Chapter 016. Back and Neck Pain (Part 16)

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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 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) 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 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 clinical trials that address optimal treatment of neck pain or cervical radiculopathy. Relief of pain, prevention of recurrence, and
improved neurologic function are reasonable goals. Symptomatic treatment includes the use of analgesic medications and/or a soft cervical collar. Most treatment recommendations reflect anecdotal experience, case series, or conclusions derived from studies of the lumbar spine. Controlled studies of oral prednisone or transforaminal glucocorticoid injections have not been performed. Reasonable indications for cervical disk surgery include a progressive radicular motor deficit, pain that fails to respond to conservative management and limits activities of daily living, or cervical spinal cord compression. Surgical management of herniated cervical disks usually consists of an anterior approach with diskectomy followed by anterior interbody fusion. A simple posterior partial laminectomy with diskectomy is an acceptable alternative approach. Another surgical approach involves implantation of an artificial disk; in one prospective trial, outcomes after 2 years favored the implant over a traditional anterior cervical discectomy with fusion. The artificial disk is not yet approved for general use in the United States. The risk of subsequent radiculopathy or myelopathy at cervical segments adjacent to the fusion is ~3% per year and 26% per decade. Although this risk is sometimes portrayed as a late complication of surgery, it may also reflect the natural history of degenerative cervical disk disease. Nonprogressive cervical radiculopathy due to a herniated cervical disk may be treated conservatively, even if a focal neurologic deficit is present, with a high rate of success. However, if the cervical radiculopathy is due to bony compression
from cervical spondylosis, then surgical decompression is generally indicated to forestall the progression of neurologic signs. Cervical spondylotic myelopathy is typically managed with either anterior decompression and fusion or laminectomy in order to forestall progression of the myelopathy known to occur in 20–30% of untreated patients. However, one prospective study comparing surgery vs. conservative treatment for mild cervical spondylotic 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: An evidence-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 suffering on the outcome of insurance claims for whiplash injury. N Engl J Med 342:1179, 2000 [PMID: 10770984]
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Jamarillo-de la Torre JJ et al: Vertebral osteomyelitis. Neurosurg Clin North Am 17:3, 2006 Kadanka Z et al: Conservative treatment vs. surgery in spondylitic cervical myelopathy: A prospective randomized study. Eur Spine J 9:538, 2000 [PMID: 11189924] Kauppi MJ et al: Cervical complications of rheumatoid arthritis. Ann Rheum Dis 64(3):355, 2005 Khadilkar A et al: Transcutaneous electrical nerve stimulation (TENS) for chronic low-back pain. Cochrane Database Syst Rev 3:CD003008 2005 Lauder TD et al: Effect of history and exam in predicting electrodiagnostic outcome among patients with suspected lumbosacral radiculopathy. Am J Phys Med Rehabil 79(1):60, 75, 2000 Luo X et al: Estimates and patterns of direct health care expenditures among individuals with back pain in the United States. Spine 29(1):79, 2004 Maksymowych WP, Landewe R: Imaging in ankylosing spondylitis. Best
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