Diseño de la estructura de las aplicaciones web

Diseño de la solución

5.2. Diseño de la estructura de las aplicaciones web

Trigger point injections with local anesthetic may be helpful for myofascial neck and shoulder pain. Improvement in pain and range of motion often lasts for long periods after the duration of the local anesthetic has elapsed. The local anesthetic may lead to vasodilatation and a decrease in muscle spasms with an enhance- ment of physical therapy tolerance.

Botulinum toxins A and B act by inhibiting presynaptic acetyl- choline release and have been utilized for treatment in cervical dys- tonia and spasticity and other pain syndromes characterized by muscle spasm. Large doses of botulinum A (>50 units) have shown benefit for myofascial pain, but the effects of small but more frequent dosing have not been as significant.

Regional techniques with blockade of peripheral nerves have been employed for neck pain. Posterior head and neck pain may be treated with occipital nerve block, which is performed medial to the occipital artery located one third of the distance from the greater occipital protuberance toward the mastoid (Fig. 18–3).

The cervical plexus is formed by C1–4 ventral branches of the cervical spinal nerves and innervates the posterior and lateral neck and head (Fig. 18–4). The superficial cervical plexus is blocked posterior to the sternocleidomastoid muscle at its midpoint. Branches of the superficial plexus include the lesser occipital (to the lateral occipital area), the great auricular nerve, and the transverse cervical and supraclavicular nerves. The deep cervical plexus is anesthetized at the level of the C2–4 transverse processes. More

commonly used for surgical anesthesia of the neck, cervical plexus blockade is another option for chronic occipital and lateral neck pain and has been used for metastatic pharyngeal pain control.

Cervical epidural steroid injections are commonly performed for cervical radicular pain with at least transient improvement in up to 70% of well-selected acute cases (Fig. 18–5). Axial neck pain has not been as responsive to this approach. The risks of epidural steroid injections range from mild side effects to severe complications. Neck stiffness, a transient increase in pain, and flushing may be experienced. Infection with epidural abscess is less common than in the lumbar area, but potential cord compression poses greater danger. Similarly, an epidural hematoma may cause far more

External occipital protuberance Greater occipital n. Lesser occipital n. Greater auricular n. Posterior br. Finger finds occipital a., nerve medial Superior nuchal line

Figure 18^3.Occipital nerve block. (From Brown D. Atlas of Regional Anesthesia. Philadelphia:WB Saunders,1999; p 145.)

Phrenic n. Greater auricular n. Lesser occipital n. C1 C2 C3 C4 5 Cranial n. XI (accessory n.) Transverse cervical n. Ansa cervicalis complex Supraclavicular n.

Figure 18^4.Cervical plexus. (From Brown D. Atlas of Regional Anesthesia. Philadelphia,WB Saunders,1999; p 182.)

neurologic compromise because of the smaller and more contained space in the neck.

Dural puncture may cause a spinal headache, and inadvertent dural injection of local anesthetic may lead to severe hypotension and respiratory arrest. Paraplegia from intracord injection and quadriparesis from a theorized increase in cerebral fluid pressure leading to a vascular insult during injection have been reported. The incidence of major complications is fortunately rare (0.4%).

Injections may be performed via an interlaminar or a transforaminal approach. The midline interlaminar approach was the most commonly used technique in the past. More recently, the transforaminal approach has been advocated to maximize the delivery of the steroid to the targeted nerve and the dorsal root ganglion (Fig. 18–6). Case reports detailing spinal cord and anterior radicular artery and vertebral artery injection have led some to aban- don this technique. Diligent fluoroscopic vigilance with multiple

A B

Figure 18^5. A, Anteroposterior (AP) view of interlaminar cervical epidural steroid injection. B, Lateral view of interlaminar

cervical epidural steroid injection with contrast. (A, Reproduced with permission of Milton H. Landers, D.O., Ph.D.)

C4 C5

R C5 SSNB

A _B

Figure 18^6. A, Lateral view of transforaminal cervical epidural steroid injection with contrast. B, AP view of transforaminal

cervical epidural steroid injections with contrast. (A and B, Reproduced with permission of Milton H. Landers, D.O., Ph.D.)

145 V CHRONIC PAIN: NONCANCER PAIN

views, real-time contrast injection, digital subtraction, nonparticu- late steroid use, and advanced technical expertise are advised.

The cervical zygapophyseal joint (often referred to as the facet joint) is a common neck pain generator, and intra-articular injections may be tried (Fig. 18–7). Alternatively, the medial branch of the dorsal rami to these joints may be blocked with local anesthetic to predict the response to radiofrequency ablation. This lesioning technique is an effective palliative intervention for axial neck pain (Fig. 18–8).

For discogenic disease unresponsive to conservative therapy, options include the evolving modality of lesioning of the disk itself. Discography is used to determine suitable candidates. Nucleoplasty and intradiskal electrothermal therapy (IDET) are practiced in advanced centers, but rigorous long-term results are as yet unknown. In summary, the diagnosis and treatment of neck pain can be challenging. However, many therapeutic options are available. One simplified approach to treatment is summarized inTable 18–7.

S

U G G E S T E D

R

E A D I N G S

Barnsley L. Percutaneous radiofrequency neurotomy for chronic neck pain: outcomes in a series of consecutive patients. Pain Med 2005;6:282–286. Bogduk N. The anatomy and pathophysiology of neck pain. Phys Med

Rehabil Clin N Am 2003;14:455–472.

Bogduk N. Medical Management of Acute Cervical Radicular Pain. Newcastle, New South Wales, Australia: Newcastle Bone and Joint Institute, 1999.

Bogduk N. Practice Guidelines for Spinal Diagnostic and Treatment Procedures. San Francisco: International Spine Intervention Society, 2004. Devereaux MW. Neck pain. Prim Care 2004;31:19–31.

Ferrari R, Russell A. Neck pain. Best Pract Res Clin Rheumatol 2003; 17:57–70.

Honet J, Ellenberg M. What you always wanted to know about the history and physical examination of neck pain but were afraid to ask. Phys Med Rehabil Clin N Am 2003;14:473–491.

Hoppenfeld S. Orthopaedic Neurology. Philadelphia: Lippincott Williams & Wilkins, 1997.

Figure 18^7. Intra-articular zygapophyseal joint

injection. (Reproduced with permission of Milton H.Landers, D.O., Ph. D.)

Figure 18^8.Radiofrequency of medial branch to

zygapophyseal joint. (Reproduced with permission of Milton H.

Landers, D.O., Ph.D.)

Table 18^7.Current Therapy of Neck Pain

Type Pharmacologic Nonpharmacologic InjectionTherapy

Mild/acute Acetaminophen NSAIDs

Muscle relaxants

Rest, immobilization Cervical collar Moderate Myofascial Short-acting opioids

Lidoderm patch Tizanidine

Physical therapy

Chiropractic manipulation TENS unit

Trigger point injections Botulinum toxin Neuropathic

Radicular

Antidepressants Anticonvulsants

Epidural steroid injections

Axial Facet injections

Chronic and refractory Long acting opioids Behavioral medicine techniques (CBT) Surgery

Radiofrequency ablation Dorsal column stimulation Discography

Nucleoplasty CBT, cognitive-behavioral therapy; NSAIDs, nonsteroidal anti-inflammatory drugs; TENS, transcutaneous electrical nerve stimulation. 146 Chapter 18 NECK PAIN

Huston C, Slipman C, Garvin C. Complications and side effects of cervical and lumbosacral selective nerve root injections. Arch Phys Med Rehabil 2005;86:277–283.

Ma D, Gilula L, Riew KD. Complications of fluoroscopically guided extraforaminal cervical nerve blocks. J Bone Joint Surg 2005;87:1025–1030. Malanga G, Peter J. Whiplash injuries. Curr Pain Headache Rep 2005;

9:322–325.

Ojala T, Arokoski J, Partanen J. The effect of small doses of botulinum toxin A on neck-shoulder myofascial pain syndrome: a double-blind, randomized, and controlled crossover trial. Clin J Pain 2006;22:90–96.

Pelosa P, et al. Medicinal and injections therapies for mechanical neck disorders. Review. The Cochrane Collaboration, Cochrane Library, Issue 2. John Wiley & Sons, Ltd, 2006. Available athttp:// www.thecochranelibrary.com

Phero J, Dionne R. Pharmacological management of head and neck pain. Otolaryngol Clin North Am 2003;36:1171–1185.

Smith HS. Drugs for Pain. Philadelphia: Hanley and Belfus, 2003. Vas J, Perea-Milla E, Me´ndez C, et al. Efficacy and safety of acupuncture

for chronic uncomplicated neck pain: a randomized controlled study. Pain 2006;126:245-255.

Chapter 19 SHOULDER

PAIN

Richard L.Uhl

INTRODUCTION

Shoulder pain is a common complaint, affecting up to 66% of the general population at some point during their lifetime. In many cases, the pain is limited in intensity and duration, resolving on its own. In some cases, the pain persists and can become disabling. The majority of these cases will resolve with accurate diagnosis and appropriate treatment, with only a small percentage of patients going on to a chronic pain syndrome.

TAXONOMY

Impingement: General term used to describe pain-producing lesions of the bursa, rotator cuff, or biceps tendon due to tissue irritation from the coracoacromial arch (acromion, acromioclavicular [AC] joint, coracoacromial [CA] ligament, or coracoid) Instability: Excess translational motion of the glenohumeral joint

that produces pain in the shoulder joint. This may be from laxity of the tissues or from a labral tear after dislocation of the glenohumeral joint.

SLAP lesion: Superior labrum anterior posterior tear. The biceps tendon is anchored to the superior labrum. If the biceps tendon tears the labrum from the glenoid, a SLAP lesion results. A SLAP lesion may also occur from repeated pinching of the superior labrum through excessive overhead use of the arm.

Adhesive capsulitis: Tightening and scarring of the shoulder joint capsule leading to profound glenohumeral stiffness and severe pain. Commonly referred to as a ‘‘frozen shoulder.’’

EPIDEMIOLOGY

The true incidence of shoulder pain is difficult to determine, in part owing to variation of the definition of shoulder pain. Of 60,131 new patient visits (or old patients with a new problem) seen in the author’s orthopedic practice over a 2-year period, 4014 patients (7% of patients seen) had a diagnosis related to shoulder pathology

(acute fractures excluded). The most common diagnoses were impingement (2016 patients; 51% of patients with shoulder problems), calcific tendinitis (522 patients; 13%), and rotator cuff tear (1059 patients; 26%).

PATHOPHYSIOLOGY

The shoulder is a highly mobile joint. According to American Medical Association guidelines, a full range of motion is from 508 of adduction to 1808 of abduction, 508 of extension to 1808 of flexion, and from 908 of external rotation to 908 of internal rotation. However, a patient with considerably less shoulder motion can still be functional for many tasks.

The shoulder joint is able to achieve this degree of motion because of the lack of bony constraints. The round humeral head sits on the relatively flat glenoid, but it must be held in place with soft tissue constraints to maintain stability. The stabilizing structures include the glenoid labrum, the glenohumeral ligaments, the rotator cuff, the biceps tendon, and the deltoid muscle. To maintain stability, the static stabilizers (labrum and ligaments) must be intact, and the dynamic stabilizers (muscles) must be balanced with each other. Injuries to the ligaments or muscle weakness will lead to instability, and pain, of the shoulder joint. Contracture of the soft tissue stabilizers will lead to pain and stiffness of the nor- mally mobile shoulder joint.

Irritation of the stabilizing structures (bursitis, tendinitis) will also lead to pain. Arthritis of the AC joint is a common cause of shoulder pain due to pain in the joint itself and due to irritation of the bursa, rotator cuff, and biceps tendon from the osteophytes that form around the AC joint. True glenohumeral arthritis will present with pain throughout the entire range of motion, rather than with impingement pain at the end of motion.

If mechanical causes have been eliminated, other causes such as cervical radiculopathy, avascular necrosis, infection, and tumor should be considered.

CLINICAL FEATURES

Shoulder pain most often presents as a deep aching on the lateral aspect of the arm, near the deltoid muscle insertion (shoulder pain is commonly referred to this area). Patients will often notice pain and weakness with overhead activities and difficulty sleeping on the affected side. Patients complain of difficulty reaching up their back (undoing a brassier for women and putting on a suit coat for men). With time, the shoulder may become stiff, which leads to additional pain with attempted motion.

Inflammation problems (bursitis or rotator cuff tendinitis) will usually start after a period of overuse, but it may occur either suddenly or insidiously without any obvious aggravation.

147 V CHRONIC PAIN: NONCANCER PAIN

Huston C, Slipman C, Garvin C. Complications and side effects of cervical and lumbosacral selective nerve root injections. Arch Phys Med Rehabil 2005;86:277–283.

9:322–325.

Phero J, Dionne R. Pharmacological management of head and neck pain. Otolaryngol Clin North Am 2003;36:1171–1185.

Smith HS. Drugs for Pain. Philadelphia: Hanley and Belfus, 2003. Vas J, Perea-Milla E, Me´ndez C, et al. Efficacy and safety of acupuncture

for chronic uncomplicated neck pain: a randomized controlled study. Pain 2006;126:245-255.

Chapter 19 SHOULDER

PAIN

Richard L.Uhl

INTRODUCTION

TAXONOMY

that produces pain in the shoulder joint. This may be from laxity of the tissues or from a labral tear after dislocation of the glenohumeral joint.

Adhesive capsulitis: Tightening and scarring of the shoulder joint capsule leading to profound glenohumeral stiffness and severe pain. Commonly referred to as a ‘‘frozen shoulder.’’

EPIDEMIOLOGY

PATHOPHYSIOLOGY

If mechanical causes have been eliminated, other causes such as cervical radiculopathy, avascular necrosis, infection, and tumor should be considered.

CLINICAL FEATURES

Inflammation problems (bursitis or rotator cuff tendinitis) will usually start after a period of overuse, but it may occur either suddenly or insidiously without any obvious aggravation.

147 V CHRONIC PAIN: NONCANCER PAIN

Instability may result from trauma, especially if there was a glenohumeral dislocation, but may also be due to tissue laxity or repetitive stretching trauma (baseball pitcher) over time.

EVALUATION

Evaluation of the patient with shoulder pain begins with a careful history, including specific questions about the location and nature of the pain, history of trauma or overuse, and previously attempted treatments (Table 19–1). Injury to the AC joint (so-called separated shoulder) often occurs after a direct blow to the shoulder, whereas glenohumeral dislocation usually occurs from a fall on the out- stretched arm. Repeated overhead activities may lead to impingement, rotator cuff tendinitis, or a SLAP lesion.

Most shoulder pain is referred to the outer arm region. When pain is radiating below the elbow, especially when in a narrow, dermatomal strip, cervical radiculopathy should be considered.

Examination begins with inspection of the shoulder region look- ing for asymmetry, swelling, discoloration, or deformity. The patient is asked to raise the arm to the side (abduction) and elevate in the forward plane (flexion). The patient is then asked to bring the arm up the back to evaluate internal rotation.

Next, the shoulder region is palpated. Begin by following along the clavicle to the AC joint. Tenderness, redness, swelling, and bony prominence over the AC joint are indicators of AC joint arthritis (Fig. 19–1). Tenderness of the biceps tendon when the bicipital groove is palpated indicates biceps tendinitis.

Various provocative tests have been described to help separate the mechanical causes of shoulder pain. The Neer and the Hawkins impingement tests look for bursa and rotator cuff impingement on the underside of the acromion or AC joint (Fig. 19–2). The cross- body test compresses the AC joint, causing pain in patients with AC arthritis (Fig. 19–3). Patients with a rotator cuff tear will have difficulty abducting the arm from the side of the body and also will

have difficulty lowering the arm from a horizontal position to the side of the body (drop-arm test).

The apprehension test (Fig. 19–4), the Jobe relocation test, and the sulcus sign indicate shoulder instability. The O’Brien test and crank test load the biceps tendon and superior labrum, which causes pain in patients with a SLAP lesion.

All patients presenting with shoulder pain should have radio- graphs. Standard views include an anteroposterior (AP) radiograph (often with internal and external rotation of the humerus) and a lateral view (axillary or scapular Y view). In the absence of trauma (and the need to rule out a dislocation), most information can be gleaned from the AP radiograph. An acromial arch view is useful to visualize the subacromial space.

The AP radiograph will visualize the AC joint, acromion, glenoid, and humeral head (Fig. 19–5). Spurs on the anterior acromion can be seen on the AP view as a second shadow below the normal inferior cortex of the acromion (Fig. 19–6). AC joint

Figure 19^2.The Neer impingement test (forward elevation of the arm) and the Hawkins impingement test (shown) exacerbate the patient’s pain by moving the greater tuberosity under the spur on the acromion or AC joint.The Hawkins test is performed by bringing the arm to 908 of forward flexion and internally rotating the shoulder.

Table 19^1.Current Diagnosis for Shoulder Pain

Diagnosis History Examination

Fracture Trauma Radiograph

Dislocation Trauma Radiograph

Impingement Pain with overhead use Pain radiating down

the deltoid

Pain when sleeping on

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