Chapter 016 Back and Neck Pain (Part 16) Shoulder Pain arising from the shoulder can on occasion mimic pain from the spine If symptoms and signs of radiculopathy are absent, then the differential diagnosis includes mechanical shoulder pain (tendonitis, bursitis, rotator cuff tear, dislocation, adhesive capsulitis, and cuff impingement under the acromion) and referred pain (subdiaphragmatic irritation, angina, Pancoast tumor) Mechanical pain is often worse at night, associated with local shoulder tenderness and aggravated by abduction, internal rotation, or extension of the arm Pain from shoulder disease may radiate into the arm or hand, but sensory, motor, and reflex changes are absent Neck Pain: Treatment There are few well-designed clinical trials that address optimal treatment of neck pain or cervical radiculopathy Relief of pain, prevention of recurrence, and improved neurologic function are reasonable goals Symptomatic treatment includes the use of analgesic medications and/or a soft cervical collar Most treatment recommendations reflect anecdotal experience, case series, or conclusions derived from studies of the lumbar spine Controlled studies of oral prednisone or transforaminal glucocorticoid injections have not been performed Reasonable indications for cervical disk surgery include a progressive radicular motor deficit, pain that fails to respond to conservative management and limits activities of daily living, or cervical spinal cord compression Surgical management of herniated cervical disks usually consists of an anterior approach with diskectomy followed by anterior interbody fusion A simple posterior partial laminectomy with diskectomy is an acceptable alternative approach Another surgical approach involves implantation of an artificial disk; in one prospective trial, outcomes after years favored the implant over a traditional anterior cervical discectomy with fusion The artificial disk is not yet approved for general use in the United States The risk of subsequent radiculopathy or myelopathy at cervical segments adjacent to the fusion is ~3% per year and 26% per decade Although this risk is sometimes portrayed as a late complication of surgery, it may also reflect the natural history of degenerative cervical disk disease Nonprogressive cervical radiculopathy due to a herniated cervical disk may be treated conservatively, even if a focal neurologic deficit is present, with a high rate of success However, if the cervical radiculopathy is due to bony compression from cervical spondylosis, then surgical decompression is generally indicated to forestall the progression of neurologic signs Cervical spondylotic myelopathy is typically managed with either anterior decompression and fusion or laminectomy in order to forestall progression of the myelopathy known to occur in 20–30% of untreated patients However, one prospective study comparing surgery vs conservative treatment for mild cervical spondylotic myelopathy showed no difference in outcome after years of followup Further Readings Atlas SJ, Nardin RA: Evaluation and treatment of low back pain: An evidence-based approach to clinical care Muscle Nerve 27:265, 2003 [PMID: 12635113] Bagley LJ: Imaging of spinal trauma Radiol Clin North Am 44:1, 2006 [PMID: 16297679] Cassidy JD et al: Effect of eliminating compensation for pain and suffering on the outcome of insurance claims for whiplash injury N Engl J Med 342:1179, 2000 [PMID: 10770984] Cavalier R et al: Spondylolysis and spondylolisthesis in children and adolescents: Diagnosis, natural history, and non-surgical management J Am Acad Orthop Surg 14:417, 2006 [PMID: 16822889] Cowan JA Jr et al: Changes in the utilization of spinal fusion in the United States Neurosurgery 59:1, 2006 Gorbach C et al: Therapeutic efficacy of facet joint blocks AJR Am J Roentgenol 186:5, 2006 Mummaneni PV et al: Clinical and radiographic analysis of cervical disk arthroplasty compared with allograft fusion: A randomized controlled clinical trial J Neurosurg Spine 6:198, 2007 [PMID: 17355018] Peul WC et al: Surgery versus prolonged conservative treatment for sciatica N Engl J Med 356:2245, 2007 [PMID: 17538084] van Alfen N, van Engelen BG: The clinical spectrum of neuralgic amyotrophy in 246 cases Brain 129:438, 2006 Weinstein JN et al: Surgical versus nonsurgical treatment for lumbar degenerative spondylolisthesis N Engl J Med 356:2257, 2007 [PMID: 17538085] ——— et al: Surgical vs nonoperative treatment for lumbar disc herniation The spine patient outcomes research trial (SPORT): A randomized trial JAMA 296:2441, 2006 Bibliography Amar AP et al: Percutaneous transpedicular polymethylmethacrylate vertebroplasty for treatment of spinal compression fractures Neurosurgery 49:1105, 2001 [PMID: 11846904] Aminoff MJ: Electrophysiological evaluation of root and spinal cord disease Semin Neurol 22(2):197, 2002 Ampil FL et al: A retrospective study of metastatic lung cancer compression of the cauda equina Chest 120:1754, 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radiculopathies: Conservative approaches to management Phys Med Rehabil Clin N Am 13:589, 2002 [PMID: 12380550] Yamashita K et al: Five-year outcomes of surgical treatment for degenerative lumbar spinal stenosis: A prospective observational study of symptom severity at standard intervals after surgery Spine 31:13, 2006 ... with cognitive intervention and exercises in patients with chronic back pain after previous surgery for disc herniation: A prospective randomized controlled study Pain 122:1, 2006 Cassidy JD... Outcome of invasive treatment modalities on back pain and sciatica: An evidence-based review Eur Spine J Suppl 1:S82, 2005 Winters ME et al: Back pain emergencies Med Clin North Am 90:3, 2006... compensation for pain and suffering on the outcome of insurance claims for whiplash injury N Engl J Med 342:1179, 2000 [PMID: 10770984] Cavanaugh JM et al: Pain generation in lumbar and cervical