Chapter 016. Back and Neck Pain (Part 16) doc

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 followup.

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]


Cavalier R et al: Spondylolysis and spondylolisthesis in children and
adolescents: Diagnosis, natural history, and non-surgical management. J Am Acad
Orthop Surg 14:417, 2006 [PMID: 16822889]

Cowan JA Jr et al: Changes in the utilization of spinal fusion in the United
States. Neurosurgery 59:1, 2006

Gorbach C et al: Therapeutic efficacy of facet joint blocks. AJR Am J
Roentgenol 186:5, 2006

Mummaneni PV et al: Clinical and radiographic analysis of cervical disk
arthroplasty compared with allograft fusion: A randomized controlled clinical trial.
J Neurosurg Spine 6:198, 2007 [PMID: 17355018]

Peul WC et al: Surgery versus prolonged conservative treatment for
sciatica. N Engl J Med 356:2245, 2007 [PMID: 17538084]

van Alfen N, van Engelen BG: The clinical spectrum of neuralgic
amyotrophy in 246 cases. Brain 129:438, 2006

Weinstein JN et al: Surgical versus nonsurgical treatment for lumbar


degenerative spondylolisthesis. N Engl J Med 356:2257, 2007 [PMID: 17538085]

——— et al: Surgical vs nonoperative treatment for lumbar disc herniation.
The spine patient outcomes research trial (SPORT): A randomized trial. JAMA
296:2441, 2006

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