Localization

The actual site of the pain is a first rough pointer. Pain may be localized or vague, and is felt either in the neighbourhood of the lesion or at a distance (see Referred pain, Ch. 1).

Very localized pain, accurately indicated by the patient, is often a ligamentous or facet joint problem. Bony lesions also give rise to localized pain. Pain that is vaguely defined and spreads over a larger area is usually referred. It is then distal to the lesion (see Rules of referred pain, Ch. 1). Referred pain that is felt in a particular dermatome (segmentally referred) is often radicular in origin but may also result from any soft tissue lesion in the region of the neck. The source is usually an inflammation and/or compression of a mid- or lower cervical nerve root, giving rise to pain in the shoulder area (C4) or in the upper limb (C5–T2). It often indicates a discoradicular interaction, but other causes of root pain should also be considered, such as degenerative conditions or a space-occupying lesion in the radicular canal.

Pain that is felt in several adjacent dermatomes at the same time is quite common and indicates a multisegmental type of reference (see Fig. 7.1). Multisegmental pain reference may be either the result of multiradicular involvement – which is extremely uncommon in the cervical spine and should immediately arouse suspicion (see Warning signs, Ch. 9) – or the result of a discodural interaction. In the latter case other dural symptoms may also be found and the functional examination shows a clinical picture of internal derangement (see Ch. 8). It should be stressed that dural symptoms are mostly discogenic in origin but may also occur in any space-occupying lesion in the spinal canal interfering with the sensitivity or the mobility of the dura mater. Dural pain is usually felt at the lower neck, in the trapezius area and the upper scapular and interscapular region, either centrally or unilaterally. The pain may spread further, upwards to the head, face and upper neck or the mid-scapular, pectoral and axillary regions.

Onset (Fig. 7.2)

Pain may come on suddenly, gradually or as the result of an injury. Pain that starts suddenly is activity-related. It is a manifestation of sudden internal derangement of an intervertebral joint, mostly the result of the displacement of a discal fragment. It is then usually accompanied by sudden twinges when moving. It comes and goes in an irregular way and tends to recur. Functional examination shows the articular involvement. Pain that comes on gradually is not very informative because many different conditions begin in that way. If the pain is related to specific activities, a mechanical condition (see Ch. 8) is probable; if such a relation between symptoms and movements or postures is not found, a non-mechanical condition should be considered (see Ch. 9). If an injury is responsible for the development of the patient’s symptoms, further technical investigation will be necessary to exclude serious disorders such as fractures and luxations.

Evolution (Fig. 7.3)

Pain may shift from one place to another, mostly from the centre of the neck to one side or from the cervicotrapezioscapular area to the upper limb. The meaning of pain that moves is important: the pain shifts because the lesion shifts. There are not that many lesions that may change their position; a loose fragment of disc is one of the few possibilities. Since discodural or discoradicular interactions occur in episodes, pain may switch sides from one attack to another. Pain may also expand, which means that it increases in extent and in intensity. Expanding pain is always a serious warning sign in that it indicates an expanding lesion: for example, a tumour. In most cases of discoradicular interactions, pain has started proximally in the neck, trapezius and/or scapular area before it shifts to the upper limb. However, in younger patients, discoradicular pain may be felt in the arm from the very beginning. The lesion is then called a primary posterolateral disc protrusion. Other instances that start with pain in the arm without previous neck or cervical pain are neurofibromas and root compressions by osteophytic outcrops or metastases.

Factors influencing pain

The questions: What brings the pain on? and What makes the pain disappear? are necessary to find out whether or not the condition is related to activity or posture. Most disorders are activity-related: discodural or discoradicular interactions, degenerative conditions, muscular and capsuloligamentous lesions. The type of activity that has an influence on symptoms may help in determining the possible type of lesion. Disc lesions are affected by certain movements, especially towards kyphosis, as well as by certain postures, whereas ligamentous conditions are mostly purely postural. In the latter case, maintenance of positions will aggravate pain and altering the position relieves the pain. When the condition is non-activity-related it is of the non-mechanical type and suggests bony lesions, rheumatoid-type conditions, infections, intraspinal or neurological disorders, or visceral pathologies.

Accompanying symptoms