Clinical implication of "shifting pain"
Clinical interpretation of a “shifting pain”
Recently I saw a patient, 45y old, suffering from a cervical internal derangement i.e. a posterior cervical disc protrusion with pressure against the dura mater. She described the typical mutlisegmental pain in the cervical, scapular area, on the right side. In the cervical examination a partial articular pattern was obvious (some pain and limitation of ROM), mainly towards right rotation.
One day, the multisegmental pain in the cervical-scapular pain shifted into monosegmental symptoms in the C6 dermatome, mainly in fingers 1 and 2.The scapular and cervical pain disappeared, as well as the limitation of ROM on cervical movements.
The clinical interpretation of a “shifting pain” is a “shifting lesion” : indeed, the disc protrusion moved laterally, no more pressure on dura mater, but now there is pressure on the C6 nerve root.
This has been confirmed by NMRI. This has also therapeutic implications : the more central a protrusion lies, the easier to reduce by conservative treatment ; the more lateral, the more difficult.
The good news however is, that in case of lateral protrusions there is a mechanism of spontaneous cure (a mechanism of resorption of the protrusion) which takes about 3-4 months counting from the moment the patient only has symptoms in the C6-dermatome and no more symptoms in the scapular and cervical area. In the second half of the spontaneous evolution, manipulation doesn’t have any beneficial effect anymore.
She needs some prophylactic advice in order to avoid further problems.
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