Cervical spondylosis is a disease in which cervical spine osteophytes, calcification of the collateral ligament and degenerative changes in the cervical discs irritate or compress the cervical nerves, crestal medulla and blood vessels, resulting in a series of symptoms and signs. Clinically, there are five types of cervical spondylosis, among which the incidence of neurogenic cervical spondylosis is the highest. Symptoms are neck pain and neck stiffness, which may be accompanied by soreness and discomfort in the interscapular region of the back of the shoulder, or sensory and motor deficits and reflex changes consistent with the distribution area of the nerve roots, and pain that increases with neck movement, coughing, sneezing, exertion and whistling. Most physicians are familiar with the pain and numbness symptoms of neurogenic cervical spondylosis, but overlook the fact that other diseases can also cause these symptoms. If a patient has a combination of degenerative changes seen in cervical spine imaging, it is very easy to misdiagnose other diseases as neurogenic cervical spondylosis clinically, and some even receive cervical spine surgery, causing great harm to patients. In this paper, we have compiled several systemic diseases that have been misdiagnosed as neurogenic cervical spondylosis at home and abroad, which are summarized as follows: 1. Whistling system diseases misdiagnosed as neurogenic cervical spondylosis Lung cancer has complex extrapulmonary manifestations with insidious onset, and many lung cancer patients lack whistling tract symptoms at the first visit. Cai Hongtao et al. reported that lung cancer with brachial plexus nerve damage as the first manifestation was misdiagnosed as neurogenic cervical spondylosis at the initial diagnosis and later confirmed as suprapulmonary sulcus carcinoma after cytological and imaging examinations. Suprapulmonary sulcus carcinoma is often associated with burning pain mainly in the axilla and radiating medially to the upper extremity, especially at night, due to tumor compression of the brachial plexus nerve. It is similar to the symptoms of neurogenic cervical spondylosis. Clinically, such patients must be asked for detailed medical history, whether there are concomitant symptoms such as chronic cough, weight loss, loss of appetite, Horner’s sign or bone pain caused by extrathoracic metastasis, pathological fracture, etc. If no abnormality is seen in the routine chest orthopantomogram, do not hastily exclude the chest tumor, and make sure to perform further chest CT examination to exclude the tumor lesions <5mm that cannot be found in the lung apical x-ray. 2. Circulatory system diseases misdiagnosed as neurogenic cervical spondylosis Circulatory system diseases such as angina pectoris, myocardial infarction, pericarditis, atherosclerotic occlusive disease, thromboembolic vasculitis, etc. can also present with symptoms such as pain and numbness in the neck, shoulder and upper limbs. It is sometimes misdiagnosed. Wang Qiongfen et al. reported a case of acute myocardial infarction misdiagnosed as neurogenic cervical spondylosis, in which the patient presented with neck and shoulder pain with numbness and swelling in the left upper limb, which was easily confused with neurogenic cervical spondylosis. Myocardial infarction is often characterized by pain following the middle or upper part of the sternal body as the main manifestation. This pain responds to the area distributed by the cremaster nerve in the same cremaster segment as the level of autonomic nerve entry, i.e., behind the sternum and in the anteromedial and little fingers of both arms, especially on the left side. In contrast, neurogenic cervical spondylosis also often presents clinically with symptoms such as numbness and pain in the left upper extremity along the distribution of the compressed nerve. Therefore, we should be alert to some infarction patients with non-thoracic pain as the main manifestation and should not easily diagnose them as neurogenic cervical spondylosis. Acute fibrinous pericarditis often manifests as pain in the precordial region, which may radiate to the neck, left shoulder, left arm and left scapula, and the pain is often associated with whistling. Upper extremity atherosclerotic occlusive disease presents with pain, numbness, weakness and dystrophic changes in the upper extremities, and asymmetric, diminished or absent arterial pulsations in the extremities. Thromboembolic vasculitis is often accompanied by recurrent episodes of superficial phlebitis and Raynaud's phenomenon. These diseases are not easily misdiagnosed after careful examination. 3. Misdiagnosis of digestive system diseases as neurogenic cervical spondylosis Hepatocellular carcinoma has an insidious onset and may be asymptomatic in the early stage, but once symptoms appear, the disease has mostly entered the middle and late stage. The phrenic nerve is mainly composed of the cervical 4 nerves, which innervate not only the diaphragm but also the right adrenal gland and the peritoneum above the liver. If the tumor is located at the top of the diaphragm in the right lobe of the liver, the pain may radiate to the right shoulder or right back. Wei Liangqu et al. reported a case of hepatocellular carcinoma misdiagnosed as cervical spondylosis, probably as a result of convergence of both visceral afferent nerve fibers and afferent nerve fibers of the crural nerve in the posterior horn of the crural medulla as well as in the process of polysynaptic transmission, leading to involvement pain in the right shoulder and back. 4. Endocrine and metabolic diseases are misdiagnosed as neurogenic cervical spondylosis Peripheral neuropathy in diabetic complications can manifest as sensory abnormalities in the upper extremities. Most patients have a long history of the disease, and the abnormal sensation in the extremities is mostly symmetrical and can be accompanied by nociceptive hypersensitivity, pain or dystrophic changes. Diabetes, smoking, alcohol consumption, rheumatoid arthritis and hypothyroidism are usually considered risk factors for peripheral nerve entrapment, and patients with these diseases or bad habits who develop peripheral nerve entrapment are easily misdiagnosed as neurogenic cervical spondylosis. 5. Peripheral nervous system diseases are misdiagnosed as neurogenic cervical spondylosis Peripheral nerve entrapment can cause inflammatory reactions in peripheral nerves, manifesting as different degrees of motor and sensory disorders in the innervated area. For example, elbow tunnel syndrome, carpal tunnel syndrome, ulnar tunnel syndrome, anterior rotator muscle syndrome and interosseous anterior nerve entrapment syndrome. The anterior rotator teres syndrome can present with sensory deficits in the muscles of the radial three and a half fingers and the median nerve innervation area similar to those seen in C6-C7 radicular cervical spondylosis, and the affected muscles include the anterior rotator teres and radial carpal flexors. The muscles of the radial innervation zone (wrist extensors and triceps brachii) are not affected by C6 and C7 radicular cervical spondylosis. Interosseous anterior nerve entrapment results in pain in the proximal forearm and weakness of the long thumb flexors, anterior rotators, and deep index finger flexors, but no sensory disturbance. In contrast, C8 nerve root cervical spondylosis will have sensory deficits in addition to the above symptoms. From a motor point of view, true C8 radicular cervical spondylosis is characterized by weakness of all ulnar nerve innervated muscles. In elbow canal syndrome, the flexor digitorum longus and minimus muscles and the median nerve innervated index and middle fingers are not involved, whereas C8 or T1 radicular cervical spondylosis can involve these muscles. Typical entrapment in ulnar canal syndrome manifests as involvement of the superficial and deep branches of the ulnar nerve, resulting in decreased sensation in one and a half fingers on the ulnar side. Sensation in the dorsal aspect of these fingers is not affected because the nerves innervating these areas do not pass through the ulnar canal. Motor involvement is consistent with the deep branches of the ulnar nerve innervating the muscles. The radial nerve is usually susceptible to entrapment by a number of structures at the elbow, usually its motor branch (interosseous dorsal nerve). This is similar to cervical spondylosis with involvement of the C7 nerve root, but without sensory changes and involvement of the triceps or wrist flexors. Thoracic outlet syndrome usually causes abnormalities in the area innervated by the lower trunk of the brachial plexus (median and ulnar nerves), but of course both vascular and neurogenic causes may be present. Thoracic outlet syndrome should be considered more often if there is a vascular murmur, asymmetrical pulses, and atrophy of the masseter muscle heavier than the interosseous muscle. Imaging findings of cervical ribs should be considered more for thoracic outlet syndrome and less for the diagnosis of C8 or T1 neurogenic cervical spondylosis. 6. Rheumatic immune diseases are misdiagnosed as neurogenic cervical spondylosis Rheumatic polymyalgia is a group of clinical syndromes characterized by significant pain and morning stiffness in the neck, scapular girdle and pelvic girdle muscles, accompanied by increased blood sedimentation. The early symptoms of the disease are non-specific, and its main manifestations of neck, shoulder, back and lumbar pain and inconvenience in movement are also common in other diseases. Such as: cervical spondylosis, rheumatoid arthritis, etc. Zhang Yaping et al. reported that 15 cases of rheumatic polymyalgia had been misdiagnosed in the clinical analysis of 19 cases. Symmetrical proximal muscle weakness is a characteristic manifestation of polymyositis, and about half of the patients have both myalgia and myalgia, which is easily confused with neurogenic cervical spondylosis, and it is not difficult to identify through detailed history, physical examination and combined with neurophysiological examination. 7. Other diseases are misdiagnosed as neurogenic cervical spondylosis Acute brachial plexus neuritis is a rare clinical disease characterized by severe burning-like pain in the back of the shoulder and upper limbs in the early stage, with the pain gradually decreasing over time and the gradual appearance of muscle weakness in the upper limbs, which mostly attacks 2-3 nerve roots. In contrast, neurogenic cervical spondylosis mostly involves a single nerve root, and symptoms such as pain and numbness consistent with the distribution of the affected nerve root dermatomes appear. Both neurogenic cervical spondylosis and herpes zoster of the neck and shoulder have pain distributed along the nerve roots in the early stages. The former is caused by compression of the cervical nerve roots due to various factors; the latter is caused by herpes zoster virus latent in the neurons of the posterior roots of the cremaster nerve or ganglion, which grows and multiplies when the body's resistance is weakened, leading to inflammation or necrosis of the ganglion. In the absence of cutaneous manifestations, early diagnosis is often difficult. Cui Hongpeng et al. reported a case of early misdiagnosis of herpes zoster as neurogenic cervical spondylosis. Herpes zoster usually appears 1-4 d after the onset of generalized or localized prodromal pain symptoms with small blisters or papules arranged in bands along the nerve roots, and is easily misdiagnosed as neurogenic cervical spondylosis at an early stage if the patient also has degenerative changes in the imaging of the cervical spine and systemic symptoms are not obvious. In contrast, patients with herpes zoster most often have a history of viral infection, long-term application of glucocorticoids or immunosuppressive agents, or the patient has some kind of immunocompromising disease prior to the onset of pain or herpes, and this information is obtained to help differentiate from neurogenic cervical spondylosis. Usually, most malignant tumors result in bilateral cremaster symptoms, and unilateral cremaster symptoms can be seen in osteochondromas that develop from structures behind the cremaster. In contrast, nerve sheath meningiomas from the nerve sheath can also present with unilateral nerve root symptoms, often progressing to cremaster symptoms. Extradural causes of radicular symptoms can result from direct spread of tumors of the thyroid, esophagus, and pharynx. Reflex upper extremity radicular symptoms can also result from direct compression secondary to nodal disease and arteriovenous fistula. The cervical spine is less frequently affected by Brucella infestation, and the early stage of the disease may be without the typical wave fever and other febrile patterns, or even without fever and night sweats, but with neck and shoulder and upper extremity pain as the first symptoms. german et al. reported that cervical Brucella cruris progresses rapidly and is more likely to compress the cremaster and nerves, requiring early diagnosis. Other diseases such as neurosis, reflex sympathetic dystrophy, cervical spine infection, Lyme disease, etc. are easily distinguished from neurogenic cervical spondylosis by detailed history taking, physical examination and various ancillary tests. When diagnosing neurogenic cervical spondylosis, it is necessary to have a broad thinking and not to be influenced by the stereotype of thinking, which is limited to explaining the patient's disorder within the scope of this disease. A detailed history should be taken, a thorough physical examination should be performed and reasonable ancillary tests should be performed. Neurophysiological tests can directly reflect the functional impairment of nerve roots and can be quantitatively analyzed according to the functional impairment status. Myelin and axonal degeneration caused by nerve root compression leads to slowing of conduction velocity, prolongation of latency, and reduction of evoked potential wave amplitude of the corresponding peripheral nerve, while abnormal potentials may appear in the corresponding segmental muscles innervated by the nerve root, and the time limit of motor unit potentials is widened and wave amplitude is increased, showing signs of neurogenic damage. Imaging examination is a common clinical examination means, and various imaging signs have important reference value for the diagnosis of cervical spondylosis, but degenerative changes of the cervical spine seen by imaging examination alone should not be diagnosed as cervical spondylosis, and some doctors in the clinic rely excessively on cervical spine X-ray, CT or MRI, and make the diagnosis of neurogenic cervical spondylosis hastily as long as there are degenerative changes, without considering whether the patient presents symptoms of the shoulder back or upper limb The diagnosis of neurogenic cervical spondylosis is made hastily as long as degenerative changes are present, without considering whether the area where the patient presents symptoms of the shoulder and back or upper extremity coincides with the imaging manifestations, and without caring whether the patient has a previous history of tuberculosis or tumor, resulting in frequent misdiagnosis. In conclusion, neurogenic cervical spondylosis is very easy to be confused with other diseases, and the correct diagnosis can be made only by mastering the knowledge of various related diseases, making full use of various auxiliary examinations, and synthesizing the patient's symptoms, signs, past history, medical history and auxiliary examination data to make a comprehensive reference.