In the diagnosis and treatment of neck and shoulder pain, the most common pain is soft tissue damage, but infectious diseases of the neck and shoulder, post-infection neuralgia, primary and metastatic tumors of the neck and shoulder, systemic diseases mainly reflected in neck and shoulder pain, central pain, and entrapment pain of the neck and shoulder and upper limbs caused by cardiothoracic diseases are not uncommon, and psychological pain is easily overlooked in the initial diagnosis. In order to reduce misdiagnosis, this article outlines the diagnostic points of common neck and shoulder pain diseases other than acute injuries to bones and joints.
I. Soft tissue damage neck and shoulder pain
1.Extra-vertebral soft tissue damage neck and shoulder pain
The former causes chronic pain in the neck and shoulder, while the latter can be aggravated or sudden due to the activation of aseptic inflammation by a fixed posture for a long time, slight twisting, wind, cold and humidity, cold and other triggers. The anatomy and physiology of the neck and shoulder are closely related to each other. Generally speaking, those with soft tissue damage in the neck must have soft tissue damage on the same side of the shoulder, but the pain and pressure points of the former often become dominant, while the latter is latent; conversely, those with soft tissue damage in the shoulder must have soft tissue damage in the neck and supraclavicular fossa at the same time. In addition, chronic soft tissue damage in the lumbosacral region and back can cause secondary damage to the soft tissues of the neck and shoulder due to muscle spasm or contracture. Depending on the site of active aseptic inflammation and the extent of involvement, different pain patterns may be clinically manifested.
Diagnostic points.
(1) Pain characteristics: chronic cases feel soreness and swelling in the neck and shoulder with tightness, which is unbearable but still tolerable. In acute cases, the pain is severe and unbearable. The pain may be reflected in one or both sides of the neck, occipital region, neck and shoulder, back of the neck, back of the shoulder, internal superior scapular, suprascapular, subscapular, subacromial, subdeltoid, anterior shoulder, long head of biceps tendon sheath, lateral elbow, medial elbow, fingers, ulnar side of the palm, and some patients have similar nerve root pain.
(2) Medical history: Detailed inquiries should be made about occupation, history of acute injury to the neck and shoulder, history of chronic strain such as long-term head down, and history of chronic low back pain.
(3) The patient may have symptoms of cervical sympathetic nerve disorder and inadequate blood supply to the vertebral artery, such as dizziness and vertigo, blurred vision, sudden collapse, tachycardia or bradycardia, abnormal sweating of the head, face and upper limbs, abnormal sensation, elevated blood pressure, chilled limbs, tinnitus and earache, etc.
(4) There are obvious pressure points in the neck and shoulder, and tense and sensitive fascial strips can be palpated.
(5) The range of motion of the neck, shoulder and neck and shoulder may be restricted. The symptoms are alleviated after the pressure pain points are pushed and the restricted range of motion is improved. Most of the pressure pain points are treated well by intensive silver needle treatment.
(6) Hoffmann’s sign is negative. Skin sensation is normal.
(7) Blood test is normal.
(8) X-ray film can be seen in the cervical spine sequence changes, such as cervical spine physiological anterior protrusion degree increased, anterior protrusion degree reduced or disappeared, retroflexion, lateral protrusion, “S” shape changes, scapular displacement, etc. Most of them are secondary changes caused by muscle spasm or contracture of soft tissue pain in the neck and shoulder, which is the result of muscle mechanics series compensation adjustment. In addition, a series of degenerative changes in the cervical spine should not be considered as the cause of neck and shoulder pain unless the hyperplastic bone lip is obviously protruding into the spinal canal and has compressed the spinal cord and induced aseptic inflammation of the epidural fat and other tissues in the spinal canal.
2.Intra-vertebral canal or mixed intra- and extra-vertebral canal soft tissue damage neck and shoulder pain
The cervical intervertebral disc protrudes or bulges backward, the bone lips of the upper and lower edges of the posterior part of the vertebral body proliferate, and the posterior longitudinal ligament calcifies, producing pressure on the spinal cord from the front; the vertebral plate hyperplasia, the small articular protrusion hyperplasia and coalescence, the yellow ligament hyperplasia and hypertrophy or ossification produce pressure on the spinal cord from the rear, causing spinal stenosis, which usually invades the vertebral body bundle and produces the vertebral body bundle sign, that is, “spinal cord type cervical spondylosis “It is generally painless. Only when the epidural soft tissue is damaged, producing aseptic inflammation or combined with extradural soft tissue damage, the spinal cord compression sign and neck and shoulder pain exist simultaneously, that is, mixed intradural or extradural soft tissue damage with degenerative protrusions. In painless “spinal cord cervical spondylosis”, after spinal cord decompression and interbody fusion fixation via the anterior cervical approach, if no irreversible degeneration of the spinal cord occurs, the symptoms of vertebral tract involvement will be relieved immediately or gradually to disappear. However, in patients with spinal cord compression with neck and shoulder pain, after anterior decompression, the symptoms of spinal cord compression may disappear but the pain may not improve, so it is often necessary to treat the pressure point, and if necessary, posterior cervical surgery is required to remove the posterior compression factors of the spinal cord, loosen the soft tissues in the spinal canal, and remove the epidural fat, otherwise it is difficult to cure persistent neck and shoulder pain.
Key points for diagnosis
(1) Pain characteristics: intractable soreness and swelling of the neck and shoulder, neck and shoulder back and upper limbs, often without typical nerve root pain, and difficulty in sleeping in severe cases.
(2) There are symptoms of spinal cord compression, such as inflexible hand movements, weakness in grip, unstable gait, numbness of upper and lower limbs, increased muscle tone, hyperreflexia, positive Hoffmann’s sign and/or Babinski’s sign, patellar clonus, ankle clonus, etc.
(3) There are dominant or no obvious pressure points in the neck and shoulder.
(4) Blood test is normal.
(5) MRI of the cervical spine indicates anterior or anterior-posterior compression of the spinal cord, and the signal of the spinal cord is altered at the place of compression.
(6) If the spinal cord compression symptoms are relieved or disappear after the anterior cervical decompression and bone graft fusion fixation, and the neck and shoulder pain still exists, the aseptic inflammation of soft tissue damage inside or outside the spinal canal should be considered.
Infectious diseases of the neck and shoulder and neuralgia related to infection
1.Acute septic infection
Acute purulent infection of the bones, joints and soft tissues of the neck and shoulder mostly has underlying or skin infection lesions.
Diagnostic points
(1) Pain characteristics: rapid onset, sudden and persistent pain centered on the foci of infection, localized refusal to touch and press, refusal to move if the joint is infected, and severe pain with slight passive movement of the joint.
(2) Local redness and swelling, increased skin temperature.
(3) Fever, and in severe cases, sepsis may be present.
(4) Significant increase in total white blood cell count and neutrophil count, accelerated blood sedimentation.
(5) Pathogenic bacteria can be found in the smear of lesion puncture fluid, and the culture may be positive.
(6) Blood culture may be positive.
(7) X-ray or CT film: bone infection is usually seen in about 10 days with osteoporosis, bone trabecular disorder, speckled osteolytic lesions, and new bone formation can be seen with continued development.
2.Neck and shoulder tuberculosis
Diagnostic points
(1) Pain characteristics: the onset is insidious, the pain is mild, the affected bones and joints are swollen, the pain is intermittent in the early stage and then persistent and dull, and the pain increases when the lesion stimulates the nerve root or nerve trunk, and radiates up and down to the lesion.
(2) Primary tuberculosis lesions in the lungs are often present.
(3) Mostly accompanied by toxic symptoms such as low-grade fever and afternoon hot flashes.
(4) Blood sedimentation is accelerated during the active phase.
(5) There may be cold abscess or sinus tract formation with anhydrous pus in the late stage.
(6) Pus smear and culture may find acid-resistant bacilli.
(7) Imaging examination: X-ray, CT film, MRI early stage is osteoporosis. In the later stage, there is joint destruction and dead bone formation.
3.Acute herpes zoster
Diagnostic points
(1) Pain characteristics: rapid onset, burning and stinging pain in the neck and shoulder with skin tearing sensation. 3~4 days gradually worsen. Most of the pain lasts 2~3 weeks and gradually decreases to disappear. In a few cases, post-herpetic neuralgia remains.
(2) Herpes in the neck and shoulder: Herpes may appear at the same time as neck and shoulder pain, or may appear 1~2 days after the pain, or herpes may appear first, followed by severe neck and shoulder pain.
(3) There is often general malaise, fever, headache, which may be accompanied by pruritus and gastrointestinal disorders.
(4) Increased protein and cell count in cerebrospinal fluid (CSF).
4.Post-herpetic neuralgia
Acute postherpetic neuralgia involves demyelination, progressive crusting and fibrosis of the nerves, in which the large A fibers are more involved than the small C fibers, causing chronic intractable neck and shoulder upper limb pain or trigeminal neuralgia.
Diagnostic points
(1) Pain characteristics: persistent burning pain in the upper extremity of the neck and shoulder or trigeminal nerve, which is aggravated by Chen and does not heal for several months to years.
(2) History of acute herpes zoster.
(3) It is common over 60 years of age.
(4) Hypoesthesia or absence of tactile sensation, abnormal sensation, and pain hypersensitivity in the affected dermatome.
(5) Skin crusting, loss of pigmentation, whitish-brown mottled or maculopapular rash.
5.Brachial plexus neuritis
The etiology is unknown and may be related to infection and autoimmune reaction.
Diagnostic points
(1) Pain characteristics: cut-like or burning pain, often radiating to the upper limbs, with persistent or paroxysmal increase in pain.
(2) Often acute or subacute onset after cold or flu.
(3) Weakness or paralysis of scapular band muscles and upper limb muscles. Tendon reflexes are weakened or absent.
(4) Sensory disorders and vegetative symptoms are rare.
(5) Most of the symptoms disappear gradually and recover completely after 2~4 weeks, but a few of them are prolonged for several months or years, and may be followed by muscle atrophy.