Sometimes the arm becomes painful. The pain shoots down one of the arms, accompanied by numbness and a tingling sensation in one or more fingers. This is due to irritation in the nerve roots emerging between the fourth cervical and the second thoracic vertebrae.
There are two factors which cause this pain:
First, pressure of the disc on the nerve root;
Second , inflammation of the nerve sheath or tissue contained in the intervertebral foramen. The pain may be in the entire upper arm or in a localised area depending upon the site of pressure. It may be a severe pain or a dull pain. It may increase during certain movements of the neck or on laughing. It usually increases when the patient is in bed and is relieved by certain movements, for example, placing one’s hand behind one’s head.
The patient usually complains of stiffness of the neck and pain between the shoulder blades for years before the disc begins to protrude. When the pain becomes acute, spreading over the upper limb, and the movements get restricted, it is then that the diagnosis of a disc prolapse can be made. A couple of more clinical tests confirm the diagnosis:
When the lower part of the neck is involved, movement in the painful side of the neck increases the pain, leading to a numbness in the arm.
When traction of the neck provides relief, it confirms the diagnosis.
A symptom frequently accompanying the pain may be in the form of weakness of the neck muscles. Sometimes the pain may be so severe that the patient has to hold his head while sitting. Even while turning his head in bed he may have to support it. If the pain has started following an injury, the patient may complain of pain several hours after the injury.
The site of pain, numbness, tingling, a feeling of pins and needles, weakening of the neck muscles, decrease in the muscle power and altered reflexes – all depend upon the level of the disc lesion. Clinical and neurological examination can determine the approximate site of the level of disc protrusion.
Treatment
In many cases of brachial neuralgia manipulation is quite effective. When there is acute pain and almost no movement of the neck is possible, manipulation should not be attempted. Prior to manipulation, immobilisation of the neck in a collar, rest and shortwave diathermy may be tried. In some cases where only a little movement is possible, manoeuvres to relax the muscles and gradual mobilisation are helpful. Manipulative manoeuvres should only be attempted when considerable movement in the neck is achieved.
Sometimes manipulation of the upper dorsal spine is also necessary along with cervical manipulation. In moderate cases manipulation can be immediately. The treatment must be conducted gently. This is more important in the region of the neck that in any other region.
Selective and gentle treatment is more effective. Thus treatment is given in the following order:
Relaxation of the cervical region, shoulders, muscles and upper back.
Mobilisation prior to manipulation.
Before manipulation, traction can be utilised, but in cases where traction has failed, manipulation must be given a fair trial. Following the reduction of disc herniation by manipulation, the patient can use the collar as a protection against strain.
Once the muscle spasm has subsided, the collar can be removed. Other physiotherapy methods may also be used. Patients should sleep on a hard bed without a pillow. Neck exercises should be started when the pain has completely subsided.
Case Histories
A bankman aged forty-two years suffered for one and a half months from pain in the neck, which radiated to the right arm. He also felt numbness and a tingling sensation in the right arm. He experienced relief by raising his arm but felt more pain when the right arm was hanging down. He had a similar attack six years before but then the pain used to radiate to the left arm and subside with cervical traction. The pain, at that time, had lasted for one month.
A similar pain had occurred six months ago, which had subsided in fifteen days with the same treatment.This time the pain was radiating in the right arm and nothing seemed to work in spite of medication and cervical traction. Manipulative treatment was started. He experienced considerable relief and the numbness and tingling completely subsided. By the third session of the treatment, he was ninety percent better. In six weeks he had no pain at all and has had no attack since.
A cloth merchant aged forty-eight years complained of neck pain for six months. The pain radiated to the right arm. It was severe for three months. It started without any injury and went on increasing, being present all the time. He felt more pain during the evening after working the whole day. He felt stiffness in the neck when he got up in the morning. Medication and traction of the neck did not help. The X-ray showed no abnormality in the cervical spine. The laboratory tests were all normal. He felt a lot of relief for 2-3 days after the first manipulative treatment. The treatment was repeated again after one week and the improvement was remarkable. After four weeks he was free of pain. Now two years have passed and he has had no repetition of pain.
A young housewife from kanpur, aged twenty-four, had been suffering from pain in the neck for four years. It started without any apparent cause and went on increasing, radiating to both arms, especially when she worked without wearing a collar. She consulted an orthopaedic surgeon and was advised medication and traction, and then given a collar which she used for three years. When she came to me, an X-ray of her cervical spine was taken again and it showed no change from the previous X-ray.
Her laboratory tests were all normal. Manipulative treatment was started for her cervical and upper dorsal spine. Her pain started getting less from the very first day of treatment. She was advised to use the collar for shorter periods, and that too only when she felt the pain. Within a month, she stopped using the collar. The pain was seventy-five per cent better. She obtained complete relief in two months. A year later I received greetings from her giving me the good news that she no longer suffered from any pain.