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The facial paresis generally comes on abruptly, but it may worsen over the following day or so Pain about the ear precedes or accompanies the weakness in many cases but usually lasts for only a few days The face itself feels stiff and pulled to one side There may be ipsilateral restriction of eye closure and difficulty with eating and fine facial movements A disturbance of taste is common, owing to involvement of chorda tympani fibers, and hyperacusis due to involvement of fibers to the stapedius occurs occasionally

A variety of congenital abnormalities may involve the cervical spine and lead to neck pain; these include hemivertebrae, fused vertebrae, basilar impression, and instability of the atlantoaxial joint Traumatic, degenerative, infective, and neoplastic disorders may also lead to pain in the neck When rheumatoid arthritis involves the spine, it tends to affect especially the cervical region, leading to pain, stiffness, and reduced mobility; displacement of vertebrae or atlantoaxial subluxation may lead to cord compression that can be lifethreatening if not treated by fixation Further details are given in 20 (including a discussion on low back pain), and discussion here is restricted to disk disease

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Other disorders that can produce a facial palsy and require specific treatment, such as tumors, Lyme disease, AIDS, sarcoidosis, and herpes zoster infection of the geniculate ganglion, must be excluded The management of Bell s palsy is controversial Approximately 60% of cases recover completely without treatment, presumably because the lesion is so mild that it leads merely to conduction block Considerable improvement occurs in most other cases, and only about 10% of all patients have permanent disfigurement or other longterm sequelae Treatment is unnecessary in most cases but is indicated for patients in whom an unsatisfactory outcome can be predicted The best clinical guide to progress is the severity of the palsy during the first few days after presentation Patients with clinically complete palsy when first seen are less likely to make a full recovery than those with an incomplete one A poor prognosis for recovery is also associated with advanced age, hyperacusis, and severe initial pain Electromyography and nerve excitability or conduction studies provide a guide to prognosis but not early enough to aid in the selection of patients for treatment The only medical treatment that may influence the outcome is administration of corticosteroids, but this is unclear Many clinicians nevertheless routinely prescribe corticosteroids for patients with Bell s palsy seen within 5 days of onset The author prescribes them only when the palsy is clinically complete or there is severe pain Treatment with prednisone, 60 or 80 mg daily in divided doses for 4 or 5 days, followed by tapering of the dose over the next 7 10 days, is a satisfactory regimen It is helpful to protect the eye with lubricating drops (or lubricating ointment at night) and a patch if eye closure is not possible It is unclear whether acyclovir or other antiviral agents confer any benefit There is no evidence that surgical procedures to decompress the facial nerve are of benefit.

Gilden DH Clinical practice Bell s palsy N Engl J Med 2004 Sep 23;351(13):1323 31 [PMID: 15385659]

Acute cervical disk protrusion leads to pain in the neck and radicular pain in the arm, exacerbated by head movement With lateral herniation of the disk, motor, sensory, or reflex changes may be found in a radicular (usually C6 or C7) distribution on the affected side (Figure 24 1); with more centrally directed herniations, the spinal cord may also be involved, leading to spastic paraparesis and sensory disturbances in the legs, sometimes accompanied by impaired sphincter function The diagnosis is confirmed by MRI or CT myelography In mild cases, bed rest or intermittent neck traction may help, followed by immobilization of the neck in a collar for several weeks If these measures are unsuccessful or the patient has a significant neurologic deficit, surgical removal of the protruding disk may be necessary

Cervical spondylosis results from chronic cervical disk degeneration, with herniation of disk material, secondary calcification, and associated osteophytic outgrowths One or more of the cervical nerve roots may be compressed, stretched, or angulated; and myelopathy may also develop as a result of compression, vascular insufficiency, or recurrent minor trauma to the cord Patients present with neck pain and restricted head movement, occipital headaches, radicular pain and other sensory disturbances in the arms, weakness of the arms or legs, or some combination of these symptoms Examination generally reveals that lateral flexion and rotation of the neck are limited A segmental pattern of weakness or derma-

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