Diagram to show where nerves in the cervical spine, or neck refer into the arm.
The nerves in your neck, or cervical region, will refer pain down the front or back of your arm if they are irritated or compressed. Usually the pain in your arm is worse than the pain (if you have any) in your neck. The nerve can also give other symptoms such as pins and needles or numbness. As the nerves also supply the muscle you can feel weakness in your arm if the nerve is compressed. There are a number of reasons why you can develop arm pain from your neck.
The most common reason for irritation or compression of the nerve is a disc bulge. When a disc bulges, the slightly softer centre of the disc (nucleus) can bulge through the fibrous outer layers (annulus). Sometimes the softer disc material can leak out. When a disc bulges, your body tries to repair the bulge. It sends in lots of cells that reabsorb and repair the bulging disc. Your body is very good at repairing the bulging (sometimes called slipped) disc. If the nerve root is compressed on its way out of the canal, in the exit hole (foramen) this causes arm pain, pins and needles and numbness. In the vast majority of people who develop arm pain from the compressed nerve in the neck, it improves within 3 months.
Illustration provided by Joanna Culley
Physiotherapy often helps resolve early symptoms. While the body reabsorbs the disc there is an active inflammatory response around the nerve and disc. The ‘inflammatory chemical soup’ that is surrounding the nerve irritates it and can also cause pain down the arm. The nerve may also be irritated if there is compression caused by the bulging disc. Your spinal specialist may consider referring you for Cervical Foraminal Injection or Anterior Discectomy and Fusion if time and physiotherapy do not help.
Our joints, ligaments and discs wear as part of the normal age related process. Most of the time this does not cause significant symptoms. If, however the spinal facet joints become enlarged and worn, alongside buckling of the ligament at the back of the canal, this can reduce space where the nerves sit. When the nerve peels away from the spinal cord and becomes a nerve root, it exits the spinal canal in a hole called the foramen. If this nerve root is compressed in the exit hole, then it will cause arm pain along the distribution of the nerve down the arm.
The spinal canal itself can also become narrowed due to these wear changes, narrowing the space where the spinal cord is sitting. This narrowing can become more significant if combined with a bulging disc, which narrows the front of the spinal canal. A combination of wear at the disc, ligament and joint can significantly compress the spinal cord as in runs through the canal. This narrowing is called spinal canal stenosis. If there is enough narrowing to cause pressure on your spinal cord, then the cord can become swollen. This is called cervical myelopathy.
Cervical myelopathy, when the spinal cord in the neck is compressed and swollen, causes a specific set of symptoms. You may experience tingling or numbness in the arms below the elbows into the hands. You may also experience tingling or numbness in the lower part of your legs, below the knees into your feet. Typically, but not always these symptoms affect both sides. You may also experience other symptoms such as unsteadiness with walking, or reduced co-ordination of your hands. In rare cases your bladder and bowel control can be effected or you could lose the use of your legs. If you develop any of these symptoms you need to seek an urgent medical opinion via your GP, who can refer you on to a specialist spinal service, such as New Hall. Surgery for Cervical Myelopathy, compression and swelling of the cord, does not always reverse symptoms that have already developed. It can prevent damage to the spinal cord from getting worse and causing more severe symptoms, therefore it is important to get a medical opinion when symptoms first develop.
Investigations in the early stages of arm pain referred from the neck pain are not usually helpful as most people will get better naturally and not require any invasive treatment. If symptoms persist however, despite medication and manual therapy, then a Magnetic Resonance Imaging (MRI) scan can help to confirm diagnosis and pinpoint an area for further treatment options. MRI is also used to assess for Cervical Myelopathy. X-Rays are not useful to diagnose neck pain or arm pain. They are sometimes helpful to show structural abnormality and are therefore occasionally requested for this reason.
It is unusual for there to be a more serious underlying reason for neck or arm pain, such as a tumour, infection or fracture. GP’s Physiotherapists and Consultants are good at identifying these rarer presentations and will organise investigations if they feel they are needed.
At New Hall Hospital we have a static MRI Scanner with rapid access. It is always best practice to see a spinal specialist prior to considering whether an MRI would be useful. NHS patients are usually seen by a community triage service who can refer for a scan if they think it would aid diagnosis and decisions about treatment options, before referring to a spinal specialist centre like New Hall. At New Hall we see a large number of NHS Patients.
If you have Private Insurance or wish to Self Pay, then New Hall offers rapid access Spinal Consultant appointments with fast access to MRI scan then review of these images to consider treatment options. A number of Consultants offer a One Stop service for assessment, MRI, review and treatment on the same day if appropriate.
Early pain relief is essential as arm pain referred from the neck can be very painful. It is common for function to be limited and for sleep to be restricted. Most pain medications reduce symptoms, but do not eliminate them entirely. If you have some pain relief the evidence suggests you move better, sleep better and therefore recover more quickly. Talk to your GP about a suitable prescription based on your other medical history. The National Institute for Clinical excellence (NICE) recommend anti-inflammatories initially. There are other pain relieving drugs that your GP can prescribe if anti-inflammatories are not suitable or do not give sufficient symptom control for you.
A group of medication called anti-neuropathic drugs can also help some people with nerve pain. Talk to your GP to see if you are a suitable candidate for these tablets.
Manual therapy has been shown to help people recover from arm and neck pain. It’s advisable to avoid high velocity manipulation techniques, but gentle manual techniques, ergonomic advice and exercises can be helpful. At New Hall Hospital we have a Physiotherapy department and offer rapid access clinics. By knowing the right way to exercise and manage flare ups of pain you are more likely to be able to manage any episodes if they occur. If you are physically fit then you are less likely to suffer with recurrent episodes.
Spinal injections are a specialist procedure that need to be done as a day case in hospital under x-ray guidance. Your spinal specialist will assess you, take a detailed medical history and undertake a physical examination. They will request any investigations that are necessary. For arm pain referred from the neck (cervical spine) there are injection options to consider. Your specialist will advise you of the pros and cons and will discuss with you which procedure is likely to present the best outcome for you, depending on your MRI scan and symptoms. Your injection will be done under X-Ray guidance as a day case procedure by either a Spinal Orthopaedic Consultant or Consultant Anaesthetist.
The following Leaflet outlines the procedure along with the risks and benefits.
A number of our Spinal Consultants offer Self Pay or Private Insurance clinics whereby you can have a fast track assessment and MRI. You can then be placed on a fast access injection list if required. We also see a large number of NHS patients.
Spinal surgery is a specialist procedure and should not be undertaken lightly. Cervical (neck) spinal surgery has a very good chance of helping arm pain symptoms if a corresponding cause can be found on an MRI that links with your symptoms. It is less likely to resolve neck pain if you have it, but can sometimes help. Your spinal specialist will assess you and take a detailed medical history alongside a physical examination. They will discuss various treatment options and together with you, will agree on a plan.