Neck, Shoulder and Arm Pain

Differential Diagnosis

Origin	Pain Location	Exacerbation	Physical Examination	Diseases
Cervical Spine	Back of neck/head + shoulder/upper arm	Neck movements	1. Limitation of neck motion 2. Tenderness to palpation over the cervical spine	OA, Osteophytes, Cervical disc herniation, RA, Trama, Whiplash injury, cervical spondylosis, thoracic outlet syndrome
Brachial Plexus	Supraclavicular region/ axilla/shoulder	Arm and neck movements/maneuvers (ex. external rotation)	Palpable abnormality above the clavicle	Brachial neuritis, metastatic infiltration, radiation damage to the plexus
Shoulder	Shoulder + (arm)	Shoulder motion	Tenderness and limitation of movement (internal/external rotation/abduction) sensorimotor and reflex changes (-)	Rotator cuff injury/tear, subacromial/subdeltoid bursitis, periarthritis or capsulitis (frozen shoulder), tendonitis, and arthritis, MI, Sudeck atrophy or Sudeck-Leriche syndrome

*Whiplash injury: If NE (+), consider brain, spinal cord injury, or carotid or vertebral artery dissection

Disc Herniation

Definition: tear in outer ring, annulus fibrosis (AF), and bulging of nucleus pulposus (NC). Usu. posterolateral

Most common: 30 ~40 y/o

                                b/c NC still gelatin-like. 

                        >40 y/o

                                NC dehydrated, reduced risk of herniation

Table 11-1 Features of the Main Root-Compressive Syndromes Due to Cervical and Lumbar Disc Herniation

INTERVERTEBRAL DISC SPACE	ROOT AFFECTED	PAIN REFERRAL	WEAKNESS	REFLEX CHANGE	ADDITIONAL FEATURES
C4-C5	C5	Shoulder, trapezius	Supra- and infraspinatus deltoid, slight biceps weakness	Slightly diminished biceps jerk
C5-C6	C6	Trapezius ridge and tip of shoulder, radiation to anterior upper arm, thumb, and index finger	Biceps, brachioradialis, extensor carpi radialis	Diminished biceps and supinator jerk	Tenderness over spine or scapula and suprascapular region; paresthesias in thumb and index finger
C6-C7	C7	Shoulder, axilla, posterolateral arm, elbow, and middle finger	Triceps, wrist extensors	Diminished or absent triceps jerk	Tenderness over medial scapula and supraclavicular region or triceps. May complain of paresthesias in most of the fingers
C7-T1	C8	Medial forearm	Intrinsic hand muscles	Slight or no decrease in triceps jerk	Mimics ulnar palsy
L2-L3	L3	Anterior thigh, over knee	Thigh adductor, quadriceps	Absent or diminished knee jerk
L3-L4	L4	Anterolateral thigh, medial foreleg	Anterior tibial, sometimes with partial foot drop	Diminished or normal knee jerk
L4-L5	L5	Posterolateral gluteal sciatica; lateral thigh, anterolateral foreleg, dorsal foot, lateral malleolus and great or second and third toe	Extensor hallucis longus and extensor digitorum brevis; some weakness of anterior tibialis, sometimes with foot drop	Unaffected (except posterior tibial)	Pain with straight-leg raising and variant tests; tenderness over fourth lumbar lateral process and lateral gluteal region
L5-S1	S1	Midgluteal sciatica; posterior thigh, posterolateral leg, lateral foot, heel, or lateral toes	Plantar-flexor and hamstring weakness	Absent or diminished ankle jerk	Pain with straight-leg raising and variant tests; tenderness over lumbosacral (L5-S1) joint and sciatic notch; discomfort walking on heels

(From Adam and Victor's Principles of Neurology)

Cervical Disc Herniation

Location: 

C7 (70%)

C6 (20%)

C5 and C8 (10%)

Features: 1. Limitated ROM of the neck and exacervation of pain with movement (esp. hyperextension)

                2. Compression of spinal cord

Lumbar Herniation

Location: 

L4-5

L5-S1 

Diagnosis and Level:

       Gold standard: MRI

Managements:

1. Analgesic: A. NSAID B. Oral steroids C. Epidural steroid injection

2. Rehabilitation

The majority improve in six weeks and do not require surgery

3. Surgical Indications:

 A. Cauda equina syndrome: difficult urination/incontinence/impotence --> Emergent surgery

 B. Progressive neurologic deficit

 C. Profound neurologic deficit

 D. Intractable and persistent pain after 4 ~6 wks of conservative treatment