258 13 Painful Syndromes

	Neuralgic shoulder amyotrophy (p. 222) also causes	alternative path for venous return and are thus more
	acute, severe pain.	clearly visible than normal. The thrombosed vein itself
		can sometimes be palpated in the axilla and is tender. It
	Peripheral Nerve Conditions	can often be unequivocally demonstrated with neuro-
		imaging studies and Doppler ultrasonography. The
	Compressive neuropathies can cause severe, in-
		prognosis is usually good; operative thrombectomy is
	tractable pain in the upper limb. These conditions are	only rarely necessary.
	described in Chapter 12. The more common types are
	sulcus ulnaris syndrome (p. 232) and carpal tunnel syn-	“Arm Pain of Overuse”
	drome (p. 228), which causes arm pain especially at
	night (brachialgia paraesthetica nocturna).	The nonphysiological, prolonged, and repeated per-
		formance of specific movements of the upper limb(s),
	Vasogenic Arm Pain	particularly at the workplace (e. g., typing, working at a
		cash register, or long and monotonous use of other kinds
	Arterial Diseases	of machines), can produce intractable pain in the upper
		limb extending well beyond the muscles that were used
	Occlusion or stenosis of the subclavian a. causes dif-
		in the repeated movement. Pain of this type leads, in
	fuse arm pain on movement, forcing the patient to stop	turn, to excessive reliance on other muscle groups, so
	using the limb (“intermittent claudication of the arm”). If	that these, too, become involved in the pain syndrome.
	the artery is occluded proximal to the origin of the	This condition and its pathogenesis are described
	vertebral a., the arm will be supplied with blood	further under “Pseudoradicular Pain” (below).
	through retrograde flow in the vertebral a. Blood can be
	“stolen” in this way from the cerebral circulation (sub-	Other Types of Arm Pain
	clavian steal syndrome): movement of the arm diverts
	blood flow away from the vertebrobasilar territory in	Glomus tumors are small, benign growths that origi-
	the brain and lightheadedness or sudden falls (drop at-
	tacks) may result. Arterial insufficiency in the upper	nate in the glomus organs of the skin. They are com-
	limb is demonstrated with the fist-clenching test: the	posed of arteriovenous anastomoses in close association
	patient holds the upper limbs high, then rapidly and re-	with autonomic fibers. Clinically, they are characterized
	peatedly clenches and reopens both hands. Pain arises	by a dull pain that worsens when the arm hangs down
	within a few minutes on the poorly perfused side and	and, particularly, when the arm swings as the patient
	the hand turns pale. When the arms are lowered again,	walks. Local pressure over the tumor also causes pain.
	the veins on the dorsum of the hand fill slowly on the af-	Glomus tumors are often found at the fingertips, where
	fected side. The arterial blood pressure is also always	they may be visible as a bluish spot under the fingernail,
	lower when measured in the affected arm.	but they can also arise practically anywhere else, includ-
		ing on the lower limbs.

Venous Thrombosis

Occlusion of the axillary or subclavian v . This condition, also known as effort syndrome or Paget−von Schrötter syndrome, is seen most commonly in young men, usually on the right side. It is rarely spontaneous; more commonly, it arises after heavy use of the arm, e. g., in sports. The venous occlusion manifests itself as a painful tension in the arm, often accompanied by swelling. The subcutaneous veins in the region of the arm provide an

“Referred pain.” Diseases of the internal organs commonly cause referred pain in the shoulder and arm. Pain is felt in the right shoulder in gall bladder disease, for example, and in the left arm in angina pectoris.

Gout. An exacerbation of gout can produce extremely severe, acute pain in a hand (chiragra) or foot (podagra). Chiragra is sometimes, but not always, restricted to the metacarpophalangeal joint of the thumb.

Pain in the Trunk and Back

The back is by far the most common site of pain in the trunk. It is usually due to pathological abnormalities of the spine, which lead, in turn, to abnormal posture and nonphysiological activation of the muscles of the back.

Table 13.11 provides an overview of these painful syndromes, their localization, and the types of pain they produce. A few of them will be described in detail in the following paragraphs.

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Pain in the Trunk and Back 259

Table 13.11 Overview of pain in the trunk and back

Designation	Mechanism	Localization and clinical features	Remarks
Pain in a band-like	unior bilateral nerve root le-	feeling of segmental tightening on	e. g., spinal tumor, disk hernia-
distribution	sion	one or both sides; continuous pain	tion, herpes zoster
Abnormally mobile	pain on displacement of the	unilateral pain at the costal margin,	after thoracic trauma, or spon-
10th rib (“slipping rib”)	free end of the 10th rib	on bending over or with local pres-	taneous
		sure; the pain may be continuous
Tear and hemorrhage	lesion (rupture) of the rectus	local pain in the abdominal wall	rarely, compartment syndrome
in the abdominal wall	abdominis m., e. g., after stre-		of the rectus abdominis m.
musculature	nuous exercise
Spiegel hernia	herniation next to the rectus	pain at a paramedian location on the	the pain disappears after the
	sheath, covered by the abdo-	abdominal wall, local tenderness	application of local anesthetic
	minal oblique m. and difficult
	to identify
Rectus abdominis	entrapment neuropathy; a me-	abdominal wall pain on movement;	differential diagnosis: inguinal
syndrome	dial cutaneous branch of one	sometimes there is a coin-sized zone	hernia, testicular torsion
	of the intercostal nerves is	of cutaneous anesthesia
	caught in a gap in the fascia
Ilioinguinal nerve	compression of the ilioinguinal	groin, external genitalia; dull, continu-
syndrome	n., or constriction by scar	ous pain, worse on hip extension,
		better on flexion; objective sensory
		deficit in the distribution of the nerve
“Referred pain”	pain from internal organs pro-	pain localization depends on the af-
(zones of Head)	jected to the surface of the	fected organ; e. g., chest pain in
	trunk	diseases of the heart and lungs, ab-
		dominal pain in GI diseases, lumbar
		pain in diseases of the retroperitoneal
		organs; typically a dull, piercing, or
		acute tearing pain

Thoracoabdominal	usually diabetic mononeuro-
neuropathy	pathy
Ankylosing spondylitis	in 90 % of cases, associated
(Bekhterev disease)	with the HLA-B27 histocompa-
	tibility antigen
Spondylolisthesis and	prolongation of the pars inter-
spondylolysis	articularis and ventral displace-
	ment of the cranial vertebra,
	ranging to spondyloptosis

Sacroiliac strain	tension on the ligamentous ap-
	paratus of the sacroiliac joint
Notalgia paresthetica	entrapment of the terminal
	sensory branch of the dorsal
	ramus of a spinal nerve in a
	fascial gap in the back

continuous pain and paresthesiae of the thoracic or abdominal wall; diminished sensation, or unilateral weakness of abdominal wall muscles

the pain usually begins in the low lumbosacral region, usually at night; progressive thoracic kyphosis and diminishing mobility of the spine; rarely, pain in the chest and heels; typical radiologic findings

lower lumbar pain, worse on exertion and after prolonged standing; palpable “step” in the back; typical radiologic findings

low back pain, sometimes pseudoradicular radiation into the lower limbs; worse when the patient stands on one leg, or with the Mennell maneuver

local, unilateral pain in the back; objective local tenderness and a coinsized area of paravertebral cutaneous anesthesia

usually affects younger men

congenital anomaly; spondylolisthesis can be induced by mechanical stress or can occur spontaneously (in the latter case, usually as a symptom of an underlying condition); differential diagnosis: pseudospondylolisthesis in degenerative osteochondrosis

relieved by wearing a trochanteric belt

the pain disappears after the application of local anesthetic

Painful Syndromes

13

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