NECK PAIN

Prof. Dr. Ece AydoğYeditepe University Medical Faculty

Department of PM&R

Anatomy

1. C1 or atlas There is no disc between C1 and C2.

2.C2 or axis 3.C3 4.C4 5.C5 6.C6 7.C7 8.Body 9.Vertebral foramen 10.Bifid spinous process or spine 11.Transverse process 12.Foramen transversarium or

transverse foramen 13.Superior articular facet

Disorders cause neck and upper extremity painCervical vertebra colon:

cervical spondylosis (OA)cervical disc herniationspinal stenosisinstabilityWiplash injuryCervical cord diseases (Tumor, syringomyeli)

Rheumatologic disorders: Ankylosing spondylitis, Rhematoid arthritis, Polymyalgia Rheumatica, Fibromyalgia, Myofascial

pain syndromeInfectious:

Osteomyelitis, dissit, epidural/intradural/subdural abces, retropharengeal abcesEndocrin: Osteoporosis, osteomalasia, paget diseaseTrauma: sport injury, work conditionsThoracic outlet syndromeNeuropathiesArtheritis (vertebral and cranial, Takayasu)Referred pain

Structures That Cause Neck Pain

• Akromioclavicular joint• Heart and coronary disease• Apex of lung, Pancoast’s tumour• Diaphragm muscle (C3-C5 inn)• Gallbladder• Spinal cord tumour• Temporomandibular joint

Axial neck pain

• Axial neck pain describes a pattern of pain that is localized to the occiput and neck region

• Degenerative arthritis within the upper cervical spine can manifest as suboccipital headache and localized pain. This is termed cervicogenic headache and is thought to result from irritation of the greater occipital nerve

Cervical strain and sprain• Strain:

– injury of contractile tissues by stretching (muscle, lig.)

– Pain is localized on neck– Decreased lordosis, paravertebral spasm– No neurologic sign

• Sprain: – Tissue rupture and bleeding by stretching

(capsule, lig., bursa, vessels, cartilage, dura)

Cervical spondylosis

• Degeneration of IVD, facet and luschka • Age, microtrauma, ergonomy, genetic• Syndromes due to spondylosis

– Radiculopathy– Vertebrobasilar insufficiency– Cervical myelopathy

Radiculopathy

• Radicular pain• Paresthesias• Superficial sensory deficits• Variation of DTR• Muscle strength loss

• If these deficits are minor and tolerable, it is reasonable to treat with conservative care with close follow-up to ensure that the deficit is not progressive

• Disabling deficits should be treated operatively because prolonged nerve compression can result in irreversible changes

• In patients without a neurologic deficit, it is reasonable to expect a good outcome with conservative care

Myelopathy

• Myelopathy is the clinical presentation of long tract signs resulting from compression of the spinal cord

• Myelopathy: – tumor or infection– instability owing to systemic

arthritides or connective tissue disorders

– degenerative changes within the cervical spine

• Factors that contribute to the development of myelopathy :– congenitally narrow spinal canal,

dynamic cord compression, dynamic thickening of the spinal cord, and vascular changes

• complaints of hand clumsiness or difficulty with balance

• worsening handwriting or difficulty buttoning buttons

• nausea and emesis caused by equilibrium dysfunction

• paresthesias and dysesthesias may be present, often involving bilateral upper extremities and not following a dermatomal distribution

• wasting of hand intrinsics and bowel and bladder dysfunction

• Definitive indications for surgery:– presence of myelopathy for 6 months or longer, – progression of signs or symptoms, – difficulty walking, or change in bowel or bladder

function.

Vertebrobasiller Insufficiency• Blood supply of inner ear, vestibular and cochlear nucleii of medulla

oblangata

• Vertigo, headache, nausea

• Coordination, memory deficit

• Tinnitus, hearing loss, diplopia

• Nistagmus, disphagia

• Common property of those symptoms is that they are related with neck movement and local/radicular symptoms

• With age, the nucleus pulposus becomes vulnerable

• With degenerative changes, – the disc space narrows, spinal column shortens– The intervertebral foramina become narrowed, movements become

restricted, unusual mechanical strains on the sinovial joints result– The formation of osteophytes leads to encroachment on the spinal

canal and intervertebral foramina– Changes in the caliber of the vertebral arteries can result because of

the degenerative changes

• Facet joints (sinovial) can be affected by various arthritic diseases

Cervical disc herniation

Treatment

• Immobilization: cervical collar

• Medication: NSAID, analgesics, myorelexan, corticosteroids

• Physical therapy: superficial and deep heat, massage, electrotherapy, traction

• Theurapatic exercises: Isometric, ROM

Thoracic outlet syndrome

• Thoracic outlet syndrome is a condition whereby symptoms are produced from compression of nerves or blood vessels, or both, because of an inadequate passageway through an area (thoracic outlet) between the base of the neck and the armpit – muscle enlargement (such as from weight lifting), injuries – an extra rib from the neck at birth (cervical rib)– weight gain – tumors at the top of the lung (rare)– often no specific cause is found

• Anatomic regions causing compression:1. Interscalene triangle

2. costaclavicular fossa

Wilbourne classification

Vascular %10Neurogenic %90

Real neurogenic:– C8-T1 pain and paresthesia– Generalised pain arm, anterior and posterior chest wall– Atrophy and muscle weakness at hand

Suspicious neurogenic:– Same symptoms but no objective signs

Symptoms• neck, shoulder, and arm pain

• numbness, or impaired circulation to the extremities (causing discoloration)

• often symptoms are reproduced when the arm is positioned above the shoulder or extended

• pains can extend to the fingers and hands, causing weakness

Provocative tests

Adson test

Costoclavicular compression test

Roos test

• Cervical graphy:– Cervical costa

• PA lung graphy: Pancoast tm

• ENMG: although these may not be positive in all patients

• Angiogram x-ray tests:demonstrate the pinched area of the blood vessel involved.

Treatment

Conservative treatment

– Postural exercises– Shoulder girdle strengthening exercises and scalene

muscles streching exercises – Myorelaxan– NSAİİ– Superficial and deep heat, iontophoresis,TENS

Surgery

• avoid prolonged positions with their arms held out or overhead

• avoid sleeping with the arm extended up behind the head

• have rest periods at work to minimize fatigue

• weight reduction

• avoid sleeping on their stomach with their arms above the head

• not repetitively lift heavy objects

Shoulder Pain

Anatomy And Function

• The shoulder joint is the most mobile joint of the body

• Joint stability: – Labrum, capsule and the glenohumeral ligaments (static stability)– Rotator cuff (dynamic stability)

• The shoulder consists of three joints;– Acromioclavicular (AC)– Sternoclavicular– Glenohumeral– (Two gliding planes: scapulothoracic and subacromial surfaces)

Shoulder Pain Causes

• Intransic causes:– Impingement– Calcific tendinits– Frosen shoulder– Biceps tendinitis– Glenohumeral instability– Degeneration– Arthritis– Avascular necrosis– Fracture– tumor

• Extransic causes:– Cervical radiculopathy– Bracial neurit, bracial plexus

injury– Toracic outlet syndrome– Cardiac referred pain– Abdomial referred pain– Tumor– Fracture– Fibromiyalgia– Myofacial pain syndrome

Bicipital Tendinitis And Rupture

• The biceps tendon aids in flexion of the forearm, supination of the pronated forearm if the elbow is flexed, and forward elevation of the shoulder.

• Anterior shoulder pain

• Yergason's supination sign

• Treatment generally is conservative and consists of rest, analgesics, NSAIDs, and local injection of glucocorticoids.

• Patients with refractory bicipital tendinitis and recurrent symptoms of subluxation are treated by arthroscopic interventions

Impingement• Impingement : encroachment of the acromion, coracoacromial ligament, coracoid process, or AC joint on the rotator cuff as it passes

beneath them during glenohumeral motion

• The mechanical impingement : shape and slope of the acromion, proliferative spur formation of the acromion or degenerative changes of the AC joint

• • Stage I lesion:

– Edema and hemorrhage– Conservative treatment

• Stage II lesions: – Fibrosis and thickening of the tendon after repeated episodes of mechanical impingement over time– Treated conservatively, but attacks may recur– If symptoms persist despite adequate conservative management for more than 6 to 12 months, surgical intervention is

warranted.• Stage III lesions:

– Rotator cuff tears, biceps tendon rupture, and bone changes– Pain, weakness, or supraspinatus atrophy– Surgical treatment

• Pain: located over the anterior and lateral aspects of the shoulder and may radiate into the lateral deltoid

• The pain may worsen with sleeping on the affected

extremity and is exacerbated by overhead activity • Tenderness on palpation: greater tuberosity bicipital

groove, AC joint

– The impingement sign: Neer test, Yergason test – Radiographs – Arthrography, MRI, and ultrasound

Rotator Cuff Tear

• Inflammatory diseases

• Metabolic conditions: Renal osteodystrophy

• Glucocorticoids

• Trauma: falling on an outstretched arm or lifting a heavy object

• Pain and weakness of abduction and external rotation

• Atrophy of the supraspinatus and infraspinatus muscles

• Drop arm test

• Conservative treatment– The mainstay of conservative therapy is exercise– Rehabilitation stresses pain relief with exercises aimed at restoring

shoulder motion and strengthening the remaining cuff muscles, deltoid, and scapular stabilizers

• Steroid and local anesthetic injections

• If the patient fails to improve after 3 months of conservative treatment, or does not continue to improve after three sequential injections, surgical options should be discussed

Calcific Tendinitis• The cause: degeneration of the tendon, which leads to calcification

through a dystrophic process

• A common clinicopathologic correlation is three distinct phases of the disease process: – Precalcific or formative phase: relatively painless– Calcific phase: which tends to be quiescent and may last months to years– Resorptive or postcalcific phase: painful phase

• Impingement-type pain • The acute inflammation can be treated with local glucocorticoid injection,

NSAIDs, or both

Adhesive Capsulitis

• Adhesive capsulitis, or frozen shoulder syndrome (FSS), is a condition characterized by limitation of motion of the shoulder joint with pain at the extremes of motion – Diabetes mellitus – Parkinsonism – Thyroid disorders – Cardiovascular diseases

• Capsular contracture is thought to result from adhesion of the capsular surfaces or fibroblastic proliferation in response to cytokine production

• More common in women in their 40s and 50s

– Diffuse, dull aching around the shoulder– Muscle weakness– Loss of motion

• Stage 1:Painful or freezing phase

• Stage 2: Adhesive or stiffening phase and generally lasts 4 to 12 months

• Stage 3:Resolution or thawing phase and may last 5 to 26 months

• In patients with a history of minimal or no trauma and FSS, a metabolic cause should be excluded– Complete blood cell count– Erythrocyte sedimentation rate– Serum chemistry– Thyroid function tests

Osteonecrosis

• The most common cause of osteonecrosis of the shoulder is avascularity resulting from a fracture through the anatomic neck of the humerus

• Steroid therapy in conjunction with organ transplantation,systemic lupus erythematosus, or asthma

• Other conditions: hemoglobinopathies, pancreatitis, and hyperbarism.

Milwaukee shoulder

• Deposition of calcium pyrophosphate dihydrate crystals, direct trauma, chronic joint overuse, chronic renal failure, and denervation

• Hemiarthroplasty or a reverse total shoulder arthroplasty may be indicated

Labral Tears

• Bankart lesion • SLAP lesion

Hand and Wrist Pain

Carpal Tunnel Syndrome

Carpal Tunnel Syndrome is a nerve disorder in the hand that causes pain and loss of feeling, especially in the thumb and first 3 fingers.

Signs and Symptoms

• Tingling or numbness in part of the hand.

• Sharp pains that shoot from the wrist up the arm, especially at night.

• Burning sensations in the fingers.

• Morning stiffness or cramping of hands.

• Thumb weakness. • Frequent dropping of

objects. • Inability to make a fist. • Shiny, dry skin on the

hand.

Causes• Pressure on the median nerve caused by swollen,

inflamed or scarred tissue• The sources of pressure include:

– Repetitive motion injury (associated with continuous and rapid use of the fingers)

– Inflammation of the tendon sheaths (sometimes from arthritis)

– Fracture of the forearm– Sprain or dislocation of the wrist

Treatments

• Wrist splint• Physical Therapy• Injections• Surgery

Ulnar Nerve Entrapment—Cubital Tunnel Syndrome • Ulnar nerve passes through the cubital tunnel just posterior to the medial

epicondyle of the elbow:– Paresthesias or numbness or both in the small and ring fingers– Tinel's sign – Prolonged elbow flexion reproduces the symptoms

• Diagnosis: Electrodiagnostic studies

• Conservative treatment : – Help the patient avoid having the elbow flexed for prolonged periods, particularly

at night – Soft, or semirigid, elbow splints prevent elbow flexion beyond 50 to 70 degrees

– Medial elbow pads

– NSAIDs

Dupuytren’s Contracture

• Flexion contracture of MP and PIP joints from shortening/adhesions in palmar aponeurosis : most common at 4th and 5th fingers

• Positive table top test

Trigger Finger

Osteoarthritis of the Digits

DeQuervain’s Syndrome• Tenosynovitis of extensor pollicis

brevis and abductor pollicis longus tendons from repetitive stress (radial deviation)

• Presents with pain/swelling to proximal thumb/distal radius, pain with radial/ulnar wrist deviation and thumb extension and abduction

• Treated conservatively with rest (immobilization), NSAIDs, modalities

Finkelstein’s Test

• Evaluative for DeQuervain’s syndrome

• Thumb flexed across palm and locked in by finger flexion – wrist placed in ulnar deviation – positive if pain reproduced or increased