PAIN IN THE BACK, NECK, AND EXTREMITIES in Microsoft Office

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PAIN IN THE BACK, NECK, AND EXTREMITIES
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and the sensory loss is in the distribution of the medial cutaneous nerve of the forearm and of the ulnar nerve in the hand The weakness largely involves the muscles supplied by the ulnar nerve, namely the intrinsic hand muscles (page 1168) The re exes are unaffected These syndromes are usually incomplete in that only one or several of the typical ndings are present Particularly noteworthy is the occurrence, in laterally placed cervical disc rupture, of isolated weakness without pain, especially with discs at the fth and sixth levels Friis and coworkers have described the distribution of pain in 250 cases of herniated disc or spondylotic nerve root compression in the cervical region Virtually every patient, irrespective of the particular root(s) involved, showed a limitation in the range of motion of the neck and aggravation of pain with movement (particularly hyperextension) Coughing, sneezing, and downward pressure on the head in the hyperextended position usually exacerbated the pain, and traction (even manual) tended to relieve it Nerve conduction studies, F responses, and EMG are extremely helpful in con rming the level of root compression and distinguishing pain of radicular origin from that originating in the brachial plexus or in individual nerves of the brachium (see page 1165) As already mentioned, in many of the cervical radicular syndromes, the onset is acute and no traumatic incident can be documented It is dif cult to relate the syndrome to osseous changes that must have been present for years Even more dif cult to explain is the tendency to recovery within a few weeks when movement of the neck is limited by traction or a collar, as discussed below Unlike herniated lumbar discs, cervical ones, if large and centrally situated, result in compression of the spinal cord (central disc causing compression of all of the cord; paracentral disc, asymmetrical but bilateral parts of the cord) (Fig 11-7) The centrally situated disc is often painless, and the cord syndrome may simulate a degenerative neurologic disease (eg, amyotrophic lateral scle-
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rosis, combined system disease) Bilateral hand numbness, paresthesias, or similar altered sensation is common Failure to consider a protruded cervical disc in patients with obscure symptoms in the legs, including stiffness and falling, is a common error A vague sensory change can often be detected several dermatomes below the level of compression The diagnosis and the level of disc protrusion should be con rmed by CT myelography or by MRI (Fig 11-7)
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Management of Herniated Cervical Disc
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Conservative measures should be instituted before turning to surgical removal of the disc unless there are signs of a rapidly or subacutely progressing myelopathy (ie, leg and arm weakness, hyperre exia in the legs, gait ataxia, sphincteric dysfunction) In the case of cervical disc with radicular pain, a close- tting foam collar is quite bene cial The collar should be tted so that little exion and extension of the neck are permitted, but it must remain comfortable enough to encourage consistent use; we have found it helpful to have the patient bring the collar when visiting the doctor in order to assure a proper t The patient is advised to wear the collar at all times during the day, especially while riding in a car, unless this becomes completely impractical Analgesic medication, either NSAIDs or narcotics, may be required for a few days While considered of little value in lumbar disc disease, traction with a halter around the occiput and chin may be of some bene t in cervical disc syndromes Treatment can be administered with the patient recumbent, or it can be performed intermittently in the sitting position, using simple equipment that applies 2 to 10 lb of upward traction while the patient is seated and the weight attached to a rope over the top of the door Many patients obtain a degree of relief in bed by the use of a cervical pillow, a foam or in atable neck rest shaped like a dog bone A similar appliance is helpful during airplane ights
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Figure 11-7 Cervical disc herniation MRI in sagittal (A) and axial (B) views of a disc extrusion at C5-C6 (arrow) that caused myelopathy and radicular pain
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