Arm Pain In Association With Neck Pain
This pain is sometimes called brachalgia, a ‘pinched nerve’, or cervical radiculopathy, it is very similar to sciatic pain but affecting a nerve in the neck rather than the lumbar spine. Irritation or compression of a nerve in the neck leads to some pain in the neck with more severe pain spreading down the arm. The pain can also be associated with tingling (parasthesia) and numbness in the arm and hand, and occasionally weakness in the arm
The distribution of the pain and numbness in the arm is dependent upon the nerve root affected, the nerves on the right and left are numbered C1, C2, C3, C4, C5, C6, C7, C8 and T1. The commonest nerves affected are C5-C7
The distribution of the pain and numbness/ tingling generally follows the pattern on the right. The muscles in the arm are also innervated by specific nerves and thus a C5 problem causes difficulty with deltoid, C6 with biceps, C7 with triceps and C8 / T1 with the muscles of the hand. In addition to this the reflexes may be depressed or absent in the appropriate tendons when your are examined
As the clinical problem involves compression of a nerve the best way of investigating this pain is to obtain some detailed images of the nerves in the neck, the ‘gold standard’ currently available is MRI of the cervical spine. The scan on the right is a sideways view of the cervical spine obtained with an MRI scanner, the red arrow shows a disc prolapse between C5 and C6. This disc prolapse is compressing the left C7 nerve root causing pain in the arm down into the hand with numbness in the ring finger and weakness of triceps
The image to the left is a cross-section through the spine at the level of the disc prolapse
This investigation can show wear and tear in the neck, but will not localise the problem to a specific disk or nerve root
Nerve Conduction Studies
These can be useful in differentiating problems coming from the neck with a trapped nerve in the arms such as carpal tunnel syndrome
Causes of Cervical Radiculopathy
Herniated cervical disc
In this situation, the outer layer (annulus) of the disc tears and the gel-like center (nucleus) breaks through. This causes the disk to protrude, putting pressure on the nerve that exits the spinal column at that point (top red arrow)
Degenerative disc disease
As part of the aging process the disc degenerates and shrinks, the facet joints form extra bone and both processes lead to a narrowing in the canal where the nerve leaves the neck to go to the arm (bottom red arrow)
Treatment of Cervical Radiculopathy
The vast majority (80%) of patients with cervical radiculopathy will improve without any active treatment within 12 weeks. During this time urgent investigation is generally not required unless there is weakness in the affected arm or severe numbness, or if the pain is severe and not being controlled, or if there is any suggestion that the spinal cord is affected. During this period it is best to remain as active as your pain allows, bed rest has not been shown to be effective treatment. The mainstay of treatment is medication with a non-steroidal painkiller such as diclofenac, low-impact excercise such as walking, swimming, cycling, and physiotherapy. Other treatments such as local injection of steroid into the spine by a pain specialist have also been shown to be beneficial in reducing pain during this period.
Only about 5% of patients with cervical radiculopathy will require surgery to improve the pain. This is usually offered if the pain has not responded to the treatments above, and the pain has persisted beyond 6-8 weeks.
Non-operative (conservative) Treatment
Rest, and use of a soft collar
Use of a collar should be limited to short periods of time only as it will weaken the neck muscles. The more active you can remain the better.
An ‘orthopaedic’ pillow.
These may help as the neck is kept straight whilst you sleep
Painkilling/ anti-inflammatory medication such as diclofenac, naproxen, or opiate based drugs can be useful for the acute period of pain.
Gentle physiotherapy is fine, manipulation should be avoided until you have had an MRI scan and it has been confirmed to be safe to manipulate your spine
This is usually performed by a pain specialist. A needle is passed near to the nerve under Xray control and a mixture of local anaesthetic and steroid injected around the nerve and facet joint. The effect is variable but can from a couple of weeks to months. This may suppress the pain whilst the nerve compression improves
Surgery is recommended if the pain has not responded to the conservative measures above within a 6-8 week time frame. If there is weakness, severe numbness, muscle wasting, or any suggestion of spinal cord compression, then surgery is likely to be offered earlier. Additionally, if the pain is very severe and unremitting despite strong analgesia surgery may be recommended earlier
The two main options for surgery are an anterior cervical decompression where the offending disc is removed and a fusion performed, and a posterior cervical foraminotomy where the narrowed channel where the nerve is pinched is widened from the back of the neck. Please visit the relevant pages listed under spinal operations
If the distribution of the pain fits closely with the MRI findings then these operations have a 85-90% chance of improving your arm pain, more detail is available on the spinal operations pages