NECK and UPPER EXTREMITY PAIN

1. NECK and UPPER EXTREMITY PAIN

2. C1 or atlas There is no disc between C1 and C2. C2 or axis C3 C4 C5 C6 C7 Body Vertebral foramen Bifid spinous process or spine Transverse process Foramen transversarium or transverse foramen Superior articular facet Anatomy

4. (a)Supraspinous ligament (b) interspinousligament (c) facet joint capsule (d) posterior longitudinal ligament

5. SCM • Scalen muscle • PV • Longus capitis • Longus colli • Rectus capitis ant • Splenius capitis

6. Each disk consists of an outer anulus fibrosus and an inner nucleus pulposus and a cephalad and caudad end plate. • The anulus fibrosus is innervated by the sinuvertebral nerve, formed by branches of the ventral nerve root and the sympathetic plexus. • The pressure within the disk is highest with flexion, which may explain why individuals with a disk herniation find this position most uncomfortable. • Disk degeneration with aging includes loss of water content with resultant loss of height, annular tears, and myxomatous changes, increasing the risk of disk herniation. • Herniation typically occurs in the posterolateral aspect of the disk, where the posterior longitudinal ligament is not present and the anulus fibrosus is at its weakest.

7. Spinal cord : posterior column, the lateral columns, and the anterior column. • The posterior column: proprioceptive, vibratory, and tactile sensation. • The lateral column • lateral corticospinal tract: motor fibers, • and the spinothalamic tract: pain and temperature sensation from the contralateral side of the body. • The anterior column: touch sensation. • Eight total cervical nerve roots on each side as the dorsal and ventral roots converge to form the spinal nerve within the vertebral foramen.

9. The cervical spine is the most mobile segment of the spine with approximately a 90-degree arc of motion in flexion and extension, with three fourths of this due to extension. • The maximal range of motion in the sagittal plane within the subaxial spine is at the C5-C6 level, making it a common site of disk degeneration. • Rotation encompasses approximately 80 to 90 degrees of motion with 50% of this occurring at the atlantoaxial joint.

10. Functıonal Anatomy • The most mobile segment of the spine • 7 cervical vertebrae • 14 apophyseal (faset) joints • 12 joints of Luschka • Ligaments (posterior longitudinal, anterior longitudinal, flaval, interspinous) • Muscles Faset joints are posterior intervertebral joints. They are true sinovial joints and enable the head movement. Luschka joints are between semilunar joint surface of upper vertebra and uncus of lower vertebra. They protect spinal colon aganist disc protrusion

11. Flexion: 60-90 • Extension • Rotation: 90 • Lateral flexion: 45 • Atlantoaxial joint: 45 degree rotation • Atlanto-occipital joint: 10 d flexion, 25 d extension • C5-C6 , C4-C5 maximal range of movement

12. Pain sensitive structures • Ligaments • Nerve roots • Articular facets and capsules • Muscles • Dura • External fibers of anulus fibrosus

13. Disorders cause neck and upper extremity pain Cervical vertebra colon: cervical spondylosis (OA) cervical disc herniation spinal stenosis instability Wiplash injury Cervical cord diseases (Tumor, syringomyeli) Rheumatologic disorders: Ankylosing spondylitis, Rhematoid arthritis, Polymyalgia Rheumatica, Fibromyalgia, Myofascial pain syndrome Infectious: Osteomyelitis, dissit, epidural/intradural/subdural abces, retropharengeal abces Endocrin: osteoporosis, osteomalasia, paget disease Trauma: hard muscle contraction, sport injury, work conditions, postur Thoracic outlet syndrome Shoulder, elbow, wrist Neuropathies Artheritis (vertebral and cranial, Takayasu) Referred pain

14. Structures That Cause Neck Pain • Akromioclavicular joint • Heart and coronary disease • Apex of lung, Pancoast’s tumour • Diaphragm muscle (C3-C5 inn) • Gallbladder • Spinal cord tumour • Temporomandibular joint

16. Axial Neck Pain • Axial neck pain describes a pattern of pain that is localized to the occiput and neck region. • Degenerative arthritis within the upper cervical spine can manifest as suboccipital headache and localized pain. This is termed cervicogenic headache and is thought to result from irritation of the greater occipital nerve.

17. Cervical Strain and Sprain • Strain: • injury of contractile tissues by stretching (muscle, lig.) • Pain is localized on neck • Decreased lordosis, pv spasm • No neurologic sign • Sprain: • Tissue rupture and bleeding by stretching (capsule, lig., bursa, vessels, cartilage, dura)

18. Cervical Spondylosis • Degeneration of IVD, facet and luschka • Age, microtrauma, ergonomy, genetic • Syndromes due to spondylosis • Radiculopathy • Vertebrobasilar insufficiency • Cervical myelopathy

19. Radiculopathy • Radicular pain • Paresthesias • Superficialsensory deficits • Variation of DTR • Muscle strength loss

20. If these deficits are minor and tolerable, it is reasonable to treat with conservative care with close follow-up to ensure that the deficit is not progressive. Disabling deficits should be treated operatively because prolonged nerve compression can result in irreversible changes. • In patients without a neurologic deficit, it is reasonable to expect a good outcome with conservative care.

21. Instability • Deterioration of cervical colon stability by physical loads • X-ray

22. Myelopathy • Myelopathy is the clinical presentation of long tract signs resulting from compression of the spinal cord. • Myelopathy: • a tumor or infection • instability owing to systemic arthritides or connective tissue disorders, • degenerative changes within the cervical spine. • Factors that contribute to the development of myelopathy : • congenitally narrow spinal canal, dynamic cord compression, dynamic thickening of the spinal cord, and vascular changes. • Cervical colon stenosis: osteophyte, disc herniation, lig. flavum and facet joint hipertrophy, posterior longitudinal lig. thickness, Paget, gout • The anteroposterior diameter in the subaxial spine for a normal adult measures 17 to 18 mm, and the cord measures 10 mm. Diameters of less than 13 mm are considered to be congenitally stenotic.

23. complaints of hand clumsiness or difficulty with balance. • worsening handwriting or difficulty buttoning buttons. • nausea and emesis caused by equilibrium dysfunction. • Paresthesias and dysesthesias may be present, often involving bilateral upper extremities and not following a dermatomal distribution. • wasting of hand intrinsics and bowel and bladder dysfunction.

24. Definitive indications for surgery: • presence of myelopathy for 6 months or longer, • progression of signs or symptoms, • difficulty walking, or change in bowel or bladder function.

25. VBI • Blood supply of inner ear, vestibular and cochlear nucleii of medulla oblangata • Vertigo, headache, nausea • Coordination, memory deficit • Tinnitus, hearing loss, diplopia • Nistagmus, disphagia • Common property of those symptoms is that they are related with neck movement and local/radicular symptoms

26. Cervical Disc Herniation • With age, the nucleus pulposus becomes vulnerable • With degenerative changes, • the disc space narrows, spinal column shortens • The intervertebral foramina become narrowed, movements become restricted, unusual mechanical strains on the sinovial joints result • The formation of osteophytes leads to encroachment on the spinal canal and intervertebral foramina • Changes in the caliber of the vertebral arteries can result because of the degenerative changes • Facet joints (sinovial) can be affected by various arthritic diseases • Uncovertebral joints have no sinovial membrane • Articular cartilage in all joints is avascular and aneural

27. All joints are supplied with sensory nerves and nutrient vessels on the segmental basis as well as with sympathetic pain fibers. • Pain from those joints are non-neuralgic and felt locally. • If the dura and its nerve are stretched, the accompanying nutrient vessels canbe narrowed and promptly cause ischemic neuralgic pain. • The main load-bearing structure of the neck is the intervertebral disk. • The IVD consists of fibroelastic envelope that has a blood supply and a nerve supply that is highly sensitive to stretching. • Nuc. Pulposus has has no nerve supply---painless • As the disk loses height, it places increased pressure on the joints • Surface areas are inadequate for the imposed pressure, they become irritaed • Irritation—inflammatory disease-----repair----formation of osteophytes

28. Clinical Evaluation • Patient’s history • Physical examination • Neuroimagining studies • Neurophysiologic procedures

29. Sensory symptoms • Weakness • Articular symptoms • Vascular symptoms • Headache and occipital neuralgia • Nerve root sympathetic nerve compression, vertebral artery pressure, posterior occipital muscle spasm • Pseudoangina pectoris • (C6-C7)

30. Clinical Examination • Inspection: lordosis, scoliosis, torticollis, active limtaiton, skin lesions • Palpation • Range of servical spine motion • Motor signs • Reflexes • Sensory signs

32. C4-C5-----C5 nerve root compression: • Pain in scholuder, lateral arm, dorsum of the forearm • Paresthesias lateral side of the arm • Weakness in biceps • Hiporeflex biceps reflex • C5-C6-----C6 nerve root compression: • Pain in scholuder, lateral arm, dorsum of the forearm • Paresthesias in1st and 2nd fingers • Weakness in biceps and dorsiflexors of the wrist • Hiporeflex brachioradial reflex • C6-C7-----C7 nerve root compression: • Similar pain pattern • Paresthesias in 2nd and 3rd fingers • Weakness in triceps and flexors of the wrist and fingers • Hiporeflex triceps reflex • C7-T1-----C8 nerve root compression: • Pain in medial side of the arm • Paresthesias in 4thnd and 5th fingers • Weakness in finger flexors and intransic muscles of the hand • Hiporeflex triceps reflex

33. Special Tests • Cervical distraction test • Spurling Test • Adson Test • Lhermitte Sign

34. Diagnostic Evaluation • Routine radiographic view • Axes, Fusion, Instability, Spondylolistesis, Degeneration of facet, osteophyte • Narrowing of intervertebral space, sclerosis of endplates, sharpening of vertebral corpus bend • MRI: • Intervertebral disc, neural elements, paraspinal structures, spinal tumours • BT • Neoplstic, degenaritve, traumatic, infectious • Radioisotope bone scans • Doppler ultrasound

35. Electrodiagnostic studies: • Distinguish sensory and motor dysfunction of the peripheral nerves. • Distinguish a lesion in the periphery from a nerve root lesion • Laboratory Studies:

36. Treatment • Immobilization: cervical collar • Medication: NSAID, analgesics, myorelexan, corticosteroids • Physical therapy: superficial and deep heat, massage, electrotherapy, traction • Theurapatic exercises: Isometric, ROM

37. Thoracic Outlet Syndrome • Thoracic outlet syndrome is a condition whereby symptoms are produced from compression of nerves or blood vessels, or both, because of an inadequate passageway through an area (thoracic outlet) between the base of the neck and the armpit. • muscle enlargement (such as from weight lifting), injuries, • an extra rib from the neck at birth (cervical rib), • weight gain, • tumors at the top of the lung (rare). • Often no specific cause is found.

38. Anatomic regions causing compression: 1. Interscalenetriangle 2. costaclavicular fossa

39. InterscaleneTriangle Anterior: Anterior skalen Posterior: Orta skalen İnferior: 1. costa • Compressing structures: • Scalenus antikus, medius, minimus • 1. costa • Shoulder • Costa fracture with callus formation, • Big transvers process of C7 • cervikal costa • Fibrous bands • Tumors

40. Costoclavicular Fossa • Anteriorclavicula, m. subclavius, kostocoracoid ligament • Posteromedial  1. costa, anterior andmed scalen musclesinsersiyo • Posterolateral  scapula superior • Compressing structures: • Clavicula or 1.costa kongenital variations • M.Subclavius structural changes, hipertrophy • Shoulder position, postural defects • Trauma • Anatomy of clavicula • Clavicula or costa fracture with callus formation

41. Wilbourne Classification Vascular %10 Nöeurogenic %90 Real neurogenic: • C8-T1 pain and paresthesia • Generalised painarm, anterior and posterior chest wall • Atrophy and muscle weakness at hand Suspicious neurogenic: • Same symptoms but no objective signs

42. Symptoms • Neck, shoulder, and arm pain • numbness, or impaired circulation to the extremities (causing discoloration) • Often symptoms are reproduced when the arm is positioned above the shoulder or extended • Pain can extend to the fingers and hands, causing weakness

43. Provocative tests Adsontest Costoclavicular compression test Wright Hiperabductiontest

44. Cervical graphy: • Cervical costa • PA lung graphy: Pancoast • ENMG: although these may not be positive in all patients. • Angiogram x-ray tests:demonstrate the pinched area of the blood vessel involved.

45. Treatment Conservativetreatment • Postural exercises • Shoulder girdle strengthening exercises and scalene muscles streching exercises • Myorelaxan • NSAİİ • Superficial and deep heat, iontophoresis,TENS Surgery

46. Avoid prolonged positions with their arms held out or overhead. • Avoid sleeping with the arm extended up behind the head. • Have rest periods at work to minimize fatigue. • Weight reduction • Avoid sleeping on their stomach with their arms above the head. • Not repetitively lift heavy objects.

47. Shoulder Pain

48. Anatomy And Function • The shoulder joint is the most mobile joint of the body • Joint stability: labrum, capsule and the glenohumeral ligaments, the rotator cuff (dynamic stability) of the joint. The shoulder consists of three joints—acromioclavicular (AC), sternoclavicular, and glenohumeral—and two gliding planes—the scapulothoracic and subacromial surfaces • Knowledge of the route of the tendon of the long head of the biceps through the bicipital groove and onto the superior aspect of the glenoid helps in understanding bicipital tendinitis