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Differential diagnosis of cervical radiculopathy and superior pulmonary sulcus tumor: 10 cases review Gu Rui, Kang Mingyang, Gao Zhongli*,Zhao Jianwu,Wang Jincheng Department of Orthopaedics, China-Japan Union Hospital of Jilin University, Changchun, 130033, China Corresponding author:Gao Zhongli, Telephone:0431-84995001, Fax:0431-84641026, E-mail:[email protected] 【Abstract】Objective: To study the differential diagnosis methods between cervical radiculopathy and superior pulmonary sulcus tumor (Pancoast tumor). Methods: Clinical manifestations, physical and radiological findings of 10 patients, whose main complaints were radiating shoulder and arm pain and later were diagnosed with superior pulmonary sulcus tumor, were reviewed and compared with those of cervical radiculopathy. Results: Superior pulmonary sulcus tumor patients have shorter mean history and fewer complain of neck pain or limitation of neck movement range. Physical exam showed almost normal cervical spine range of motion. neck compression test was negative in all patients. Spurling’s Anteroposterior cervical radiographs showed the lack of pulmonary air at the top of the affected lung in all cases and first rib encroachment in 1 case. The diagnosis of superior pulmonary sulcus tumor can be further confirmed by CT and MRI. Conclusions: By the method of combination of history, physical exam and radiological findings, superior pulmonary sulcus tumor can be efficiently differentiated from cervical radiculopathy. Normal motion range of cervical spine, negative Spurling’s neck compression test and the lack of pulmonary air at the top of the affected lung in anteroposterior cervical radiographs should be considered as indications for further chest radiograph exams. Key Words: Superior pulmonary sulcus tumor (Pancoast tumor); Cervical radiculopathy; Physical exam; Anteroposterior cervical radiograph; Differential diagnosis Superior pulmonary sulcus tumor (Pancoast tumor) is a kind of malignant tumor with relatively low incidence. tumors.1,2 It approximately accounts for 5% of all pulmonary The superior pulmonary sulcus tumor may cause symptoms of pain or radiating pain in neck and upper extremity, motor weakness, atrophy of the intrinsic muscles and sensory disturbunce in certain cervical nerve root dermatomes which mimic the symptom of cervical radiculopathy by encroaching intervertebral foramens, vertebral bodies, or brachial plexus.3,4 surgeon first. Such patients tended to consult a spinal The result would be disastrous if the tumor were misdiagnosed as degenerative cervical spine diseases. The pathological and radiological findings of the superior pulmonary sulcus tumor that may produce the symptom of cervical radiculopathy has been reported in a few papers.3-5 But to our knowledge, the differential diagnosis method that combined history, physical and radiological findings aiming at scalping superior pulmonary sulcus tumors in patients suspected of cervical radiculopathy has not been reported before. The current study was undertaken to investigate the differential diagnosis method that may identify superior pulmonary sulcus tumor among the patients with complaints of neck pain, radiating shoulder and arm pain in the out-patient of spinal disorders by the reviewing of 10 such cases. Methods From March 1998 to March 2005, 7132 patients with main complaints of neck pain and radiating shoulder and arm pain visited the out-patient department of spinal disorders in the China-Japan Union Hospital of Jilin University in Changchun, China. Among them, ten cases (0.14%) were diagnosed with superior pulmonary sulcus tumors later and transferred to the thoracic surgery department. Diagnose were further confirmed by needle biopsy. Clinical manifestations, physical and radiological findings of these 10 patients were reviewed and compared with those of the cervical radiculopathy. Results The general condition, history of disease and main complains are shown in Table 1. Anterior-posterior, lateral and oblique view radiograph were administered in 4 patients (case 2, 4, 6, 7) in other hospitals before they visited us. They were diagnosed as degenerative cervical diseases or cervical radiculopathy. Two patients (case 2, 4) underwent systematic conservative treatment (collar fixation, band traction and nonsteroidal anti-inflammatory drugs) 15 and 45 days respectively, but the symptom deteriorated and patients went to our hospital. All patients referred the pain localized in scapular or interscapular region. There was no tenderness in cervical spine region. The cervical motion range was normal in all patients, except case 9. Spurling’s sign was negative in all patients. Physical findings are shown in Table 2. A-P view, lateral view and oblique view cervical spine radiographs were administrated in all patients. The curvature of the cervical spine became straight in 4 cases. Mild degenerative changes were found in 7 cases. Anteroposterior cervical radiographs showed the lack of pulmonary air at the top of the affected lung, which made the asymmetry of superior margins of the pulmonary opacity, as shown in figure 1, in all 10 cases. Encroachment of 1st rib in the affected side was found in a patient (case 7). All patients went on to receive chest radiographic exam because of the abnormalities found above. Posteroanterior (PA) chest radiographs showed unilateral apical opacity in all cases. Diffused tumorous shadows in the unilateral lung were found in 1 patient (case 4). MRI was administrated in 2 patients (case 2 and 6). The encroachment of vertebral bodies and brachial plexus were clearly shown on coronary planes (Fig. 2). After consulting with thoracic surgeons, all patients were transferred to the department of thoracic surgery. Transthoracic aspiration needle biopsy confirmed epidermoid carcinoma in 5 cases (case 1,3,6,8,10) , adenocarcinoma in 4 cases(case 2,5,7,9) and small cell lung cancer in 1 case(case 4). Discussions Cervical Radiculopathy is one of the most common diseases in the cervical spine disorder clinic. Most patients would undergo conservative treatments including band traction, physical therapy, collar fixation and nonsteroidal anti-inflammatory drugs once the diagnosis were made.6 Superior pulmonary sulcus tumor (Pancoast tumor) is a malignant tumor lesion developed at the apices of lungs with relatively lower incidence but much poorer prognosis.1,2,4,7 As mentioned above, the tumor may produce the symptom that mimic the symptom of cervical radiculopathy by encroaching intervertebral foramens, vertebral bodies, or brachial plexus. So, it is very important for a spine doctor to understand some clues or hints that may lead to the diagnosis of superior pulmonary sulcus tumor among patients whose diagnose would be cervical radiculopathy otherwise. In the current study, the mean history of the disease was 2.7 months, which was significantly shorter than degenerative cervical radiculopathy. Some patients also complained nonspecific malignant tumor symptoms of night pain, fever and losing weight. In contrast to typical cervical radiculopathy, physical exam showed almost normal cervical spine range of motion and negative Spurling’s sign in all patients. In cervical radiculopathy, the nerve root is compressed by a herniated disc or spur at the entrance of the foramen.8 In the extension and lateral bending position, the decreased volume of the foramen may exaggerate the symptom of radiculopathy. 9 Authors believe, such mechanism may not exist if the root is compressed by the tumor from out-let of the foramen. Villas et al.10 reported retrospective study of 10 patients diagnosed with superior pulmonary sulcus tumor. Five out of these 10 patients had previously been diagnosed with degenerative, inflammatory, or infectious diseases of the cervical spine or shoulder. They pointed out that the lack of pulmonary air at the top of the affected lung on a standard anteroposterior (AP) cervical radiograph may indicate suspicion of a superior pulmonary sulcus tumor. The current study confirmed Villas’ opinion in that the radiographic changes in cervical spine AP view were found in all cases. Authors recommend chest radiographic examination should be administrated if asymmetry of superior margins of the pulmonary opacity was observed on AP cervical radiograph. Conclusions The application of combining medical history, physical exams and radiograph studies could effectively improve the detection rate of patients, whose main complaints were radiating shoulder and arm pain and later were diagnosed with superior pulmonary sulcus tumor. The history of disease was significantly shorter than the degenerative disease, during this course, there were night pain, fever, fatigue, weight loss and other symptoms; The physical exams found that the cervical motion range was normal, pain and tenderness points were not clear, neck compression test was negative, but brachial plexus traction test was positive, paresthesia area was located in the upper limb and ulnar palm, and might be associated with decreased elbow extension and grip power. The lack of pulmonary air at the top of the affected lung in anteroposterior cervical radiographs should be considered as indications for further chest radiograph exam. Patients with superior pulmonary sulcus tumors who were diagnosed by chest radiograph exam should accept CT or MRI for further diagnosis. Pathological biopsy was used to confirm the lesion. Reference 1. Arcasoy SM, Jett JR. Superior pulmonary sulcus tumors and Pancoast's syndrome. N Engl J Med 1997; 337: 1370-6. 2. Khosravi Shahi P. Pancoast's syndrome (superior pulmonary sulcus tumor): review of the literature. An Med Interna 2005;22:194-6. 3. Owen TD, Ameen A. Cervical radiculopathy: pancoast tumour? Br J Clin Pract 1993;47:225-6. 4. Kraut MJ, Vallieres E, Thomas CR: Pancoast (superior sulcus) neoplasms. Curr Probl Cancer 2003; 27: 81-104. 5. Vargo MM, Flood KM. Pancoast tumor presenting as cervical radiculopathy. Arch Phys Med Rehabil 1990;71:606-9. 6. Kokubun S, Sato T, Ishii Y, Tanaka Y. Cervical myelopathy in the Japanese. Clin Orthop 1996; 323: 129-38. 7. Komaki R, Roth JA, Walsh GL, et al: Outcome predictors for 143 patients with superior sulcus tumors treated by multidisciplinary approach at the University of Texas M. D. Anderson Cancer Center. Int J Radiat Oncol Biol Phys 2000; 48: 347-54. 8. Tanaka Y, Kokubun S, Sato T. Cervical radiculopathy and its unsolved problems. Curr Orthop 1998;12:1-6. 9. Spurling RG, Scoville WB. Lateral rupture of the cervical intervertebral discs. A common cause of shoulder and arm pain. Surg Gynecol Obstet 1944; 78: 350-8. 10. Villas C, Collia A, Aquerreta JD, et al. Cervicobrachialgia and pancoast tumor: value of standard anteroposterior cervical radiographs in early diagnosis. Orthopedics 2004;27:1092-5. Table 1 General data, History and Complaints Case No. Age (yr) Sex History (mo) Complaint Night Pain Cough and Fever Losing weight 1 74 M 5.0 A + + + 2 71 M 1.5 B + 3 74 F 0.8 A 4 55 M 2.5 C 5 77 M 1.0 A + + 6 72 M 3.0 A 7 43 M 3.3 B 8 68 F 4.5 A 9 63 F 3.0 C 10 74 F 2.4 B Mean 67.1 + + + + + + 2.7 Complaint A: Unilateral radiating pain and numbness in shoulder and upperarm. Complaint B: Unilateral Neck and shoulder pain. Complaint C: Unilateral radiating pain and numbness in neck, shoulder, upperarm, arm and hand. Table 2 Physical Examination Findings Triceps tendon reflex Triceps power Grab power Atrophy of intrinsic muscle Posterior and medial arm and 4 fingers in medial side decrease Ⅲ Ⅴ + Medial upperarm normal Ⅴ Ⅲ Medial arm and little finger decrease Ⅳ Ⅳ Posterior arm and index, long fingers no Ⅲ Ⅴ + Posterior and medial arm and 4 fingers in medial side no Ⅲ Ⅴ + Medial arm and little finger normal Ⅳ Ⅲ + Posterior arm and index, long fingers decrease Ⅳ Ⅴ 8 Medial arm and little finger no Ⅲ Ⅴ 9 Posterior and medial arm and 4 fingers in medial side decrease Ⅲ Ⅳ Posterior arm and index, long fingers no Ⅲ Case No. 1 Brachial plexus traction test + 2 3 + 4 5 6 7 10 + Sensory disturbance + + + + + + Ⅳ + L Fig. 1 The asymmetry of superior margins of the pulmonary opacity (arrows). pulmonary air at the top of the right lung. Note the lack of Fig. 2 The encroachment of vertebral body and brachial plexus by the tumor is shown on coronary plane of MRI.