Neck and scapula pain

by Nathan Wei, MD, FACP, FACR

Nathan Wei is a nationally known board-certified rheumatologist and author of the Second Opinion Arthritis Treatment Kit. It's available exclusively at this website... not available in stores.

Click here: Second Opinion Arthritis Treatment Kit

The cervical spine (neck) is made up of seven vertebrae.

The top vertebra, called the atlas, (C-1) interacts with the occiput of the skull above and with the axis (C-2) below. The atlas-occipital joint allows flexion and extension, while the atlantoaxial articulation permits rotation. Vertebrae C-3 through C-7 contribute to varying degrees of flexion, extension, lateral bending, and rotation. Flexion centers on C-5 and C-6 and extension on C-6 and C-7, which is why degenerative changes and spine injuries most commonly occur at these levels.

Intervertebral disks are found from C2-3 and below. Disk degeneration may be painful, while herniation can lead to compression of the nerve root (radiculopathy) or spinal cord (myelopathy). Eight pairs of cervical spinal nerves exit through the intervertebral foramina. Each spinal nerve is named for the vertebra above which it exits; for example, the C-6 nerve exits above the C-6 vertebra. Therefore, a herniated disk or significant foraminal narrowing at the C5-6 level will most commonly involve the C-6 nerve. The exception is the C-8 spinal nerve, which exits between the C-7 and T-1 vertebrae.

The posterior part of the vertebrae have facet joints, which are true synovial joints, while a lip off the outside margin of the upper vertebral body forms the uncovertebral joint with the vertebra below. Both joints develop degenerative changes over time that produce pain with neck extension combined with lateral bending and rotation.

The muscles of the neck are divided into four major compartments: anterior (flexion), posterior (extension), and the lateral groups (lateral bending). The posterior muscles are the strongest group and the most likely source of pain. Poor posture causes these muscles to be in a state of constant contraction to hold the head upright. The anterior and lateral muscles are injured more in whiplash type injuries.

The most common type of injury is muscle strain. Muscle strains usually resolve within a few days to a couple of weeks. By contrast, ligament sprains may take up to a couple of months, and disk injuries or herniations with nerve root damage can take 3 to 6 months for full recovery. Chronic pain beyond 6 months is likely associated with a degenerative process.

Pain that increases with activity but improves rest is referred to as mechanical pain. Pain that persists or worsens despite rest and treatment and persists or pain that worsens at night indicates the possibility of malignancy. It's important, therefore, to inquire about systemic symptoms such as fevers, weight loss, or history of cancer. Questions about worker's compensation, or third-party liability cases may provide clues to secondary gain motives.

Localized pain points to muscle strains, ligament sprains, and facet or disk processes. There may also be radiating pain to the scapula or upper trapezius muscle from the cervical spine. Pain that radiates into the arms frequently comes from nerve involvement.

Upper cervical nerve injuries refer pain to the head (C-1, C-2), the neck (C-3), and the upper trapezius region (C-4). The C-5 nerve leads to pain in the shoulder and lateral arm, and occasionally the forearm. C-6 pain is very similar but includes the thumb, and index finger. The C-7 nerve refers pain to the back of the arm, forearm, and the index and middle fingers. The C-8 nerve radiates pain to the forearm, and the ring and little fingers.

The lower cervical nerve roots and facet joints refer pain to the scapula and muscles in the scapular region.

With the increasing incidence of repetitive stress injury related to the workplace, many patients complain of vague symptoms in the neck and upper extremities that results from overuse at work.

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