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NECK and UPPER EXTREMITY
PAIN
Anatomy
1. C1 or atlas
There is no disc between C1 and C2.
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2.
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4.
5.
6.
7.
8.
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10.
11.
C2 or axis
C3
C4
C5
C6
C7
Body
Vertebral foramen
Bifid spinous process or spine
Transverse process
Foramen transversarium or
transverse foramen
12. Superior articular facet
(a)Supraspinous
ligament
(b) interspinousligament
(c) facet joint capsule
(d) posterior longitudinal
ligament
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SCM
Scalen muscle
PV
Longus capitis
Longus colli
Rectus capitis ant
Splenius capitis
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Each disk consists of an outer anulus
fibrosus and an inner nucleus pulposus
and a cephalad and caudad end plate.
The anulus fibrosus is innervated by the
sinuvertebral nerve, formed by branches
of the ventral nerve root and the
sympathetic plexus.
The pressure within the disk is highest
with flexion, which may explain why
individuals with a disk herniation find this
position most uncomfortable.
Disk degeneration with aging includes loss
of water content with resultant loss of
height, annular tears, and myxomatous
changes, increasing the risk of disk
herniation.
Herniation typically occurs in the
posterolateral aspect of the disk, where
the posterior longitudinal ligament is not
present and the anulus fibrosus is at its
weakest.
• Spinal cord : posterior column, the lateral columns, and the
anterior column.
• The posterior column: proprioceptive, vibratory, and tactile
sensation.
• The lateral column
– lateral corticospinal tract: motor fibers,
– and the spinothalamic tract: pain and temperature sensation from
the contralateral side of the body.
• The anterior column: touch sensation.
– Eight total cervical nerve roots on each side as the dorsal and ventral
roots converge to form the spinal nerve within the vertebral foramen.
• The cervical spine is the most mobile segment of the
spine with approximately a 90-degree arc of motion
in flexion and extension, with three fourths of this
due to extension.
• The maximal range of motion in the sagittal plane
within the subaxial spine is at the C5-C6 level,
making it a common site of disk degeneration.
• Rotation encompasses approximately 80 to 90
degrees of motion with 50% of this occurring at the
atlantoaxial joint.
Functıonal Anatomy
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The most mobile segment of the spine
7 cervical vertebrae
14 apophyseal (faset) joints
12 joints of Luschka
Ligaments (posterior longitudinal, anterior
longitudinal, flaval, interspinous)
• Muscles
Faset joints are posterior intervertebral joints. They are true sinovial joints and enable
the head movement.
Luschka joints are between semilunar joint surface of upper vertebra and uncus of
lower vertebra. They protect spinal colon aganist disc protrusion
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Flexion: 60-90
Extension
Rotation: 90
Lateral flexion: 45
– Atlantoaxial joint: 45 degree rotation
– Atlanto-occipital joint: 10 d flexion, 25 d extension
– C5-C6 , C4-C5 maximal range of movement
Pain sensitive structures
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Ligaments
Nerve roots
Articular facets and capsules
Muscles
Dura
External fibers of anulus fibrosus
Disorders cause neck and upper extremity pain
Cervical vertebra colon:
cervical spondylosis (OA)
cervical disc herniation
spinal stenosis
instability
Wiplash injury
Cervical cord diseases (Tumor, syringomyeli)
Rheumatologic disorders:
Ankylosing spondylitis, Rhematoid arthritis, Polymyalgia Rheumatica, Fibromyalgia,
Myofascial pain syndrome
Infectious:
Osteomyelitis, dissit, epidural/intradural/subdural abces, retropharengeal abces
Endocrin: osteoporosis, osteomalasia, paget disease
Trauma: hard muscle contraction, sport injury, work conditions, postur
Thoracic outlet syndrome
Shoulder, elbow, wrist
Neuropathies
Artheritis (vertebral and cranial, Takayasu)
Referred pain
Structures That Cause Neck Pain
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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, pv 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
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Radicular pain
Paresthesias
Superficialsensory 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.
Instability
• Deterioration of cervical colon stability by
physical loads
• X-ray
Myelopathy
• Myelopathy is the clinical presentation of long tract signs resulting from
compression of the spinal cord.
• Myelopathy:
– a 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.
• Cervical colon stenosis: osteophyte, disc herniation, lig. flavum and facet
joint hipertrophy, posterior longitudinal lig. thickness, Paget, gout
• The anteroposterior diameter in the subaxial spine for a normal adult
measures 17 to 18 mm, and the cord measures 10 mm. Diameters of less
than 13 mm are considered to be congenitally stenotic.
• 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.
VBI
• 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
Cervical Disc Herniation
• 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
• Uncovertebral joints have no sinovial membrane
• Articular cartilage in all joints is avascular and aneural
• All joints are supplied with sensory nerves and nutrient vessels on the
segmental basis as well as with sympathetic pain fibers.
• Pain from those joints are non-neuralgic and felt locally.
• If the dura and its nerve are stretched, the accompanying nutrient vessels
canbe narrowed and promptly cause ischemic neuralgic pain.
• The main load-bearing structure of the neck is the intervertebral disk.
• The IVD consists of fibroelastic envelope that has a blood supply and a
nerve supply that is highly sensitive to stretching.
• Nuc. Pulposus has has no nerve supply---painless
• As the disk loses height, it places increased pressure on the joints
• Surface areas are inadequate for the imposed pressure, they become
irritaed
• Irritation—inflammatory disease-----repair----formation of osteophytes
Clinical Evaluation
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Patient’s history
Physical examination
Neuroimagining studies
Neurophysiologic procedures
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Sensory symptoms
Weakness
Articular symptoms
Vascular symptoms
Headache and occipital neuralgia
– Nerve root sympathetic nerve compression, vertebral
artery pressure, posterior occipital muscle spasm
• Pseudoangina pectoris
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(C6-C7)
Clinical Examination
• Inspection: lordosis, scoliosis, torticollis, active
limtaiton, skin lesions
• Palpation
• Range of servical spine motion
• Motor signs
• Reflexes
• Sensory signs
Nerve Root
Symptom
Correlate
C3
Suboccipital pain with extension to back of ear
C4
Pain from caudad aspect of neck to superior
aspect of shoulder
C5
Numbness over shoulder and down lateral
aspect of arm to midportion. Deltoid muscle
may be weak and biceps reflex, which is
innervated by C5-C6, may be affected
C6
Radiating pain and numbness down lateral
aspect of arm and forearm to thumb and index
finger (“six shooter”). Weakness in wrist
extension, elbow flexion, and supination.
Diminished brachioradialis and biceps reflex
Sensory component can mimic carpal tunnel syndrome
C7
Numbness and pain down posterior aspect of
arm and forearm to long finger. Weakness in
triceps, wrist flexion, and finger extensors
Most frequent. Entrapment of posterior interosseous nerve
can mimic motor component, but no sensory deficits are
present
C8
Numbness into ulnar two digits. Weakness in
FDP to IF and LF and FPL
T1
Numbness into ulnar aspect of forearm and
weakness in hand intrinsics
Anterior interosseous nerve entrapment can mimic a
radiculopathy of C8 or T1, but sensory changes and
involvement of thenar muscles are not present. Ulnar nerve
entrapment spares short thenar muscles with exception of
adductor pollicis.
If C3, C4, C5 all are involved, may cause paradoxical
breathing
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C4-C5-----C5 nerve root compression:
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C5-C6-----C6 nerve root compression:
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Pain in scholuder, lateral arm, dorsum of the forearm
Paresthesias in1st and 2nd fingers
Weakness in biceps and dorsiflexors of the wrist
Hiporeflex brachioradial reflex
C6-C7-----C7 nerve root compression:
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Pain in scholuder, lateral arm, dorsum of the forearm
Paresthesias lateral side of the arm
Weakness in biceps
Hiporeflex biceps reflex
Similar pain pattern
Paresthesias in 2nd and 3rd fingers
Weakness in triceps and flexors of the wrist and fingers
Hiporeflex triceps reflex
C7-T1-----C8 nerve root compression:
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Pain in medial side of the arm
Paresthesias in 4thnd and 5th fingers
Weakness in finger flexors and intransic muscles of the hand
Hiporeflex triceps reflex
Special Tests
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Cervical distraction test
Spurling Test
Adson Test
Lhermitte Sign
Diagnostic Evaluation
• Routine radiographic view
– Axes, Fusion, Instability, Spondylolistesis, Degeneration of facet,
osteophyte
– Narrowing of intervertebral space, sclerosis of endplates, sharpening
of vertebral corpus bend
• MRI:
– Intervertebral disc, neural elements, paraspinal structures, spinal
tumours
• BT
– Neoplstic, degenaritve, traumatic, infectious
• Radioisotope bone scans
• Doppler ultrasound
• Electrodiagnostic studies:
– Distinguish sensory and motor dysfunction of the
peripheral nerves.
– Distinguish a lesion in the periphery from a nerve
root lesion
• Laboratory Studies:
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.
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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
Interscalene Triangle
Anterior: Anterior skalen
Posterior: Orta skalen
İnferior: 1. costa
• Compressing structures:
– Scalenus antikus, medius,
minimus
– 1. costa
– Shoulder
– Costa fracture with callus
formation,
– Big transvers process of C7
– cervikal costa
– Fibrous bands
– Tumors
Costoclavicular Fossa
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Anterior  clavicula, m. subclavius,
kostocoracoid ligament
Posteromedial  1. costa, anterior
and med scalen muscles
insersiyo
Posterolateral  scapula superior
Compressing structures:
– Clavicula or 1.costa kongenital
variations
– M.Subclavius structural changes,
hipertrophy
– Shoulder position, postural defects
– Trauma
– Anatomy of clavicula
– Clavicula or costa fracture with callus
formation
Wilbourne Classification
Vascular %10
Nöeurogenic %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
• Pain can extend to the fingers and hands,
causing weakness
Provocative tests
Adson test
Costoclavicular compression test
Wright Hiperabduction test
• Cervical graphy:
– Cervical costa
• PA lung graphy: Pancoast
• 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, the rotator cuff (dynamic stability) of the joint. The
shoulder consists of three joints—acromioclavicular (AC),
sternoclavicular, and glenohumeral—and two gliding planes—
the scapulothoracic and subacromial surfaces
• Knowledge of the route of the tendon of the long head of the
biceps through the bicipital groove and onto the superior
aspect of the glenoid helps in understanding bicipital
tendinitis
Shoulder Pain Causes
• Intransic causes:
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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
Radiographic Assessment
• Anteroposterior views with a 30-degree caudal tilt
(Rockwood view),
• Outlet view (scapular Y with 10- to 15-degree caudal
tilt),
• Axillary view.
• Internal and external rotational views
• Scapular Y view, and an axillary view: traumatic
injury
• Posterior or anterior subluxation of the humeral
head : axillary view
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Computed tomography
Ultrasonography
Magnetic resonance imaging
EMG
Bicipital Tendinitis And Rupture
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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
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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
• Radiographs
• Arthrography, MRI, and ultrasound
Rotator Cuff Tear
• Inflammatory diseases
• Metabolic conditions such as
renal osteodystrophy
• Agents such as glucocorticoids
• A traumatic episode, such as
falling on an outstretched arm or
lifting a heavy object
• The usual presenting symptoms
are pain and weakness of
abduction and external rotation
• Atrophy of the supraspinatus and
infraspinatus muscles
• Drop arm test
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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:
– the precalcific or formative phase, which can be relatively painless
– the calcific phase, which tends to be quiescent and may last months to years
and the resorptive or
– postcalcific phase, which tends to be painful, as calcium crystals are resorbed
• Impingement-type pain
• The symptoms may last a few weeks or a few months. During the latter
phase, pain and decreased motion can lead to adhesive capsulitis
• 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
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Diabetes mellitus
Parkinsonism
Thyroid disorders
Cardiovascular disease
• 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.
• Typically, the patient relays a history of diffuse, dull
aching around the shoulder, with weakness and loss
of motion occurring over a few months.
• Stage one is the painful or freezing phase.
• Phase two is the adhesive or stiffening phase
and generally lasts 4 to 12 months.
• The third phase is the 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. A complete blood cell count,
erythrocyte sedimentation rate, serum
chemistry, and thyroid function tests
Glenohumeral Instability
• Glenohumeral instability is a pathologic condition that manifests as pain
associated with excessive translation of the humeral head on the glenoid
during shoulder motion.
• Anterior dislocation usually occurs with the arm in an abducted and
externally rotated position, and the diagnosis is usually obvious.
• Posterior dislocation is frequently associated with convulsive disorders or
unusual trauma with the arm in a forward flexed and internally rotated
position.
• Plain radiographs are generally normal, although some inferior
subluxation may be shown by obtaining stress radiographs with weights.
• Activities that stress the shoulder and produce symptoms are avoided.
• Strengthening exercises of the shoulder girdle
Osteonecrosis
• The most common cause of osteonecrosis of
the shoulder is avascularity resulting from a
fracture through the anatomic neck of the
humerus.
• Fracture, 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
• Elbow ROM:
– Flexion: 135-150
– Extension:0-5
– Supination and
pronation: 90
• Wrist:
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Flexion: 80
Ekstension:70
Abduction:20
Adduction:30
supin&pron: 90
Examination
• Inspection
• Palpation
• Special tests
– Varus stress test
– Valgus stress test
– Lateral epicondilitis test
– Medial epycondilitis test
– Tinnel test
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
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A wrist splint
Hot and cold compresses
Physical Therapy
Surgery
Ulnar Nerve Entrapment—Cubital Tunnel Syndrome
• Entrapment of the ulnar nerve as it passes through the cubital tunnel just
posterior to the medial epicondyle of the elbow can manifest with
symptoms localized to the ulnar border of the hand
• Paresthesias or numbness or both in the small and ring fingers
• Tinel's sign
• Prolonged elbow flexion reproduces the symptoms
• 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
Flexor Carpi Radialis and Flexor Carpi Ulnaris Tendinitis
• Similar to other tendinopathies around the wrist, irritation of the wrist
flexors occurs with stress of the wrist in a particular position.
• Activities that require forced wrist flexion for prolonged periods or with
repetition put patients at risk for inflammation around the flexor carpi
radialis tendon or the flexor carpi ulnaris tendon or both.
• The condition manifests with tenderness along the course of the tendon,
especially near its insertion.
• Wrist flexion against resistance with radial or ulnar deviation reproduces
the symptoms.
• Treatment consists of splinting and rest, elimination of activities that
cause pain, and oral NSAIDs. Injection of corticosteroid into the flexor
carpi radialis or flexor carpi ulnaris sheath may be curative.
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
• Can present with falsepositive results