Case Study: Does This Patient's Pain Originate at the Neck? - Clinical Pain Advisor

Case Study: Does This Patient’s Pain Originate at the Neck?

Slideshow

  • Anteroposterior cervical spine radiograph of a 48-year-old woman with severe right shoulder and neck pain that has been present for 2 to 3 months.

    Slide

    Anteroposterior cervical spine radiograph of a 48-year-old woman with severe right shoulder and neck pain that has been present for 2 to 3 months.

  • Lateral cervical spine radiograph of the patient.

    Slide

    Lateral cervical spine radiograph of the patient.

A 48-year-old woman presents with severe right shoulder and neck pain that has been present for 2 to 3 months. She denies any injury or known precipitating event. The pain seems to be worse with shoulder and neck motion, and most of the pain is located in the lateral arm and neck area. The arm pain seems to stop at the middle of the arm, and the patient denies numbness or tingling in the hands. She is difficult to examine because of the pain, although she seems to have full passive and active motion of the shoulder and neck. She has mildly positive shoulder impingement signs and a negative Spurling test to the right arm. Anteroposterior and lateral radiographs of the cervical spine are taken.

This case has been brought to you in partnership with the Journal of Orthopedics for Physician Assistants.

A herniated cervical disk can compress the nerve roots exiting the neck, causing radiating pain to the shoulder and arm, or cervical radiculopathy. The pattern of radiculopathy does not always follow a classic dermatomal pattern and may be confused with...

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A herniated cervical disk can compress the nerve roots exiting the neck, causing radiating pain to the shoulder and arm, or cervical radiculopathy. The pattern of radiculopathy does not always follow a classic dermatomal pattern and may be confused with pain originating from the shoulder. Confusing things further is that some patients presenting with cervical radiculopathy can also have painful shoulder impingement.

A careful review of the patient’s symptoms and physical examination findings is crucial to distinguish between cervical spine and shoulder pathologies. Electromyography and advanced imaging of the shoulder and cervical spine with magnetic resonance imaging can ultimately determine the source of pain but are too costly to be used as first-line screening tests.

Turning the patient’s neck to the affected side can decrease the space in the neural foramen, which increases nerve root compression and pain. A positive Spurling maneuver, which is performed by gently moving the patient’s neck in extension, leaning the head to the affected side, and placing slight axial compression, is very specific for cervical radiculopathy. However, Spurling test has a relatively low sensitivity for cervical radiculopathy, with one study showing a positive test in only 30% of patients who had positive electromyography studies. Abducting the affected arm offers relief of the radicular symptoms by releasing tension off the compressed nerve root, also called the shoulder abduction relief sign. An arm squeeze test involves placing a moderate squeeze to the mid biceps and triceps area on the affected side. The rationale behind the test is that the musculocutaneous, radial, ulnar, and median nerves are relatively superficial in that area and an arm squeeze stretches the nerve, worsening the compression of the nerve roots from C5-T1.

Cervical traction should help relieve radicular symptoms from the neck by opening up the neuroforamen and reducing compression on the nerve root.1,2

Dagan Cloutier, MPAS, PA-C, practices in a multispecialty orthopedic group in the southern New Hampshire region and is editor-in-chief of the Journal of Orthopedics for Physician Assistants (JOPA).

References

  1. Tong HC, Haig AJ, Yamakawa K. The Spurling test and cervical radiculopathy. Spine (Phila Pa 1976). 2002;27:156-159.
  2. Gumina S, Carbone S, Albino P, Gurzi M, Postacchini F. Arm squeeze test: a new clinical test to distinguish neck from shoulder pain. Eur Spine J. 2013;22:1558-1563.