Pain in the neck and upper limbs.

Pain in the neck and upper limbs. The pain localized in the neck (cervicalgia) or in the neck and arm (cervicobrahialgia) may be vertebrogenic (caused by spine pathology) or non-itrogenic, skeletal-muscular (caused by changes in muscles, joints, ligaments) or neuropathic (caused by lesion of roots, plexus, nerves ). Sometimes cervicobrahialgia is visceral pain (reflected pain associated with the pathology of internal organs) or psychogenic pain. During the examination, diseases requiring urgent intervention should be excluded: spine tumors , osteomyelitis, epidural abscess , meningitis, subarachnoid hemorrhage, pharyngeal abscess , fracture in the cervical spine, stratification of the carotid or vertebral arteries.

Osteochondrosis of the cervical spine is the main cause of vertebrogenic pain in the neck. Osteochondrosis of the spine is usually understood as degenerative changes affecting the intervertebral discs, joints, ligaments and other spinal tissues that form the vertebral-motor segment (PDS). Pain syndrome can be associated with herniated intervertebral disc, functional blockade of PDS, arthrosis of intervertebral (facet) and unco-vertebral joints, hypertrophy of ligaments, osteophytes.

With a herniated disc, the pain syndrome can be caused by: 1) irritation of adjacent tissues containing pain receptors (outer layers of the fibrous ring, ligaments, capsules of joints, etc.), which can cause both local and reflected (reflex) pain in the distant Zone (scapula and interblade area, occiput, shoulder girdle, arm); 2) irritation or compression of the spinal root (radiculopathy).

With radiculopathy, the pain often has a paroxysmal shooting character, irradiates along the course of the dermatome, is combined with paresthesia and decreased sensitivity, a decrease or loss of tendon reflexes, less often with weakness and atrophy of the muscles innervated by this rootlet. CVI roots are the most common (pain and sensitivity disorders on the outer surface of the forearm and hand to the I-II fingers, decrease or fall of the reflex from the biceps) and CVII (pain and sensitivity impairment on the back of the shoulder and forearm to II-III fingers, Or loss of reflex from the triceps muscle).

With the middle disc herniation in patients with a narrow vertebral canal, spinal cord compression may occur, manifested by weakness, hyperreflexia and increased tonus in the legs, muscle atrophy and decreased reflexes on the hands, abnormal wrist reflexes, Lermitt's symptom (sensation of current flow through the spine and legs when flexing Neck), pelvic disorders (spondylogenous cervical myelonatia).

Pain with a disc herniation is worse when coughing, sneezing, straining, bending the head, tilting or turning the head to the sore side, but easier when the head or the head of the sick arm is tied. The examination reveals a restriction of the mobility of the cervical region, especially when flexing, and the tension of the neck muscles.

Against the background of degeneration of the intervertebral discs and a decrease in their height, the facet joints in the intervertebral joints are displaced relative to each other, which leads to instability or functional blockade of the PDS and further degeneration of its structures.

Arthrosis of the facet joints can be the result of systemic joint damage (eg, generalized osteoarthritis, rheumatoid arthritis, ankylosing spondylitis), trauma or increased stress on these joints, including in patients with herniated disc. It manifests itself as acute or chronic unilateral or bilateral pain in the neck, which usually occurs within 7-10 days. Exacerbation can be triggered by unsuccessful movement, hypothermia, prolonged stay in an uncomfortable position (for example, during sleep). In contrast to the disc herniation, arthrosis often suffers from upper cervical roots (CIII-CV), so pain is noted in the nape, neck, shoulder girdle, proximal part of the hands. As a result of a protective muscular spasm, torticollis may develop. The pain increases with the extension of the neck or tilt in the direction of the more affected joint. On examination, the restriction of extension, as well as flexion, as in the case of herniated disc, bilateral soreness of the facet joints is revealed (they are palpated at a distance of 2 cm from the midline). The diagnosis is confirmed by a reduction in pain after blockade of the joint.

Osteophytes perform a compensatory function, stabilizing the PDS, but they can squeeze the vertebral artery or esophagus. The narrowing of the intervertebral openings and the spinal canal, associated with the formation of osteophytes, thickening of the ligaments, hypertrophy of the articular processes, protrusion of the discs, is also the cause of compression of the roots or spinal cord.

Diagnosis. Radiographs of the cervical spine may show a decrease in the height of the intervertebral discs, sclerosis of the end plates, hypertrophy of the articular processes, osteophytes, uneven narrowing of the spinal canal. However, the correspondence between the severity of the pain syndrome and the radiographic changes is often not traced. X-ray signs of osteochondrosis can be found in the vast majority of persons of mature and advanced age, many of whom will never have pain. On the other hand, in young people with a herniated disc, there can be no x-ray changes. Therefore, the main goal of radiography is to exclude swelling, spondylitis, or osteoporosis.

Treatment. Most patients with cervicalgia or cervicobrahialgia complete spontaneous recovery within a few days or weeks, but sometimes, especially when rootlets are involved, it lasts for several months. With exacerbation, rest, immobilization of the neck with the help of the cervical collar, which should be worn primarily at night, analgesics (paracetamol, analgin, tramadol), non-steroidal anti-inflammatory drugs, muscle relaxants (see Back pain and lower limbs) are shown. With arthrosis of the facet joints, pain syndrome can be reduced by repeated paravertebral blockades with the use of a local anesthetic and corticosteroid. Subsequently, the gradual mobilization of the neck, post-isometric relaxation, reflexotherapy, physiotherapeutic procedures (diadynamic currents, phonophoresis with hydrocortisone, etc.), stretching are shown. With a severe pain syndrome, a short course of corticosteroids is effective (prednisolone 60 to 80 mg once a day for 5 to 10 days, followed by a rapid dose reduction and drug cancellation).

In subacute and chronic phases, the main emphasis is on curative gymnastics, manual therapy, massage, balneotherapy. In chronic pain syndrome, tricyclic antidepressants (for example, amitriptyline) are sometimes effective in small doses. Surgical intervention is indicated with symptoms of compression of the spinal cord and severe pain syndrome (if the entire arsenal of conservative treatment is ineffective for several months).

Injury of the cervical spine. A slight injury caused by an awkward or unprepared movement and accompanied by stretching of muscles, tendons, ligaments, capsules of the facet joints without damaging the bone or nervous structures is manifested by pain in the neck and head, stiff neck, dizziness, blurred vision, unsteady walking. The examination reveals the limitation of the mobility of the cervical region, the soreness of the spinous processes, the tension of the paravertebral muscles. Characteristic decrease in cervical lordosis due to muscle spasm. There are no symptoms of loss. Degenerative changes in the spine significantly increase the sensitivity to trauma. Radiography is performed to exclude a fracture, dislocation, tumor or inflammatory lesion of the spine. Treatment : rest (cervical collar), use of analgesics, non-steroidal anti-inflammatory drugs, therapeutic gymnastics, physiotherapy methods, blockade of painful points. Early mobilization helps to avoid long-term disability.

Neuralgia of the occipital nerve is manifested by short-term attacks of pain in the occiput. Pain is enhanced by percussion of nerve exit points. In the zone of innervation, sensitivity disorders are detected. Blockade of nerve exit points leads to pain relief.

Myofascial pains are associated with the formation of muscular spasm in muscles, with the properties of trigger points: when they are irritated, pain occurs in the remote zone. More often, trigger points are found in trapezius, scapular, and suboccipital muscles. Reflected pain is noted in the head, eye, shoulder. Spasm of the stair or small pectoral muscle can cause compression of the brachial plexus. Lechenie includes injections of anesthetics and corticosteroids into trigger points, passive stretching of the affected muscle, massage, therapeutic gymnastics, applications with dimexide and novocaine to the affected area. Simultaneously, non-steroidal anti-inflammatory drugs and tricyclic antidepressants are prescribed. Myofascial pains often occur in the background of osteochondrosis of the spine.

Infectious diseases (nonspecific or tuberculous spondylitis, epidural abscess , discitis) is a rare but clinically important cause of neck pain. Unlike degenerative changes in the spine, pain is not mechanical (it is not facilitated by rest), accompanied by systemic manifestations, changes in blood (increased ESR, leukocytosis, anemia).

Tumors of the cervical spine rarely cause pain in the neck. Most of these tumors are metastatic in nature (the primary tumor is localized in the lungs, lactic or prostate gland). Characterized by increased pain at rest, at night, systemic manifestations of the disease. Metastases in the dentate process can be complicated by fracture and subluxation in the atlanto-axial articulation, accompanied by intense pain in the occiput and compression of the spinal cord (tetraparesis). The absence of changes in the X-ray of the spine does not always exclude a tumor.

Inflammatory or tumor diseases of the thyroid gland can cause pain along the front surface of the neck, radiating into the ear, the lower jaw, the back of the neck.

Pain in the hand that occurs separately from neck pain (brachialgia) is usually associated with defeat of the brachial plexus, tunnel neuropathies, reflex sympathetic dystrophy, soft tissue damage or somatic diseases that cause reflected pain (eg, angina).

Plechelopatochny syndrome is mainly associated with the pathology of soft periarticular tissues. With tendinitis of the rotator cuff, the pain is diffuse or limited to the lateral surface of the shoulder; The most painful is the withdrawal of the shoulder. When palpation, soreness is detected in the subacromial region. Tendonitis of the biceps muscle is manifested by pain in the shoulder and tenderness of the muscle tendon that is palpated when the shoulder is rotated outside on its front surface. Arthritis of the acromioclavicular joint is manifested by diffuse pain, which increases with the raising of the hand, and soreness in the joint region. Adhesive capsulitis ("frozen shoulder") is the final stage of various variants of periarticular soft tissue damage. Often, it also occurs with paralysis - as a result of a long absence of movements in the shoulder joint. Adhesive capsulitis manifests itself by limiting both active and passive movements, diffuse pain. The treatment is aimed at a gradual increase in joint mobility and includes the use of analgesics, nonsteroidal anti-inflammatory drugs, dimexid application, topical administration of corticosteroids, phonophoresis with hydrocortisone and other physiotherapy procedures, therapeutic gymnastics.

Pain in the elbow area can be caused by myofascial syndrome, compression of the superficial branch of the radial nerve, epicondylitis, arthrosis of the elbow joint, bursitis of the elbow process. Lateral epicondylitis is manifested by pain in the elbow, concentrating around the external epicondyle and increasing when the wrist or fingers are extended against resistance. This syndrome often occurs with the often repeated extension of the hand ("elbow tennis player"). Medial epicondylitis occurs due to repeated flexion and pronation of the brush. Treatment includes immobilization of the elbow and wrist joints, curative gymnastics, non-steroidal anti-inflammatory drugs, local administration of corticosteroids. Arthritis of the elbow joint is manifested by diffuse pain, which increases when moving in the joint, is usually detected in elderly patients or after trauma. Bursitis of the ulnar process, inflammation of the bag located between the elbow and the tendon of the triceps muscle, resulting from repeated movements in the elbow joint. Differential diagnosis is carried out with an infectious lesion of the joint, gout and other arthritis.

Vascular diseases. When the vessels are damaged (for example, with thrombosis or compression of the subclavian artery), pain is accompanied by blanching of the phalanx of the fingers, in severe cases - by gangrene or syndrome of the muscular lodges. The cause of pain and paresthesias in the distal limbs can be vasospastic disorders, for example, Raynaud's syndrome or acrocyanosis.