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Masquerade: Nonspinal musculoskeletal disorders that mimic spinal conditions

Cleveland Clinic Journal of Medicine. 2008 January;75(1):50-56
January 1, 2008|Cleveland Clinic Journal of Medicine
Dhruv B. Pateder, MD;John Brems, MD;Isador Lieberman, MD, FRCS(C);Gordon R. Bell, MD;Robert F. McLain, MD
Author and Disclosure Information

Dhruv B. Pateder, MD
Attending Spine Surgeon, Steadman Hawkins Clinic Spine Surgery, Frisco/Vail, CO

John Brems, MD
Cleveland Clinic Spine Institute, Cleveland Clinic

Isador Lieberman, MD, FRCS(C)
Cleveland Clinic Spine Institute, and Departmen tof Orthopaedic Surgery, Cleveland Clinic; Professor of Surgery, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University

Gordon R. Bell, MD
Associate Director, Center for Spine Health, The Neurological Institute, Cleveland Clinic

Robert F. McLain, MD
Cleveland Clinic Spine Institute, Cleveland Clinic

Address: Dhruv B. Pateder, MD, Steadman Hawkins Clinic Frisco/Vail Spine Surgery, 360 Peak One Drive, Suite 340, PO Box 4815, Frisco, CO 80443 ;e-mail drpateder@steadman-hawkins.com

Dr. Lieberman is a founder and is on the board of Merlot OrthopediX and has received royalties, consulting fees, or honoraria from the Axiomed Spine, CrossTrees Medical, DePuy Spine, Kyphon, Mazor Surgical Technologies, Stryker Spine, and Trans1 corporations.

ABSTRACTNonspinal musculoskeletal disorders frequently cause neck and back pain and thus can mimic conditions of the spine. Common mimics are rotator cuff tears, bursitis in the hip, peripheral nerve compression, and arthritis in the shoulder and hip. A thorough history and physical examination, imaging studies, and ancillary testing can usually help determine the source of pain.

KEY POINTS

  • Neck pain is commonly caused by shoulder problems such as rotator cuff disease, glenohumeral arthritis, and humeral head osteonecrosis.
  • Brachial neuritis involves acute, severe neck or shoulder pain, followed by weakness as pain resolves.
  • Low back pain can be caused by hip or spine arthritis, femoral head osteonecrosis, an occult or impending femoral neck fracture, hip dysplasia, piriformis syndrome, and bursitis.
  • Bony and soft tissue masses can be detected with imaging studies.
  • Peripheral nerve compression can mimic cervical or lumbar spine radiculopathy. Electromyography and eliciting symptoms by tapping over the compressed nerve aid in making a diagnosis.
  • Patients with human immunodeficiency virus infection, alcoholism, or corticosteroid use are at increased risk of developing osteonecrosis of the humeral or femoral head.

Peripheral nerve compression may mimic cervical radiculopathy

Peripheral nerve compression is common and may present with paresthesias mimicking a cervical radiculopathy.9

Carpal tunnel syndrome usually presents with hand numbness and tingling or decreased sensation in the median nerve distribution (the radial three digits). Thenar atrophy is present in advanced cases.1,9 Carpal tunnel syndrome may also present with nonspecific hand pain or other symptoms. Chowet al9 found that 84% of patients with carpal tunnel syndrome had nocturnal hand paresthesias, 82% had paresthesias that were aggravated by hand activity, and 64% had hand pain. However, some patients with cervical spondylosis also had these symptoms: 10% had hand pain, 7% had nocturnal hand paresthesias, and 10% had paresthesias that were aggravated by hand activity.

Cubital tunnel syndrome can also present with radiating arm symptoms and is usually associated with pain at the elbow and a positive Tinel sign (ie, tapping over the cubital tunnel—at the elbow between the olecranon process and the medial epicondyle—elicits pain and tingling in the small and ring fingers).1 Electromyography and a nerve conduction study can help determine the diagnosis.

Suprascapular nerve impingement is another peripheral nerve problem that can mimic a cervical spine problem.1,10 The supraspinatus and infraspinatus muscles and can become entrapped by a ganglion cyst at the suprascapular notch of the scapula. The condition is more commonly seen in young, active patients who participate in overhead activities (eg, volleyball or tennis).

Chronic suprascapular nerve impingement can cause weakness and atrophy of the supraspinatus or infraspinatus muscles or both and can be detected on physical examination and confirmed by electromyography.1,10 Electromyography is best for diagnosing peripheral nerve compression: a decreased amplitude and increased latency indicates severe nerve compression. MRI can reveal a ganglion cyst if it is the source of nerve compression at the notch.

Brachial neuritis: Acute, severe neck or shoulder pain, followed by weakness

Brachial neuritis (Parsonage-Turner syndrome) presents with abrupt onset of intense pain in the neck or shoulder, mimicking a cervical spine radiculopathy. The pain typically improves over several days to weeks,11 but may be followed by weakness of the arm muscles. The cause of this condition is unclear.

Brachial neuritis characteristically involves multiple nerve roots and the rapid onset of severe pain.11 Cervical radiculopathy, on the other hand, usually starts insidiously and has a single dermatomal distribution. Another distinguishing feature is that neck movement typically exacerbates the symptoms of cervical radiculopathy but not of brachial neuritis.12 Brachial neuritis should be suspected in patients who have these features and who do not respond to conventional therapy.11

A mass can be detected with imaging studies

A mass in or around the shoulder can present as neck or arm pain by compressing or stretching nervous structures or connective tissues in the shoulder.13

Bony masses. Although most bony lesions in the shoulder are benign (osteochondromaor bone cysts), malignant osseous lesions such as metastatic disease and primary bone sarcomas also occur. Metastatic disease should be suspected in older patients with a history of malignancy, even if the presentation is atypical.13 Most bony lesions can be diagnosed by radiography or CT.

Soft tissue masses (eg, lipomas, elastofibromas, and sarcomas) can also cause a confusing pain pattern when they arise in the shoulder. They can be diagnosed with MRI.13

NONSPINAL MUSCULOSKELETAL CAUSES OF BACK PAIN

More than 80% of people experience significan tlow back pain at some time in their life.14 While most patients have no obvious pathology, physicians should be meticulous in evaluating for serious conditions (Table 2). Sometimes nonspinal musculoskeletal problems cause signs and symptoms of lumbar radiculopathy such as mechanical low back pain, referred pain, radicular pain, paresthesias, weakness, neurogenic claudication, or changes in bowel or bladder function.10,12

Hip and spine arthritis are commonly found together

Figure 2. Hip arthritis with decreased joint space, subchondral sclerosis, and osteophytes.
Hip arthritis can be confused with back pain from a spinal cause if it causes pain in the back or buttocks rather than in the groin.15 The presentation can be further complicated because radiographic evidence of hip and spine arthritis is not necessarily proof that these are the source of the pain: both conditions frequently occur as people age (Figure 2).2–4,6,7

Several studies found that if a patient has problems in both the spine and the hip, treating only one of the conditions may not relieve the pain.11,16,17 Birrell et al15 evaluated patients with concomitant hip and spinal disease and found that most patients who underwent total hip arthroplasty followed by spinal decompression had excellent results.

Other studies suggested that it is better to treat spinal stenosis first, because neurologic sequelae could result if it is left untreated.16 On the other hand, several other studies found that patients with symptoms and spinal stenosis seen by radiography can function for years without neurologic compromise.14,15,18 Conflicting data such as these make it difficult to determine whether hip disease or spinal disease should be treated first in patients with both conditions. Generally, the more symptomatic condition is treated first, unless a neurologic problem is progressing.

Recent studies examined clinical features that help distinguish symptomatic hip disease from spine disease in patients with concomitant radiographic hip and spine arthritis.15,18 Limping, groin pain, and limited and painful internal rotation of the hip strongly implicate the hip as the source of pain. Brown et al18 found that patients with a limp were seven times more likely to have pain from the hip alone or from the spine and hip combined than from the spine alone. Patients with groin pain or painful and limited internal rotation of the hip were 14 times more likely to have either the hip or the hip and spine as the source of pain. A positive straight-leg-raising sign or a contralateral straight-leg-raising sign strongly suggests the spine as the source of pain.12 (Straight-leg tests are performed with the patient lying on a table and the examiner lifting the leg while the knee is straight. The test is positive if pain is elicited between 30 and 70 degrees.)

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