Pain in shoulder area

As in the diagnosis of many other pathological conditions, the diagnostic algorithm for pain in the shoulder region is simplified by preliminary separation of possible pathological conditions into two groups, depending on the nature of the onset of the disease (acute, gradual).

I. Sharp beginning:

1. Frozen shoulder syndrome
2. Neuralgic shoulder amyotrophy
3. Lateral herniation of the cervical intervertebral disc
4. Metastatic affection of the cervical spine
5. Inflammatory diseases of the cervical spine
6. Shingles Herpes
7. "Whiplash injury"
8. Spinal epidural hemorrhage.

II. Gradual beginning:

1. Degenerative and other diseases of the spine at the cervical level
2. Extramedullary tumor at the cervical level
3. Pancoast Tumor
4. Syringomyelia and intramedullary tumor
5. Arthrosis of the shoulder joint
6. Disorders of the brachial plexus
7. Postherpetic neuralgia
8. Tunnel Nerve of the Suprath Nerve
9. Regional psychogenic pain

[1], [2]

Gradual onset of shoulder pain

Degenerative and other diseases of the spine at the cervical level

With degenerative processes of the cervical spine, clearly limited radicular pains and sensitive disorders occur infrequently; the same applies to motor symptoms of muscle weakness or loss of reflexes. This is because the symptomatology, as a rule, is not a consequence of the compression of the spinal roots; The source of pain is more often intervertebral joints, which are richly innervated by sensory fibers. There is reflected pain in the shoulder area - this pain has a more diffuse spread, with it there are no segmental sensory or motor disorders (symptoms of loss). Movement in the neck is limited, but they do not necessarily provoke pain. In the pleural movements are free; restriction of movements in the shoulder may occur with the secondary wrinkling of the joint capsule due to immobilization of the proximal arm.

The source of pain can be other diseases of the spine: rheumatoid arthritis, ankylosing spondylitis, osteomyelitis.

[3], [4]

Extramedullary tumor at the cervical level

In contrast to the degenerative pathology of the spine, extramedullary tumors tend to damage the corresponding nerve root in fairly early stages of the disease, since more than half of the cases are neurinomas originating from the posterior root. Meningiomas occur mainly in women (95%) and are often localized on the posterior surface of the spinal cord. There is radicular pain in the shoulder region, which is worse with coughing. Sensitive disorders and changes in reflexes occur in the early stages of the disease. It is extremely important to identify the involvement of one or two nerve roots, since the diagnosis should be established before signs of damage to the spinal cord itself, which may be irreversible. Serious skills and experience are required for conducting electrophysiological studies. At a roentgenography pathological changes can not be revealed. It is necessary to study the cerebrospinal fluid, carry out neuroimaging studies and CT-myelography.

[5], [6], [7], [8], [9], [10], [11], [12]

Pancoast Tumor

Pain in the innervation zone of the lower trunk of the brachial plexus, that is, along the ulnar surface of the arm to the wrist, arises at a rather late stage of the development of the disease. If the patient has ipsilateral Gorner syndrome, then there is usually no alternative to the diagnosis of "Pancost tumor" (with the exception of syringomyelia).

Syringomyelia and intramedullary puhol

The initial symptom of syringomyelia can be radicular pain in the shoulder area, since the cavity in the spinal cord exerts pressure on both the lateral horn of the spinal cord (that is, the preanglionic part of the peripheral sympathetic path) and the horn (that is, the segment of the sensory information in the spinal cord). As a rule, pain is not limited to one or two segments, but diffuse in the entire arm. At this stage of the disease, ipsilateral central Gorner syndrome and sweating paralysis can occur on the ipsilateral focal point of the lesion of the half of the face, the ipsilateral arm and the proximal arms.

Another possible diagnosis is an intramedullary tumor, usually benign. The key point that determines the prognosis for both syringomyelia and intramedullary tumor is early diagnosis: in both diseases spinal cord injury is irreversible if the diagnosis is made when the patient already has segmental muscular atrophy due to anterior horn lesion or spastic paraplegia due to injury pyramidal tract, or a transverse lesion of the spinal cord with a characteristic loss of pain and temperature sensitivity. Neurovisualizing studies are mandatory, it is desirable to combine neuroimaging with myelography.

Arthrosis of the shoulder joint

With arthrosis of the shoulder joint, there may be reflected pain in the shoulder region, in the proximal parts of the arm without compromising sensitivity or motor defect. A characteristic feature is the gradual limitation of mobility in the shoulder joint and the pain that occurs when the arm is withdrawn.

Other (similar pathogenesis) states: shoulder-brush syndrome, epicondylosis of the shoulder.

[13],

Disorders of the brachial plexus

Trauma, tumor infiltration, radiation plexopathy and other diseases that can be accompanied by pain in the shoulder area include staircase syndrome (the four lower cervical spinal nerves that form the brachial plexus, after exiting the intervertebral foramen, are located first in the interstitial space between the anterior and middle staircases ), the syndrome of the upper trunk (V and VI cervical nerves), the syndrome of the middle trunk plexus (VII cervical nerve), the syndrome of the lower trunk (VIII cervical and nerve) rvy thoracic nerve) and other pleksopaticheskie syndromes.

[14], [15], [16], [17]

Postherpetic neuralgia

Postherpetic neuralgia is often mistaken for painful manifestations associated with degenerative spine pathology, which is facilitated by the elderly age of patients and the conduct of an X-ray examination not after a clinical examination, as it should be done, but before it. With postherpetic neuralgia, pain is much more intense and exhausting compared to pain in osteochondrosis and does not change during movements or coughing. As a rule, it is possible to detect the consequences of existing herpetic eruptions in the form of areas of hyperpigmentation located in the zone of the corresponding segment.

Tunnel Nerve of the Suprath Nerve

This rare syndrome is usually associated with trauma or develops spontaneously. It is characterized by deep pain near the upper edge of the scapula. Leaving the shoulder increases pain. The weakness m is revealed. Infraspinatus m. Supraspinatus. A typical painful point is found in the place of nerve compression.

Regional psychogenic pain

Finally, the patient may have local regional pain in the shoulder area of a psychogenic nature. This condition is quite frequent, but such a diagnosis should be made with caution, as with psychogenic pain syndromes of other localization. The absence of any deviations from the data of neurological and additional research methods can not fully guarantee the absence of a neurological or somatic cause of local pain syndrome. Therefore, in parallel with the appointment of antidepressants, which have analgesic effect, it is expedient to conduct dynamic observation; Do not neglect regular re-examination and examination, analysis of mental status and objective history, that is, an anamnesis collected from the next of kin.

Pain in the shoulder region is also possible with the syndrome of the anterior staircase, small chest muscle syndrome, posterior cervical sympathetic syndrome, dissection of the carotid artery, carotidinia, tumors in the jugular orifice, infection of the retrofaringeal space, skin and subcutaneous tissue disorders, hemiplegia (frozen shoulder syndrome ); and also with some other diseases (polymyositis, rheumatic polymyalgia, osteomyelitis, fibromyalgia, occlusion of the subclavian artery). However, these diseases are significantly different in the topography of the pain syndrome have characteristic additional clinical manifestations that allow them to be recognized.

Sharp pain in shoulder area

Frozen shoulder syndrome

The term "frozen shoulder" is usually used to describe the symptom complex, which is more often formed at the final stage of gradually developing shoulder pathology (shoulder-shoulder periarthropathy syndrome). At a radiography of a humeral joint in such cases arthrosis and (or) calcium deposits in lateral departments of an articulate capsule is defined. However, sometimes this syndrome develops sharply: there is pain in the shoulder and a reflected pain in the hand, which forces the patient to avoid movements in the shoulder joint. Movement in the neck does not affect the pain or only slightly strengthen it; an increase in cerebrospinal pressure also does not affect the intensity of pain. With the removal of the hand, there is intense pain and reflex contraction of the muscles of the shoulder girdle. In this condition, it is very difficult to investigate motor functions. Deep reflexes are not reduced, there are no sensitive disorders. Such a clinical picture is often based on myofascial syndrome.

In this case, the trigger point often appears first in the subscapular muscle, then in the large and small pectoral muscles, in the latissimus muscle of the back and in the triceps muscle of the shoulder (less often in other muscles). Restrain movement in the shoulder joint pain and muscle spasm, which in this case is part of the analgesic reaction. There are possible secondary changes in the tendons and tissues of spasmodic muscles.

Neuralgic shoulder amyotrophy (Persononeja-Turner syndrome)

The disease arises sharply. As a rule, the leading hand is involved (in most cases, the right hand). Mostly men of young age are ill. The main symptom is intense pain in the shoulder area and proximal arms, which can spread down the radial surface of the forearm to the thumb of the hand. A few hours or on the second day of the disease, there is a restriction of movements in the shoulder due to weakness of the muscles of the shoulder girdle and pain, which is increased with hand movements. An important differential diagnostic criterion allowing to exclude the herniation of the intervertebral disc is the absence of pain intensification when moving in the neck.

The degree of muscle weakness can be estimated by the end of the first week of the disease, when the pain is dulled. In the neurological status, the symptoms of damage to the motor fibers of the upper part of the brachial plexus are revealed. The majority of patients have paresis of deltoid, anterior dentate and supraspinous muscles. Possible involvement of the biceps arm muscle. In rare cases, an isolated paresis of one muscle is determined, for example, a jagged or diaphragm. Characteristic is the rapid development of muscle atrophy. Reflexes, as a rule, are preserved, in some cases the reflex with the biceps muscle of the shoulder can decrease. Sensitive disorders are absent (not counting transient pain) or they are minimal, which is explained by the fact that the affected part of the brachial plexus contains mainly motor fibers (with the exception of the axillary nerve, the innervation zone of which is located on the outer surface of the upper part of the shoulder and comparable in area to the area palms).

When investigating the rates of conduction along the nerves, a delay in the excitation of the brachial plexus is revealed. By the end of the second week of the disease, EMGs show signs of denervation of the muscles concerned. There are usually no changes in cerebrospinal fluid with this disease, therefore, in the presence of a characteristic clinical picture, the lumbar puncture is not necessary. The forecast is favorable, however, functional recovery can take several months. The pathogenesis is not entirely clear.

Lateral herniation of the cervical intervertebral disc

To form a herniated intervertebral disc at the cervical level, excessive loading is not necessary. The fibrous ring involved in the degenerative process is very thin, and its rupture can occur spontaneously or during the production of the most common motion, for example - with the extension of the arm. The patient has radicular pain. The most important diagnostic value is the fixed position of the head with its slight inclination forward and into the diseased sternum. Movement in the neck, especially - extension, more painful than the movements in the hand.

The study of reflexes from the hand at the acute stage of the disease (when the patient was not yet able to at least partially adapt to acute pain) is usually of little informative; the same applies to the study of sensitivity. With EMG-study there are no deviations. At a radiography degenerative changes of a backbone can not be revealed; it should not necessarily be expected in all cases to reduce the height of the intervertebral fissure. In neuroimaging methods (CT or MRI), studies can reveal protrusion or prolapse of the intervertebral disc. It is extremely important to detect the compression of the cervical spine in the posterior-lateral corner of the cervical canal or the compression of the spinal cord itself, which is clinically manifested by an increase in deep reflexes with a limb below the expected level of lesion and a violation of sensitivity on the trunk. Some patients develop a clinical picture of the Brown-Sekar syndrome.

Metastatic affection of the cervical spine

When metastasizing into the cervical spine, acute radicular pain in the shoulder region without a preceding long enough period of local pain occurs rarely. If there is a history of previous local pain, it is usually mistakenly interpreted as a manifestation of the degenerative pathology of the spine (frequent mistake).

The establishment of the correct diagnosis only on the basis of the study of anamnesis and evaluation of the neurological status is practically impossible at first (!). Symptoms are very similar to the manifestations of the discogenic process. A definite indication of the possibility of metastatic lesions may be the level of segmental disorders: hernial protrusions of disks located above the sixth cervical segment are extremely rare. Useful information can be given by laboratory research, however, every doctor knows cases of a metastatic stage of the tumor process with normal ESR values. The most informative neuroimaging and radiography, according to the results of which, if necessary, carry myelography, which is convenient to combine with neuroimaging. In the case when the patient does not have a complete transverse lesion of the spinal cord, one should not waste time searching for the primary localization of the tumor process. The patient is shown a surgical intervention, which, on the one hand, allows spinal cord decompression, and on the other hand, to obtain material for histological examination.

Inflammatory diseases of the cervical spine

Spondylitis has become quite a rare pathology. With spondylitis, there is local and reflected pain in the shoulder area. Diagnosis is established by radiography or neuroimaging. Intervertebral discitis can be a consequence of surgical treatment of a herniated intervertebral disc. The patient has pain with any movement in the spine and reflected radicular pain. In the neurological status, there is usually no change, except for the reflex immobilization of the affected part of the spinal column. The diagnosis is based on radiographic examination.

Approximately 15% of all epidural abscesses occur at the cervical level. The clinical manifestations of the epidural abscess are very vivid. The patient acutely experiences intolerable pain, leading to immobilization of the spinal column. The symptoms of compression of the spinal cord, which overlap less pronounced radicular symptoms, quickly develop. In laboratory studies, there are pronounced "inflammatory" changes, a significant increase in ESR. Carrying out neuroimaging studies is problematic, because the level of localization of the lesion is clinically difficult to determine clinically. The best method is computed tomography in combination with myelography, in the production of which it is possible to take the liquor for research. In those rare cases when epidural compression is caused by a tumor or lymphoma, important information is provided by a cytological study of the cerebrospinal fluid.

Shingles Herpes

In the first 3-5 days of the disease, when there is no vesicular rash in the area of a certain segment, it is difficult or even impossible to diagnose herpes zoster, since at this stage the only manifestation is the radicular pain. Pain in the shoulder area usually has a burning sensation, comparable to sensations when a skin burns; the pain is constant and does not increase with movement or with increasing pressure of the cerebrospinal fluid (for example, with coughing). By the end of the first week, the diagnosis due to skin rashes becomes not difficult. In rare cases, symptoms of prolapse in the motor sphere are possible - prolapse of deep reflexes and segmental paresis.

"Whiplash injury"

Such a specific trauma to the cervical spine occurs when a car accident occurs when a moving or stationary car is hit back from a car driving at a higher speed. Slowly moving machine first gets a sharp acceleration, then abruptly slows down, which causes, respectively, overdistension of the passenger's neck (hyperextension injury), quickly replaced by its excessive flexion. This leads to damage to the mainly intervertebral joints and ligaments.

A few hours or the day after the injury, pain occurs on the back of the neck, forcing the patient to keep the neck and head still; pain radiates to the shoulder and arm. This painful condition can last several weeks. Reflexes are preserved, there are no sensitive disorders, electrophysiological and radiologic studies of pathology do not reveal. The diagnosis is made taking into account a specific anamnesis. Objectively evaluate the actual duration and severity of pain manifestations is quite difficult.

Spinal epidural haemorrhage

Spinal epidural hemorrhage is a rare disease characterized by the sudden appearance of severe pain, often with a radicular component, the rapid development of lower paraplegia or tetraplegia. The most common cause is anticoagulant therapy. In 10% of cases there is a vascular anomaly (more often cavernous angioma). One third of all cases of hemorrhage develops at the level between C5 and D2 segments. MRI or CT scan is detected with hematoma. The prognosis depends on the severity and duration of the neurological deficit.

Differential diagnosis includes acute transverse myelitis, anterior spinal artery occlusion, acute subarachnoid hemorrhage, aortic dissection, spinal cord infarction.