Chapter 016. Back and Neck Pain (Part 15)

Other Causes of Neck PainRheumatoid arthritis (RA) (Chap. 314) of the cervical apophyseal joints produces neck pain, stiffness, and limitation of motion. In advanced RA, synovitis of the atlantoaxial joint (C1-C2; Fig. 16-2) may damage the transverse ligament of the atlas, producing forward displacement of the atlas on the axis (atlantoaxial subluxation). Radiologic evidence of atlantoaxial subluxation occurs in 30% of patients with RA. Not surprisingly, the degree of subluxation correlates with the severity of erosive disease. When subluxation is present, careful assessment is important to identify early signs of myelopathy. Occasional patients develop high spinal cord compression leading...
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Chapter 016. Back and Neck Pain (Part 15) Chapter 016. Back and Neck Pain (Part 15) Other Causes of Neck Pain Rheumatoid arthritis (RA) (Chap. 314) of the cervical apophyseal jointsproduces neck pain, stiffness, and limitation of motion. In advanced RA, synovitisof the atlantoaxial joint (C1-C2; Fig. 16-2) may damage the transverse ligament ofthe atlas, producing forward displacement of the atlas on the axis (atlantoaxialsubluxation). Radiologic evidence of atlantoaxial subluxation occurs in 30% ofpatients with RA. Not surprisingly, the degree of subluxation correlates with theseverity of erosive disease. When subluxation is present, careful assessment isimportant to identify early signs of myelopathy. Occasional patients develop highspinal cord compression leading to quadriparesis, respiratory insufficiency, anddeath. Surgery should be considered when myelopathy or spinal instability ispresent. Ankylosing spondylitis can cause neck pain and less commonly atlantoaxialsubluxation; surgery may be required to prevent spinal cord compression. Acuteherpes zoster presents as acute posterior occipital or neck pain prior to theoutbreak of vesicles. Neoplasms metastatic to the cervical spine, infections(osteomyelitis and epidural abscess), and metabolic bone diseases may be thecause of neck pain. Neck pain may also be referred from the heart with coronaryartery ischemia (cervical angina syndrome). Thoracic Outlet The thoracic outlet contains the first rib, the subclavian artery and vein, thebrachial plexus, the clavicle, and the lung apex. Injury to these structures mayresult in postural or movement-induced pain around the shoulder andsupraclavicular region. True neurogenic thoracic outlet syndrome (TOS) resultsfrom compression of the lower trunk of the brachial plexus or ventral rami of theC8 or T1 nerve roots by an anomalous band of tissue connecting an elongatetransverse process at C7 with the first rib. Signs include weakness of intrinsicmuscles of the hand and diminished sensation on the palmar aspect of the fourthand fifth digits. EMG and nerve conduction studies confirm the diagnosis.Treatment consists of surgical resection of the anomalous band. The weakness andwasting of intrinsic hand muscles typically does not improve, but surgery halts theinsidious progression of weakness. Arterial TOS results from compression of thesubclavian artery by a cervical rib; the compression results in poststenoticdilatation of the artery and thrombus formation. Blood pressure is reduced in theaffected limb, and signs of emboli may be present in the hand. Neurologic signsare absent. Ultrasound can confirm the diagnosis noninvasively. Treatment is withthrombolysis or anticoagulation (with or without embolectomy) and surgicalexcision of the cervical rib compressing the subclavian artery or vein. DisputedTOS includes a large number of patients with chronic arm and shoulder pain ofunclear cause. The lack of sensitive and specific findings on physical examination orlaboratory markers for this condition frequently results in diagnostic uncertainty.The role of surgery in disputed TOS is controversial. Multidisciplinary painmanagement is a conservative approach, although treatment is often unsuccessful. Brachial Plexus and Nerves Pain from injury to the brachial plexus or peripheral nerves of the arm canoccasionally mimic pain of cervical spine origin. Neoplastic infiltration of thelower trunk of the brachial plexus may produce shoulder pain radiating down thearm, numbness of the fourth and fifth fingers, and weakness of intrinsic handmuscles innervated by the ulnar and median nerves. Postradiation fibrosis (most commonly from treatment of breast cancer)may produce similar findings, although pain is less often present. A Pancoasttumor of the lung (Chap. 85) is another cause and should be considered, especiallywhen a Horners syndrome is present. Suprascapular neuropathy may producesevere shoulder pain, weakness, and wasting of the supraspinatous andinfraspinatous muscles. Acute brachial neuritis is often confused with radiculopathy; the acuteonset of severe shoulder or scapular pain is followed over days to weeks byweakness of the proximal arm and shoulder girdle muscles innervated by the upperbrachial plexus. The onset is often preceded by an infection. The suprascapular and long thoracic nerves are most often affected; thelatter results in a winged scapula. Brachial neuritis may also present as an isolatedparalysis of the diaphragm. Complete recovery occurs in 75% of patients after 2years and in 89% after 3 years. Occasional cases of carpal tunnel syndrome produce pain and paresthesiasextending into the forearm, arm, and shoulder ...