Neck and shoulder pain

Introduction The main pain point of neck and shoulder pain is around the shoulder joint, so it is called the inflammation around the shoulder joint. It is called shoulder periarthritis. It is commonly called condensed shoulder, leaking shoulder wind or frozen shoulder. The onset of the disease is mostly caused by freezing, trauma, and infection of tissues around the shoulder joints, such as tendons and bursae. Many patients are caused by rheumatism. The main symptoms are continuous pain in the neck and shoulders. The upper limbs of the affected side are elevated, rotated, and the swinging is limited. The feeling of cold in the wind is heavy and painful. If not treated in time, prolonged prolongation can cause joint adhesion, the upper limbs of the affected side become thin, weak and even form a disuse atrophy. The disease is more common in middle-aged people around the age of 50, and young people and the elderly also occur. The pain is characterized by pain in the movement of the arm, no pain or slight pain, and it is difficult to comb, dress, lift, and lift. When the attack is severe, it can be painful and it will not sleep all night.

Cause

Etiology and mechanism:

The etiology and mechanism of neck and shoulder pain are similar to those of low back pain, but have the following characteristics. The cervical vertebra has the smallest volume of vertebrae in the entire spine, but its activity is the largest and the activity frequency is the most, so it is also the most likely to cause strain, degeneration and trauma. The vertebral artery is a hook-and-shoulder joint that is prone to degeneration in the neck-to-neck transverse process, which causes compression of the vertebral artery. Because the vertebral artery wall is rich in sympathetic ganglia, it is When the vertebral artery is stimulated by compression, it also stimulates the cervical sympathetic nerve and presents gastrointestinal, cardiovascular symptoms and even a few sympathetic symptoms such as Homer syndrome.

According to the biomechanical characteristics of the cervical vertebra, the neck 5, 6 and the neck 6 and 7 have the largest range of motion, and the neck 5, 6 and neck 6, 7 are the most commonly used in the cervical vertebrae. It is also the most prone to degeneration compared to other parts. The cervical intervertebral disc first degenerates, and the nucleus pulposus protrudes from the weak part. Causes compression symptoms. In the case of weak posterior longitudinal ligament, it is easy to protrude backward. Whether the spinal cord is compressed or not depends on the state of the spinal canal, that is, the presence or absence of spinal stenosis. The intervertebral disc protrudes backward and urges the sinus nerve to cause neck pain. Under pressure, compression of the anterior central artery or sulcus artery causes dyskinesia, and compression of the posterior spinal artery causes sensory disturbance. If the anterior horn of the spinal cord or the anterior cord is compressed, there will be vertebral body bundle symptoms on one side or both sides, mainly dyskinesia. The degree of pathological changes in the spinal cord depends on the strength of the compression and the length of time. Once the spinal cord is degenerated, it is difficult to recover, so it should be treated as soon as possible. The nucleus pulposus protrudes laterally or hooks the joints of the joints. The hyperplasia of the facet joints can cause compression and stimulation of the spinal nerve roots, causing nerve root congestion and edema and aseptic inflammation, resulting in a sense, movement and reflex consistent with the distribution of the spinal nerve roots. obstacle. From the aforementioned anatomical features of the vertebral artery, hyperplasia of the hook joint, or hyperemia of the joint capsule synovial membrane, swelling and exudation, nucleus pulposus detachment, cervical instability and vertebral arteriosclerosis can cause compression or stimulation of the vertebral artery The sympathetic nerves on the wall of the vertebral artery cause the vertebral artery to stenosis and stenosis, thereby causing symptoms of insufficient blood supply to the vertebral artery.

an examination

Related inspection

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First, medical history

Patients with trauma should have a detailed understanding of the entire process of injury, including the direction and strength of the external force, the condition after the injury, and the treatment after the injury. No history of trauma should pay attention to neck and shoulder pain with fever is often an inflammatory disease, should pay attention to the pharyngeal infection induced by the paravertebral dislocation. Neck and shoulder pain accompanied by headache or respiratory muscle paralysis are mostly upper cervical lesions. Neck and shoulder pain accompanied by radiation pain in the upper extremities, numbness, severe muscle atrophy, mostly due to compression of the brachial plexus by compression of the lower neck; neck pain, post-occipital pain with broken, migraine, tinnitus Or cardiovascular symptoms are mostly caused by vertebral artery compression and ischemia. If the patient's limbs are numb, the walking is unstable and the gait is sloppy, and the chest and abdomen have a sense of tying, which is caused by the compression of the cervical spinal cord or ischemia. Simple neck and shoulder pain is caused by local muscle fiber inflammation, cervical tuberculosis and other tumors.

Second, physical examination

Tension of the neck muscles can restrict the movement of the neck, reduce or straighten the physiological curvature, and the cervical spine tuberculosis has a kyphosis, and the sternocleidomastoid contracture can cause the torticollis deformity.

In the early stage of the lesion, the tenderness of the spinous process is consistent with the affected vertebrae. The paravertebral tenderness is mostly in the side of the spinous process, the neck and shoulders, the back of the ear, etc. The nerve root can be compressed and the upper extremity can be radiated. Patients should be treated with cervical flexion, extension, rotation and lateral flexion to see if they are restricted. Common test tests for the neck are:

(1) Intervertebral foramina extrusion test

The patient tilts the head to the affected side, and the examiner gradually presses the pressure on the head or the right fist slams the left hand back to make the intervertebral foramen smaller, so that the compressed nerve root is further compressed to generate limb radiation pain and numbness. Positive.

(2) neck extension test

The neck is stretched from the neutral position and pressurized on the head, and the limbs are radioactively painful and numb positive. This test is also called the Jack-son indenter test.

(three) brachial plexus pulling test

The patient's head was slightly lower and turned to the healthy side. The examiner reached the patient's head with one hand and the patient's wrist was pulled in the opposite direction with the other hand. The upper limb was radioactively painful and numb was positive. This test can be positive in patients with cervical spondylotic radiculopathy, brachial plexus injury, and anterior scalene muscle syndrome.

(four) anterior scale muscle compression test

The examiner used the thumb to press the anterior horn muscle at the inner side of the supraclavicular fossa, and the upper limb pain and numbness were positive. It was found in patients with cervical spondylotic radiculopathy and anterior oblique muscle syndrome.

(5) Spin neck test

This test is to check the functional status of the vertebral artery. The patient's neck is slightly extended and rotated to the left and right, causing dizziness, headache, tinnitus, unclear vision, vomiting or shattering. This test should be carried out with care to prevent accidents.

The examination of feelings is of great significance. It should be compared with the upper and lower sides to accurately judge the allergies, dullness, disappearance and painful temperature perception, positional party, deep pressure and so on. The muscle strength and muscle capacity of the whole body or part of the muscle should be examined step by step as appropriate. Examination of the reflection includes deep and shallow reflections and pathological reflections. Deep reflections include sacral and triceps reflexes, sacral muscle reflexes, and knee and Achilles tendon reflexes. The corresponding relationship with the reflex center is the biceps muscle reflex and the neck of the neck, 5 and 6 segments; The 6th segment of the medulla; the triceps button reflects the 7th and 8th segments of the cervical spine; the knee reflects a 2~4 segment of the waist, and the Achilles tendon reflects the 7th and 8th segments of the cervical spine. Commonly used for shallow reflections are abdominal wall reflection and lifting reflection. Pathological reflex is the re-emergence or segmental hyperreflexia caused by the inhibition of upper neurons; commonly used Hoffman sign, Barbinski sign, Oppenheim sign, Charddock sign, Gordon sign. If necessary, an autonomic examination should be performed, as well as an ataxia test, such as a finger-nose test or a closed-head standing test.

Differential diagnosis

First, simple neck and shoulder pain

Simple neck and shoulder pain refers to neck and shoulder pain without radioactive pain or numbness in the extremities. Common diseases are:

(1) neck trauma

Injury of the bones and joints and surrounding soft tissues caused by neck trauma, but no compression and stimulation of the spinal cord and nerve patients have a significant history of trauma, neck and occipital pain, neck movement difficulty is the appearance of "military neck", the injured part has obvious tender points. The muscles are paralyzed and the cervical vertebrae are restricted. X-ray examination is the most basic and can be observed in the case of the axis. CT can clearly show the displacement of the fracture line and bone.

(two) neck muscle fibrositis

Any cold, damp, chronic injury and poor posture such as high neck and long-term bowing work can cause edema, congestion and aseptic inflammation of the myofascial tissue of the neck and back. The patient complains of diffuse pain in the neck and back, heavy in the morning, activity After the exercise can be slightly relieved, but after the activity is too much, the weight is increased again. I feel that there is a sense of weight in the neck and back. I can find the tender area or point in the lesion. The neck activity is normal, the test is negative, and the laboratory test and X-ray examination are normal. Found that this disease does not require CT or MRI.

(three) cervical cervical spondylosis

The patient feels discomfort in the posterior neck, soreness and pain, and has a sense of weight. It often catches cold and suddenly aggravates after a long period of work. The patient has a soreness in the muscles of the posterior neck, but the pain is not obvious. The neck activity may have a mildly restricted J-ray film. The cervical curvature may be straightened or disappeared. There may be some in the overflexion or overextension. The patient has a sign of cervical instability that is slightly stepped. The disease can heal itself when the neck is compensated for stability.

(4) Ankylosing spondylitis.

This disease first invades the sacroiliac joints and gradually progresses upwards, causing the lumbar and thoracic spine to be strong, but it can cause neck pain when it invades the cervical vertebrae. It is stiff and heavier in the morning, relieves after the activity, and can be relieved in the late stage. Causes the rigidity of the spine or the rigidity of the medullary joint. Because the pain is mostly located in the flexion position, it often causes kyphosis deformity. If the neck is flexed and straight, the body becomes arched. The patient can't look up and the eyes can't look flat. The patient's life is very inconvenient, HLA- The positive rate of B27 is more typical than that of X-ray, and the spine is bamboo-like. The positive position of the iliac joint is important for the diagnosis.

(5) Benign tumor of the cervical spine

Benign bone tumors of the cervical vertebrae are more common in osteoid osteoma, eosinophilic granuloma and bone hemangioma, and because the nerve endings of the neck are more sensitive, the patient has more local pain in the early stage, and the pain is mild or sore, which is easily misdiagnosed as the neck. Muscle fibroin, with the growth of the tumor, the pain is gradually worsening, with nighttime pain, the examination can be more tender in the tumor site, the muscles behind the neck can be paralyzed, the test is mostly positive, pay attention to this test should be careful The force can not be violent X-ray examination has the following characteristics: osteoid osteoma is generally round and translucent, and the diameter is not easy to exceed 1.0cm, the edge hardening has a nested density increase, but if it is located outside the cortex, because the cortex is thicker, The bones overlap and the diseased nest may not be obvious. If necessary, tomography, TC or MRI can be used to clearly show the lesion. Cervical hemangioma typical of the "fence-like" performance is due to the large, vertical trabecular image, the shape of the vertebral body can be normal or due to compression fractures are wedge-shaped or flat, a few can be honeycomb or osteolytic or Hardened spotted changes. Eosinophilic granuloma is flat or wedge-shaped, with uniform bone density, no paravertebral shadow, normal intervertebral space, but increased eosinophils in the blood.

(6) Cervical malignant tumor

Cervical malignant tumors are mostly metastases, and primary tumors are rare. Malignant tumors in any part of the body can be caused by blood and lymphatic metastasis, and the nasopharynx tumor can also spread to the cervical vertebrae. Patients have a history of primary tumors, and some primary tumors are not obvious, and metastases develop faster. Because the metastatic tumor grows faster, the intraosseous pressure increases rapidly, the patient can feel pain, and the pain at night is very serious, and gradually worsens. Generally, the analgesic drug is ineffective. The neck activity can aggravate the pain, the neck muscles are tight, and the hit test should be used with caution. May be associated with cachexia. X-ray findings are mostly osteolytic destruction, vertebral body is flattened and intervertebral space is normal, a few are osteogenic, vertebral density is increased or speckled bone sclerosis, mostly for prostate cancer metastasis, mixed type is both, but both Often based on a type. CT helps to detect early lesions. ECT examinations may also be considered for those with a history of primary malignancy. Alkaline phosphatase is increased, acid phosphatase can be elevated in patients with prostate cancer metastasis, and anemia can be advanced in the late stage.

(7) Cervical tuberculosis

Early cervical tuberculosis without nerve compression symptoms can cause pain in the neck and back. It can be aggravated after exertion. It can be relieved at night, and the cough is aggravated. Patients often hold the lower jaw, the neck activity is obviously limited, and the affected part has tenderness and snoring pain. Lighter. ESR can be accelerated. X-ray examination has a typical change. The common clinical phenomenon is the vertebral body edge type. The bone destruction occurs on both sides and the front and rear of the upper and lower edges of the vertebral body. The intervertebral space is narrowed, and there may be dead bone and abscess of the posterior pharyngeal wall. The central type of the vertebral body is less common, and the cancellous bone in the middle of the vertebral body is first destroyed, and the vertebral body is flattened. This should be differentiated from the vertebral body tumor. The posterior wall abscess of the cervical vertebrae tuberculosis on the X-ray showed a softening of the soft tissue shadow of the posterior pharyngeal wall, mostly fusiform and elliptical. The position of the abscess is often at the level of the diseased vertebral body. CT examination can avoid the overlap of the structure, can show the early vertebral body damage that is not easy to find on the X-ray film, and can accurately locate the dead bone.

(eight) cervical spondylitis

Infectious inflammation of the cervical vertebrae is rare. Patients may have general fever or high fever. The neck pain, stiffness, and activity are obviously limited. The paraspinal tendons on both sides of the neck can be seen. The neck activity makes the pain worse, local tenderness, and stroke. The test was positive. Abdominal wall abscess can still cause sore throat and inconvenient swallowing. Blood routine examination may have leukocyte elevation J line manifested after 14 days, vertebral margin osteoporosis, bone destruction, CT examination can be found earlier than X-ray film lesion MRI in the early stage of inflammation can provide a basis for early diagnosis But its price is more expensive and not yet popular. Special infections of the cervical spine include mold, Brucella, syphilis and yaw. Its diagnosis is based on its corresponding specificity check. But its onset is even rarer.

Second, neck and shoulder pain accompanied by numbness of the limbs

This type of disease is caused by a series of symptoms caused by compression of the neck lesions that stimulate the meridians of the nearby spinal cord. Common ones are:

(a) nerve root type cervical spondylosis

Due to the protrusion or prolapse of the cervical disc, the hyperplasia of the hook joint or facet joint oppresses the nerve root. Mainly manifested as neck and shoulder pain with pain or numbness on one or both upper limbs. In severe cases, muscle atrophy, muscle weakness, and poor finger movement may occur. Biliary reflexes involved in the affected nerve roots are active at an early stage, but decrease or disappear in the middle and late stages, but attention should be paid to bilateral contrast. The topping test, the intervertebral foramen crush test and the nerve root traction test may be positive. X-ray examination showed instability of the cervical vertebrae, bone hyperplasia at the posterior margin of the vertebral body, narrowing of the intervertebral space, hyperplasia of the hook joint, and stenosis of the intervertebral foramen. The disease generally does not require CT or MRI.

(two) cervical spondylosis

It is a series of symptoms manifested by spinal cord compression. If the front of the spinal cord is compressed, the patient feels that the lower limbs are heavy and the activity is not working. The difficulty of lifting is like the feeling of binding the leggings. The walking is unstable and the gait is sloppy. In severe cases, it can be weak and weak. If the cervical spinal canal stenosis is the first to manifest as a sensory disorder, the upper limb gradually develops into numbness of the extremities, and it is in a continuous state. The above-mentioned dyskinesia occurs several weeks or months later. If the side of the spinal cord is stressed, the Brown-Sequard sign appears. The pressure of the limbs is weak, the autonomous movement disappears, and the temperature of the contralateral pain disappears. The plane of the sensory disappearance is inconsistent with the compression plane of the spinal cord. Into, , is positive. Pathological signs such as Hoffman, Barbinski, Chaddock, Oppenhim, and palmar reflex were positive. Abdominal wall reflex and cremaster reflex can be reduced or disappeared. In severe cases, muscle atrophy and urinary dysfunction can be achieved. If the cervical medullary artery is compressed or stimulated, it will first manifest as upper extremity symptoms, then the lower extremities will be involved, but the lower extremity symptoms are still severe. If the surface of the cervical spinal cone is compressed, the lower limbs are first involved and then the upper limbs are involved, but the symptoms of the lower limbs are still heavy. If the anterior cervical artery is compressed or stimulated, the upper and lower limbs will develop at the same time, but the lower limbs are heavy. Those who are under pressure in the cervical cord are mainly dyskinesia, and those who are under pressure are mainly dysphoric.

X-ray plain films can be characterized by hyperosteogeny, unstable vertebral nodes, narrowing of intervertebral space and sagittal stenosis of the spinal canal. Spinal angiography helps to identify the extent and extent of compression, and to identify intraspinal tumors, arachnoiditis, and spinal vascular malformations. However, due to the development of CT, especially MRI, this method is gradually being reduced. CT can clearly show the bone spur, posterior longitudinal ligament, CT can observe the state of the spinal canal after spinal canal angiography, the whole picture of the spinal cord section and the presence or absence of space-occupying lesions. The emergence of MRI has epoch-making significance for the diagnosis and treatment of cervical spondylotic myelopathy. It can clearly show the compression, injury, cavity, and degeneration of the spinal cord. The cervical disc herniation, the inflammatory reaction around the spinal canal or the abscess can clearly reflect its extent and extent.

(C) vertebral artery type cervical spondylosis

The disease is due to instability of the cervical spine, degeneration of the intervertebral disc or prolapse. Hook vertebral joint hyperplasia or its joint capsule congestion and edema and arteriosclerosis and other factors oppress or stimulate the vertebral artery, resulting in vertebral artery spasm. Stenosis and flexion cause a series of clinical symptoms caused by insufficient blood supply to the vertebral-basal artery. In addition to conscious neck and neck pain, the patient is mainly characterized by insufficient blood supply to the push-based arteries, such as migraine, dizziness, tinnitus, hearing loss, vision loss, unconscious disturbance, degeneration, autonomic disorders, and a small number of patients A dysphonic disorder occurs. The above-mentioned vertebral-based arterial ischemia symptoms are often positive in the cervical spine induction test. Should pay attention to ophthalmology and otology consultation to exclude eye-borne or otogenic diseases. Patients with dysphonia should be excluded from laryngeal disease and lateral sclerosis. It should also be noted whether the trachea is centered to identify the presence or absence of a retrosternal tumor. X-ray films showed instability and degeneration of the cervical spine. The lateral position should pay attention to the presence or absence of a neck depression. The vertebral artery blood flow diagram is for reference only. Vertebral angiography can clearly diagnose and suggest the choice of surgical methods, but its technical requirements are high, not yet widespread and have some trauma. In recent years, with the introduction of MRI, MRI examination of vertebral artery can provide clear images, which is helpful for vertebral artery type cervical spondylosis, but it is expensive and difficult to popularize.

(4) Traumatic hook and joint disease

The symptoms of vertebral-based arterial ischemia caused by the impact of the head and neck. As a result of trauma, the soft tissue edema caused by the hook joint trauma, fibrosis and even ossification, coupled with loosening of the hook joints caused by vertebral artery compression or stimulation caused neck pain. Limited mobility, migraine, dizziness, and sometimes nausea and vomiting. There may be tenderness and sputum pain at the cervical vertebrae, the test is negative, the cervical spine test is negative, and the cervical nystagmus is mostly positive. The EEG is normal. No special findings were found on the X-ray, and vertebral angiography or MRI showed its compression.

(5) Cervical spinal canal tumor

Cervical spinal canal tumors are more common in schwannomas, meningioma, hemangioma and lipoma, and are mostly gliomas. When the tumor is small, it first stimulates the sinus nerve to cause neck and shoulder pain. When the tumor grows and compresses the nerve root, it causes upper limb pain, numbness, weak muscle strength, etc., and the patient may aggravate the symptoms by closing the air or coughing. This symptom is aggravated at night and can be alleviated during the day or when the work is busy. As the tumor gradually increases, the spinal cord can be compressed, and different signs are generated depending on the compression site. Clinically, the spinal anterior horn and posterior horn compression syndrome, Brown-Sequard spinal cord hemisection syndrome, etc. In this period, if the surgical treatment is relieved, the spinal cord function can be restored. If the tumor continues to grow and the spinal cord is completely compressed, the prognosis is poor. X-ray plain films generally have no positive findings. The vertebral canal showed a "cup-shaped" defect in the tumor, which was not in the same plane as the intervertebral space. After angiography, CT can still show tumor size, intradural and extra-oral, intramedullary and extra-malignant, MRI more clearly shows the shape, size, exact location of the tumor, and can observe the spinal cord compression, and should seek early examination.

(6) Cervical tumors, tuberculosis

Early manifestations of cervical tumors and tuberculosis: As mentioned above, when tumors, tuberculosis, nerves, spinal cords, and vertebral arteries can produce corresponding compression symptoms. Compression of nerve roots caused pain and numbness of upper limbs, should pay attention to the identification of cervical spondylotic radiculopathy; compression of vertebral artery caused by vertebral-basal artery blood supply deficiency, should pay attention to the differentiation of vertebral artery type cervical spondylosis, atherosclerosis and hypertension; When the spinal cord is compressed, it should be diagnosed with cervical spondylotic myelopathy and intraspinal tumor.

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