Neck and Arm Pain (Pain Series)

NECK AND ARM PAIN

NECK AND ARM PAIN Edition 2

RENE CAILlIET, M.D. Professor and Chairman Department of Rehabilitative Medicine University of Southern California School of Medicine Los Angeles, California

Illustrations by R. Cailliet, M.D.

'F.

A. DAVIS COMPANY. Phil.d"ph,.

Also by Rene CailHet: FOOT AND ANKLE PAIN HAND PAIN AND IMPAIRMENT KNEE PAIN AND DISABILITY LOW BACK PAIN SCOLIOSIS SHOULDER PAIN SOFT TISSUE PAIN AND DISABILITY THE SHOULDER IN HEMAPLEGIA

Copyright © 1981 by F. A. Davis Company Second printing 1981 Third printing 1982 Fourth printing 1984 Fifth printing 1985 Sixth printing 1987 Copyright 1964 by F. A. Davis Company All rights reserved. This book is protected by copyright. No part of it may be reproduced, stored in a retrieval system, or transmitted in any fOIm or by any means, electronic, mechanical, photocopying, recording, or otherwise, without written permission from the publisher. Printed in the United States of America

Library of Congress Cataloging in Publication Data Cailliet, Rene. Neck and arm pain. Includes bibliographical references and index. 2. Brachialgia. I. Title. I. Arm. 2. Neck. 3. Pain. 4. Shoulder. C134nl WE805 RC936.C26 1981 617' .53 80-1 7352 IS B N 0-8036-1609-0 I.

Neck pain.

[DNLM:

Preface to Second Edition

Over the years since the first edition of Neck and Arm Pain there have been numerous additions and changes in diagnostic procedures and in treatment concepts of these syndromes. The second edition is presented in an attempt to update these newer concepts. Cervical myelopathy was omitted from the previous edition and neglected a very important consideration of painful, disabling aspects of cervical spine disease. The frequency of cervical spondylosis caus­ ing myelopathy yet being unrecognized encouraged me to add this important chapter to the second edition. Numerous concepts of treatment, both surgical and nonsurgical, al­ ways benefit from careful review and revision. Numerous theories of local pain and referred pain are always being reviewed clinically and in research laboratories and their pertinence to clinical application needs to be reviewed for the busy clinician who has too little time to assimi­ late and make applicable these many factions of a common clinical syndrome. The medical-legal aspect of painful and disabling conditions is con­ tinually mandating better medical evaluation and patient care.A better educated patient population also expects better infomled medical care delivery as well as explanation of a painful, disabling condition. The following statement by a legal specialist in a medical journal well summarizes these thoughts: Cervical trauma is one of those areas of physicai injury which like head and back injuries, often results in subjective complaints that are extremely dif­ ficult for the courts, industrial commissioners, insurance carriers and attor­ neys to properly evaluate. Leading neurosurgical and orthopedic specialists tell us that there is still much that is unknown about the pathology of cervical trauma, that many times they do not know exactly what to look for in injuries

v

to this area, and that they usually cannot deny subjective complaints in view of lack of precise infomlation.·

This revision has been prepared in an attempt to add to this knowl­ edge. It is always with the idea that specialists will also benefit but, more importantly, that students, interns, residents of all specialties, and practitioners of every field of medicine will acquire a sufficient knowl­ edgeable basis for evaluation and treatment of the patient suffering from cervical spine pathology . This is the purpose of the second edition of Neck and Arm Pa;n. RENE CAILLlET, M.D .

•

Allen, W. S.: Mediclll·legal aspects of cervical tmul1la. Clin. Neurosurg. 2: 106-13,

1954.

vi

Preface to First Edition

Of all the musculo-skeletal and neuromuscular conditions causing pain and disability in man. pain and dysfunction originating in the neck. shoulders. and upper extremities is exceeded only by low back pain. The early manifestations of neck pain and the significance of limited motion are frequently overlooked because of ignorance of normal . In later life. neck pain and its functions and abnormal deviations sequelae are attributed toaging or to the weartlIld tear of life. SuITerers from these effects would have benefitted from earlier recognition and a more physiological approach to treatment . The musculo-skeletal system must be fully understood in its static anatomical sense and in its kinetic function before abnormality and the mechanism of pain production and dysfunction can be recognized and understood . Pathological changes can be prevented; and when a com­ plete reversal of abnormal changes is impossible. at least the symptoms and disability caused by these changes can be ameliorated. The neck in this monograph is discussed in a didactic. positive manner principally from the author's viewpoint . The bibliography is small and selective regarding the more controversial aspects. but the text is based on voluminous literature as well as personal observation and opinion . The stick-man drawings and the simplified sketches have been ef­ fective in similar monographs and as teaching aids in the classroom. They are used here to aid the busy practitioner. the burdened medical student or intern. and the practicing physical therapist; and they should be helpful as well in informing the patient during office practice. l owe my publishers a debt of gratitude for oITering this text in an inexpensive paperback volume. This manner of presenting medical texts brings medical information in a practical. low-cost form to the physician who is staggered by the annual deluge of medical texts. vii

I am sincerely grateful to the physicians of the Gaylord Seminar under the direction of Sidney Licht, M.D., who reviewed the manu­ script and made invaluabJe constructive criticisms . RENE CAILLlET, M.D.

viii

Contents

xi xv

Illustrations Introduction Chapter 1.

Functional Anatomy

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Anterior Portion of the Functional Unit Posterior Portion of the Functional Unit Static Spine Posture .

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Kinetic Spine

Ligamentous Support

Musculature of the Neck

Tissue Sites of Pain Production

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The Cervical Nerves The Sympathetic Nervous System .

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Upper Cervical Segments

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Chapter 2.

Neck Pain Originating in the Soft Tissues

Chapter 3.

Diagnosis of Neck Pain

Physical Examination X-Ray Examination Chapter 4. Disability

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18 21 23 27 34 38

42 50 51 52

Cervical Disk Disease as a Factor in Pain and .

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Nature and Mechanism of Radicular Pain Cervical Disk .

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Localization of Root Level by Clinical Examination Chapter 5.

1 1 7 8 9 II

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Subluxations of the Cervical Spine Including the

"Whiplash" Syndrome

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73

Syndrome of Acute Central Spinal Cord Injury Diagnosis of Deceleration Sprain Injury Chapter 6.

Degenerative Disk Disease

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Chapter 7.

Cervical Spondylotic Myelopathy Symptoms Prognosis Examination Laboratory Findings Myelography Treatment .

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Chapter 8.

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Treatment: General and Specific

Chapter 9. Differential Diagnosis Anterior Scalene Syndrome

Claviculocostal Syndrome

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Pectoralis Minor Syndrome (Hyperabduction Syndrome) Scapulocostal Syndrome Fibromyositis Pericapsulitis Shoulder Pain Shoulder-Hand Syndrome Carpal Tunnel Syndrome Brachial Plexus euritis (Plexitis) .

Index

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90 92 94 106 111 112 112 112 113 115 118 137 139 143 145 145 146 150 154 154 156 159

IIIustrations

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2. Hydraulic mechanism of the intervertebral disk . . ... . . . . . .. .. 3. Elasticity of annulus fibers

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1. The functional unit

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3

4. Comparative lateral views of cervical and lumbar functional units .

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5.

Comparative curves of cervical and lumbar spine: . .. Related to disk shapes

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Vertebral bodies of cervical and lumbar region:

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Comparing joints and disks . . .

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Static spine considered erect posture

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B 10

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B. Chronological development of cervical lordosis . ... ,',.. 9. Gravity effect on a "forward head" posture with increased lordosis .. ... ,. . .

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10. Composite movements of the cervical spine

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. ......... . . . . . . 11. Occipital-atlas movement 12. Rotation of the atlas about the odontoid process of the ais

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13. Locking mechanism of C, on C, .. ...... .... ,',.,.,',.. 14. "Gliding" movement in flexing spine

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15. Alteration in spinal canal length . . . . . . . . . . . .. . . . . ..... . 16. Foraminal closure in head lateral flexion and turning . . . 17. Influence of sequence upon neck flexion lB. Ligamentous support of the neck . .

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19. 1lanslatory gliding on cervical flexion

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15 15 16

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. . . . . ... .

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23. Postulated mechanism of "disk pain" (sciatica or .. . .. . brachialgia) . . .

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19 . .. ,. ,. ,. . . . . . . 20 21 . . 22 . .

. 20. Musculature of the head and neck 21. Sites of major muscle bulk in the cervical spine 22. Tissue sites of pain production . . .

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23 24 25

24. Pain production from myofascial-periosteal strain and muscle ischemia . .. .... .... . . .... . . . ... . . .

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25. Component fibers of a cervical nerve .. . .... ...

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. 26. Formation and location of cervical nerve roots .. . . . . 27. Nerve root location with regard to disk level . .. .. . . 28. Direction of foraminal grooves ........... . . .. ....... 29. Reaction of the dura in neck flexion and extension .. . .. 30. Relationship of nerve root within foramen during neck .. ... . . .. .. .. .. ... . . . .. . movement .... .. 31. Anatomical boundaries of the intervertebral canal. ..... 32. Dura-arachnoid sleeve of nerve root in the intervertebral canal................................................. ... 33. Cross section of contents of intervertebral canal . . . 34. Peri radicular sheath of nerve . .... .. . . . 35. Sympathetic nervous system of the cervical region .... . . 36. Vertebral artery pathway ... .. .. . ... . .... . 37. Upper cervical functional units .. ... .. ... .. .. ... . ... 38. Reflex mechanism for relief of cramps: Concept . .. . 39. Mechanisms by which irritations result in functional ...................... . ... . .. . .... .. disability . . . 40. Unilateral subluxation from excessive rotation . .. 41. Referral sites of pain elicited by intranuclear diskogram. 42. Movement of nerve roots about their point of attachment 43. Comparison of lumbar and cervical disk containers ... 44. Possible results from direction of disk herniation . . . 45. Muscle examination of the triceps (C,) . . .. . . 46. Muscle testing--external rotators (C,) ... . ..... . 47. Brachioradialis reflex 48. Pronator reflex . . ..... . . .. . . . ...... . ...... 49. Sixth cervical nerve root irritation 50. Seventh cervical nerve root irritation 51. Eighth cervical nerve root irritation .. . ... .. . .. ... 52. Hyperextension injury ... .. ............. . .... . . .. . .. .. .. . . . 53. Muscle spindle system . . . .. . 54. Muscular reaction to "whiplash" injury .. . . .. . .. 55. Mechanism of hyperflexion sprain injury to the neck .... 56. Tissues involved in hyperflexion sprain injury of the neck ..... ... .. ... ... . .. .... .. .

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Hyperextension-hyperflexion injury .. . ......... . . ... .

27 28 29 30 30 31 32 33 35 36 37 38 39 40 45 46 47 58 60

63 65 66 67 68 69 70 70 71 75 76 77 78 79

58. Rear-end impact with neck hyperextension sprain . .. 59. Flexion phase of acceleration injury to the neck (sprain). . ..... . 60. Compression theory of "whiplash" injury

79 80 81 82

61. Compression-plus-torque theory of cervical injury resulting from "whiplash" ..... . ... . ... . . .. . .. .. ...

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62. Mechanism of disk injury ............................ 63. ElTect of deceleration injury to neck with head turned ..

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Sites of fracture-dislocations in the cervical spine ......

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65. Dermatomal areas of occipital nerves ................. . 66. Referral areas of upper cervical roots .................. 67. Vascular supply to the cervical cord ................... 68. Evolutionary stages of disk degeneration .............. 69. Mechanism of spondylosis ........................... 70. Disk degeneration with formation of "spondylosis'· .... 71. Sagittal diameter of the cervical spinal canal .......... 72. Normal nutrition and lubrication of posterior articulation 73. Mechanism of osteoarthritic changes in facet joints..... 74. Foraminal opening variations ......................... 75. Sites of greatest osteophyte formation

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76. ElTect of posture upon cervical spine ................. 77. Gravity effect upon cervical lordosis .................. 78. Sensory and motor tracts of the spinal cord ............ 79. Spinal cord arterial supply ........................... SO. Spinal arterial supply .

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81. Spinal canal stenosis: Neck extension 82. Spinal canal stenosis: Neck flexion 83. Spinal canal width ................................... 84. Measurement of subluxation .......................... .

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86. Soft cervical collar

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90. 91. 92. 93. 94. 95. 96. 97. 98. 99. 100. 101. 102. 103. 104.

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Cervical pillow ...................................... Bed cervical traction, hospital type Supine traction Overhead cervical traction for home use .............. Angle of traction on head halter ...................... Home cervical traction-not recommended ............ Recording of range of motion ......................... Localization of painful segment....................... Rhythmic stabilization exercises to neck .............. Posture training-