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Hendriks EJ et al Prognostic factors for poor recovery in acute whiplash patients Pain 2005 Apr;114(3):408 16 [PMID: 15777866] Kaiser MG Multilevel cervical spondylosis Neurosurg Clin N Am 2006 Jul;17(3):263 75 [PMID: 16876027] Peloso PM et al Medicinal and injection therapies for mechanical neck disorders: a Cochrane systematic review J Rheumatol 2006 May;33(5):957 67 [PMID: 16652427]
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Thoracic outlet syndromes result from compression of the neurovascular structures supplying the upper extremity Symptoms and signs arise from intermittent or continuous pressure on elements of the brachial plexus and the subclavian or axillary vessels (veins or arteries) by a variety of anatomic structures of the shoulder girdle region The neurovascular bundle can be compressed between the anterior or middle scalene muscles and a normal first thoracic rib or a cervical rib Most commonly thoracic outlet obstruction is caused by sagging of the shoulder girdle resulting from aging, obesity, or pendulous breasts Faulty posture, occupation, or thoracic muscle hypertrophy from physical activity (eg, weight-lifting, baseball pitching) may be other predisposing factors Thoracic outlet obstruction presents in most patients with some combination of four symptoms involving the upper extremity, namely pain, numbness, weakness, and swelling The predominant symptoms depend on whether the obstruction chiefly affects neural or vascular structures The onset of symptoms is usually gradual but can be sudden Some patients spontaneously notice aggravation of symptoms with specific positioning of the arm Pain radiates from the point of compression to the base of the neck, the axilla, the shoulder girdle region, arm, forearm, and hand Paresthesias are common and distributed to the volar aspect of the fourth and fifth digits Sensory symptoms may be aggravated at night or by prolonged use of the extremities Weakness and muscle atrophy are the principal motor abnormalities Vascular symptoms consist of arterial ischemia characterized by pallor of the fingers on elevation of the extremity, sensitivity to cold, and, rarely, gangrene of the digits or venous obstruction marked by edema, cyanosis, and engorgement Reflexes are usually not altered When the site of compression is between the upper rib and clavicle, partial obliteration of subclavian artery pulsation may be demonstrated by abduction of the arm to a right angle with the elbow simultaneously flexed and rotated externally at the shoulder so that the entire extremity lies in the coronal plane Neck or arm position has no effect on the diminished pulse, which remains constant in the subclavian steal syndrome Chest radiography will identify patients with cervical rib (although most patients with cervical ribs are asymptomatic) MRI with the arms held in different positions is useful in identifying sites of impaired blood flow Intraarterial or venous obstruction is confirmed by angiography Determination of conduction velocities of the ulnar and other peripheral nerves of the upper extremity may help localize the site of their compression
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Cervical spondylosis (degenerative arthritis) is a collective term describing degenerative changes that occur in the apophysial joints and intervertebral disk joints, with or without neurologic signs Osteoarthritis of the articular facets is characterized by progressive thinning of the cartilage, subchondral osteoporosis, and osteophytic proliferation around the joint margins Degeneration of cervical disks and joints may occur in adolescents but is more common after age 40 Degeneration is progressive and is marked by gradual narrowing of the disk space, as demonstrated by x-ray Osteocartilaginous proliferation occurs around the margin of the vertebral body and gives rise to osteophytic ridges that may encroach upon the intervertebral foramina and spinal canal, causing compression of the neurovascular contents Osteoarthritis of the cervical spine is often asymptomatic but may cause diffuse neck pain A minority of patients with neck pain also suffer from radicular pain or myelopathy Myelopathy develops insidiously and is manifested by sensory dysfunction and clumsy hands Some patients also complain of unsteady walking, urinary frequency and urgency, or electrical shock sensations with neck flexion or extension (Lhermitte s sign) Weakness, sensory loss, and spasticity with exaggerated reflexes develop below the level of spinal cord compression Amyotrophic lateral sclerosis, multiple sclerosis, syringomyelia, spinal cord tumors, and tropical spastic paresis from HTLV-1 infection can mimic myelopathy from cervical arthritis The mainstay of conservative therapy is immobilizing the cervical spine with a collar With moderate to severe neurologic symptoms, surgical treatment is indicated Atlantoaxial subluxation may occur in patients with either rheumatoid arthritis or ankylosing spondylitis Inflammation of the synovial structures resulting from erosion and laxity of the transverse ligament can lead to neurologic signs of spinal cord compression Treatment may vary from use of a cervical collar or more rigid bracing to operative treatment, depending on the degree of subluxation and neurologic progression Surgical treatment for stabilization of the cervical spine is a last resort
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