Pain in the shoulder region can be difficult to separate clearly from neck pain. If the symptoms and signs of radiculopathy are absent, then the differential diagnosis includes mechanical shoulder pain (tendonitis, bursitis, rotator cuff tear, dislocation, adhesive capsulitis, and cuff impingement under the acromion) and referred pain (subdiaphragmatic irritation, angina, Pancoast tumor). Mechanical pain is often worse at night, associated with local shoulder tenderness, and aggravated by abduction, internal rotation, or extension of the arm. The pain of shoulder disease may at times radiate into the arm or hand, but the sensory, motor, and reflex changes that indicate disease of the nerve roots, plexus, or peripheral nerves are absent.
Treatment
A paucity of well-designed clinical trials exists for the treatment of neck pain. Symptomatic treatment of neck pain can include the use of analgesic medications and/or a soft cervical collar. Current indications for cervical disk surgery are similar to those for lumbar disk surgery; because of the risk of spinal cord injury with cervical spine disease, an aggressive approach is generally indicated whenever spinal cord injury is threatened. Surgical management of cervical herniated disks usually consists of an anterior approach with diskectomy followed by anterior interbody fusion. A simple posterior partial laminectomy with diskectomy is an acceptable alternative approach. The cumulative risk of subsequent radiculopathy or myelopathy at cervical segments adjacent to the fusion is approximately 3% per year and 26% per decade. Although this risk is sometimes portrayed as a late complication of surgery, it may also reflect the natural history of degenerative cervical spine disease. Nonprogressive cervical radiculopathy (associated with a focal neurologic deficit) due to a herniated cervical disk may be treated conservatively with a high rate of success. Cervical spondylosis with bony, compressive cervical radiculopathy is generally treated with surgical decompression to interrupt the progression of neurologic signs. Cervical spondylotic myelopathy is typically managed with either anterior decompression and fusion or laminectomy. Outcomes in both surgical groups vary, but late functional deterioration occurs in 20 to 30% of patients; a prospective, controlled study comparing different surgical interventions is sorely needed.