considering surgery. 1, 2, 6

Specific conservative interventions:

• Intermittent cervical traction (reduces foraminal compression and nerve root irritation) 1
• Rigid or soft cervical collar for immobilization during acute exacerbations 2
• Physical therapy focusing on cervical spine stabilization and posture correction 1, 2
• NSAIDs for anti-inflammatory effect and pain control 1, 2
• Muscle relaxants for associated cervical muscle spasm 1

Important caveat: NSAIDs carry cardiovascular risks including increased risk of myocardial infarction and stroke, particularly in patients with known cardiovascular disease or risk factors—use the lowest effective dose for the shortest duration 7

Surgical Management (When Conservative Treatment Fails)

Anterior cervical discectomy and fusion with complete decompression of the spinal cord and/or nerve root effectively relieves cervical angina symptoms in patients who fail conservative management. 2, 6

Surgical indications:

• Persistent disabling symptoms after 6-12 weeks of adequate conservative therapy 1, 6
• Progressive neurologic deficits (motor weakness, myelopathy) 2
• Severe spinal cord compression on imaging 2, 3

Surgical outcomes:

• Every patient assessed at follow-up in a systematic review reported complete relief from cervical angina symptoms after surgical intervention 6
• Surgical interventions (84.4%) predominated over conservative management (13.0%) in published case series, though this likely reflects publication bias toward surgical cases 6

Clinical Pitfalls to Avoid

The most dangerous error is attributing cardiac chest pain to cervical pathology without adequate cardiac workup. 1, 3

• Patients with cervical spine disease can simultaneously develop acute coronary syndrome 3
• The presence of neurologic symptoms does not exclude cardiac disease 3
• Elderly patients with cardiovascular risk factors require particularly thorough cardiac evaluation before diagnosing cervical angina 3

Delayed diagnosis is common because cervical angina is under-recognized:

• Patients often undergo extensive cardiac workups and multiple cardiology visits before cervical spine is considered 5
• Consider cervical angina early in the differential diagnosis of non-cardiac chest pain when any cervical spine symptoms or history of cervical spondylosis exists 5

Follow-Up and Monitoring

After initiating conservative treatment, reassess at 2-4 weeks to evaluate symptom response and neurologic status. 1

• Document changes in pain intensity, radiation pattern, and neurologic examination 1
• If symptoms worsen or new neurologic deficits develop, expedite MRI and surgical consultation 2
• If symptoms completely resolve with conservative treatment, continue therapy for 6-12 weeks total, then gradually wean cervical collar and traction 1