THE CLINICAL SYNDROME

• Because of their proximity to the spinal nerves, the interspinous ligaments of the lower cervical and higher thoracic spines, as well as the muscles that are connected with these regions, are at risk of developing acute and chronic pain sensations as a result of overuse.

• It is suspected that bursitis is the cause of this pain.

• Frequently, the patient will present with midline pain after engaging in an activity for an extended period of time that requires hyperextension of the neck, such as painting a ceiling, or after engaging in an activity for an extended period of time that involves using a computer monitor with a focal point that is too high.

SIGNS AND SYMPTOMS

• The discomfort is confined to the interspinous region between C7 and T1, and it does not radiate to other parts of the body.

• It never stops, never lets up, and always aches.

  • The patient might try adopting a position of dorsal kyphosis, which involves bending backward at the waist and extending the neck forward in order to get some relief from the persistent soreness.

• The pain associated with cervicothoracic interspinous bursitis, in contrast to the pain associated with cervical strain, typically improves with activity and gets worse when the patient is allowed to rest.

• During the patient's physical examination, discomfort is evoked by deep probing of the C7-T1 region.

• This sensitivity is sometimes accompanied by reflex spasm of the corresponding paraspinous musculature.

• Reduced range of motion is almost always present, and the intensity of the pain increases with extension of the upper thoracic and lower cervical spine.

TESTING

• There is no one test that can definitively diagnose cervicothoracic bursitis; however, magnetic resonance imaging (MRI) may be able to detect inflammation of the interspinous bursae.

• The primary goal of the testing is to uncover a hidden pathologic process or another disease that may have symptoms similar to those of cervicothoracic bursitis.

• A bone abnormality of the cervical spine, such as arthritis, a fracture, a congenital anomaly (such as an Arnold-Chiari malformation), or a tumor, can be delineated using plain radiographs.

• Every patient who has recently been diagnosed with cervicothoracic bursitis should have an MRI performed on their cervical spine and, if substantial occipital or headache symptoms are present, an MRI should also be performed on their brain.

• Imaging with ultrasound may also be helpful in further differentiating solid interspinous masses from cystic interspinous masses.

• It is important to rule out the possibility of occult inflammatory arthritis, infections, and tumors by doing screening laboratory tests.

  • These tests should include a complete blood count, erythrocyte sedimentation rate, antinuclear antibody testing, and automated blood chemistry.

DIFFERENTIAL DIAGNOSIS

• The clinical diagnosis of cervicothoracic bursitis is based on the elimination of all other possible diagnoses and is supported by a combination of clinical history, physical examination, radiography, and MRI.

• Pain syndromes including cervical strain, cervical anesthetic, and steroid may also be evaluated when diagnosing cervicothoracic bursitis because they have similar symptoms.

  • If the symptoms continue, antimyotonic drugs like tizanidine may be prescribed to the patient.

• Beginning treatment with a tricyclic antidepressant like nortriptyline, which can be taken as a single 25-mg dose before going to bed, is the most effective way to treat underlying sleep disturbances as well as depression.

TREATMENT

• A multidisciplinary approach is ideal for the treatment of cervical and thoracic bursitis.

• It is reasonable to begin with physical therapy that consists of the correction of functional irregularities (such as poor posture, improper chair or computer height), heat modalities, and deep sedative massage, along with nonsteroidal antiinflammatory medications (NSAIDs) and skeletal muscle relaxants.

• In the event that these therapies are unable to offer prompt relief, a local anesthetic and steroid injection into the region that lies between the interspinous ligament and the ligamentum flavum is a sensible next step to take.

• In addition to a cervical epidural block, a blockage of the medial branch of the dorsal ramus or an intraarticular injection of the facet joint with a local anesthetic and steroid could be attempted with the purpose of providing symptomatic relief.

• If the symptoms continue, antimyotonic drugs like tizanidine may be prescribed to the patient.

• Beginning treatment with a tricyclic antidepressant like nortriptyline, which can be taken as a single 25-mg dose before going to bed, is the most effective way to treat underlying sleep disturbances as well as depression.

COMPLICATIONS AND PITFALLS

• Due to the close proximity to the spinal cord and exiting nerve roots, it is absolutely necessary that injections be administered only by those who are well-versed in the anatomy of the region and have previous expertise with interventional methods of pain management.

  • Because of its close proximity to the vertebral artery and the highly vascular nature of this region, there is a considerable risk of intravascular injection occurring here.

• Seizures can be brought on by the injection of even a very little dose of local anesthetic into the vertebral artery.

• After receiving an injection in this location, it is not unusual for the patient to have ataxia due to the vascular uptake of the local anesthetic.

  • This is because the brain and brainstem are located in close proximity to one another.

• After receiving an injection of the cervical facet joints, a significant number of patients report that they experience a temporary worsening of their headache and cervicalgia symptoms.