[Donald Corenman, MD, DC]

#11366

There are two ways to determine the cause of your symptoms. One is to take the symptoms and add them together to see what diagnosis they fit into. The other way is to look at a diagnosis (such as TOS) and look at what the symptoms should be for that diagnosis.

TOS symptoms should be pain, numbness and paresthesias that radiate from the shoulder to the inside (ulnar side-pinky side) of the hand. The symptoms should be worse with raising the arms above your chest. There can be some shoulder discomfort as the thoracic outlet (the area where the nerves leave the neck into the shoulder) can have problems that have led to this disorder. Usually, there is no evidence of muscle weakness.

Cervical nerve root compression (cervical radiculopathy-see website) has another different set of symptoms. This would be neck pain (normally but not absolutely necessary) and shoulder pain that radiates down the arm (depending upon the nerve involved) and symptoms would be worse with neck extension (bending backwards). Weakness can occur with more severe compression of the nerve root.

Some of your symptoms fit better with degenerative neck conditions and radiculopathy “Lower neck/upper/mid back -right side – trapezius extending down to shoulder blades: 7…muscle just seizes up on the right side”.

Some symptoms do not fit with cervical problems (as long as there is not significant spinal cord compression which is not reported in your case); “left foot is always vibrating. after i took a medicine, prescribed by a doctor, its reduced…foot vibration/electrical sensation.. its in the background but tolerable, and spikes when i sit on a chair or in the car etc”.

Some complaints point more to degenerative disc disorders “any slight forward head posture triggers my right side – upper middle/trapezius parasthesias and then burning pain followed by spasm”.

The complaint “my hands burn all the time” sounds more like peripheral neuropathy (see website).

The associated complaints “Is the skin hypersensitive to touch?-Not at all places. But at some spots near my wrist etc, when tapping it, it vibrates/pains and referred signals to my hands”. You also note “Noticed handwriting, i find it hurts if i attempt to write for long periods, then again, it could be that i am fully a computer person now and haven’t written anything for around 8 years. i am definitely weaker in picking up things and more butterfingered. hands are numb many times, begins with fingers”.

This sounds more like carpel tunnel syndrome (see website).

The MRI does not note significant compression of a nerve root or the spinal cord.

You need a good diagnostician (possibly a neurologist) to go through all your symptoms and figure out what diagnosis (or diagnoses) you have to get appropriate treatment.

Dr. COrenman

PLEASE REMEMBER, THIS FORUM IS MEANT TO PROVIDE GENERAL INFORMATION ON SPINE ANATOMY, CONDITIONS AND TREATMENTS. TO GET AN ACCURATE DIAGNOSIS, YOU MUST VISIT A QUALIFIED PROFESSIONAL IN PERSON.
 
Donald Corenman, MD, DC is a highly-regarded spine surgeon, considered an expert in the area of neck and back pain. Trained as both a Medical Doctor and Doctor of Chiropractic, Dr. Corenman earned academic appointments as Clinical Assistant Professor and Assistant Professor of Orthopaedic Surgery at the University of Colorado Health Sciences Center, and his research on spine surgery and rehabilitation has resulted in the publication of multiple peer-reviewed articles and two books.

[venkat]

#11368

Thanks a ton Dr – it really helps us when you patiently explain how these symptoms tie together and how to differentiate amongst them.

I followed your advice and did some digging around on matching symptoms to issues.

The WUSTL/Barnes Jewish Hospital neurogenic website (run by a vascular surgeon familiar with TOS) notes:

I have put my symptoms in bold.

Symptoms consist of one or more of the following:

Pain, numbness or tingling in the shoulder, arm, or hand
Tingling (paresthesias) in the arm or hand
Perception of arm or hand weakness, particularly in elevated positions of the arm
Substantial symptoms of pain and tension in the neck and/or upper back (often perceived to be the most functionally disabling)
Headaches in the back of the head
Difficulty or exacerbation of symptoms while lying on the back with the face up
Cold sensations, swelling, or intermittent discoloration in the hands and fingers

Many patients with neurogenic TOS describe substantial symptoms of pain and tension in the neck and/or upper back, and these symptoms are often perceived to be the most functionally disabling. These symptoms are considered to be caused by excessive stretch and muscle spasm in the neck, shoulder, and back (particularly the sternocleidomastoid, trapezius, rhomboid, and other peri-scapular muscles). This most likely occurs as a result of inadvertent alterations in posture and carry of the shoulder girdle that patients may subconsciously make, in order to minimize positions that worsen their symptoms.

The functionally disabling part really rings true.

So, could it be TOS alone?

I was also pointed to facet joint injections & disc referred pain diagnostics as possible explanations.

My state seems to be the classic six blind men & the elephant one, each time I think i have the situation somewhat clear something else pops up and I realize how little i really know.

I have had occasion to see a neurosurgeon but he was unsure about what my issues were (not spondylitis he said) but could be “something else”. Finally, a dr who specializes in RSI sort of issues said it could be TOS.

In your experience, do facet joint issues or disc issues cause upper back spasm/burning/gnawing pain like the ones I described.

[Donald Corenman, MD, DC]

#11371

I would disagree with the website you have perused regarding TOS and neck pain. Neck pain generally is a result of degeneration of the cervical discs, facets or even occasional compression of the nerve roots. TOS patients who have no additional cervical degeneration generally do not have neck pain.

I think you need to consider a neurologist to go through the symptoms, physical examination and perform an EMG/NCV test. This test will not be able to diagnose TOS but will be able to diagnose ulnar and median neuropathy (carpel or cubital tunnel syndrome) and peripheral neuropathy.

“Do facet joint issues or disc issues cause upper back spasm/burning/gnawing pain like the ones I described”. Yes.

Dr. Corenman

PLEASE REMEMBER, THIS FORUM IS MEANT TO PROVIDE GENERAL INFORMATION ON SPINE ANATOMY, CONDITIONS AND TREATMENTS. TO GET AN ACCURATE DIAGNOSIS, YOU MUST VISIT A QUALIFIED PROFESSIONAL IN PERSON.
 
Donald Corenman, MD, DC is a highly-regarded spine surgeon, considered an expert in the area of neck and back pain. Trained as both a Medical Doctor and Doctor of Chiropractic, Dr. Corenman earned academic appointments as Clinical Assistant Professor and Assistant Professor of Orthopaedic Surgery at the University of Colorado Health Sciences Center, and his research on spine surgery and rehabilitation has resulted in the publication of multiple peer-reviewed articles and two books.

[venkat]

#11374

Thanks Dr. I got a NCV test done, it showed ulnar compression at the elbows in both hands, but clinical tests were carpal like pains (in addition to the trapezius pain) – the Dr who said I had NTOS said these were “double crush symptoms”.
My biggest disabling symptoms are my upper/mid back pains/spasms. From what you note, I better investigate facet joints and referred pains from my discs.
Does your clinic treat NTOS as well? I think I have spasming neck muscles – they are very very tight and limit my range of motion. In your experience do any conservative methods to break up spasming and scarring? I get tension headaches whenever my neck muscles are messed around with by myofascial release folks (we don’t have skilled chiropractors in India and MFR is the one thing I have recourse to).

[Donald Corenman, MD, DC]

#11377

“Upper/mid back pains/spasms” typically are a result of the discs or facets of the cervical spine. You could consider trigger point injections or acupuncture to help relieve these symptoms.

I diagnose TOS but leave the treatment to the therapists and chiropractors.

Dr. Corenman

PLEASE REMEMBER, THIS FORUM IS MEANT TO PROVIDE GENERAL INFORMATION ON SPINE ANATOMY, CONDITIONS AND TREATMENTS. TO GET AN ACCURATE DIAGNOSIS, YOU MUST VISIT A QUALIFIED PROFESSIONAL IN PERSON.
 
Donald Corenman, MD, DC is a highly-regarded spine surgeon, considered an expert in the area of neck and back pain. Trained as both a Medical Doctor and Doctor of Chiropractic, Dr. Corenman earned academic appointments as Clinical Assistant Professor and Assistant Professor of Orthopaedic Surgery at the University of Colorado Health Sciences Center, and his research on spine surgery and rehabilitation has resulted in the publication of multiple peer-reviewed articles and two books.

[venkat]

#20499

Hi Dr Corenman, greetings – its been a while. I hope you are doing well.

My pain and diagnosis journey continues and I was hoping to get your advice based on some new feedback I received. I didn’t want to come back before I got some clear idea of what to look for and some more effort based on our prior discussion.

I am copying my earlier post below for additional details.

Symptoms – started when I fell from a bike, had 7 fractures on the left side of my face, implying head was either rotated or I fell on my left side.

Immediate burning pain in a few days time on my right upper back (traps, levator, rhomboid area), bilateral nerve pain and arm pain + finger weakness (all fingers).

Have C6-C7 disc bulge and now a minor C4-C5, but several neuros thought it wasn’t a contributor. However, I didn’t get any flex/extension work done – more on that below.

Was diagnosed with Thoracic Outlet Syndrome by an orthopedist (Dr). Another PT aware person told me I had a serratus weakness on right side. Also my head was rotated to right, indicating neck spasm. Based on this, I tried activating my right serratus anterior muscle and also spoke to some PTs about what my symptoms were being caused by. I was very concerned my repeated trips to neurosurgeons and Drs were not resulting in any clear diagnosis.

Finally, a hypothesis sort of emerged.

My symptoms are worse when my neck is propped up. Or when I look down and then up. When I look to the left.

On my left side of the head/neck, when I lay down or get on my hands and knees (quadraped) and roll my head up and down, raise it up and down (flex/extend) it wobbles to the right. The muscles on the left seem very weak, to the point they appeared very very weak. Head pulls to the right at the top of the movement and near the bottom. The latter especially.

Plus sports PTs showed a text which showed that my head was rotated similar to a case of torticollis, wherein left SCM was hyperactive (probably to compensate for the deep cervical muscles) and the right scalenes likewise, plus levator (perhaps accounting for the pain on the right). The initial muscle spasm post my accident may have stretched my long thoracic nerve shutting off my serratus. That’s what probably caused/worsened the Thoracic Outlet Syndrome on the right side.

But by working on the muscle over months I managed to start moving my right arm better again. However, its not completely fixed. My left upper back remains problematic as does the right to some extent. Overall my left side of the body feels much tighter from top to bottom (all the way to my calves). Any extended period of time that I work, makes my upper back burn and the muscles start seizing up and nerve pain in my arms and hands follows. Not just the ulnar but complete distribution. However, tightest sensation (of pulling) in my 3rd finger which seems to imply C6-C7 level involvement?

My nerve pain in hands arms remains, although some improvement is definitely there. Another PT told me I was rotated with rotated hips – could be postural, but I believe my cervical issues and head rotation is def, worsening things.

Now I was also told spasmodic torticollis (which seems similar to what I developed post my accident) can be caused by Cranio Cervical Instability, with the SCM muscle in particular on the side of instability getting overactive. This is usually the result of accidents similar to “head on the car dashboard” which would be very similar to how I fell from the bike. Jam the head against the ground.

I still can’t rotate my head much to the left. On the face of it, this appears to be due to tight muscles. However, when I do attempt to do so, my fingers and arms on both sides hurt. And my upper back starts spasming. Might be a protective mechanism I was thinking.

While my torticollis is not very visible, I still believe its there since I can feel the contrasting muscle groups firing more than they should. My left SCM and right splenius/Upper Traps in particular.

Other symptoms are left eye “weeps” more than usual, my left side of the mouth is numb and drools occasionally plus tinnitus on my left side. I was always more worried about my right side (I am a right hander) and its related to my sustenance and the pain and symptoms remain, but I am beginning to think the left is what is provoking the right

Sir, is there any way I may test myself for cervical instability especially on the left side? I don’t have dizziness (which seems to be a standard issue mentioned by many), but I do feel that my left side is having some kind of impingement or myelopathy (I believe that’s the term? Correct me if I am wrong). But I do have problems with flexion, extension, and rotation. Especially flexion and rotation (especially to the left). I was having an issue wherein if a vehicle moved, I would fall forwards. But then i started doing some neck exercises and surprisingly, that has reduced.

I think that my disc bulge at C6-C7 actually gets “provoked” or starts getting pinched, or the cord at the level is being messed up whenever I flex or rotate my head as the deep cervical flexors or ligaments which hold the vertebra together are weakened. My neck also crunches when I rotate my head though I can’t exactly say where the issue is.

I was also told that my fibromyalgia symptoms could be due to “Positional Cord sydrome” which sorta matches what I am thinking above. Weak neck muscles cant hold the neck in a neutral position and the ligament flavum pokes the cord causing the issue. This has been researched by Dr Andrew Holman of Washington who has several papers on this. I was surprised by the concept but it seems to be similar to what has happened to me, as he mentions many of his patients developed fibro etc post a traumatic whiplash injury.

A Dr on prolotherapy (Dr Ron Hauser) has also written a lot on cranio-cervical instability and how muscles spasm to compensate – in my case the torticollis seems to have been provoked by CCI which would match the reports on how spasmodic torticollis happens – though I hope its not that and its more at a lower level.

I would post links to all the above but I know your antivirus policy prevents that – but I hope I am making some sort of sense.

On the plus side, when I do deep cervical neck flexor exercises with a blood pressure cuff, I do see reduction in pain and symptoms.

Sir, so is there a protocol I may follow to check for cervical instability especially on my left side? Where I think I took the maximum damage. I am praying that I dont have upper cervical spine instability – it seems to be a huge bother even more so than the regular. But can an issue at C6-C7 cause the symptoms I mentioned, wherein I have lost segmental stability, either the nerves themselves from the disc level are getting pinched or the cord at that level or both, and hence it’s causing all my spasms and general fibro?

I would welcome any advice on how to go about discussing this with my doctors and seeing which tests to do and take. I have been advised flexion, extension X-Rays (wouldn’t rotation be also required) and if I can do them, manually try flexion/extension MRIs.

Unfortunately, I developed claustrophobia after my accident, so I do MRIs only with sedation, which worries about flexing or extending my neck under such conditions wherein I am not fully aware.

Any advice or insight would be very welcome. To reiterate, my hypothesis (which may be very flawed) is that I am having direct nerve/cord impingement on the left side as the neck is scrunched up on that side, and on the right side, its TOS (compensatory).

I am unfortunately having to navigate this issue somewhat on my own, as till date I haven’t found a person who is well versed with trauma induced cervical issues locally. I would welcome any thoughts of yours on the matter,

Thanks,
Venkat

venkat wrote:

My thinking was that my latest MRI in late 2013 was merely a cervical screening (as versus detailed) so not sufficient.

Then i realized that my symptoms were already there when i had my 2009 MRI done a year and a half after my symptoms appeared. If so, what that MRI showed would apply (as my main issues already existed moreorless by that time). This would help me crosscheck the validity of what procedures to continue with and what to skip.

One doctor recently diagnosed me with Thoracic Outlet Syndrome but I have heard that many cervical issues can coexist with TOS & i just wanted to make sure I could address all the possible modalities.

I am wondering whether my upper/middle trapezius problem on the right side is due to any referred pain from a disc or the like (harder to diagnose? versus a “conventional” issue of std nerve compression at the disc.) so it could coexist with TOS.

My guess is that its my scalenes which are the cause of the mess post the injury, but your insight counts for 100x. also with your hands on background as a chiropractor + spinal specialist, you’d know far more about how to resolve a possible TOS issue and the differential dx. i fear many of the specialists i have consulted with don’t really “get” soft tissue entrapment etc and TOS is something associated with extra cervical ribs alone.

Symptoms

Hi Dr Corenman, is there a way to send you my MRI and other reports? An email address? I a male in his mid 30s, and have chronic pain after an accident a few years back. I fell on my face, left side from the back of a motorcycle. Pain is not reducing / body doesnt seem to be healing, and diagnosis of the whole thing remains unclear. I would appreciate any help as I really don’t seem to have a clear understanding of the issue. Based on your forum posts and other content, I seem to have a mild bulge in my C6-C7 (as was originally diagnosed) and also in C4-C5. I am no expert and would appreciate your thoughts if I could send you the MRIs by mail after getting copies from the hospital.

My symptoms as per your FAQ -please excuse any typos as I find it hard to type, my upper back – right side of the trapezius/lower neck seizes up on the right.

What is the quality of the pain?

Hands:I’d put it as 5 on a scale of 1-10…tolerable, but very irritating. Symptoms worsen if i strain my neck, eg on a pillow on the bed, laying on my back, trying to read a book. Or, at a desk, trying to use a computer.

Lower neck/upper/mid back -right side – trapezius extending down to shoulder blades: 7…muscle just seizes up on the right side.

My symptoms become worse i am on te computer or cross my legs when lying down. At night they seem to worsen.

Is the pain burning, stabbing, sharp, shooting, dull, aching, electrical, gnawing or pins and needles?

mostly burning, aching and pins and needles. occasionally sharp.

in my left and right hands both, all over.
fingers especially.

left foot is always vibrating. after i took a medicine, prescribed by a doctor, its reduced…foot vibration/electrical sensation.. its in the background but tolerable, and spikes when i sit on a chair or in the car etc.

medicine is methylcobalamine, alpa lipoleic acid, biotin, vitam b12 and folic acid.

big issue is shoulder seizes up, id rate it a 7 in pain, complete spasm, basically trapezius muscle, base of neck on right side to near the shoulder …it just seizes up. medicine doesnt reduce it.

Does the quality of pain change with activity?

pain picks up mostly when i am at the computer, or i am lying down on my side or back with a pillow, reduces when there is no pillow and i am flat on my back/neck. sitting has it worse then standing, and standing, my feet hurt or are somewhat sensitive but thats probably because of lack of exercise.

any slight forward head posture triggers my right side – upper middle/trapezius parasthesias and then burning pain followed by spasm.

Is the skin hypersensitive to touch?

Not at all places. But at some spots near my wrist etc, when tapping it, it vibrates/pains and referred signals to my hands.

Are there associated skin changes like thickening, color change or nail changes? This is important in the shoulder, arm and hand.

my nails appear to be more brittle, and color is more blueish and pale, after myofascial therapy (on traps/levator scapula) have become more pinkish with blue tinge.

Percentage of Pain by Location

What is the percentage of pain in the neck vs. shoulder and arm?
This is important as lateral shoulder region can be typically associated with arm pain or nerve pain while posterior shoulder pain can originate from neck or nerve sources. Don’t forget that the shoulder joint itself can cause pain.

Is it 80% neck vs. 20% shoulder and arm pain or the reverse? Is it 70/30, 60/40 or 50/50 (equal in both areas). This percentage number is quite valuable to determine what type of pain the disorder is causing. The pain may be all posterior shoulder (100%) or even only 100% in the hand (or both hands).

the distribution between my neck and shoulder vs my hands is like 50-50% but to be honest the neck hurts when i turn it etc or is stiff, but my hands burn all the time.

i have grown used to pain and work through it, but the neck/shoulder pain are unstoppable. the muscle seizes up. so fingers hurt all the time, and neck/shoulder hurt when i sit down and attempt to use the computer, extending the hand to mouse or keyboard …seizes up on right side, and i am right handed.

its my upper back/middle back pain/spasms which are truly disabling.

Rate each area that you have pain. If the neck has 4-6 VAS, the shoulder has 0-2 VAS, and the arm has 8-10 VAS, make sure that is noted.

i dont know the VAS method but if a rank of 0-10 is employed,
i’d say neck has around 4, shoulder/upperback around 8 and hands around 4-5 too. neck becomes stiff and aches along with feet if i sit for more than 15 mins and lower neck/upperback/right side of trapezius portion just seizes up. hands left and right keep burning 24/7. sometimes both, sometimes one. since my back is seized up (upper) i cant do many exercises. fingers and feet hurt if i walk too fast or attempt to jog.

Is there weakness associated with the pain?

Is the weakness due to pain inhibition (the muscle is weak from use due to pain) vs. neuropathic weakness (is muscle is

weak because the signal from the brain is interrupted due to a pinched nerve)?

Is there now an inability to lift the arm due to pain or to weakness?

Are certain activities more problematic like pushing away or throwing (due to weakness and not pain- such as a weak triceps muscle) or lifting due to a weak deltoid or biceps muscle?

i would say i have become weaker in terms of pulling and lifting things.. but it could be due to lack of exercise.. apart from walking my exercise regimen is non existent and even walking is occasional. my arms hurt if i lift them above my head and if i extend my arms at the shoulder and keep them akimbo, my back hurts (muscles)

i cannot raise my arm (right especially) above the shoulder without being fatigued.

both hands become numb and burn if raised above shoulders.

Incoordination and Numbness

Are there now some noticeable problems with coordination and walking?

Do you find yourself unbalanced when you walk?

Do you “misstep” unintentionally much more than you use to do?

Do you have trouble keeping your balance in a pitch black room?

Has your handwriting changed?

Do you now have trouble picking up a dime off a counter, zipping a zipper or buttoning a button?

Do you find lightening type electrical charges down your spine if you tilt your head backwards?

Have your bowel and bladder function substantially changed in association with any of the above symptoms..

Noticed handwriting, i find it hurts if i attempt to write for long periods, then again, it could be that i am fully a computer person now and havent written anything for around 8 years.

but i am definitely weaker in picking up things and more butterfingered.

hands are numb many times, begins with fingers.

i tried the tennis in the sky method a few days back from the mckenzie neck exercises, basically tuck chin in, look towards the roof and move head sideways…when i moved head from side to side, i got severe dizziness and loss of movement control. went away though.

Onset and Length of Time Symptoms Have Been Present

How did the pain start?

Was it a gradual onset over years or was there one specific activity or injury that caused it?

When did that injury occur?

Describe the activity or action that brought on the pain. Was it a lifting injury, a bike accident or did the pain onset come on gradually?

How long have the symptoms been present and have they changed in quality or intensity?

For example, did you lift something one year ago that caused neck pain and in the last month you have developed severe

arm pain that radiates down to the hand?

Six years now since the issue became apparent.

Fell down from the back of a motorcycle, face down on the road, injuring the left side of my face, too fast for me to stop,
i was too tired/sleepy to even prevent it, and was trying to catch a bag that was falling off. the bike was going around 30 mph. i had some fractures around my left eye (plastic surgeon said around 5-7 fractures), and deep cuts which required stitches. i then developed a problem sleeping, and that night itself could not sleep due to neck pain. after chronic discomfort for around a year, istarted seeing doctors, and was told the disc bulge at c6-c7 was a probable cause but not a clear answer. after i started making notes and the pain became constant, and i went back to spinal specialists, one diagnosed it as possible whiplash, another said probably due to the minor bulge at c6-c7 in MRI.

as things stand, its become worse since the past 3 years ?(been five years since the accident) as my sedentary lifestyle, thanks to this issue and high stress computer work, probably worsened my posture and also i have been unable to get proper diagnosis on the issue. a doctor told me i have significant anterior postural issue. as i type this, my left hand is burning and right shoulder/upper back are seizing up.

since i hurt my back down a staircase recently, i got another MRI done and CAT scan showed probable hairline fractures to transverse process at L1-L2. so i went back to doctor and on mentioning my issues with burning was prescribed medicines and isometrics.

upon taking the pill, within 1-2 hrs, my left foot’s intense tingling (basically buzzing vibration) reduces to a tolerable level. but my hand burning remains, upper back muscle seizing up remains.

I would appreciate any answers, insights on how to get you my MRI pics, whether they are sufficient and if my above symptoms show any evidence that its actually from nerve root compression at C5-C6 or C6-C7, or it could be any other issue. this issue has badly affected my life and forced me to curtail my activities. not being able to work on the computer or undertake any activities is another serious issue.

2009 MRI

History: Neck pain since 1yr 6 month
Technique: Multiplanar, Multisequence MRI imaging

Findings MRI:

Vertabrae:
Cervical spine shows normal alignment with morphology
Facetal joints: No significant facetal hypetrophic changes noted
CV Junction: Normal. No marrow pathology
Spinal canal:No bony canal stenosis

Intervertebral discs:
C6-C7: Diffuse disc bulge with mild impression on thecal sac. No focal root compressions. No extension into the foramina
Other discs: No significant disc herniations (2013 MRI shows mild bulge at C4-C5)
Cord: Shows normal signal morphology
Pre and para vertabral soft tissues appear normal

Impression:
Diffuse disc bulge at c6-c7 level with mild impression on thecal sac

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