Avaliação da dor cervical

A espondilose cervical é um achado universal com o aumento da idade.[15]Theodore N. Degenerative cervical spondylosis. N Engl J Med. 2020 Jul 9;383(2):159-68.​ Apenas um subconjunto de pacientes apresenta dor cervical axial; muitos pacientes são assintomáticos.[16]Binder AI. Cervical spondylosis and neck pain. BMJ. 2007 Mar 10;334(7592):527-31.[17]Kelly JC, Groarke PJ, Butler JS, et al. The natural history and clinical syndromes of degenerative cervical spondylosis. Adv Orthop. 2012;2012:393642. http://www.ncbi.nlm.nih.gov/pubmed/22162812?tool=bestpractice.com

A regra canadense para coluna cervical pode ser aplicada em pacientes com lesões menos graves para avaliar a necessidade de radiografia.[57]Stiell IG, Wells GA, Vandemheen KL, et al. The Canadian C-spine rule for radiography in alert and stable trauma patients. JAMA. 2001 Oct 17;286(15):1841-8. https://jama.ama-assn.org/cgi/content/full/286/15/1841 http://www.ncbi.nlm.nih.gov/pubmed/11597285?tool=bestpractice.com

É importante determinar se o mecanismo da lesão foi grave o suficiente para justificar exames de imagem para descartar fratura ou luxação cervical.

Uma radiografia da coluna cervical pode ser realizada, em vez da TC, em pacientes que tiverem sofrido trauma quando a lesão for menos grave, quando os critérios de alto risco não forem satisfeitos e quando não houver outras características que tornem os achados do exame menos confiáveis (por exemplo, intoxicação por álcool e lesões por distração dolorosas).

A tomografia computadorizada (TC) da coluna cervical é o estudo de escolha para suspeita de lesão da coluna cervical no cenário de trauma multissistêmico ou com mecanismo de alto risco.[34]Expert Panel on Neurological Imaging and Musculoskeletal Imaging, Beckmann NM, West OC, et al. ACR appropriateness criteria: suspected spine trauma. J Am Coll Radiol. 2019 May;16(5S):S264-85. https://www.jacr.org/article/S1546-1440(19)30142-5/fulltext http://www.ncbi.nlm.nih.gov/pubmed/31054754?tool=bestpractice.com [41]Cain GS, Shepherdson J, Elliott V, et al. Imaging suspected cervical spine injury: plain radiography or computed tomography? systematic review. Radiography. 2010;16(1):68-77. https://www.sciencedirect.com/science/article/abs/pii/S1078817409000698

Os pacientes podem apresentar dor cervical não complicada, a qual pode evoluir para mielopatia decorrente de subluxação da coluna cervical. Se houver sinais de mielopatia, uma RNM deve ser solicitada em busca de subluxação da articulação atlanto-axial.

Geralmente já terá sido realizado.

Obtido pelo exame inicial.

Recomenda-se o uso de um único bloco de diagnóstico.[82]Hurley RW, Adams MCB, Barad M, et al. Consensus practice guidelines on interventions for cervical spine (facet) joint pain from a multispecialty international working group. Reg Anesth Pain Med. 2022 Jan;47(1):3-59. https://rapm.bmj.com/content/47/1/3 http://www.ncbi.nlm.nih.gov/pubmed/34764220?tool=bestpractice.com ​ Os bloqueios duplos aumentam os diagnósticos falsos-negativos (mas podem reduzir a taxa de diagnósticos falsos-positivos e aumentar as taxas de sucesso do tratamento por radiofrequência).[82]Hurley RW, Adams MCB, Barad M, et al. Consensus practice guidelines on interventions for cervical spine (facet) joint pain from a multispecialty international working group. Reg Anesth Pain Med. 2022 Jan;47(1):3-59. https://rapm.bmj.com/content/47/1/3 http://www.ncbi.nlm.nih.gov/pubmed/34764220?tool=bestpractice.com [83]Cohen SP, Huang JH, Brummett C. Facet joint pain-advances in patient selection and treatment. Nat Rev Rheumatol. 2013 Feb;9(2):101-16. http://www.ncbi.nlm.nih.gov/pubmed/23165358?tool=bestpractice.com

Indicada se houver alto risco de lesão da coluna cervical segundo critérios clínicos.[34]Expert Panel on Neurological Imaging and Musculoskeletal Imaging, Beckmann NM, West OC, et al. ACR appropriateness criteria: suspected spine trauma. J Am Coll Radiol. 2019 May;16(5S):S264-85. https://www.jacr.org/article/S1546-1440(19)30142-5/fulltext http://www.ncbi.nlm.nih.gov/pubmed/31054754?tool=bestpractice.com [50]Stiell IG, Clement CM, McKnight RD, et al. The Canadian C-spine rule versus the NEXUS low-risk criteria in patients with trauma. N Engl J Med. 2003 Dec 25;349(26):2510-8. https://www.nejm.org/doi/full/10.1056/NEJMoa031375 http://www.ncbi.nlm.nih.gov/pubmed/14695411?tool=bestpractice.com [51]Vandemark RM. Radiology of the cervical spine in trauma patients: practice pitfalls and recommendations for improving efficiency and communication. AJR Am J Roentgenol. 1990 Sep;155(3):465-72. https://www.ajronline.org/doi/abs/10.2214/ajr.155.3.2117342 http://www.ncbi.nlm.nih.gov/pubmed/2117342?tool=bestpractice.com

Indicada se houver alto risco de lesão da coluna cervical segundo critérios clínicos.[34]Expert Panel on Neurological Imaging and Musculoskeletal Imaging, Beckmann NM, West OC, et al. ACR appropriateness criteria: suspected spine trauma. J Am Coll Radiol. 2019 May;16(5S):S264-85. https://www.jacr.org/article/S1546-1440(19)30142-5/fulltext http://www.ncbi.nlm.nih.gov/pubmed/31054754?tool=bestpractice.com [50]Stiell IG, Clement CM, McKnight RD, et al. The Canadian C-spine rule versus the NEXUS low-risk criteria in patients with trauma. N Engl J Med. 2003 Dec 25;349(26):2510-8. https://www.nejm.org/doi/full/10.1056/NEJMoa031375 http://www.ncbi.nlm.nih.gov/pubmed/14695411?tool=bestpractice.com [51]Vandemark RM. Radiology of the cervical spine in trauma patients: practice pitfalls and recommendations for improving efficiency and communication. AJR Am J Roentgenol. 1990 Sep;155(3):465-72. https://www.ajronline.org/doi/abs/10.2214/ajr.155.3.2117342 http://www.ncbi.nlm.nih.gov/pubmed/2117342?tool=bestpractice.com

Luxação observada no raio-X.[Figure caption and citation for the preceding image starts]: Luxação da faceta bilateralCom permissão do Departamento de Radiologia da Universidade do Colorado [Citation ends].

A RNM cervical é um exame definitivo para avaliar pacientes com radiculopatia cervical. Deve ser solicitada se o paciente com dor cervical apresentar sintomas e sinais neurológicos. A RNM não é indicada como exame de imagem de primeira linha para pacientes com dor cervical crônica e descomplicada.[42]Expert Panel on Neurological Imaging, McDonald MA, Kirsch CFE, et al. ACR appropriateness criteria: cervical neck pain or cervical radiculopathy. J Am Coll Radiol. 2019 May;16(5S):S57-76. https://www.jacr.org/article/S1546-1440(19)30164-4/fulltext http://www.ncbi.nlm.nih.gov/pubmed/31054759?tool=bestpractice.com

Geralmente, o exame de TC é indicado apenas se uma RNM não puder ser realizada.[42]Expert Panel on Neurological Imaging, McDonald MA, Kirsch CFE, et al. ACR appropriateness criteria: cervical neck pain or cervical radiculopathy. J Am Coll Radiol. 2019 May;16(5S):S57-76. https://www.jacr.org/article/S1546-1440(19)30164-4/fulltext http://www.ncbi.nlm.nih.gov/pubmed/31054759?tool=bestpractice.com A mielotomografia é usada para visualizar a invasão neurológica, como a RNM. Ela requer a colocação invasiva de contraste radiológico no espaço epidural e o uso de radiação (e, portanto, só é recomendada quando a RNM cervical é contraindicada).

RNM cervical é um exame definitivo para avaliar pacientes com mielopatia cervical.[78]Expert Panel on Neurological Imaging, Agarwal V, Shah LM, et al. ACR appropriateness criteria: myelopathy: 2021 update. J Am Coll Radiol. 2021 May;18(5s):S73-82. https://www.jacr.org/article/S1546-1440(21)00116-2/fulltext http://www.ncbi.nlm.nih.gov/pubmed/33958120?tool=bestpractice.com ​ Deve ser solicitada se o paciente com dor cervical apresentar sintomas e sinais neurológicos. A RNM não é indicada como exame de imagem de primeira linha para pacientes com dor cervical crônica e descomplicada.[42]Expert Panel on Neurological Imaging, McDonald MA, Kirsch CFE, et al. ACR appropriateness criteria: cervical neck pain or cervical radiculopathy. J Am Coll Radiol. 2019 May;16(5S):S57-76. https://www.jacr.org/article/S1546-1440(19)30164-4/fulltext http://www.ncbi.nlm.nih.gov/pubmed/31054759?tool=bestpractice.com

O raio-X da coluna cervical seria apenas um exame inicial.

Geralmente, o exame de TC é indicado apenas se uma RNM não puder ser realizada.[42]Expert Panel on Neurological Imaging, McDonald MA, Kirsch CFE, et al. ACR appropriateness criteria: cervical neck pain or cervical radiculopathy. J Am Coll Radiol. 2019 May;16(5S):S57-76. https://www.jacr.org/article/S1546-1440(19)30164-4/fulltext http://www.ncbi.nlm.nih.gov/pubmed/31054759?tool=bestpractice.com A mielotomografia é usada para visualizar a invasão neurológica, como a RNM. Ela requer a colocação invasiva de contraste radiológico no espaço epidural e o uso de radiação (e, portanto, só é recomendada quando a RNM cervical é contraindicada).

Em um paciente com história de câncer, a etiologia da dor cervical deve ser considerada como decorrente do câncer até que seja descartada. A RNM tem alta sensibilidade e especificidade para detecção e discriminação de lesões ósseas malignas.[42]Expert Panel on Neurological Imaging, McDonald MA, Kirsch CFE, et al. ACR appropriateness criteria: cervical neck pain or cervical radiculopathy. J Am Coll Radiol. 2019 May;16(5S):S57-76. https://www.jacr.org/article/S1546-1440(19)30164-4/fulltext http://www.ncbi.nlm.nih.gov/pubmed/31054759?tool=bestpractice.com

Pacientes com novo episódio de dor cervical e história de câncer, não importa o quão remota, devem ser avaliados em relação à recorrência de seu câncer com uma cintilografia óssea em busca de doença metastática.[81]Canale ST, Beaty JH, eds. Campbell's operative orthopaedics. Philadelphia, PA: Mosby Elsevier; 2007.

A RNM tem alta sensibilidade e especificidade para detecção e discriminação de lesões ósseas malignas.[42]Expert Panel on Neurological Imaging, McDonald MA, Kirsch CFE, et al. ACR appropriateness criteria: cervical neck pain or cervical radiculopathy. J Am Coll Radiol. 2019 May;16(5S):S57-76. https://www.jacr.org/article/S1546-1440(19)30164-4/fulltext http://www.ncbi.nlm.nih.gov/pubmed/31054759?tool=bestpractice.com

Pressão de abertura elevada é maior que 200 mm H20.

Positiva em 74% dos casos de meningite bacteriana.[35]Durand ML, Calderwood SB, Weber DJ, et al. Acute bacterial meningitis in adults: a review of 493 episodes. N Engl J Med. 1993 Jan 7;328(1):21-8. https://www.nejm.org/doi/full/10.1056/NEJM199301073280104#t=article http://www.ncbi.nlm.nih.gov/pubmed/8416268?tool=bestpractice.com Negativa para meningite asséptica.

tipicamente leucócitos >1000 células/microlitro na meningite bacteriana

Proteína >25 g/L (>250 mg/dL).

Glicose <2.5 mmol/L (<45 mg/dL).

Indicado para pacientes com suspeita de meningite bacteriana antes de punção lombar quando um ou mais dos seguintes aspectos estiverem presentes: estado imunocomprometido, história de doença do sistema nervoso central (SNC), novos episódios de convulsão, papiledema, nível alterado de consciência ou deficit neurológico focal.[27]van de Beek D, Cabellos C, Dzupova O, et al. ESCMID guideline: diagnosis and treatment of acute bacterial meningitis. Clin Microbiol Infect. 2016 May;22 Suppl 3:S37-62. https://www.clinicalmicrobiologyandinfection.com/article/S1198-743X(16)00020-3/fulltext [36]Hasbun R, Abrahams J, Jekel J, et al. Computed tomography of the head before lumbar puncture in adults with suspected meningitis. N Engl J Med. 2001 Dec 13;345(24):1727-33. https://www.nejm.org/doi/10.1056/NEJMoa010399 http://www.ncbi.nlm.nih.gov/pubmed/11742046?tool=bestpractice.com ​

RNM detecta alterações consistentes com osteomielite em 91% dos pacientes com sintomas com duração <2 semanas e em 96% dos pacientes com sintomas com duração >2 semanas.[86]Carragee EJ, Kim DH. A prospective analysis of magnetic resonance imaging findings in patients with sciatica and lumbar disc herniation: correlation of outcomes with disc fragment and canal morphology. Spine (Phila Pa 1976). 1997 Jul 15;22(14):1650-60. http://www.ncbi.nlm.nih.gov/pubmed/9253102?tool=bestpractice.com

Podem ser observadas no estágio tardio da doença.[Figure caption and citation for the preceding image starts]: Discite da C3-4 com destruição da placa terminalCom permissão do Departamento de Radiologia da Universidade do Colorado [Citation ends].

Geralmente, a TC é usada para avaliar uma suspeita de infecção na coluna quando a RNM é ambígua.[37]Expert Panel on Neurological Imaging, Ortiz AO, Levitt A, et al. ACR appropriateness criteria: suspected spine infection. J Am Coll Radiol. 2021 Nov;18(11S):S488-501. https://www.jacr.org/article/S1546-1440(21)00724-9/fulltext http://www.ncbi.nlm.nih.gov/pubmed/34794603?tool=bestpractice.com [79]Diehn FE. Imaging of spine infection. Radiol Clin North Am. 2012 Jul;50(4):777-98. http://www.ncbi.nlm.nih.gov/pubmed/22643395?tool=bestpractice.com

A RNM deve ser realizada sem e com contraste intravenoso.[37]Expert Panel on Neurological Imaging, Ortiz AO, Levitt A, et al. ACR appropriateness criteria: suspected spine infection. J Am Coll Radiol. 2021 Nov;18(11S):S488-501. https://www.jacr.org/article/S1546-1440(21)00724-9/fulltext http://www.ncbi.nlm.nih.gov/pubmed/34794603?tool=bestpractice.com ​ O uso de um agente de contraste IV aumenta a conspicuidade da lesão e ajuda a definir a extensão do processo infeccioso.[37]Expert Panel on Neurological Imaging, Ortiz AO, Levitt A, et al. ACR appropriateness criteria: suspected spine infection. J Am Coll Radiol. 2021 Nov;18(11S):S488-501. https://www.jacr.org/article/S1546-1440(21)00724-9/fulltext http://www.ncbi.nlm.nih.gov/pubmed/34794603?tool=bestpractice.com [79]Diehn FE. Imaging of spine infection. Radiol Clin North Am. 2012 Jul;50(4):777-98. http://www.ncbi.nlm.nih.gov/pubmed/22643395?tool=bestpractice.com ​

Cerca de dois terços dos casos são causados por Staphylococcus aureus; outros organismos causadores incluem bacilos Gram-negativos.[24]Darouiche RO. Spinal epidural abscess. N Engl J Med. 2006 Nov 9;355(19):2012-20. http://www.ncbi.nlm.nih.gov/pubmed/17093252?tool=bestpractice.com

Cerca de dois terços dos casos são causados por Staphylococcus aureus; outros organismos causadores incluem bacilos Gram-negativos.[24]Darouiche RO. Spinal epidural abscess. N Engl J Med. 2006 Nov 9;355(19):2012-20. http://www.ncbi.nlm.nih.gov/pubmed/17093252?tool=bestpractice.com

Teste de anticorpo fluorescente direto para varicela a partir da raspagem da pele da vesícula. Raramente necessário, mas útil na distinção entre varicela-zóster e herpes simples.

As diretrizes da American Heart Association recomendam que a ATG e a angiografia por RM (ARM) podem ser usadas para avaliar pacientes com suspeita de doença arterial carótida e vertebral extracraniana.[29]Yaghi S, Engelter S, Del Brutto VJ, et al. Treatment and outcomes of cervical artery dissection in adults: a scientific statement from the American Heart Association. Stroke. 2024 Mar;55(3):e91-106. https://www.ahajournals.org/doi/10.1161/STR.0000000000000457 http://www.ncbi.nlm.nih.gov/pubmed/38299330?tool=bestpractice.com [85]Brott TG, Halperin JL, Abbara S, et al. 2011 ASA/ACCF/AHA/AANN/AANS/ACR/ASNR/CNS/SAIP/SCAI/SIR/SNIS/SVM/SVS guideline on the management of patients with extracranial carotid and vertebral artery disease: executive summary: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, and the American Stroke Association, American Association of Neuroscience Nurses, American Association of Neurological Surgeons, American College of Radiology, American Society of Neuroradiology, Congress of Neurological Surgeons, Society of Atherosclerosis Imaging and Prevention, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of NeuroInterventional Surgery, Society for Vascular Medicine, and Society for Vascular Surgery. Developed in collaboration with the American Academy of Neurology and Society of Cardiovascular Computed Tomography. Catheter Cardiovasc Interv. 2013 Jan 1;81(1):E76-123. https://onlinelibrary.wiley.com/doi/full/10.1002/ccd.22983 http://www.ncbi.nlm.nih.gov/pubmed/23281092?tool=bestpractice.com ​​​

As diretrizes da American Heart Association recomendam que tanto a ATG quanto a ARM podem ser usadas para avaliar pacientes com suspeita de doença arterial carótida e vertebral extracraniana.[29]Yaghi S, Engelter S, Del Brutto VJ, et al. Treatment and outcomes of cervical artery dissection in adults: a scientific statement from the American Heart Association. Stroke. 2024 Mar;55(3):e91-106. https://www.ahajournals.org/doi/10.1161/STR.0000000000000457 http://www.ncbi.nlm.nih.gov/pubmed/38299330?tool=bestpractice.com [85]Brott TG, Halperin JL, Abbara S, et al. 2011 ASA/ACCF/AHA/AANN/AANS/ACR/ASNR/CNS/SAIP/SCAI/SIR/SNIS/SVM/SVS guideline on the management of patients with extracranial carotid and vertebral artery disease: executive summary: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, and the American Stroke Association, American Association of Neuroscience Nurses, American Association of Neurological Surgeons, American College of Radiology, American Society of Neuroradiology, Congress of Neurological Surgeons, Society of Atherosclerosis Imaging and Prevention, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of NeuroInterventional Surgery, Society for Vascular Medicine, and Society for Vascular Surgery. Developed in collaboration with the American Academy of Neurology and Society of Cardiovascular Computed Tomography. Catheter Cardiovasc Interv. 2013 Jan 1;81(1):E76-123. https://onlinelibrary.wiley.com/doi/full/10.1002/ccd.22983 http://www.ncbi.nlm.nih.gov/pubmed/23281092?tool=bestpractice.com ​

As diretrizes da American Heart Association recomendam que tanto a ATG quanto a ARM podem ser usadas para avaliar pacientes com suspeita de doença arterial carótida e vertebral extracraniana.[29]Yaghi S, Engelter S, Del Brutto VJ, et al. Treatment and outcomes of cervical artery dissection in adults: a scientific statement from the American Heart Association. Stroke. 2024 Mar;55(3):e91-106. https://www.ahajournals.org/doi/10.1161/STR.0000000000000457 http://www.ncbi.nlm.nih.gov/pubmed/38299330?tool=bestpractice.com [85]Brott TG, Halperin JL, Abbara S, et al. 2011 ASA/ACCF/AHA/AANN/AANS/ACR/ASNR/CNS/SAIP/SCAI/SIR/SNIS/SVM/SVS guideline on the management of patients with extracranial carotid and vertebral artery disease: executive summary: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, and the American Stroke Association, American Association of Neuroscience Nurses, American Association of Neurological Surgeons, American College of Radiology, American Society of Neuroradiology, Congress of Neurological Surgeons, Society of Atherosclerosis Imaging and Prevention, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of NeuroInterventional Surgery, Society for Vascular Medicine, and Society for Vascular Surgery. Developed in collaboration with the American Academy of Neurology and Society of Cardiovascular Computed Tomography. Catheter Cardiovasc Interv. 2013 Jan 1;81(1):E76-123. https://onlinelibrary.wiley.com/doi/full/10.1002/ccd.22983 http://www.ncbi.nlm.nih.gov/pubmed/23281092?tool=bestpractice.com ​

As diretrizes da American Heart Association recomendam que tanto a ATG quanto a ARM podem ser usadas para avaliar pacientes com suspeita de doença arterial carótida e vertebral extracraniana.[29]Yaghi S, Engelter S, Del Brutto VJ, et al. Treatment and outcomes of cervical artery dissection in adults: a scientific statement from the American Heart Association. Stroke. 2024 Mar;55(3):e91-106. https://www.ahajournals.org/doi/10.1161/STR.0000000000000457 http://www.ncbi.nlm.nih.gov/pubmed/38299330?tool=bestpractice.com [85]Brott TG, Halperin JL, Abbara S, et al. 2011 ASA/ACCF/AHA/AANN/AANS/ACR/ASNR/CNS/SAIP/SCAI/SIR/SNIS/SVM/SVS guideline on the management of patients with extracranial carotid and vertebral artery disease: executive summary: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, and the American Stroke Association, American Association of Neuroscience Nurses, American Association of Neurological Surgeons, American College of Radiology, American Society of Neuroradiology, Congress of Neurological Surgeons, Society of Atherosclerosis Imaging and Prevention, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of NeuroInterventional Surgery, Society for Vascular Medicine, and Society for Vascular Surgery. Developed in collaboration with the American Academy of Neurology and Society of Cardiovascular Computed Tomography. Catheter Cardiovasc Interv. 2013 Jan 1;81(1):E76-123. https://onlinelibrary.wiley.com/doi/full/10.1002/ccd.22983 http://www.ncbi.nlm.nih.gov/pubmed/23281092?tool=bestpractice.com ​