Cervical angina is an often-overlooked etiology of noncardiac chest pain that may mimic true angina pectoris but is due to cervical spine disease. Diagnosis can be difficult, and treatment ranges from conservative therapy to surgical management. However, of patient’s refractory to conservative therapy, approximately ninety percent experience postoperative relief of angina symptoms. Here, we present a case report on cervical angina and performed a systematic review of the literature. A 34-year-old male with prior surgery for thoracic outlet syndrome presented with persistent anterior neck and chest pain as well as posterior left scapular and upper lateral arm pain. The pain was refractory to 12 months of conservative therapy. Cardiac workup was negative and cervical spine imaging revealed a C6–7 herniation with neuroforaminal stenosis. A systematic literature search was conducted in PubMed, Web of Science, and Cochrane databases from database inception to April 2020. Studies reporting cervical level, average symptom duration, location of pain, and postoperative pain improvement were included. The patient's atypical symptoms were completely resolved after C6–7 anterior cervical discectomy and arthroplasty. To our knowledge, this is the first study which reports on the use of arthroplasty in the treatment of cervical angina. The systematic review included 11 articles from 1989–2020 consisting of 1,186 total patients and 109 patients (age range, 36–84 years; 60.7% male) meeting inclusion criteria. Symptom duration range was 2 days to 90 months, with the most common location of pain being localized to the anterior chest wall (66.7% of patients). All patients (100%) had postoperative resolution of their pain symptoms. The most common herniation level was C6–7 (87.3% of patients). We conclude that a broad and multidisciplinary approach is necessary for the diagnosis and management of noncardiac chest pain. When cervical disease is identified as the underlying cause for the angina-like pain, conservative therapy should be sought. Refractory cases should be treated surgically depending on the cervical pathology.
Cervical angina, or pseudoangina, is a rare and likely underdiagnosed clinical syndrome in which cervical spondylarthropathy and degenerative disc disease presents as chest and scapular pain due to either nerve root irritation and compression or, less commonly, central stenosis and myelopathy [
The prevalence of cervical angina has not been clearly established. It has been reported that up to 50% of patients evaluated for chest pain have normal coronary arteriography [
As with more typical cervical radiculopathy and stenosis, conservative measures including rest, physical therapy, cervical orthosis, intermittent cervical traction, nonsteroidal anti-inflammatory drugs, and muscle relaxants should be attempted first [
We present here a case study on the management of cervical angina with anterior cervical discectomy and arthroplasty at C6–7 level. We also performed a systematic review on the relevant literature.
A 34-year-old male with a prior history of thoracic outlet syndrome treated with multiple surgeries including a first rib and anterior and middle scalene resection presented with 2 years of persistent left anterior neck and chest pain, as well as posterior left scapular and upper outer arm pain refractory to 12 months of physical therapy, epidural steroid injections, stellate ganglion injection, and smoking cessation. After a negative cardiology work up was performed a neurologic work up was performed. He demonstrated 5/5 bilateral upper extremity strength throughout with fully intact sensation. Of note, he displayed no hyperreflexia, a negative Hoffman's bilaterally, negative Romberg and the ability to tandem walk without difficulty. Multimodal cervical spine imaging was performed. Magnetic resonance imaging demonstrated herniation of the C6–7 disc upon weight-bearing, with a protrusion of 3.6 mm, and disc material abutting the anterior aspect of the spinal cord (
A left-sided standard Smith-Robinson approach was utilized to expose the anterior vertebrae. The appropriate level was localized with an x-ray at C6–7 and the longus coli were elevated bilaterally. The patient's disc was removed in its entirety at C6–7 using bilateral foraminotomies and a left-sided uncinate decompression. The region was then reconstructed with a Prestige LP, 6× 16 mm, arthroplasty implant after templating it to an appropriate size.
The patient reported complete resolution of his pain immediately upon waking up postoperation. Radiographic images of the cervical spine demonstrated good positioning of the C6–7 arthroplasty implant. At 6-month follow-up, the patient has maintained complete resolution of his cervical angina pain and has discontinued all pain medications. Repeat radiographs at 6 months showed his implant to be in good stable position (
With Institutional Review Board exemption, a systematic review was performed targeting studies investigating cervical disc herniation in the subaxial cervical spine (C3–7) resulting in chest pain. This systematic review evaluated cervical level, average symptom duration, location of pain, and postoperative improvement of pain.
On April 10th, 2020, a literature search was conducted using PubMed, Web of Science, and Cochrane databases using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) recommendations [
Our search yielded 83 results from PubMed, 40 results from Web of Science, and 0 result from Cochrane, with a total of 89 unique articles after the removal of duplicates. The reference lists from articles identified during our search were analyzed individually for additional studies that met inclusion criteria, yielding an additional 10 papers (
All articles reviewed were subject to the following inclusion criteria: (1) availability of the manuscript in English or an English translation, (2) primary clinical studies investigating cervical disc herniation in the subaxial cervical spine (C3-7) resulting in chest pain. All articles reviewed were also subject to the following exclusion criteria: (1) axial cervical spine, (2) nonherniation pathologies of the cervical spine.
Titles and abstracts of studies for this systematic review were evaluated independently by 2 authors (RS and LDA). The reviewers then compared these selections, and disagreements were resolved by further discussion with the senior author. Final selections were chosen by both authors independently after examining full-text articles, after which the methodological index for nonrandomized studies (MINORS) criteria was used to objectively evaluate the quality of the studies and evaluate the risk of bias for selected studies [
Out of the 89 unique papers from the database search and review of reference lists, 75 papers were examined in full text. Out of 89 papers, 11 papers met both inclusion and exclusion criteria (
Accepted articles were then assessed for sample size, year of publication, institution and country of authors, patient demographics (i.e., sex and age), cervical level, symptom duration, location of pain, and postoperative improvement in pain.
A total of 11 articles were selected matching our inclusion and exclusion criteria for this systematic review (
The mean MINORS criteria score was 5.45 (range, 3–8) for the 11 studies selected for this systematic review. The studies by Ozgur and Marshall [
The pathogenesis of cervical angina is an area of study and speculation and is a widely reported source of unrecognized chest pain [
The particular pathogenic processes involved in a cervical angina case can be significant in informing therapy.
Ozgur and Marshall [
Better guidelines should be established for the diagnosis and management of cervical angina. Clinicians must consider a broad differential diagnosis for chest pain unexplained by coronary artery disease. When present, neurological symptoms should not be overlooked as a separate clinical entity. Guidelines for diagnoses should involve a thorough physical examination, including neurological examination, cooperation among specialties and should consider the cost of exhaustive cardiac examination. Once diagnosed, management of cervical angina must balance the risk factors and cost of surgical intervention with the probability of patient pain relief and life-style improvement. The majority of cervical angina patients achieve symptomatic relief through conservative management [
Cervical arthroplasty, or total disc replacement, is a well-established alternative in appropriate patients who would benefit from motion sparing discectomy. As traditional fusion surgery is typically extremely well tolerated, there is some equanimity among the neurosurgical community about the benefit of arthroplasty. However, numerous clinical trials and meta-analyses are showing at least noninferiority and in most cases are describing improved patient pain outcomes, decreased recovery times, preserved motion, and decreased adjacent level disease with arthroplasty when compared with fusion [
We present this unique case to highlight the nuance involved in the diagnosis and treatment of cervical angina. The patient presented with atypical symptoms complicated by a history of thoracic outlet syndrome and multiple surgeries. The patient's symptoms of left anterior neck and chest pain as well as posterior left scapular and upper outer arm pain were refractory to several conservative therapies and had persisted for greater than 2 years. The patient’s symptoms were consistent with cervical angina with a component of C7 radiculopathy, which was potentially referable to his disc herniation and neuroforaminal stenosis at C 6/7. We, therefore, pursued surgical management given his failure of conservative management and debilitating pain with correlative imaging findings. This is the first study which reports on the use of arthroplasty in the treatment of cervical angina. The patient's atypical symptoms of cervical angina appear to have completely resolved with the discectomy and arthroplasty at the C6–7 level.
We also present the first reported systematic review on cervical disc herniation in the subaxial cervical spine (C3–7) resulting in chest pain. The results are consistent with the reported literature, with all patients experiencing postoperative symptomatic recovery from their chest pain. The majority of included studies were small single institutional retrospective analyses or case reports, which reported extremely heterogeneous clinical data. Though great care was taken in collecting relevant studies an performing the appropriate analyses, this study has a number of limitations. First, this systematic review was comprised of several collective studies and case reports with intrinsic heterogeneity in treatment guidelines and measurement of outcome variables. There were inconsistent patient baselines and follow-up timelines in the included cases, which makes the analysis difficult to control or standardize. Furthermore, differences in reported outcomes and the incomplete presentation of clinical data for patients meeting inclusion criteria, coupled with the relative rarity of relevant cases, increases the susceptibility for type II error and false-negative conclusion. Nonetheless, this systematic review is the first to synthesize the reported cervical level, average symptom duration, location of pain, and postoperative improvement of pain of patients with chest pain secondary to cervical disc herniation in the subaxial cervical spine (C3–7) [
Diagnosis of cervical angina can be difficult, and treatment ranges from conservative therapy to surgical management. We present a patient who experienced complete resolution after C6–7 anterior cervical discectomy and arthroplasty.
The authors have nothing to disclose.
T2-weighted magnetic resonance imaging showing sagittal view (A) of the cervical spine and sagittal view (B) demonstrating increased signal within the spinal cord from C2–T1.
T2-weighted magnetic resonance imaging showing an axial view of the cervical spine demonstrating mild to moderate bilateral neural foraminal narrowing and annular fissure at C6–7 level.
X-ray showing anteriorposterior (A) and lateral views (B) of the cervical spine prior to cervical arthroplasty.
X-ray showing dynamic extension (A) and flexion views (B) of the cervical spine prior to cervical arthroplasty.
X-ray showing anteriorposterior view of cervical spine. Red arrow points to the left uncinatectomy for full decompression of the foramen.
X-ray showing anteriorposterior (A) and lateral views (B) of the cervical spine after anterior cervical discectomy and arthroplasty at the C6–7 level.
X-ray showing dynamic extension (A) and flexion views (B) of the cervical spine after anterior cervical discectomy and arthroplasty at the C6–7 level.
PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) study selection flow diagram.
Demographic and clinical variables of included studies
Study | Year | Study design | Institution | No. | No. of after exclusion criteria | Cervical level | Minors score | Age | Sex | Average symptom duration | Location of pain | Pain improved after surgery? |
---|---|---|---|---|---|---|---|---|---|---|---|---|
Jain and Sharma [ |
2020 | Retrospective cohort study | SMS Medical College, Jaipur, India | 25 | 8 | C5–8 | 7 | mean: 57.24 (range: 40-84) | 5M, 3F | 4.36 mo | N/A | N/A |
Ozgur and Marshall [ |
2003 | Retrospective cohort study | University of California, San Diego, CA, USA | 241 | 39 | C7 | 8 | N/A | N/A | N/A | N/A | Yes |
Nakajima [ |
2006 | Retrospective cohort study | University of Fukui, Fukui, Japan | 706 | 6 | C4–5 (1), C5–6 (3), C6–7 (2) | 8 | Mean: 54.5 (range: 36–74) | 6M, 4F | 5.6 mo (range, 2–12 mo) | 1 case had retrosternal pain, three cases had left lower anterior chest pain, and two cases had epigastric pain. | Yes |
Sussman et al. [ |
2015 | Retrospective cohort study | Worcester Medical Center, Worcester, MA, USA | 6 | 4 | C5–6 (2), C6–7 (2) | 8 | Range, 39–64 | 3M, 1F | Range, | Left anterior chest (1), substernal (2), unspecified (1) | Yes |
Brodsky et al. [ |
1989 | Retrospective cohort study | Hospital for Special Surgery, Cornell University Medical College, New York, NY, USA | 164 | 38 | N/A | 8 | N/A | N/A | 2 d–90 mo | N/A | Yes |
Htay et al. [ |
2019 | Case report | Melaka Manipal Medical College (MMMC), Melaka, Malaysia | 1 | 1 | C6–7 | 3 | 53 | F | 11 wk | left-sided chest pain and back pain between the spine and left scapula | N/A |
Noji et al. [ |
2017 | Case report | Ashigarakami Kanagawa Prefectural Hospital, Kanagawa, Japan | 1 | 1 | C3–4 | 3 | 78 | F | 1 yr | left chest and back area | Yes |
Hammad [ |
2015 | Retrospective cohort study | Al-Azhar University, Cairo, Egypt | 38 | 8 | N/A | 6 | N/A | M2, F6 | N/A | N/A | N/A |
Tominaga et al. [ |
2019 | Case report | Kyoto Katsura Hospital, Kyoto, Japan | 1 | 1 | C6–7 | 3 | 42 | M | 1 yr | Anterior chest and upper back pain | Yes |
Yeung and Hagen [ |
1993 | Case report | Foothills Medical Centre, Calgary, Canada | 2 | 2 | C6–7 | 3 | 40, 48 | 2F | 10 d | Anterior chest | Yes |
Grgic [ |
2008 | Case report | N/A | 1 | 1 | C6–7 | 3 | 41 | F | 6 mo | Anterior chest | N/A |
N/A, not applicable.