What is referred pain from the neck or back?
Referred pain is pain which is experienced either in the shoulder or arm but which is arising from the cervical spine (neck). In the case of the lower limb, the pain occurs in the leg and is arising from the Lumbar spine (lower back). The latter example is one that many people will know as sciatica, where pain, which is often excruciating, is referred down the leg with the sensation that the pain is localised in either the hip, the knee or even in the foot.
There are several causes of referred pain, but it can be divided into two main causes:
- nerve root entrapment
- inflammation of the joints of the neck or lumbar spine
In the first case the main cause relates to either disc prolapse (protrusion) hitting the nerve as it leaves the area of the spine. This can also occur secondary to arthritis in the joints of the cervical or lumbar spine (facet joints), which results in extra bone formations which then catch on the nerve.
In the second scenario it is purely either inflammation or arthritis which causes the sensation of pain in the muscles around the vertebra that leads to the referred pain.
Is referred pain different to that normally felt in either the arm or leg?
Yes, the pain can be different. In particular, referred pain is usually a dull, heavy, deep seated pain. It often causes emotional distress and is often present all the time. Pain referred from the neck is often felt between the shoulder blades or in the base of the neck as the neck joins the chest wall. Pain arising from the lumbar spine is often felt in the buttock and lateral thigh, running down the back of the leg and into the foot. If a nerve is irritated the patient can have a sensation of numbness or tingling in areas of the arms or legs. In particular, when the nerve is injured it classically leads to reduction in sensation and weakness which affects the particular area that nerve normally innervates.
Is pain referred from the neck and lumbar spine a common presentation to an orthopaedic surgeon?
Yes. Whilst the majority of neck and back conditions are treated by physiotherapy and the general practitioner, with more severe cases being referred to a spinal surgeon, it is not rare for such a case to be referred to a general orthopaedic surgeon because it can masquerade as pain referred from the shoulder or hip. It is important for the orthopaedic surgeon to identify this as it can be a reason why surgery to such areas of the upper and lower limb may not be successful.
How can one differentiate between pain referred from the neck or lumbar spine and that arising from the arm or leg?
A trained orthopaedic surgeon will take particular care to keep an open mind when assessing the history so as to not miss pain referred from other areas. The examination will also help confirm whether the pain is arising locally or being referred from the spine or neck. Often investigations, in particular the use of local anaesthetic in the affected area, can help pinpoint the causation of pain. Finally, investigations such as MRI scan may be warranted to exclude nerves being trapped in the neck or lumbar spine.
What is the treatment for referred pain from the neck or lumbar spine?
Treatment always involves simple measures first such as giving it time to settle, resting the affected area, physiotherapy and pain relief. If the area from which the pain is thought to arise can be identified, then steroid injections may also help. If these measures fail then you may warrant referral to a spinal surgeon who will then discuss options for surgery.
Remember that whilst pain can seem to arise from one particular area such as the shoulder, there are mimickers such as pain referred from the spine that can confuse the uninitiated and result in a poor outcome of surgery, should these not be identified or addressed.
At Glenelg Orthopaedics we take care to identify the cause of the pain, utilising a holistic approach and keeping an open mind to exclude all other possible causes.