Cervical Angina: A Literature Review on Its Diagnosis, Mechanism, and Management
Asian Spine Journal
August 2021; Vol. 15; No. 4; pp. 550-556
Fan Feng, Xiuyuan Chen, Hongxing Shen; from the Department of Spine Surgery, Renji Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China.
KEY POINTS FROM THIS ARTICLE:
1) “Chest pain is a common and highly challenging clinical problem in emergency departments. However, only 15%–25% of patients with acute chest pain actually have acute coronary syndrome.”
2) “Cervical angina has been defined as chest pain that resembles true cardiac angina but originates from the disorders of the cervical spine.”
3) “Cervical angina appears to be a relatively unknown clinical syndrome compared with other angina symptoms.”
4) “When neurologic signs and symptoms are present, there should be a strong suspicion for cervical angina in any patient with inadequately explained noncardiac chest pain.”
5) “Cervical angina can be diagnosed according to negative cardiac workups, positive neurologic examination, and cervical radiographic findings (herniated disk, spinal cord compression, or foraminal encroachment).”
6) The first description of cervical angina without any cardiac function abnormalities appeared in 1927.
7) Presentation
- “Patients with cervical angina often present with anterior chest pain that has been described as sharp, achy, or crushing in quality.”
- “The pain may be present at rest or exacerbated by cervical range of motion or movement of the upper extremity.”
- Other symptoms may include neck pain, upper arm radicular symptoms (weakness or sensory changes), and occipital headaches.
- “More than half of patients have been identified to experience autonomic symptoms such as dyspnea, nausea, vertigo, diplopia, and other sympathetic nervous signs.”
- “The patients usually have restricted cervical motion, paraspinal tenderness, and/or positive Spurling maneuver.”
- “Common manifestations associated with cervical angina include neck and arm pain, upper arm radicular symptoms and fatigue, parasternal tenderness, and occipital headache.”
8) Diagnostics
- “Varying degrees of cardiac workups must be performed in order to rule out true angina pectoris.”
- “The use of coronary angiography has enabled us to rule out heart disease as the cause of chest wall pain more often and with greater accuracy than in the past.”
- “Cervical imaging can be critical evidence in the diagnosis of cervical angina once coronary artery disease has been adequately ruled out.”
- “Routine cervical magnetic resonance imaging (MRI) examination has been recommended for the functional assessment of cervical angina.”
- “MRI may demonstrate degenerative changes in the cervical spine, including herniated disk, spinal cord compression, or foraminal encroachment.”
- Degenerative changes are frequently found in the asymptomatic population, and functional tests (discography, selective nerve root block) may help to confirm the etiology of cervical angina.
- Discography and/or selective nerve root block are “invasive tests, which are not risk-free, [and] should be considered carefully and only applied in patients contemplating surgery.”
9) Mechanism of Chest Pain
- “Most cases with cervical angina have been attributed to cervical nerve root compression.”
- Since 1934, it has been suspected that cervical angina is linked to compression/irritation of the anterior (motor, efferent) root by the uncinate process (joint of Luschka).
- Compression or irritation of the anterior nerve root can induce diffuse pain; “the pain is not clearly radicular but is less discrete, which may be referred to a muscle innervated by the cervical myotomes, resulting in precordial pain.”
- “Cervical angina may be mediated by the cervical sympathetic afferent fibers to the heart and coronary arteries.”
- “Other autonomic symptoms, such as nausea and diaphoresis, can occur and are mediated through the sympathetic nervous system.”
- This occurs from compression/irritation of the sympathetic fibers that travel in the anterior root or from the plexus of sympathetic fibers that are anatomically associated with the longus colli muscle.
- “Referred pain may be mediated by the sinuvertebral nerve, which is a branch from the initial part of each spinal nerve passing in a recurrent fashion back through the intervertebral foramen to supply the spinal meninges, the posterior longitudinal ligament, posterolateral periphery of the intervertebral disc, and periosteum of the vertebrae.”
- Some cervical angina patients have hyperplasia of the Luschka’s joint in their degenerative cervical spines.
- “It is reasonable to speculate a close association between cervical angina and the Luschka’s joint osteophytes.”
- “The protrusion of Luschka’s joint osteophytes jacks up the homolateral longus colli, which might compress or stimulate adjacent sympathetic afferent fibers to the heart and coronary arteries and result in noncardiac chest pain.”
10) “Conservative treatment has been determined to be successful in most patients with cervical angina.”
- “At least 3 months of conservative treatment is recommended in all but the most severe cases.”
- “Conservative treatment should continue as long as the patient’s condition improves.”
- “Surgical intervention may be recommended if conservative measures fail or in cases where neurologic compromise is evident by spinal cord and/or nerve root compression.”
- The surgical option with the best long-term benefits is anterior cervical discectomy and fusion.
11) In a series of 438 cases with cervical angina, the levels of involvement were:
12) Conclusions by Authors:
- “The possibility of cervical angina should be considered once myocardial ischemia is ruled out in patients with inadequately explained chest pain, especially when neurologic signs and symptoms are also present.”
- “It is essential that more family doctors, internists, and spine surgeons are more aware of this condition.”
- “Luschka’s joint osteophytes may be one of pathogenic factors in cervical angina.”
Please see these Article Reviews:
Article Review 12-23:
Cervical Angina: An Overlooked Source of Noncardiac Chest Pain
Article Review 13-23:
Cervical Radiculopathy as a Hidden Cause of Angina: Cervicogenic Angina
The Luschka’s joint and how its osteophytic hypertrophy can affect the adjacent sympathetic nerves, which might result in cervical angina.
