CERVICOBRACHIAL PAIN SYNDROMES

Pain guide

A large group of articular and extra-articular disorders is characterized by pain that may involve simultaneously the neck, shoulder girdle, and upper extremity. Diagnostic differentiation is often difficult. Some of these entities and clinical syndromes represent primary disorders of the cervicobrachial region; others are local manifestations of systemic disease. The clinical picture is further complicated when 2 or more of these conditions occur coincidentally.

Clinical Findings

A. Symptoms and Signs: Neck pain may be limited to the posterior neck region or, depending upon the level of the symptomatic joint, may radiate segmentally to the occiput, anterior chest, shoulder girdle, arm, forearm, and hand. It may be intensified by active or passive neck motions. The general distribution of pain and paresthesias corresponds roughly to the involved dermatome in the upper extremity. Radiating pain in the upper extremity is often intensified by hyperextension of the neck and deviation of the head to the involved side. Limitation of cervical movements is the most common objective finding. Neurologic signs depend upon the extent of compression of nerve roots or the spinal cord. Compression of the spinal cord may cause long-tract involvement resulting in paraparesis or paraplegia.

B. Imaging: The radiographic findings depend on the cause of the pain; many are completely normal. An early finding is loss of the normal anterior convexity of the cervical curve (loss of cervical lordosis). Comparative reduction in height of the involved disk space is a frequent finding. The most common late x-ray finding is osteophyte formation anteriorly, adjacent to the disk; other late changes occur around the apophyseal joint clefts, chiefly in the lower cervical spine. Computer-assisted myelography is a valuable radiographic means of demonstrating nerve root or spinal cord compression; MRI may be preferable but is less apt to be available.

Differential Diagnosis & Treatment

The causes of neck pain include acute and chronic cervical strain or sprains, hemiated nucleus pulposus, osteoarthritis, ankylosing spondylitis, rheumatoid arthritis, osteomyelitis, neoplasms, spinal stenosis, compression fractures, and functional disorders.

A. Acute or Chronic Cervical Musculotendinous Strain: Cervical strain is generally caused by mechanical postural disorders, overexertion, or injury (eg, whiplash). Acute episodes are associated with pain, decreased cervical spine motion, and paraspinal muscle spasm, resulting in stiffness of the neck and loss of motion. Muscle trigger points can often be localized. Management includes neck and head immobilization by traction, a cervical collar, and administration of analgesics. Gradual return to full activity is encouraged.

Patients with chronic symptoms often have few objective findings. Mechanical stress due to work or recreational activities is often implicated. Chronic pain, especially that radiating into the upper extremity, may require additional treatment such as bracing.

B. Herniated Nucleus Pulposus: Rupture or prolapse of the nucleus pulposus of the cervical disks into the spinal canal causes pain that radiates to the arms at the level of C6-7. When intra-abdominal pressure is increased by coughing, sneezing, or other movements, symptoms are aggravated, and cervical muscle spasm may often occur. Neurologic abnormalities may include decreased reflexes of the deep tendons of the biceps and triceps and decreased sensation and muscle atrophy or weakness in the forearm or hand. Cervical traction, bed rest, and other conservative measures are usually successful. Myelography or electromyography help delineate lesions that may require surgical treatment (laminectomy, fusion). Chemonucleolysis is not a useful treatment alternative in cervical disk disease.

C. Arthritic Disorders: Cervical spondylosis (degenerative arthritis) is a collective term describing degenerative changes that occur in the apophyseal joints and intervertebral disk joints, with or without neurologic signs. Osteoarthritis of the articular facets is characterized by progressive thinning of the cartilage, subchondral osteoporosis, and osteophytic proliferation around the joint margins. Degeneration of cervical disks and joints may occur in adolescents but is more common after age 40. Degeneration is progressive and is marked by gradual narrowing of the disk space, as demonstrated by x-ray. Osteocartilaginous proliferation occurs around the margin of the vertebral body and gives rise to osteophytic ridges that may encroach upon the intervertebral foramens and spinal canal, causing compression of the neuro-vascular contents. A large anterior osteophyte may occasionally cause dysphagia.

Ankylosing spondylitis.  Rheumatoid arthritis can mimic ankylosing spondylitis, with intervertebral disk and connective tissue involvement. Atlantoaxial subluxation may occur in patients with rheumatoid arthritis, regardless of the severity of disease. Inflammation of the synovial structures resulting from erosion and laxity of the transverse ligament can lead to neurologic signs of spinal cord compression. Treatment may vary from use of a cervical collar or more rigid bracing to operative treatment, depending on the degree of subluxation and neurologic progression. Surgical treatment may involve stabilization of the cervical spine.

D. Other Disorders: Osteomyelitis; neoplasms; compression, fractures and osteoporosis; and functional disorders on.

Pain guide