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NECK PAIN
Prof. Dr. Ece Aydoğ
Yeditepe University Medical Faculty
Department of PM&R
Anatomy
1. C1 or atlas
There is no disc between C1 and C2.
2.C2 or axis
3.C3
4.C4
5.C5
6.C6
7.C7
8.Body
9.Vertebral foramen
10.Bifid spinous process or spine
11.Transverse process
12.Foramen transversarium or
transverse foramen
13.Superior articular facet
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: sport injury, work conditions
Thoracic outlet syndrome
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, paravertebral 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
Superficial sensory 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
Myelopathy
• Myelopathy is the clinical
presentation of long tract signs
resulting from compression of
the spinal cord
• Myelopathy:
– 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
• 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.
Vertebrobasiller Insufficiency
• 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
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
Wilbourne classification
Vascular %10
Neurogenic %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
• pains can extend to the fingers and hands, causing weakness
Provocative tests
Adson test
Costoclavicular compression test
Roos test
• Cervical graphy:
– Cervical costa
• PA lung graphy: Pancoast tm
• 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 (static stability)
– Rotator cuff (dynamic stability)
• The shoulder consists of three joints;
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Acromioclavicular (AC)
Sternoclavicular
Glenohumeral
(Two gliding planes: scapulothoracic and subacromial surfaces)
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
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.
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Anterior shoulder pain
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Yergason's supination sign
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Treatment generally is conservative and consists of rest, analgesics, NSAIDs, and local
injection of glucocorticoids.
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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
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The mechanical impingement : shape and slope of the acromion, proliferative spur formation
of the acromion or degenerative changes of the AC joint
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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: Neer test, Yergason test
– Radiographs
– Arthrography, MRI, and ultrasound
Rotator Cuff Tear
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Inflammatory diseases
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Metabolic conditions: Renal
osteodystrophy
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Glucocorticoids
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Trauma: falling on an outstretched
arm or lifting a heavy object
• 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:
– Precalcific or formative phase: relatively painless
– Calcific phase: which tends to be quiescent and may last months to years
– Resorptive or postcalcific phase: painful phase
• Impingement-type pain
• 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 diseases
• 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
– Diffuse, dull aching around the shoulder
– Muscle weakness
– Loss of motion
• Stage 1:Painful or freezing phase
• Stage 2: Adhesive or stiffening phase and
generally lasts 4 to 12 months
• Stage 3: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
– Complete blood cell count
– Erythrocyte sedimentation rate
– Serum chemistry
– Thyroid function tests
Osteonecrosis
• The most common cause of osteonecrosis of the
shoulder is avascularity resulting from a fracture
through the anatomic neck of the humerus
• 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
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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Wrist splint
Physical Therapy
Injections
Surgery
Ulnar Nerve Entrapment—Cubital Tunnel Syndrome
• Ulnar nerve passes through the cubital tunnel just posterior to the medial
epicondyle of the elbow:
– Paresthesias or numbness or both in the small and ring fingers
– Tinel's sign
– Prolonged elbow flexion reproduces the symptoms
• Diagnosis: 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
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