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| CASE REPORT |
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| Year : 2014 | Volume
: 28
| Issue : 1 | Page : 44-46 |
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An unusual cause of chest pain: Fused cervical vertebra (C3-C4)
Daipayan Chatterjee
Department of Orthopaedics, Vardhaman Mahavir Medical College and Safdarjung Hospital, New Delhi, India
| Date of Web Publication | 15-Mar-2014 |
Correspondence Address:
Daipayan Chatterjee
118/5 Gautam Nagar, New Delhi
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/0970-5333.128896
Cervicogenic angina is paroxysmal precordialgia usually due to lower cervical vertebral involvement. But upper cervical vertebral segmental anomaly causing cervicogenic angina is rare. Herein, we report a case of cervicogenic angina due to fused 3 rd and 4 th cervical vertebra in a 37-year female, which was initially misdiagnosed as angina and treated likewise. But, persistence of symptoms led to evaluation of her cervical spine and subsequent diagnosis. Cervical traction, physiotherapy and posture training relieved her of her symptoms with no recurrence till 6 months of follow-up. Fused C3-C4 can be a cause of precordialgia and physicians should be aware of it. Keywords: Cervicogenic angina, fused C3-C4, pseudoangina, vertebral segmental anomaly
How to cite this article:
Chatterjee D. An unusual cause of chest pain: Fused cervical vertebra (C3-C4). Indian J Pain 2014;28:44-6 |
| Introduction | |  |
Cervicogenic angina is defined as paroxysmal precordialgia of cervical vertebral origin resembling true angina. [1] Its pain mechanism is thought to be related to cervical nerve root irritation most commonly of C-7. [2] The common causes of cervicogenic angina are segmental dysfunction and degenerative changes at the level of the lower cervical and upper thoracic spine. [3] However, cervicogenic angina due to vertebral segmental anomaly involving upper cervical vertebrae is rare. Herein, we report a case of cervicogenic angina due to fused 3 rd and 4 th cervical vertebra. Written informed consent was taken from the patient.
| Case Report | | |
A 37-year-old lady presented with a 6-month history of left-sided acute onset moderate to severe chest pain. She had previously consulted a medical physician who diagnosed it as "angina" and prescribed isosorbide dinitrate tablets to be taken as necessary. As the pain was not relieved by the medication, she decided to take an orthopedic consultation.
The pain did not radiate to the arms, neck or abdomen. But she had occasional pain in her left shoulder. It was noted more often in the evenings, and was relieved on lying down and was not affected by forceful inspiration or expiration. There was no tingling, numbness of the upper extremities, vertigo, heart burn, acidity, dysphagia, syncopal attacks or neurovascular deficits. She had no history of fever, trauma or any other constitutional symptom in recent past. There was no history of similar illness in her family or history of major illness.
Examination revealed an alert healthy female with normal vitals. No local tenderness or skin changes suggestive of local inflammation were present. Examination of breast, cardiovascular, respiratory, gastrointestinal systems were normal.
She was evaluated with chest x-ray, x-ray abdomen erect and supine view, lipid profile, complete hemogram, kidney function test, liver function test, serum electrolytes, blood sugar, ultrasonography abdomen all of which came out to be normal. Electrocardiography revealed non-specific ST-T segment changes. Her echocardiography and stress echocardiography were normal. She was further investigated for d-dimer assay, arterial blood gas analysis, serum lipase, troponin-T and 24-hour esophageal pH monitoring, which were also normal.
Failure to reach to a definitive diagnosis led to an enquiry of her profession. It was found that she was a pathology technician and had to spend at least 4-5 hours in front of microscope. On further enquiry, she gave a history of increase in her chest pain after a tiresome day at work. X-ray of cervical spine was done which showed presence of fused 3 rd and 4 th cervical vertebra with obliteration of cervical lordosis [Figure 1] and [Figure 2]. The height of the patient was 158 cm and her neck length (from inion to C7 spine) was 15.8 cm with neck in neutral position. Scapula was in normal position bilaterally. Hairline was also normal. Restriction of active and passive neck movements were noted especially in left lateral flexion. No spinal tenderness was noted. Mild Hypo-aesthesia was noted in C7-T1 region. Left triceps reflex was decreased (grade 1+) as compared to the right side (grade 2). | Figure 1: X-ray lateral view of cervical spine showing fusion of 3rd and 4th cervical vertebrae
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 | Figure 2: X-ray lateral view of cervical spine showing fusion of 3rd and 4th cervical vertebrae (enlarged view)
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Intermittent cervical traction (30 minutes with 10 pounds weight followed by 10 minutes of rest repeated for 2 hours every alternate day), non-steroidal analgesics, warm moist towel application twice daily, neck muscle physiotherapy and proper posture training relieved the symptoms within 2 weeks and there was no recurrence of the symptoms over the next 6 months of follow-up. She was recommended a soft cervical collar to be used during daytime for first 1 month to acclimatize her with her occupational posture training.
| Discussion | | |
Correct diagnosis of the cause of chest pain is crucial. In this case, the continual presence of the symptoms, absence of relief from nitrates and absence of secondary symptoms of myocardial ischemia (e.g. diaphoresis) with normal ECG and echocardiography tended to rule out true angina pectoris and other cardiac causes of precordialgia. Normal chest x-ray, blood gas analysis, d-dimer assay and absence of related history and examination findings ruled out pulmonary causes of chest pain. Gastrointestinal causes of precordial pain were excluded by absence of related symptoms and examination findings along with normal abdominal x-ray, ultrasonography, 24-hour esophageal pH, and pancreatic lipase. Absence of local signs ruled out chest wall and breast as causes of precordialgia. Presence of history of pain increasing after a long day's work involving neck flexion, evidence of fusion of C3-C4 with obliteration of cervical lordosis along with relief of symptoms with cervical traction and physiotherapy pins our diagnosis to cervicogenic angina due to cervical vertebral fusion (C3-C4).
To the best of my knowledge, no case of cervicogenic angina due to fusion of C3-C4 fusion has been reported previously. Vertebral segmental anomalies refers to fusion of contiguous vertebral segments resulting from embryonic failure of normal vertebral segmentation most likely due to decreased local blood flow during 3 rd to 8 th week of fetal development. [4] Among cervical vertebral segmental defects, fusion of C2-C3 is commonest (0.4-0.7%) [4] followed by C5-C6. [5] Incidence of fusion of C3-C4 is rare and that too with a presentation of cervicogenic angina is rarer. [3] Presence of block vertebrae has been found to result in greater biomechanical stress in adjoining segments leading to premature degenerative changes, disc prolapse and nerve root irritation. [6]
By analyzing anamnestic data, we deduce that fusion of C3-C4 led to restricted neck motion thus predisposed her for the development of nerve root irritation of C7-T1. This was further aggravated by her improper occupational postures leading to cervicogenic angina. The main reason of late diagnosis was rarity of the disease and unawareness regarding the presentation. Cervical vertebral fusion may be missed in an anteroposterior view of the cervical spine. Therefore, a lateral view x-ray of cervical spine must always be done in cases of non-cardiogenic precordialgia.
| Conclusion | | |
Although cervicogenic angina due to fused C3-C4 is one of the rare differential diagnoses of non-cardiogenic precordialgia, physicians should be aware of it and if there are no abnormal findings on cardiac examinations for chest pain, they should evaluate the cervical spine with a lateral view x-ray.
| References | | |
| 1. | Ito Y, Tanaka N, Fujimoto Y, Yasunaga Y, Ishida O, Ochi M. Cervical angina caused by atlantoaxial instability. J Spinal Disord Tech 2004;17:462-5. 
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| 2. | Wiles M. Pseudo-angina pectoris of cervical origin. JCCA 1980;24:74-5.
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| 3. | Grgiæ V. Vertebrogenic chest pain - "pseudoangina pectoris": Etiopathogenesis, clinical manifestations, diagnosis, differential diagnosis and therapy. Lijec Vjesn 2007;129:20-5.
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| 4. | Soni P, Sharma V, Sengupta J. Cervical vertebral anomalies-incidental findings on lateral cephalograms. Angle Orthod 2008;78:176-80.
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| 5. | Wazir S, Mahajan A. Fusion of axis with the third cervical vertebrae-a case report. Indian J Fundament Appl Life Sci 2011;1:164-6.
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| 6. | Shankar VV, Kulkarni RR. Block vertebrae: Fusion of axis with the third cervical vertebrae-a case report. Int J Anatomical Variations 2011;4:15-8.
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[Figure 1], [Figure 2]
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