Approach to the Patient with Neck Pain and/or Arm Pain
Scott A. Shapiro
I. TRAUMATIC NECK PAIN WITHOUT ARM PAIN
A. Introduction.
Trauma to the neck secondary to a motor vehicle accident, work-related injury, or athletic injury is a common cause of musculoskeletal neck pain. In the vast majority of patients, post-traumatic neck pain is a self-limited problem that is not serious.
B. Etiology.
Straining of anterior/posterior cervical muscles and tendons is the mechanism of pain for most post-traumatic neck pain syndromes. The most common cause in clinical practice is vehicular accidents with hyperextension/flexion to the neck (whiplash). Altercations, athletic injuries (especially football), and lifting/tugging work injuries also occur.
C. Evaluation.
1. History and physical examination.
The primary complaints are post-traumatic neck pain and neck stiffness. The paracervical muscles are tender with limitation of motion, spinous process point tenderness may be present and there may be some associated interscapular pain and headache. Complaints of patchy arm numbness are occasionally reported but the neurologic exam is normal for the vast majority of patients.
2. Radiographs.
Plain X-rays rule out most fractures and ligamentous instability. In the under-40 age group, the most common finding is loss of the lordotic curve from muscle spasm. In the over-40 age group, X-rays often show degenerative changes such as narrowed disc spaces and osteophyte (bone spur) formation. The accident is not the cause of these X-ray changes but certainly these changes can predispose the patient to more pain than a normal spine.
CT scan/MRI scan. Any clinical or radiographic evidence for acute fracture, subluxation (instability), or spinal cord injury requires a thorough evaluation including a cervical CT scan, consultation with a spine specialist and, more often than not, a cervical MRI scan.
D. Referral.
1. First 2 to 3 weeks (medicate and wait).
Soft collar. Post-traumatic neck pain will usually subside on its own over a week or. A narrow soft cervical collar can be helpful in taking the weight of the head off the neck and transferring it to the shoulders. The collar should not be so tall that it forces that patient into hyperextension, which is uncomfortable.
Medication. Over the counter nonsteroidal anti-inflammatory medication (ibuprofen) with/without acetaminophen is the ideal analgesic. Other analgesics, such as propoxyphene, codeine, or codeine analogs, are acceptable but no schedule-3 narcotics, such as oxycodone, demerol, or morphine, should be used. Muscle relaxants such as Robaxin (methocarbamol) 500 mg P.O. every 6 to 8 hours, Flexeril (cyclobenzaprine) 10 mg P.O. three times a day, or Parafon Forte (chlorzoxazone) 500 mg P.O. every 6 to 8 hours can help. Do not use benzodiazepines due to the abuse potential. In the patient whose stomach is sensitive to nonsteroidal medication, an evening dose of an H-2 receptor blocker such as cimetidine 300 to 600 mg P.O. can help prevent gastritis.
Time-off from work. Desk-bound workers with mild to moderate neck pain can work, and most ambitious people are able to function. Heavy laborers may benefit from light duty or 1 to 2 weeks off work. Beware of patients who exhibit symptom magnification and functional overlay due for purposes of secondary gain (worker’s compensation and litigation). They have the tendency to abuse time-off work. In these scenarios, early referral to a physical medicine and rehabilitation specialist who can scientifically assess for malingering may be helpful.
2. Weeks 3 to 6 if pain still present.
Physical therapy. If the neck pain does not subside after 2 weeks, physical therapy—heat, ultrasound, massage, and transcutaneous electrical nerve stimulation (TENS)—is reasonable.
Pain clinic. Trigger point injections of anesthetic/steroid can be helpful but are probably best scheduled after evaluation by a spine specialist.
3. After 6 to 8 weeks.
When neck pain persists after 6 to 8 weeks, despite rest and therapy, and the pain remains severe enough to interfere with work or recreation, the next diagnostic test should be a cervical MRI scan to evaluate the cervical discs. Usually the study is normal or shows mild cervical disc dehydration with disc bulging. Neck pain from cervical disc dehydration can best be treated by cervical traction. Minor cervical disc bulging presenting with chronic pain, with a normal neurologic exam, is rarely sufficient indication for surgery. At this point, it is best to get the opinion of a neurosurgeon.
II. NONTRAUMATIC NECK PAIN OF ARTHRITIC ORIGIN
A. Introduction.
Neck pain from degenerative arthritis of the neck is of epidemic proportion (60% to 80%) in the elderly population.
B. Etiology.
Degenerative arthritis of the cervical spine occasionally manifests itself as early as the third decade of life but is much more common with increasing age. Disc dehydration and disc space narrowing with osteophyte formation is a process that occurs naturally with age. Facet arthritis also occurs. Small nerve fibers innervating the disc and facet can be involved leading to neck pain. Dural impingement by osteophytes can also produce neck pain—especially with extension or lateral gaze.
C. Evaluation.
1. History and physical examination.
Nontraumatic neck pain in the over 40 age group is most often secondary to cervical degenerative arthritis. The pain is gradual in onset and initially intermittent and then becomes more constant. There can be associated occipital headache and interscapular pain. Motion, especially extension or lateral gaze, can aggravate the pain.
2. Radiographs.
X-rays show narrowing of disc spaces with bone spur formation. At least 70% of the populations over the age of 65 have significant changes of degenerative arthritis. Regardless of how bad the X-rays look, if the patient is neurologically normal, MRI or surgery is not absolutely indicated.
D. Referral.
1. Medication. (Same as for traumatic neck pain.)
2. Physical therapy.
Heat, ultrasound, massage, and TENS unit therapy can help.
3. Pain clinic.
Trigger point injections can help.
4. Alternative therapies.
Although chiropractors can help many people, we cannot advocate manipulation of the neck when obvious bone spurs exist. Neurologic catastrophes and lawsuits have occurred. Patients can seek chiropractic care at their own risk. Recently, magnets have become popular in relieving arthritic complaints with some scientific credence. Finally, oral glucosamine has been shown somewhat effective against arthritis, although its effect on cervical spondylosis remains to be determined.
5. Spine specialists.
In the majority of patients with neck pain and no arm pain, surgery is not indicated. The removal of large osteophytes ventral to the spinal cord can improve severe neck pain, occipital headache, and actually improve the range of motion. Only an experienced spinal surgeon should make this decision based on a CT scan/MRI scan and repetitive physical exams over a period of time.
III. NECK PAIN WITH ARM PAIN (RADICULOPATHY) FROM SOFT CERVICAL DISC BULGES/HERNIATIONS
A. Etiology.
In the under-50 age group, the most common cause will be a single-level soft cervical disc. The concept of a soft cervical disc means either an eccentric disc bulge or a free fragment herniation compressing a root. A disc consists of an inner water-laden
mucoid nuclear material and an outer fibrous annulus. The annulus can fissure, allowing the nucleus either to bulge or to herniate out. There is no osteophyte involved in the compression. The posterior longitudinal ligament extends beneath the entire spinal cord, protecting the cord from disc herniation, and so a disc herniation primarily projects laterally into the foramen, compressing the nerve only. In rare cases, sufficient force, such as in trauma, can lead to a large disc herniation, causing an acute myelopathy.
mucoid nuclear material and an outer fibrous annulus. The annulus can fissure, allowing the nucleus either to bulge or to herniate out. There is no osteophyte involved in the compression. The posterior longitudinal ligament extends beneath the entire spinal cord, protecting the cord from disc herniation, and so a disc herniation primarily projects laterally into the foramen, compressing the nerve only. In rare cases, sufficient force, such as in trauma, can lead to a large disc herniation, causing an acute myelopathy.
B. Anatomy.
A disc is named by the bordering vertebral bodies. Thus, the disc between vertebral bodies C5 and C6 is named the C5-C6 disc. The nerve root whose number corresponds to that of a given vertebral body exits above that body’s pedicle. Thus a C5-C6 disc compresses the C6 nerve root.
C. Evaluation.
1. History.
In the classic story, there is intermittent neck pain and then severe neck pain, and arm pain develop. Rarely is this condition traumatic in origin. The pain radiates down the shoulder and into the arm. There are some dermatomal patterns of radiation that can help discern the level of herniation. Patients may complain of various combinations of suboccipital headache, interscapular pain, numbness, tingling, and weakness. The pain often awakens the patient from sleep.
2. Physical exam.
Neck exam. There is posterior tenderness, especially tenderness at the spinous process near the level of involvement and paracervical tenderness. Painful limitation of motion with extension and lateral gaze to the side of arm pain is classic.
Arm exam.
C5 radiculopathy (C4-C5 disc herniation) presents with pain and numbness radiating to the shoulder along with a weak deltoid muscle (shoulder abduction). Simultaneous testing of both deltoid muscles by compression on the outstretched upper arms detects minor weakness (Table 22.1). There is no true muscle stretch reflex to test.
C6 radiculopathy (C5-C6 disc herniation). C5-C6 disc herniation is the second most common cervical disc herniation. Pain and numbness radiate across the top of the neck and along the biceps to the lateral aspect of the forearm, and dorsal thumb and index finger. Numbness is usually more distal. A weak biceps, a reduced biceps reflex and weak wrist extension are observed.
C7 radiculopathy (C6-C7 disc herniation). This is the most common disc herniation. Pain radiates across the top of the neck, across the triceps, and down the posterolateral forearm to the middle finger. Numbness again is more distal. A weak triceps and reduced triceps reflex are observed.
C8 radiculopathy (C7-T1 disc herniation) is very uncommon. Pain and numbness radiate across the neck and down the arm to the small finger and ring finger. Wrist flexion and the intrinsic muscles of the hand are weak.Related posts:
Approach to the Patient with Gait Disturbances and Recurrent Falls
Approach to the Hyperkinetic Patient
Movement Disorders
Approach to the Patient with Lower Extremity Pain, Paresthesias, and Entrapment Neuropathies
Approach to the Patient with Chronic and Recurrent Headache
Neuroimaging of Common Neurologic Conditions
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