Chapter 016. Back and Neck Pain (Part 16)

ShoulderPain arising from the shoulder can on occasion mimic pain from the spine. If symptoms and signs of radiculopathy are absent, then the differential diagnosis includes mechanical shoulder pain (tendonitis, bursitis, rotator cuff tear, dislocation, adhesive capsulitis, and cuff impingement under the acromion) and referred pain (subdiaphragmatic irritation, angina, Pancoast tumor). Mechanical pain is often worse at night, associated with local shoulder tenderness and aggravated by abduction, internal rotation, or extension of the arm. Pain from shoulder disease may radiate into the arm or hand, but sensory, motor, and reflex changes are absent.Neck Pain: Treatment There are few well-designed...
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Chapter 016. Back and Neck Pain (Part 16) Chapter 016. Back and Neck Pain (Part 16) Shoulder Pain arising from the shoulder can on occasion mimic pain from the spine.If symptoms and signs of radiculopathy are absent, then the differential diagnosisincludes mechanical shoulder pain (tendonitis, bursitis, rotator cuff tear,dislocation, adhesive capsulitis, and cuff impingement under the acromion) andreferred pain (subdiaphragmatic irritation, angina, Pancoast tumor). Mechanicalpain is often worse at night, associated with local shoulder tenderness andaggravated by abduction, internal rotation, or extension of the arm. Pain fromshoulder disease may radiate into the arm or hand, but sensory, motor, and reflexchanges are absent. Neck Pain: Treatment There are few well-designed clinical trials that address optimal treatment ofneck pain or cervical radiculopathy. Relief of pain, prevention of recurrence, andimproved neurologic function are reasonable goals. Symptomatic treatmentincludes the use of analgesic medications and/or a soft cervical collar. Mosttreatment recommendations reflect anecdotal experience, case series, orconclusions derived from studies of the lumbar spine. Controlled studies of oralprednisone or transforaminal glucocorticoid injections have not been performed.Reasonable indications for cervical disk surgery include a progressive radicularmotor deficit, pain that fails to respond to conservative management and limitsactivities of daily living, or cervical spinal cord compression. Surgicalmanagement of herniated cervical disks usually consists of an anterior approachwith diskectomy followed by anterior interbody fusion. A simple posterior partiallaminectomy with diskectomy is an acceptable alternative approach. Anothersurgical approach involves implantation of an artificial disk; in one prospectivetrial, outcomes after 2 years favored the implant over a traditional anterior cervicaldiscectomy with fusion. The artificial disk is not yet approved for general use inthe United States. The risk of subsequent radiculopathy or myelopathy at cervicalsegments adjacent to the fusion is ~3% per year and 26% per decade. Althoughthis risk is sometimes portrayed as a late complication of surgery, it may alsoreflect the natural history of degenerative cervical disk disease. Nonprogressive cervical radiculopathy due to a herniated cervical disk maybe treated conservatively, even if a focal neurologic deficit is present, with a highrate of success. However, if the cervical radiculopathy is due to bony compressionfrom cervical spondylosis, then surgical decompression is generally indicated toforestall the progression of neurologic signs. Cervical spondylotic myelopathy is typically managed with either anteriordecompression and fusion or laminectomy in order to forestall progression of themyelopathy known to occur in 20–30% of untreated patients. However, oneprospective study comparing surgery vs. conservative treatment for mild cervicalspondylotic myelopathy showed no difference in outcome after 2 years of follow-up. Further Readings Atlas SJ, Nardin RA: Evaluation and treatment of low back pain: Anevidence-based approach to clinical care. Muscle Nerve 27:265, 2003 [PMID:12635113] Bagley LJ: Imaging of spinal trauma. Radiol Clin North Am 44:1, 2006[PMID: 16297679] Cassidy JD et al: Effect of eliminating compensation for pain and sufferingon the outcome of insurance claims for whiplash injury. N Engl J Med 342:1179,2000 [PMID: 10770984] Cavalier R et al: Spondylolysis and spondylolisthesis in children andadolescents: Diagnosis, natural history, and non-surgical management. J Am AcadOrthop Surg 14:417, 2006 [PMID: 16822889] Cowan JA Jr et al: Changes in the utilization of spinal fusion in the UnitedStates. Neurosurgery 59:1, 2006 Gorbach C et al: Therapeutic efficacy of facet joint blocks. AJR Am JRoentgenol 186:5, 2006 Mummaneni PV et al: Clinical and radiographic analysis of cervical diskarthroplasty compared with allograft fusion: A randomized controlled clinical trial.J Neurosurg Spine 6:198, 2007 [PMID: 17355018] Peul WC et al: Surgery versus prolonged conservative treatment forsciatica. N Engl J Med 356:2245, 2007 [PMID: 17538084] van Alfen N, van Engelen BG: The clinical spectrum of neuralgicamyotrophy in 246 cases. Brain 129:438, 2006 Weinstein JN et al: Surgical versus nonsurgical treatment for lumbardegenerative spondylolisthesis. N Engl J Med 356:2257, 2007 [PMID: 17538085] ——— et al: Surgical vs nonoperative treatment for lumbar disc herniation.The spine patient outcomes research trial (SPORT): A randomized trial. JAMA296:2441, 2006 Bibliography ...