Chapter 29 Arm and Neck Pain
Clinical Assessment
History
Neurological Causes of Pain
Plexus Pain
Peripheral pathology may involve the brachial plexus (Fig. 29.1) or individual nerves extending to the hand. Infiltrative or inflammatory lesions of the brachial plexus produce severe brachialgia radiating down the upper limb and also spreading to the shoulder region. Radiation to the ulnar two fingers suggests that the origin is in the lower brachial plexus, and radiation to the upper arm, forearm, and thumb suggests an upper plexopathy. Patients with a thoracic outlet syndrome complain of brachialgia and numbness or tingling in the upper limb or hand when working with objects above the head.
Examination
Motor Signs
The distribution of weakness is all important in localizing the problem to nerve root, plexus, peripheral nerve, muscle, or even upper motor neuron (central weakness). It is useful to use a simplified schema of radicular anatomical localization when evaluating nerve root weakness because overlap of segmental innervation of muscles can complicate the analysis (Table 29.1).
Segment Level | Muscle(s) | Action |
---|---|---|
C4 | Supraspinatus | First 10 degrees of shoulder abduction |
C5 | Deltoid | Shoulder abduction |
Biceps/brachialis/brachioradialis | Elbow flexion | |
C6 | Extensor carpi radialis longus | Radial wrist extension |
C7 | Triceps | Elbow extension |
C7 | Extensor digitorum | Finger extension |
C8 | Flexor digitorum | Finger flexion |
T1 | Interossei | Finger abduction and adduction |
Abductor digiti minimi | Little finger abduction |
Sensory Signs
Skin sensation is tested in a standardized manner starting with pinprick appreciation at the back of the head (C2), followed by sequentially testing sensation in the cervical dermatomes, down the shoulder, over the deltoid, down the lateral aspect of the arm to the lateral fingers, and then proceeding to the medial fingers and up the medial aspect of the arm (Fig. 29.2). The procedure is repeated with a wisp of cotton to test touch sensation and test tubes filled with cold and warm water to test temperature sensation. Vibration sense is rarely abnormal in the fingers. Position sense in the distal phalanx of a finger is tested by immobilizing the proximal joint and supporting the distal phalanx on its medial and lateral sides and then moving it up or down; the patient, with closed eyes, reports movement and its direction. Loss of position sense in the fingers usually indicates a very high cervical cord lesion.