Medical mystery: Chronic shoulder pain masked a more serious problem

William, 77, had been dealing with chronic right shoulder pain for years due to significant osteoarthritis. He had been treating the symptoms conservatively with activity modification, over-the-counter pain medication, and cortisone injections.

Within a short period of time, he started to have increased shoulder pain and the cortisone injections stopped providing significant or long-lasting relief. He also started to develop decreased range of motion and weakness in his right arm. He was even having difficulty brushing his teeth and combing his hair. He considered undergoing a total shoulder replacement, as he had exhausted much of his non-operative options.

First, he started to work with a physical therapist to see whether this would improve his strength in the interim. He also began to experience numbness and tingling radiating down the right arm into his hands, affecting his finger dexterity. At this time, he increasingly noticed problems with his balance, too. His physical therapist thought it was time for him to seek another opinion, as he did not believe the symptoms were coming from the arthritic shoulder.

An X-ray of William’s neck showed arthritis, as well as kyphotic deformity, where the spine begins to lose its normal curvature and bend forward, instead. An MRI of his neck revealed moderate to severe nerve and spinal cord compression, and myelomalacia, or scarring/bruising of the spinal cord.

On examination, William had decreased range of motion of his neck, as well as weakness in the right arm. He also demonstrated an involuntary reflex of the thumb and index finger that can indicate significant compression of the spinal cord.

This compression on his cervical spinal cord, known as cervical myelopathy, was the real cause of his shoulder pain and subsequent symptoms.

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Your cervical spine contains seven vertebrae (C1 to C7) with six intervertebral discs and eight nerve roots. The spinal cord travels inside the vertebral column, which is comprised of bony vertebrae in the front, cushioned in between by the intervertebral disc. The eight cervical nerve roots branch out and control the movement of the shoulders, arms and hands.

Two types of symptoms can stem from cervical degenerative myelopathy: the ones you may feel from the neck, and the ones appearing elsewhere in the body or below the compression level of the spinal cord. Symptoms in the neck include pain, stiffness and reduced range of motion. Other symptoms include weakness in the arms and hands, numbness/tingling and/or pain in the arms and hands, clumsiness and poor coordination of the hands, difficulty with fine motor skills, and issues with balance. William presented a culmination of these symptoms.

One common type of cervical myelopathy is cervical spondylotic myelopathy. This term “spondylotic” refers to the gradual degeneration of the spine that happens as one ages. This type is more common in people 50 and older.

The earlier that cervical myelopathy is diagnosed, the more successful the treatment is expected to be. However, symptoms are not unique to the condition, and can often be mistaken for “normal” signs of aging. A physical examination measuring muscle strength, sensation and reflexes, as well imaging studies such as an X-ray and MRI, are typically needed for diagnosis.

Nonsurgical options for treatment include physical therapy, medication management and monitoring for progression of symptoms. However, surgery is typically recommended to eliminate the compression on the spinal cord and to prevent worsening of the condition.

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Within a month of our evaluation, William underwent an anterior (front of the neck) cervical decompression and fusion to take the pressure off of his spinal cord and nerves to his arm. He noted immediate and significant relief of his neck and arm pain and is slowly seeing improvement in his strength, fine motor skills and balance.

Alexander R. Vaccaro is a spine surgeon and the president of Rothman Orthopaedic Institute.