SOURCES OF REFERRED PAIN

Cervical Spine

(i) Brain

(ii) Chest
(a) cardiac (b) pulmonary (c) diaphragm

(iii) Entrapment neuropathy
(a) arm (b) forearm (c) cervical rib

(iv) Shoulder joint
i. A.C. joint
ii. glenohumeral

(v) Sternoclavicular joint

Thoracolumbar spine

(i) gastric/duodenal ulcer / pancreatitis
(ii) renal pathology
(iii) gynecological problems
(iv) Retro-peritoneal pathology
(v) Hip and sacroiliac joint pathology
(vi) Aneurysms

NECK PAIN

Neck pain in the absence of neurologic signs are the most common symptoms of cervical disk degeneration. Patients generally complain of aching, stiffness, and limited motion. The pain is commonly posterior and paracentral but may be referred into the trapezius, rhomboids, and interscapular area. Associated pain commonly occurs in one or both shoulders (71%), arm (44%), forearm (31%), and hands (28%). Headaches, typically suboccipital or temporal, are reported by one-third of patients.

Branches from the dorsal and ventral rami of the spinal nerves innervate surrounding structures such as the annulus fibrosus, anterior and posterior longitudinal ligaments, periosteum, and facet capsules. Primary muscle afferents also travel with motor nerves to the paraspinal, shoulder girdle, and scapular muscles. Reproduction of axial pain during provocative procedures such as discography or direct stimulation of the facet joints or annulus fibrosus.

The neck pain of cervical disk degeneration is frequently precipitated, aggravated, and perpetuated by motion, especially neck extension. The pain is relieved by rest. Activities such as shaving, putting on socks and shoes, reading with bifocals, vacuuming, reaching for high shelves, and maintaining incorrect posture while driving or using the telephone can all precipitate or aggravate degenerative symptoms. The pain also can be exacerbated by fatigue, anxiety, or stress.

The patient commonly assumes a slightly flexed position to maximize comfort. In cervical disk degeneration, extension is the first movement lost.

MYELOPATHY

Cervical spondylosis is the most common cause of myelopathy in middle-aged and elderly patients. A combination of several factors contributes to the development of the myelopathy. When cervical spondylosis (which includes annular bulging, osteophyte formation, facet hypertrophy, and ligamentum flavum infolding) is superimposed on a developmentally narrow cervical canal, myelopathy is most likely to develop. The excessive reduction in cross-sectional area available for the spinal cord causes clinically significant compression of the spinal cord and production of the signs and symptoms of myelopathy

RADICULOPATHY

Cervical radiculopathy is a clinical diagnosis based on a sclerotomal distribution of motor and/or sensory changes or complaints. Any process in the cervical spine that causes impingement of exiting nerve roots can lead to a radiculopathy. Impingement may be brought about by acute pathologic changes or by progressive degenerative changes, as seen with cervical spondylosis. Nerve root compression due to a soft disk herniation is the most common cause of cervical radiculopathy in young adults. In older patients, spondylosis, manifested by annular bulging and uncovertebral oseophytes, compresses the nerve root anteriorly, causing a radicular syndrome.

BACK PAIN

Acute Low Backache

Degenerative disc disease
Pathological fractures accompanied by
Infections constitutional symptoms
tumour LOA, L.O.W

Predominant leg pain with minimal back pain - sciatica

Chronic Backache

spondylolysis
spondylolisthesis
Spinal stenosis
Failed back surgery

Nonspcific Low Back Pain

Nonspecific low back pain also may be described as “simple backache,” the everyday bodily symptom that most adults get at some time in their life. This is the common “mechanical” back pain of musculoskeletal origin in which symptoms vary with physical activity. Clinically simple backache commonly is related to physical “strains”, although these often are normal daily activities, and perhaps in reality, it usually develops spontaneously. Nonspecific low back pain may be very painful and often spreads as referred pain to one or both buttocks or thighs, but it is a benign, self-limiting condition.

RISK FACTORS

(i) Smoking
(ii) Obesity
(iii) Repetitive lifting
(iv) Use of jackhammers and heavy machinery