Ischemic heart disease is the leading cause of death worldwide. It may also be referred to as coronary artery disease and/or atherosclerotic cardiovascular disease. The most up-to-date epidemiological data from the Global Burden of Disease dataset which collates data from a large number of sources, including research studies, hospital registries, and government reports, indicates that ischemic heart disease affects around 126 million individuals globally (1,655 per 100,000), which is approximately 1.72% of the world’s population. About 9 million deaths are caused by ischemic heart disease globally each year (1).

Recent analysis indicates that ischemic heart disease is the number one cause of death, disability, and human suffering globally.

The most classic acute clinical presentation of an ischemic heart event is chest pain or discomfort (2). This presentation of chest pain is referred to as angina. This is the main focus of the following presentation.

In 1927, nearly a century ago, it was established that angina symptoms could be caused ty irritation of the cervical nerve roots (3). Angina-like symptoms caused by irritation of cervical nerve roots is commonly referred to as cervical angina. Often, a cervical spine origin of chest pain is described as mild, nagging, frequent, with bilateral arm radiation (3).

A decade later (1937), a robust study involving 600 cases of chest pain indicated that nearly a third of them could be traced to a cervical spine origin (4).

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The journal Spine is the most cited orthopedic journal. Its first published edition was in March 1976. In this issue, an article appeared titled (5):

Cervical Angina

The authors, Robert Booth, MD, and Richard Rothman, MD, PhD, were from the Department of Orthopaedic Surgery, Pennsylvania Hospital, Philadelphia, Pennsylvania. The abstract from this article states:

“Cervical angina, an uncommon constellation of symptoms produced by cervical osteoarthritis but closely mimicking coronary ischemic disease, will be discussed and its meager literature reviewed.  

A series of 7 cases from Pennsylvania Hospital will be evaluated, emphasizing that distinct clinical diagnosis can be made and that mechanical therapeutic techniques can be effective.  

A discussion of both known and suggested pathophysiologic mechanisms of pain production and their anatomic significance will be offered.”

The authors note that the typical patient presentation was “nagging, aching, or glowing discomfort in the chest.” These symptoms were unassociated with dyspnea (difficult breathing), nausea and/or diaphoresis (excessive sweating).

Symptoms often included shoulder/arm pain, paresthesias, numbness and/or weakness. These symptoms were usually related to cervical spine motion (suggesting a musculoskeletal etiology) rather than from exertion (which would suggest a vascular etiology).

Examination showed reduced cervical ranges of motion, along with cervical spine spasm and tenderness.

X-rays on these subjects showed cervical spine spondylosis at C5-C6 in all cases.

Importantly, these authors state that these patients “will best respond to mechanical intervention.” This would include chiropractic care.

••••

In 1991, the journal Orthopedics & Traumatology published a study titled (6):

Clinical Study of Cervical Angina

The authors are from the Department of Orthopaedic Surgery, Tottori University, School of Medicine, Japan. They evaluated eight patients with cervical angina. These patients included six women and two men; their ages ranged from 35 to 68 years of age, averaging 50 years of age. The authors state:

“Cervical angina, resembling true angina pectoris, but resulting from cervical spondylosis and nerve root compression, is also known as pseudoangina.”

“It may be concluded that the pathophysiologic mechanism of cervical angina is related with C7 root and sympathetic nerve system.”

The study from the journal Spine (6) suggested that the primary nerve root responsible for the symptoms of cervical angina is C6. In contrast, this study suggests it is primarily C7. Additionally, this study mentions the involvement of the sympathetic nervous system.

••••

The sympathetic nervous system is the portion of the nervous system that controls visceral function, including that of the heart. The sympathetic innervation of the viscera involves two nerves: the pre sympathetic chain ganglion and the post sympathetic chain ganglion.

At the nerve root level, the pre sympathetic ganglion fibers travel in the anterior root, along with the motor nerve root to the muscles. These pre sympathetic ganglion fibers terminate in the sympathetic chain ganglion (there are exceptions to this) where they synapse with the post sympathetic chain ganglion fibers that then travel to the viscera, like the heart.

Since 1916, it has been held that the cells of origin of pre sympathetic ganglion neurons are found only in T1 to L2 segments of the spinal cord, and therefore only found in nerve roots of T1-L2 (7). The pre sympathetic ganglion fibers to the heart are usually said to be from T1-T4 spinal segmental levels.

In 1960, Eugene Neuwirth, MD, published a study in the journal Lancet, titled (7):

Current Concepts of the Cervical Portion of the Sympathetic Nervous System

Dr. Neuwirth was a specialist in physical medicine, rehabilitation, and rheumatic diseases. In this article he notes that in 1940, French researchers showed that presympathetic ganglion neurons are found at the spinal cord levels of C4, C5, C6, C7, and C8. He notes that this was confirmed in 1947. This anatomical observation is quite relevant to the discussion presented here.

Although the sympathetic nervous system is considered to be an efferent system to the viscera, the sympathetic nerves also contain afferent fibers that carry pain. When a visceral organ is diseased or injured (like the heart), it is these afferent sympathetic fibers that carry the pain to the spinal cord and hence to the brain.

Musculoskeletal pain is often pinpointable. In contrast, visceral pain, transmitted by the sympathetic nervous system, is usually much more diffuse and more poorly localized.

When the sympathetic nerves are inflamed, irritated, or compressed, they are capable of sending a visceral pain signal to the brain. This can happen in the absence of heart disease.

For the heart, there are four locations for sympathetic afferent involvement:

• The anterior nerve root at any level between C4 to T4.
• The mixed spinal nerve root at any level between C4 to T4.
• The sympathetic chain ganglion, located in the front of the spinal column, traveling with the longus colli muscle.
• Post sympathetic chain ganglion fibers that exist in and around the longus colli muscle.

••••

In 2015, an article was published in the journal Neurohospitalist, titled (8):

Cervical Angina
An Overlooked Source of Noncardiac Chest Pain

The authors present a series of 6 cases of cervical angina. They note that each year, more than 7 million patients present to emergency departments with chest pain. Yet, only 15% to 25% of patients with acute chest pain will actually have acute coronary syndrome. The authors state:

“The prevalence of noncardiac chest pain is estimated to be more than 50% of all cases with chest pain that present to the emergency department.”

The authors note that cervical angina is one potential cause of noncardiac chest pain and originates from disorders of the cervical spine. Up to 70% of patients with cervical angina have cervical nerve root involvement. The most frequently affected nerve root levels are:

• C5-C6 37%
• C6-C7 30%
• C4-C5 27%
• C3-C4 4%

The authors recognize that 50% to 60% of patients who experience cervical angina also experience other autonomic symptoms such as dyspnea, vertigo, nausea, diaphoresis, pallor, fatigue, diplopia, and headaches. This adds to the model that suggests there is sympathetic nervous system involvement in cervical angina. Consistent with studies cited above (6), these authors state:

“Pain may be mediated by the sympathetic afferent fibers to the heart and coronary arteries, which originate in the dorsal root ganglia of C8 to T9.”

In this study, all subjects had been evaluated for cardiac etiology for their chest symptoms, including:

• Cardiac stress testing
• Coronary angiogram
• Electrocardiogram
• Chest x-ray
• Cardiac enzymes

All of these tests were deemed to be normal or unremarkable.

In the diagnosing of cervical angina, the authors found the most revealing physical test was the Spurling maneuver. They state:

“The Spurling maneuver, performed by rotating the cervical spine toward the symptomatic side while providing a downward compression through the patient’s head, has been shown to reproduce symptoms of cervical angina in case reports.”

“A positive Spurling maneuver correlates with findings on computer tomography with a sensitivity of 95% and specificity of 94%.”

The authors suggest that cervical angina should be suspected when a patient has a negative cardiac workup, and has positive signs of cervical radiculopathy, including the Spurling Maneuver. The authors state:

“There should be a strong suspicion for cervical angina in any patient with inadequately explained noncardiac chest pain, especially, when neurologic signs and symptoms are present.”

“A greater awareness of this unusual radiating pattern for cervical pathology will hopefully lead to early diagnosis and a recognition that this symptom pattern is not due to dual clinical entities but unified by the diagnosis of cervical angina.”

Lastly, the authors indicate the value of conservative management of these patients, stating:

“The majority of patients with cervical angina from cervical radiculopathy will respond to conservative care.”

••••

In 2021, a study was published in the Asian Spine Journal, titled (9):

Cervical Angina:
A Literature Review on Its Diagnosis, Mechanism, and Management

The authors were from the Department of Spine Surgery, Renji Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China. They state:

“Cervical angina has been defined as chest pain that resembles true cardiac angina but originates from the disorders of the cervical spine.” 

“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.”

“Cervical angina appears to be a relatively unknown clinical syndrome compared with other angina symptoms.”

“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.” 

“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).”

The authors indicate that patients with cervical angina often present with anterior chest pain that is exacerbated by cervical range of motion or movement of the upper extremity. The patient may also have neck pain, upper arm radicular symptoms (weakness or sensory changes), and occipital headaches.

Consistent with above (8), cervical angina patients have a positive Spurling’s maneuver.

The Sympathetic Nervous System

Consistent with the studies cited above (6, 8), these authors discuss involvement of the sympathetic nervous system, stating:

“More than half of patients have been identified to experience autonomic symptoms such as dyspnea, nausea, vertigo, diplopia, and other sympathetic nervous signs.”

“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.”

The authors indicate that irritation of the sympathetic fibers that travel in the anterior root or from the plexus of sympathetic fibers are also anatomically associated with the longus colli muscle.

Diagnostic Suggestions and Precautions

The authors note that degenerative changes of the cervical joints are frequently found in the asymptomatic population, and functional tests (discography, selective nerve root block) may help to confirm the etiology of cervical angina. However, they also caution that discography and/or selective nerve root blocks are “invasive tests, which are not risk-free, [and] should be considered carefully and only applied in patients contemplating surgery.”

They also note:

“Varying degrees of cardiac workups must be performed in order to rule out true angina pectoris.”

“Cervical imaging can be critical evidence in the diagnosis of cervical angina once coronary artery disease has been adequately ruled out.”

“MRI may demonstrate degenerative changes in the cervical spine, including herniated disk, spinal cord compression, or foraminal encroachment.”

Joints of Luschka

The joints of Luschka are also known as the uncinate process. It has been suspected that cervical angina is linked to these joints. The joints of Luschka can irritate the anterior nerve root, causing diffuse pain; this pain is not clearly radicular but is less discrete. The authors state:

“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.” 

“Luschka’s joint osteophytes may be one of pathogenic factors in cervical angina.”

The authors do not detail the clinical management of cervical angina, but do make these comments:

“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.”

They note that if the surgical option is used, the best long-term benefits use the anterior cervical discectomy and fusion approach.

Chiropractic Care for Cervical Angina

In 2005, an article was published in the Journal of Manipulative Physiological Therapeutics, titled (10):

Manual Therapy for Patients with Stable Angina Pectoris:
A Nonrandomized Open Prospective Trial

The objective of this study was to examine if participants with chest pain originating from the spine would benefit from manual therapy. It is a prospective clinical trial. It involved 50 subjects who were cleared of cardiac involvement following coronary angiography. These subjects were given standard chiropractic care. Assessment used the 11-point box scale and the Short Form 36 quality of life tool. The follow-up period was 4 weeks.

Approximately 75% of the patients reported improvement of pain and of general health after treatment. The authors concluded:

“This study suggested that patients with known or suspected angina pectoris and a diagnosis of cervical angina may benefit from chiropractic manual therapy.”

••••

In 2012, another study was published in the Journal of Manipulative Physiological Therapeutics, titled (11):

Chiropractic Treatment vs Self-management in Patients with Acute Chest Pain:
A Randomized Controlled Trial of Patients Without Acute Coronary Syndrome

The authors were from the Nordic Institute of Chiropractic and Clinical Biomechanics and Institute of Sports Science and Clinical Biomechanics, University of Southern Denmark. The purpose of the present study is to evaluate the relative effectiveness of two treatment approaches for acute musculoskeletal chest pain:

• Chiropractic treatment that included spinal manipulation
• Self-home management

This is a randomized, controlled trial that used 115 patients with chest pain, set at an emergency cardiology department and 4 outpatient chiropractic clinics. The clinical trial involved 4 weeks of chiropractic treatment or self-management, with post-treatment assessment 4 and 12 weeks later. The authors found:

“Observed between-group significant differences were in favor of chiropractic treatment at 4 weeks regarding the primary outcome of self-perceived change in chest pain and at 12 weeks with respect to the primary outcome of numeric change in pain intensity.”

••••

In 2022, an article was published in the Journal of Medical Cases, titled (12):

Cervical Radiculopathy as a Hidden Cause of Angina:
Cervicogenic Angina

Journal of Medical Cases
November 2022; Vol. 13; No. 11; pp. 545-550

The author presented a case report of a 56-year-old man with non-traumatic chest pain and chronic neck pain for 2 years, as well as numbness in his right third and fourth fingers for 6 months. The patient was medically diagnosed with cervical radiculopathy, and he was treated with analgesics and physical therapy. These treatments had only provided temporary improvement over a period of 6 months. The patient then sought chiropractic care. Three months of chiropractic care completely resolved all symptoms.

The author notes that 77% of the patients with chest pain symptoms presenting to the emergency department are not cardiac related. He states:

“Cervicogenic angina is defined as paroxysmal angina-like pain that originates from the disorders of the cervical spine or other neck structures.”

“Chiropractic care aims to alleviate neck pain, improve cervical alignment, restore cervical mobility, and prevent neurological damage.”

Patient examination showed reduced neck movement, a positive Spurling test (consistent with above studies 8, 9), and hypoesthesia in the right C7 dermatome. Cervical x-rays showed degenerative spondylosis with right C5/C6 neuroforaminal stenosis and bilateral C6/C7 neuroforaminal stenosis.

Chiropractic management of this case included cervical manipulation and neck traction. Treatment was given 3 times per week for 4 weeks, then reduced to 2X per week for 8 weeks. The authors found:

“After 3 months, the patient reported that the chest pain, neck pain, and radicular symptoms had completely resolved.”

“Analgesic medicines were discontinued, and the patient received monthly chiropractic maintenance care.”

“He is currently pain-free.”

Summary

These studies inform the reader that chest pain is often not caused by a heart problem; it may be caused by inflammation-irritation-compression of the cervical nerve roots, often secondary to cervical spondylotic changes. The authors insist that in patients with chest symptoms, a cardiac etiology should be ruled out. The musculoskeletal evaluation should include radiography, motor and sensory assessments, and the Spurling’s maneuver. Chiropractic care is very often successful at managing these patients and in helping them avoid a surgical intervention.

References:

1. Khan MAB, Hashim MJ, Mustafa H Baniyas Y, and eight more; Global Epidemiology of Ischemic Heart Disease: Results from the Global Burden of Disease Study; Cureus; July 23, 2020; Vol. 12; No, 7; Article e9349.
2. https://www.mayoclinic.org/diseases-conditions/acute-coronary-syndrome/symptoms-causes/syc-20352136 Accessed 11/5/24’
3. Phillips J; The Importance of Examination of the spine in the presence of Intrathoracic or Abdominal Pain; Proceedings International Postgraduate MA North American; 1927; Vol. 3; p 70.
4. Ollie JA; Differential Diagnosis of Pain in the Chest; The Canadian Medical Association Journal; September 1937; Vo. 37; No. 3; pp. 209-216.
5. Booth RE, Rothman RH; Cervical Angina; Spine; March 1976; Vol. 1; No, 1; pp. 28-32.
6. Shimizu M, Mono Y, Okuno M, Kuranobu K, Yamamoto K; Clinical Study of Cervical Angina; Orthopedics & Traumatology; November 25, 1991; Vol. 40; No. 1; pp. 149-151.
7. Neuwirth E; Current Concepts of the Cervical Portion of the Sympathetic Nervous System; Lancet; July 1960; pp. 337-338.
8. Sussman WI, Makovitch SA, Merchant SHI, Jayant Phadke J; Cervical Angina: An Overlooked Source of Noncardiac Chest Pain; Neurohospitalist January 2015; Vol. 5; No. 1; pp. 22-27.
9. Feng F, Chen X, Shen H; Cervical Angina: A Literature Review on Its Diagnosis, Mechanism, and Management; Asian Spine Journal; August 2021; Vol. 15; No. 4; pp. 550-556.
10. Christensen HW, Vach W, Gichangi A, Manniche C, Haghfelt T, Hoilund-Carlsen PF; Manual Therapy for Patients with Stable Angina Pectoris: A Nonrandomized Open Prospective Trial; Journal of Manipulative Physiological Therapeutics; Nov-Dec 2005; Vol. 28; No. 9; pp. 654-61.
11. Stochkendahl MJ, Christensen HW, Vach W, Hoilund-Carlsen PF, Haghfelt T, Hartvigsen J; Chiropractic Treatment vs Self-management in Patients with Acute Chest Pain: A Randomized Controlled Trial of Patients Without Acute Coronary Syndrome; Journal of Manipulative Physiological Therapeutics; January 2012; Vol. 35; No. 1; pp. 7-17.
12. Chu ECP; Cervical Radiculopathy as a Hidden Cause of Angina: Cervicogenic Angina; Journal of Medical Cases; November 2022; Vol. 13; No. 11; pp. 545-550.