Electric shock-like pain on the outside of the forearm and fingers

Introduction The radiculopathy of cervical spondylosis is severe paroxysmal pain, which is distributed along the nerve roots to the outside of the forearm and the fingers are electrically shocked.

Cause

(1) Causes of the disease

Prominence or prolapse of the nucleus pulposus, bone hyperplasia or traumatic arthritis of the posterior small joint, spur formation of the hook joint, and loosening of the adjacent three joints (intervertebral joint, hook joint and posterior small joint) Both the displacement and the like can cause stimulation and compression to the spinal nerve roots. In addition, the narrowing of the root canal, the adhesive arachnoiditis at the root sleeve, and inflammation and tumors in the surrounding area can also cause symptoms similar to this disease.

(two) pathogenesis

Because of the many pathogenic factors of this type, the pathological changes are also more complicated. Therefore, the location and degree of involvement of the vertebral nerve roots vary, and their symptoms and clinical signs vary. If the root is mainly stressed, the muscle strength changes (including muscle tension reduction and muscle atrophy, etc.) are more obvious; after the root pressure is dominant, the symptoms of the sensory disorder are heavier. However, both of them are coexisting in clinical practice. This is mainly because, in a narrow root canal, a variety of tissues are densely packed together, and it is difficult for everyone to have room for retreat. Therefore, when the anterior side of the spinal nerve root is compressed, pressure is also present at the same time behind the root canal. The mechanism of its occurrence, in addition to due to the hedging effect of the force, is also caused by congestion and congestion of local blood vessels under pressure, and is affected by each other. Therefore, both feeling and motor dysfunction occur at the same time. However, because the sensory nerve fibers are more sensitive, the symptoms of abnormal feelings will be manifested earlier.

There are three mechanisms for cervical spondylosis that cause various clinical symptoms:

First, various kinds of pressure-induced substances directly cause compression, traction and local secondary reactive edema on the spinal nerve roots, and this is a root symptom.

Second, the neck symptoms were manifested by the sinus nerve endings on the dural wall of the root sleeve.

The third is to cause imbalance of internal and external cervical vertebrae on the basis of the former two, so that the ligaments, muscles and joint capsules of the vertebral joints are implicated and cause symptoms (such as the affected part of the vertebral joint and the interrelated longissimus dorsi and anterior scalene muscles). And the sternocleidomastoid muscles are involved in the whole pathological process.

an examination

Related inspection

Blood routine limb CT examination

1. Neck and upper limb pain and numbness. The cervical disc protrudes to the lateral posterior aspect, and the hook joints proliferate and hypertrophy, stimulating and compressing the cervical nerve roots, causing pain and numbness in the posterior and shoulders of the neck and upper limbs. The light ones only show dull pain, numbness and soreness; Paroxysmal severe pain, distributed along the nerve roots to the front arm and fingers, accompanied by electric shock like tingling. Symptoms worsen when coughing, defecation, and exertion. At the same time, there are often symptoms such as lower limb muscle strength and less flexible finger movement.

2. The neck muscle tension can be seen during the examination. The shoulder flexion, extension and abduction of the affected shoulder are limited to varying degrees. There are tenderness in the spinous process, paravertebral, ganglia and shoulder spleen. The upper limb traction test is positive: the surgeon stands on the affected side, one hand holds the affected side neck, and the other hand holds the affected side wrist and pulls in the opposite direction. At this time, the brachial plexus is stretched, and the nerve root that is stressed is stimulated to cause radiation pain. The topping test was positive: the patient took the sitting position, the head leaned back and leaned toward the affected side, and the surgeon pressed the palm of his hand with the palm of his hand. At this time, neck pain occurred and was radiated to the affected hand. The upper limbs may have mild muscle atrophy, weak grip strength, decreased forearm and hand, and decreased biceps reflex and periosteal reflex.

3. The X-ray plain film shows that the cervical vertebrae physiological curve disappears, the cervical vertebra becomes straight, the intervertebral space narrows, the anterior and posterior margin of the vertebral body hyperplasia, the hook joint hyperplasia, and the corresponding intervertebral foramen become smaller and deformed. CT or magnetic resonance imaging (MRI) showed disc degeneration, protrusion, spinal stenosis, dural sac and nerve root compression.

Differential diagnosis

There are 8 pairs of cervical spinal nerves, and they control different parts. Therefore, when they are involved, the distribution of symptoms varies greatly depending on the affected part. In clinical practice, the 5-8 spinal nerve roots are more involved, so this is the focus of the identification of confusing wounds.

Ulnar neuritis

(1) Overview: The ulnar nerve is composed of the neck 7, 8 and the thoracic 1 spinal nerve. The disease is more common in elderly and old elbow injuries, and the incidence of elbow valgus deformity is higher. The disease is easily confused with those with cervical spinal nerve involvement.

(2) Identification points:

After 1 elbow, the ulnar nerve groove tenderness: There is more obvious tenderness in the ulnar nerve groove located in the posterolateral aspect of the elbow joint, and the degenerated ulnar nerve can be touched.

2 Sensory disturbance: The distribution of sensory disturbance is smaller than that of the eighth cervical nerve distribution area, and the ulnar side of the forearm is not affected.

3 The impact of the inner muscles of the hand: When the ulnar nerve is severely affected, it is often a typical "claw-shaped hand"; the Tinel sign of the ulnar nerve tube of the wrist is mostly positive. Mainly because of the involvement of the interosseous muscle, resulting in over-extension of the metacarpophalangeal joint and flexion of the interphalangeal joint, especially the ring finger and the little finger.

4 imaging changes: can refer to X-ray film (neck X-ray films of patients with ulnar neuritis are mostly negative, but X-ray films of the elbow joint, especially those with deformity may have positive findings), medical history and past History and so on.

2. Median nerve damage

(1) Overview: The median nerve is composed of the neck 7 and the thoracic 1 spinal nerve. The damage is mostly caused by trauma or fiber tube compression. The former factor can be diagnosed at the time of trauma, no need to identify, while the latter It is easy to be confused with the 7th cervical spinal nerve root compression, and needs to be carefully identified.

(2) Identification points:

1 Sensory disorder: As shown in Fig. 7, the sensory disorder distribution area is mainly the dorsal finger end and the thumb, the middle finger and the middle finger palm side, while the forearm part is not affected.

2 Muscle strength changes: the muscle strength of the hand is weakened, and the appearance is a "hand rubbing" deformity, which is mainly caused by atrophy of the great fish muscle (Fig. 8).

3 autonomic symptoms: due to a large number of sympathetic nerve fibers mixed in the median nerve, the blood vessels, hair follicles, etc. in the hand are mostly in an abnormal state, which is characterized by flushing, sweating, etc., and the pain is often burning pain.

4 reflex: more no effect; but when the cervical 7 spinal nerve is involved, the triceps reflex can be weakened or disappeared.

3. Nerve nerve damage

(1) Overview: The sacral nervous system consists of the neck 5-7 and the thoracic 1 spinal nerve. It is located in the sacral nerve sulcus in the upper arm, close to the bone surface, and is easily affected by the humeral shaft fracture. Traumatic nerve injury caused by trauma is easy to identify, such as fiber adhesion, local compression and other factors, it needs to be distinguished from the sixth cervical spinal nerve involvement.

(2) Identification points

1 wrist sign: the symptoms of the sacral nerve damage, mainly due to the loss of dominance of the wrist extensors and extensors. In patients with high sacral nerve involvement, the elbow function is also affected.

2 Sensory Disorder: Unlike the sixth cervical nerve involvement, the sensory disorder area is mainly the dorsal side of the hand (thumb, index finger, middle finger) and the dorsal side of the forearm except the fingertip, and there should be no obstacle on the volar side of the thumb and forefinger.

3 reflection changes: no significant impact. In the neck 6 spinal nerve involvement, both the biceps and triceps muscles were weakened or disappeared (early hyperthyroidism).

4 Others: You can refer to the medical history, local examination and X-ray film.

4. Thoracic outlet syndrome

(1) Overview: thoracic outlet syndrome (TOS), also known as thoracic outlet stenosis, is more common in clinical, can directly compress the brachial plexus, or due to anterior scalene contracture, inflammatory Stimulation causes the anterior branch of the cervical spinal nerve to be affected, causing symptoms of the upper limbs, mostly caused by sensory disturbances, and can cause atrophy of the hand muscles and weakened muscles. The disease mainly includes the following three types, namely the anterior scalene syndrome, the cervical rib (or the 7th cervical transverse process is too long) syndrome and the rib lock syndrome. Although there are differences between the three, they all have similar characteristics, and thus differentiated from cervical spondylotic radiculopathy.

(2) Identification points:

1 brachial plexus involvement: mainly in the lower trunk of the brachial plexus, clinical manifestations: from the upper arm ulnar side down and the forearm and hand ulnar sensory disturbance, as well as ulnar wrist flexor, finger shallow flexor and bone Intermuscular involvement.

2 Partial signs of thoracic outlet: the upper part of the supraclavicular fossa is full, and the anterior scalene or bony neck rib can be touched during the examination. When the thumb is pressed deep into the body (or let the patient do deep inhalation) Exercise) can induce or exacerbate symptoms.

3Adson sign: mostly positive. That is, let the patient sit, the head slightly backwards, hold the breath after deep inhalation, and turn the head to the affected side. The examiner held the patient's lower jaw with one hand and gave a little resistance. The other hand touched the affected side of the radial artery, and if the pulse weakened or disappeared, it was positive. This is a special test for this disease.

4 Others: including imaging changes. In this disease, X-ray plain films are mostly positive, and if necessary, CT or MRI examinations are helpful for the identification of the two. In addition, the disease is negative in the neck test, and there are no tenderness and other signs in the spinous process and the cervical vertebrae. Therefore, the two are not difficult to identify.

5. Carpal Tunnel Syndrome

(1) Overview: Carpal tunnel syndrome is mainly caused by compression of the median nerve through the carpal tunnel. It is also common in clinical practice, especially in the middle, the elderly and the wrist.

(2) Identification points:

1 wrist middle pressure test: the examiner presses with the hand or slams the middle of the patient's wrist (palm side) with the middle finger, which is equivalent to the proximal end of the transverse ligament of the wrist. If there is numbness or tingling of the thumb, index finger or middle finger, It is positive and has diagnostic significance.

2 wrist back extension test: that is, let the patient extend the affected wrist joint to the dorsal side for 0.5 to 1 min. If there is numbness or tingling in the thumb, the middle finger or the middle finger, it is positive and has diagnostic significance.

3 closed test: 1% 2% procaine 1 ~ 2ml partial closure of the wrist pain points, if effective, it is positive.

4 Others: Symptoms of sensory disorder with distal median nerve endings (expressed as thumb, index finger, middle finger, numbness, hypersensitivity or tingling), no corresponding changes in cervical X-ray films, cervical spondylotic radiculopathy All tests are negative, and if necessary, refer to MRI results.

6. Surgery around the shoulder joints and other shoulder disorders

(1) inflammation around the shoulder joint: not only needs to be differentiated from cervical cervical spondylosis, but also should be distinguished from cervical spondylotic radiculopathy. In addition to the characteristics described in the previous section, the disease does not have root symptoms of the spinal nerve, so it is easy to identify. However, it should be noted that some cases of cervical spondylosis may be accompanied by symptoms of inflammation around the shoulder joint. After treatment (such as traction or surgical treatment), the shoulder symptoms may disappear with other symptoms of cervical spondylosis. This is mainly due to the involvement of the phrenic nerve waves and the shoulders after the involvement of the 5-7 spinal nerves.

(2) Other shoulder disorders: including shoulder joint impingement, rotator cuff lesions, shoulder joint degeneration and shoulder instability, should be differentiated from cervical spondylotic radiculopathy. Mainly based on clinical examination and imaging results, it is generally not difficult to identify. Individuals with difficulty in diagnosis can be judged by closed therapy.

7. Tumors at the spinal canal and root canal

Tumors that invade the roots of the spinal nerves and their vicinity, including the lateral side of the dural sac, the root canal and its adjacent tissues (mainly bone tissue), can cause root pain. Among them, metastatic people are more common. It can also affect the spinal nerve roots and the cervical plexus or brachial plexus, causing various root or plexus symptoms. Therefore, in addition to routine examination of the supraclavicular fossa and neck and shoulder, the X-ray, CT and MRI should be performed on the shoulder and neck to prevent missed diagnosis or misdiagnosis.

8. In addition to the above injuries, attention should be paid to the differentiation of peripheral neuritis, syringomyelia, rheumatism, tennis elbow (extraorbital epicondylitis), biceps tendonitis and angina pectoris.

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