Those common, nagging pains
View(s):Senior Consultant Neurologist Dr.J.B Peiris answers some frequently asked queries on neck, shoulder and arm pain
What causes neck, shoulder and arm pain?
Neck pain arises from structures in the back of the neck – namely the bones in the spine (vertebrae), discs, spinal muscles, and nerves arising from the spinal cord and supplying the neck , shoulder and arms. In the front of the neck are the thyroid gland, trachea and oesophagus which usually presents with symptoms other than neck pain. There are similarities between pain in the neck and arms and backache with pain in legs or sciatica.
How common is neck and arm pain?
Neck and arm pain is as common as backache, as the neck moves several thousands of times a day with resultant wear and tear, particularly in the discs of the middle of the cervical spine. Pain may be aggravated by neck movements in a particular direction.
Pain may be acute but may last a few days or weeks.
Structures in the back of neck
The neck or cervical spine is made up of seven cervical vertebrae (C1-C7), and includes the fibrocartilaginous discs, which act as cushions allowing flexibility and preventing the vertebrae from rubbing together. At the same time it protects the spinal cord, situated between the vertebral bodies in front and the arches of vertebrae behind. Nerves come to and go from the  spinal cord through specific openings between the vertebrae, providing the skin with sensations and messages to move the muscles of the upper limbs. The spinal cord travels down to the thoracic and lumbar spine and gives off nerves supplying the chest, abdomen and leg muscles…
What are the common causes of neck and arm pain?
Trauma – either acute or mild repeated trauma, including indirect minor trauma like awkward position of head while sleeping or sudden jolt or twist of neck.
A degenerating intervertebral disc
Acute or subacute disc prolapse causing pressure on the nerves (pinched nerves)
Brachial neuritis – inflammation of nerves going to limbs. Inflammation produces painful swelling with loss of function due to infective or non-infective causes.
‘frozen shoulder’
Many neck problems while causing pain of varying degrees may also cause muscle spasm with tenderness – pain on pressure.
What is cervical spondylosis?
Cervical spondylosis is a term used for degenerative changes in the neck bones and discs. Changes are related to wear and tear of ageing and repeated trauma of neck movements of day-to-day activities. The displaced disc touches the nerve or nerves causing pain down the arms as shown in the diagram.
What is brachial neuritis?
The nerves from the spinal cord in the neck pass to the front of the neck and form a complex network of nerves, called the brachial plexus before branching out to supply individual muscles and sensation in the upper limbs.
The brachial plexus is sometimes damaged in traffic trauma, especially if the crash victim is pulled out from under the vehicle by his hand. The upper two nerves C5, C6 can also be affected by inflammation. This also produces pain in the shoulder and upper arm and may be accompanied by wasting of shoulder muscles.
Shoulder and upper arm pain
The shoulder is a ball and socket joint – the ball of the upper end of humerus fits into the cup of the shoulder- around it is a capsule with lubricating fluid allowing free movement of joint. When the joint is stiffened or frozen, shoulder movements, particularly lifting and rotating shoulder inwards is limited and painful. Even lifting the shoulder with the help of the other hand is difficult and painful. Treatment requires physiotherapy, pain killers, neck traction and sometimes a steroid injection.
A frozen shoulder needs to be differentiated from a brachial neuritis, which also causes painful difficulty of shoulder movement.
Is surgery indicated in all patients showing a disc displacement in the MRI scan?
Do not forget that the neck moves thousands of times for a day and a MRI will show ‘wear and tear’ changes in most patients with increasing age (over the age of 50-60 years), like sagging and wrinkling of skin . Unfortunately the MRI scan shows age related changes which need correlation with symptoms. Surgery is indicated if the MRI changes correlate with the indications for surgery listed below and if a 3-6 month period of medical treatment has not helped.
Do all patients with neck and arm pain need a MRI scan
and surgery? If not, who needs surgery?
Only a few patients with neck and arm pain need a MRI scan. Surgery is not essential even if the MRI shows a prolapsed disc. Pain arising from the neck may radiate to shoulder, upper arm and even fingers (as shown in figure above) depending on which nerve is affected. Surgery may be needed if there is
Severe pain not responding to medical treatment.
Persisting weakness of the arm, forearm or fingers
Detectable loss of sensation in upper limb or fingers
What is the medical treatment of neck pain and pain down the arm and forearm?
The treatment of acute nonspecific neck pain is typically with simple pain medications and the continuation of as much normal activity as the pain allows. Listen to your body is a useful advice – avoid any activity which causes pain. Pain is the most important protective mechanism in our body which tells us ‘be careful’.
Medications are recommended for the duration that they are helpful, with paracetamol as the preferred first medication. Stronger pain killers and steroids which reduce swelling of nerve sheaths, and cervical traction may be considered after a few weeks of simple treatment. As neck movements tend to aggravate the condition a comfortable neck collar may be considered. When sleeping a thin pillow and resting both the head, neck and shoulder on the pillow placed in the long position rather than the usual transverse position may help.
Carpal tunnel syndrome
Carpal tunnel syndrome is a common condition causing numbness in the fingers and hand. It is commoner in over weight females but can occur in males too. It is the commonest neurological symptom in pregnancy. It is due to compression of the median nerve by the carpal ligament in the wrist.
Though the median nerve is compressed and its sensory supply is only the thumb, index and middle two fingers, numbness may be felt in the whole hand. The numbness is worse at night and with any activity which produces a grip and is temporally improved by shaking/wringing the hand. It is easily diagnosed on the symptoms and does not always need nerve conduction tests for confirmation. Though sometimes surgical decompression is required, often it may respond to diuretics and a short course of oral steroids