CHAPTER 21 NECK AND ARM PAIN Ronald Kanner, MD, Gary McCleane, MD 1. What factors predispose a person to the development of neck pain on the job? In the work setting, high quantitative job demands and low co-worker support appear to be independent risk factors for neck pain. In the general population, women are more likely than men to develop neck pain. A history of previous neck injury is a risk factor for subsequent chronic pain. A past history of low back pain also may predict the appearance of neck pain. Psychosocial factors may be as important as physical abnormalities in the development of chronic neck pain, paralleling the prevalent issues in low back pain. 2. What precautions can reliably diminish the risk of neck pain? Although many occupational standards have been established to reduce neck pain, the literature supports only exercise as a clear preventive agent. There are relatively few controlled studies that have yielded a positive outcome for ergonomic reconfiguring, avoidance of repetitive stress injury, and lumbar supports. These interventions may have some role, but their benefit has not been demonstrated adequately in controlled trials. 3. Who had the first case of neck pain? In his book on neck and arm pain, Dr. Rene Cailliet cites writings in the Papyrus, over 4600 years ago, describing cervical vertebral dislocation and sprains. He goes on to say that Tutankhamen described what may have been the first cervical laminectomy. At any rate, it appears that cervical pain has been present since humans walked erect. 4. Why does the neck hurt? As in the lumbar spine, there are a number of pain-sensitive structures in the cervical spine. These include the vertebral bodies, laminae, dura, and surrounding muscles. Inflammation or destruction of any one of these structures produces pain. 5. What is the normal configuration of the cervical spine? In the pain-free, normal cervical spine, there is a gentle lordosis from C1 to T1. As the head flexes forward, this lordosis normally disappears. Anterior flexion should be pain free, even with the chin touching the chest. On lateral flexion, the ears should come within a few centimeters of the shoulder. Flexion and extension have a combined excursion of about 70 degrees. Rotations about the vertical axis (left and right) are approximately 90 degrees in each direction. Lateral flexion should be about 45 degrees in each direction. When testing range of motion (ROM) of the cervical spine, always have the patient try active ROM before passive ROM. If there are structural abnormalities, the patient will guard the area. 6. What is an early sign of neck pain? One of the earliest signs is straightening of the cervical lordosis. Normally, the cervical spine demonstrates a gentle curve with the convex to the posterior. As the patient tries to guard the neck from movement, the lordosis disappears. 7. What is the prevalence of neck pain? Neck pain appears to be less common than low back pain in the general population. There are very few demographic studies of neck pain in the literature. The vast majority of pain prevalence studies have been done on low back pain. Acute attacks of stiff neck appear to be relatively common, occurring in 25% to 50% of workers. Chronic neck pain, however, is less prevalent. 8. How many cervical vertebrae and roots are there? There are seven cervical vertebrae and eight cervical spinal nerves. C1, however, has no sensory root and innervates the muscles that support the head. 9. How do the exiting characteristics of the nerves in the cervical spine differ from those in the rest of the spine? In the thoracic and lumbar spines, the spinal nerves exit through the intervertebral foramen subjacent to the vertebral body numbered for that root. Therefore, the L1 root exits between the L1 and L2 vertebral bodies, L2 between L2 and L3, and so on. The root is numbered for the body under which it exits. In the cervical spine, however, the numbering is somewhat different. Except for the C8 nerve root, the cervical roots exist above its corresponding vertebrae. The C8 root exits between the seventh cervical and the first thoracic vertebrae. C7 exits between C6 and C7, and so on in a cephalad direction. 10. What is whiplash injury? Whiplash refers to acceleration/deceleration of the head, whipping the neck. It most commonly occurs in motor vehicle accidents, usually when a car is struck from behind. Patients complain of soreness and tenderness in the neck, usually occurring a day or two after the initial injury. In most cases, pain resolves spontaneously. In some, it can go on for many months or years. On examination, there is tenderness of the neck muscles and limitation of ROM. Focal neurologic dysfunction is uncommon. 11. What is the presumed mechanism of whiplash injury? Whiplash is a widely disputed entity. The mechanistic theory holds that a rear impact causes the sixth cervical vertebrae to be rotated back into extension before movement of the upper cervical vertebrae. This produces an “S-shaped” deformity in the cervical spine. The neck mobility is reduced immediately after trauma, but may be normal when measured more than 3 months later. Whiplash, much like chronic low back pain, should probably be viewed as a biopsychosocial phenomenon. 12. Which articulations in the neck are critical to anteroposterior flexion? Fifty percent of the AP flexion of the neck is centered on the atlantooccipital joint, and 50% is divided relatively evenly among the other cervical vertebral articulations. Therefore, even with relatively severe cervical spondylosis, some degree of nodding ability is maintained. 13. How does movement of the head affect the intervertebral foramina through which cervical roots exit? Anterior flexion of the head opens the neuroforamina. As the head turns from side to side or tilts from side to side, the ipsilateral intervertebral foramen closes. If there is nerve root compromise, tilting or turning the head toward that side increases radicular pain. 14. What is the most benign cause of cervical pain? Stress, with accompanying muscle tension, can produce neck pain and tenderness. With tension and anxiety, the shoulders are held shrugged and muscle pain ensues. The ideal treatment for this would be removal of the stress, though this is rarely possible. More practically, local applications of heat or cold or relaxation techniques may be useful. 15. Only gold members can continue reading. Log In or Register to continue Share this:Click to share on Twitter (Opens in new window)Click to share on Facebook (Opens in new window) Related Related posts: Neuroimaging in the Patient with Pain Pharmacologic Management Tension-Type Headache Neuropathic Pain Migraine Temporary Neural Blockade Stay updated, free articles. Join our Telegram channel Join Tags: Pain Management Secrets Jun 14, 2016 | Posted by admin in PAIN MEDICINE | Comments Off on Neck and Arm Pain Full access? Get Clinical Tree
CHAPTER 21 NECK AND ARM PAIN Ronald Kanner, MD, Gary McCleane, MD 1. What factors predispose a person to the development of neck pain on the job? In the work setting, high quantitative job demands and low co-worker support appear to be independent risk factors for neck pain. In the general population, women are more likely than men to develop neck pain. A history of previous neck injury is a risk factor for subsequent chronic pain. A past history of low back pain also may predict the appearance of neck pain. Psychosocial factors may be as important as physical abnormalities in the development of chronic neck pain, paralleling the prevalent issues in low back pain. 2. What precautions can reliably diminish the risk of neck pain? Although many occupational standards have been established to reduce neck pain, the literature supports only exercise as a clear preventive agent. There are relatively few controlled studies that have yielded a positive outcome for ergonomic reconfiguring, avoidance of repetitive stress injury, and lumbar supports. These interventions may have some role, but their benefit has not been demonstrated adequately in controlled trials. 3. Who had the first case of neck pain? In his book on neck and arm pain, Dr. Rene Cailliet cites writings in the Papyrus, over 4600 years ago, describing cervical vertebral dislocation and sprains. He goes on to say that Tutankhamen described what may have been the first cervical laminectomy. At any rate, it appears that cervical pain has been present since humans walked erect. 4. Why does the neck hurt? As in the lumbar spine, there are a number of pain-sensitive structures in the cervical spine. These include the vertebral bodies, laminae, dura, and surrounding muscles. Inflammation or destruction of any one of these structures produces pain. 5. What is the normal configuration of the cervical spine? In the pain-free, normal cervical spine, there is a gentle lordosis from C1 to T1. As the head flexes forward, this lordosis normally disappears. Anterior flexion should be pain free, even with the chin touching the chest. On lateral flexion, the ears should come within a few centimeters of the shoulder. Flexion and extension have a combined excursion of about 70 degrees. Rotations about the vertical axis (left and right) are approximately 90 degrees in each direction. Lateral flexion should be about 45 degrees in each direction. When testing range of motion (ROM) of the cervical spine, always have the patient try active ROM before passive ROM. If there are structural abnormalities, the patient will guard the area. 6. What is an early sign of neck pain? One of the earliest signs is straightening of the cervical lordosis. Normally, the cervical spine demonstrates a gentle curve with the convex to the posterior. As the patient tries to guard the neck from movement, the lordosis disappears. 7. What is the prevalence of neck pain? Neck pain appears to be less common than low back pain in the general population. There are very few demographic studies of neck pain in the literature. The vast majority of pain prevalence studies have been done on low back pain. Acute attacks of stiff neck appear to be relatively common, occurring in 25% to 50% of workers. Chronic neck pain, however, is less prevalent. 8. How many cervical vertebrae and roots are there? There are seven cervical vertebrae and eight cervical spinal nerves. C1, however, has no sensory root and innervates the muscles that support the head. 9. How do the exiting characteristics of the nerves in the cervical spine differ from those in the rest of the spine? In the thoracic and lumbar spines, the spinal nerves exit through the intervertebral foramen subjacent to the vertebral body numbered for that root. Therefore, the L1 root exits between the L1 and L2 vertebral bodies, L2 between L2 and L3, and so on. The root is numbered for the body under which it exits. In the cervical spine, however, the numbering is somewhat different. Except for the C8 nerve root, the cervical roots exist above its corresponding vertebrae. The C8 root exits between the seventh cervical and the first thoracic vertebrae. C7 exits between C6 and C7, and so on in a cephalad direction. 10. What is whiplash injury? Whiplash refers to acceleration/deceleration of the head, whipping the neck. It most commonly occurs in motor vehicle accidents, usually when a car is struck from behind. Patients complain of soreness and tenderness in the neck, usually occurring a day or two after the initial injury. In most cases, pain resolves spontaneously. In some, it can go on for many months or years. On examination, there is tenderness of the neck muscles and limitation of ROM. Focal neurologic dysfunction is uncommon. 11. What is the presumed mechanism of whiplash injury? Whiplash is a widely disputed entity. The mechanistic theory holds that a rear impact causes the sixth cervical vertebrae to be rotated back into extension before movement of the upper cervical vertebrae. This produces an “S-shaped” deformity in the cervical spine. The neck mobility is reduced immediately after trauma, but may be normal when measured more than 3 months later. Whiplash, much like chronic low back pain, should probably be viewed as a biopsychosocial phenomenon. 12. Which articulations in the neck are critical to anteroposterior flexion? Fifty percent of the AP flexion of the neck is centered on the atlantooccipital joint, and 50% is divided relatively evenly among the other cervical vertebral articulations. Therefore, even with relatively severe cervical spondylosis, some degree of nodding ability is maintained. 13. How does movement of the head affect the intervertebral foramina through which cervical roots exit? Anterior flexion of the head opens the neuroforamina. As the head turns from side to side or tilts from side to side, the ipsilateral intervertebral foramen closes. If there is nerve root compromise, tilting or turning the head toward that side increases radicular pain. 14. What is the most benign cause of cervical pain? Stress, with accompanying muscle tension, can produce neck pain and tenderness. With tension and anxiety, the shoulders are held shrugged and muscle pain ensues. The ideal treatment for this would be removal of the stress, though this is rarely possible. More practically, local applications of heat or cold or relaxation techniques may be useful. 15. Only gold members can continue reading. Log In or Register to continue Share this:Click to share on Twitter (Opens in new window)Click to share on Facebook (Opens in new window) Related Related posts: Neuroimaging in the Patient with Pain Pharmacologic Management Tension-Type Headache Neuropathic Pain Migraine Temporary Neural Blockade Stay updated, free articles. Join our Telegram channel Join Tags: Pain Management Secrets Jun 14, 2016 | Posted by admin in PAIN MEDICINE | Comments Off on Neck and Arm Pain Full access? Get Clinical Tree
