This document discusses neurological causes of arm and neck pain, including muscle spasm, central pain from spinal cord dysfunction, nerve root pain, peripheral nerve entrapment like ulnar and median nerve pain, brachial plexus issues, and non-neurological causes like muscle pain and arthritis. It covers clinical assessment including motor signs, sensory examination, tendon reflexes, and localization of symptoms. Specific pathologies discussed include spinal cord syndromes from intramedullary lesions like tumors or myelitis and extramedullary lesions like spondylosis.

1. Dr rzgar hamed abdwl
BRADLY CHAPTER 31
Arm and Neck Pain

5. CLINICAL ASSESSMENT
Neurological Causes of Pain:
A- Sites That Can Trigger Pain
1- Muscle Spasm:
* Posterior cervical muscles spasm trigger local pain that is
aggravated by neck movement, and the diagnosis is
supported by the finding of palpable spasm and
tenderness.
* The pain may radiate upward to the occipital region
and to the bifrontal area.
* It is usually described as constant, aching, or bursting, or
as a tight band or pressure sensation on top of the head.
* Pain can be triggered by abnormalities of the facet joints,
cervical vertebrae, and even intervertebral disk pathology,
*Neck mobility is best assessed by testing for movement in
each of the main planes of movement

6. 2- Central Pain:
* Dysfunction affecting the ascending sensory tracts in the
spinal cord may generate pain or paresthesias in the arm(s)
or down the trunk and lower limbs.
* An electric shock-like sensation provoked by neck flexion
and spreading to the arms, down the spine, and even into
the legs is thought to originate in the posterior columns of
the cervical spinal cord (Lhermitte sign) is frequent in
patients with multiple sclerosis (MS) .
* Sharp, superficial, burning pain or itching points to
dysfunction
in the spinothalamic system
* Deep, aching, boring pain with paresthesias of tightness,
squeezing, or a feeling of swelling suggests dysfunction in
the posterior column system.

7. 3- Nerve Root Pain:
* it is referred into the upper limb in a dermatome
distribution.
* Brachialgia (arm pain) aggravated by neck movement,
coughing, or sneezing suggests radiculopathy
* It is lancinating in character, but it can present as a dull
ache in the arm.
* Repetitive sudden shooting pains radiating from the
occipital
region to the temporal areas or vertex suggest the
diagnosis
of occipital neuralgia.
* There may be local tenderness over the greater or lesser
occipital nerve, and a local injection of corticosteroid plus
local anesthetic is both diagnostic and therapeutic.

8. 4- Ulnar Nerve Pain:
* Numbness or pain radiating down the medial aspect of
the arm to the little and ring fingers.
* Symptoms are often worse at night when the patient
sleeps with a flexed elbow.
* Ulnar paresthesias are also triggered by pressure on the
nerve when resting the elbow on the arm of a chair or desk.
* Tapping on the nerve in the ulnar groove at the elbow may
evoke a tingly electrical sensation in the little and ring finger
(Tinel sign)

9. 5- Median Nerve Pain:
* Median nerve entrapment in the carpal tunnel classically
awakens the patient from sleep with numbness and tingling
in the thumb, index, and middle fingers, which is relieved by
“shaking out” the hand.
* Pain generated in the median nerve can be sharp and
lancinating and radiates to the thumb, index, and middle
fingers.
* entrapment in the carpal tunnel is common, occasionally
the site of entrapment is at the elbow as the nerve
passes under the pronator muscle.

10. 5- Plexus Pain:
* Infiltrative or inflammatory lesions of the brachial plexus
produce severe brachialgia radiating down the upper limb
and also spreading to the shoulder region.
* Radiation to the ulnar two fingers suggests that the origin
is in the lower brachial plexus.
* radiation to the upper arm, forearm, and thumb suggests
an upper plexopathy.
* Patients with thoracic outlet syndrome complain of
brachialgia and numbness or tingling in the upper limb or
hand when working with objects above the head.

11. # maneuvers are designed to test for TOS:
* The arm is extended at the elbow, abducted at the
shoulder, and then rotated posteriorly.
* The examiner palpates the radial pulse while listening
with a stethoscope over the brachial plexus in the
supraclavicular fossa.
* The patient takes a deep inspiration and turns the head to
one or the other side.
* Many normal individuals lose their radial pulse, but the
emergence of a bruit does suggest at the least vascular
entrapment (Adson test).
* The patient then exercises the hands held above the head
with extended elbows—numbness, pain, or paresthesias,
often with pallor of the hand, supports the diagnosis (Roos
test)

12. Non-Neurological Causes of Neck Pain and Brachialgia
# Pain arising in muscle : is deep, aching, and boring. In
the cervical region, it is localized to the shoulders and
sometimes radiates down the arm.
* If the patient is over 50 years of age, ESR should be
checked; if it is markedly elevated, the diagnosis of
polymyalgia rheumatica should be considered.
* Patients with fibromyalgia may have pain in the neck,
shoulders, and arms, with trigger spots or nodules that are
exquisitely tender even to light pressure.
* If pain is triggered or aggravated by joint movement of the
upper limb, arthritis or tendonitis is the likely cause.
* pain on shoulder abduction is usually tendinitis, rotator
cuff pathology, or pericapsulitis related.

13. * More diffuse tenderness anterior to the shoulder joint
indicates bursitis.
* Tenderness over the medial or lateral epicondyle at the
elbow indicates local inflammation.
* pain on active or passive wrist or finger joint movement
suggests tendonitis or arthritis of the fingers.
* The pain of epicondylitis may radiate down the forearm
in a pseudoneuralgic fashion, but precipitation by active
wrist extension or grip indicates a rheumatological cause.

14. Examination
Motor Signs—Atrophy and Weakness
* Particular attention is paid to atrophy of muscles
* Fasciculations are often due to anterior horn cell
disease, but they may be part of the neurology of cervical
spondylosis and radiculopathy.
* Significant sensory signs would argue against anterior
horn cell degeneration.
* When there is unilateral weakness, the contralateral side
can act as a control, but some standard measure of
strength is necessary for accurate evaluation when bilateral
weakness is present.

15. * Motor power grading:
Grade 5 represents normal strength
Grade 4 represents “weakness” somewhere between
normal strength
Grade 3 the ability to move the limb only against gravity.
Grade 2 When the muscle can move the joint with the
effect of gravity eliminated
Grade 1 is just a flicker of movement.
* Even when the patient complains primarily of symptoms in
the upper limbs, the lower limbs must be examined for
signs of myelopathy.

16. * The finding of hypertonia, weakness, sensory loss,
increased tendon reflexes, and/or extensor plantar
reflexes indicates cord dysfunction.
* These signs, when combined with radicular signs in the
upper limbs,indicate a spinal cord lesion in the neck.
* The distribution of weakness is all important in localizing
the problem to nerve root, plexus, peripheral nerve, muscle,
or even upper motor neuron (central weakness).
*A distribution of weakness that does not conform to a
clearly defined anatomical distribution of cervical roots or a
single peripheral nerve in the upper limb suggests
plexopathy.
* Upper plexus lesions cause mainly shoulder abduction
weakness, and lower plexus lesions will affect the small
muscles of the hand.

17. Sensory Signs
* Starting with pinprick appreciation at the back of the
head (C2), followed by sequentially testing sensation in the
cervical dermatomes, down the shoulder, over the deltoid,
down the lateral aspect of the arm to the lateral fingers, and
then proceeding to the medial fingers and up the medial
aspect of the arm.
* The procedure is repeated with a wisp of cotton to test
touch sensation and test tubes filled with cold and warm
water to test temperature sensation.
* Position sense in the distal phalanx of a finger is tested by
immobilizing the proximal joint and supporting the distal
phalanx on its medial and lateral sides and then moving it
up or down in small increments.
* Loss of position sense in the fingers usually indicates a
very high cervical cord lesion

18. Tendon Reflexes
* Examination of the tendon reflexes helps localize
segmental nerve root levels.
* in cervical spondylosis, the reflexes are often preserved
or even increased despite radiculopathy, because of an
associated myelopathy.
* An absent or decreased biceps reflex localizes the root
level to C5, and an absent triceps reflex localizes the level
to C6 or C7.
* An absent biceps reflex but with spread so that triceps or
finger flexors contract is called an inverted biceps jerk
and is strong evidence for C5 radiculopathy.

19. PATHOLOGY AND CLINICAL SYNDROMES
One : Spinal Cord Syndromes
1- Intramedullary Lesions
* It may be neoplastic, inflammatory, or developmental.
* The most common presenting symptom of spinal cord
tumor is pain in radicular in distribution(two-thirds of them)
,often aggravated by coughing or straining, and worse at
night.
* Dissociated sensory signs (segmental loss of pinprick
and
temperature sensation with preserved light touch, vibration,
and position sense) in the upper limbs suggests central
cord
pathology.
* Long-tract signs in the lower limbs will, ultimately,
develop in progressive acquired lesions. Magnetic
resonance imaging (MRI) reveals swelling of the spinal

20. * Cervical myelitis presents with rapid onset of radicular
and long-tract symptoms and signs and may be due to MS,
postinfectious encephalomyelitis, or neuromyelitis optica, or
it may be without an obvious cause (idiopathic).
* Syringomyelia, a cystic intramedullary lesion of variable
and unpredictable progression, may present with deep
aching or boring pain in the upper limb, often
characteristically referred to the ear.
* Asymmetrical lower motor neuron signs (radiculopathic) in
the upper limbs, with dissociated suspended sensory loss
(i.e., has an upper and lower border to the impairment of
pinprick and temperature sensation), is suggestive of a
syrinx.
* the most common cause of intramedullary cord
dysfunction is extrinsic spinal cord compression.

21. 2- Extramedullary Lesions
* The most common cause of cervical nerve root and spinal
cord compression is cervical spondylosis.
* the degree of bony change does not always correlate with
the severity of the signs and symptoms it produces.
* Patients with cervical spondylosis often awake in the
morning with a painful stiff neck and diffuse nonpulsatile
headache that resolves in a few hours.
* The lesion is most commonly at C5/6 and/or C6/7
* Wasting and weakness of the small muscles of the hands,
but particularly weakness of abduction of the little finger is
often present.
* Restricted neck movement is always present with
significant
cervical spondylosis.
* Bladder dysfunction with frequency, urgency, and urgency
incontinence or the finding of long-tract signs indicates the

22. 3- Extramedullary cord compression by pathology in
the epidural space:
* may be due to a primary or metastatic tumor.
* A Schwannoma or nerve sheath tumor produces signs
and symptoms related to the nerve root on which it arises,
and as it enlarges, progressive myelopathic dysfunction
occurs.
* Plain radiographs of the cervical spine may demonstrate
an enlarged intervertebral foramen and the MRI is
diagnostic.
* A meningioma may present more frequent in the thoracic
region.
* The initial presenting symptom of epidural spinal cord
compression due to metastatic malignancy is pain in over
90%
of patients.
* Malignant bone pain is usually localized to the vertebra

23. * As the pathology spreads to the epidural space radicular
pain occurs.
* The whole spinal column should be scanned because the
pathology is often at multiple sites.
* Spinal cord compression due to metastatic disease
is a neurological emergency requiring treatment with
immediate high-dose steroids and either local irradiation
or surgical decompression.