Cervicothoracic Interspinous Bursitis
Cervicothoracic interspinous bursitis is an uncommon cause of pain in the lower cervical and upper thoracic spine. The interspinous ligaments of the lower cervical and upper thoracic spine and their associated muscles are susceptible to the development of acute and chronic pain symptoms after overuse. Bursitis is believed to be responsible for this pain syndrome.
Frequently, the patient presents with midline pain after prolonged activity requiring hyperextension of the neck, such as painting a ceiling or prolonged use of a computer monitor with too high of a focal point. The pain is localized to the interspinous region between C7 and T1 and does not radiate.
It is constant, dull, and aching. The patient may attempt to relieve the constant ache by assuming a posture of dorsal kyphosis with a thrusting forward of the neck. The pain of cervicothoracic interspinous bursitis often improves with activity and worsens with rest and relaxation.
What are the Symptoms of Cervicothoracic Interspinous Bursitis
A patient with cervicothoracic bursitis presents with the complaint of dull, poorly localized pain in the lower cervical and upper thoracic region. The pain spreads from the midline to the adjacent paraspinous area, but is nonradicular.
The patient often holds the cervical spine rigid, with the head thrust forward to splint the affected ligament and bursae. Flexion and extension of the lower cervical spine and upper thoracic spine tend to cause more pain than rotation of the head.
The neurological examination of patients with cervicothoracic bursitis should be normal.
Focal or radicular neurological findings suggest a central or spinal cord origin of pain symptoms and should be followed with magnetic resonance imaging (MRI) of the appropriate anatomical regions.
How is Cervicothoracic Interspinous Bursitis diagnosed?
MRI of the lower cervical and upper thoracic spine should be performed in all patients thought to have cervicothoracic bursitis.
Electromyography of the brachial plexus and upper extremities is indicated if neurological findings or pain that radiates into the arms are present.
Clinical laboratory tests, including a complete blood cell count, automated chemistry profile, antinuclear antibody testing, and erythrocyte sedimentation rate, are indicated to rule out infection; collagen-vascular disease, including ankylosing spondylitis; and malignancy that may mimic the clinical presentation of cervicothoracic bursitis.
Injection of the affected interspinous bursae with local anesthetic and steroid may serve as a diagnostic and therapeutic maneuver and may help strengthen the diagnosis of cervicothoracic bursitis.
Plain radiography of the sacroiliac joints is indicated if ankylosing spondylitis is being considered in the differential diagnosis.
The diagnosis of cervicothoracic bursitis is usually made on clinical grounds as a diagnosis of exclusion. The clinician needs to rule out intrinsic disease of the spinal cord, including syringomyelia and tumor, which may mimic the clinical presentation of cervicothoracic bursitis.
Ankylosing spondylitis also may manifest in a manner similar to that of cervicothoracic bursitis. Fibromyalgia may coexist with cervicothoracic bursitis and should be identifiable by its characteristic trigger points and positive jump sign.
Initial treatment of the pain and functional disability associated with cervicothoracic bursitis should include a combination of nonsteroidal antiinflammatory drugs (NSAIDs) or cyclooxygenase-2 (COX-2) inhibitors and physical therapy.
The local application of heat and cold also may be beneficial. For patients who do not respond to these treatment modalities, the following injection technique with a local anesthetic and steroid may be a reasonable next step.
The skin overlying the C7 to T1 interspace is prepared with antiseptic solution. A syringe containing 20 mL of 0.25% preservative-free bupivacaine and 40 mg of methylprednisolone is attached to a 25-gauge, 112−112− inch needle.
The needle is carefully advanced through the supraspinal ligament into the interspinous ligament. Care must be taken to keep the needle in the midline and not to advance it too deeply, or inadvertent epidural, subdural, or subarachnoid injection could occur.
After careful aspiration, a volume of 2 to 3 mL is gently injected into the ligament.
The patient should be informed that two to five treatment sessions may be required to abolish the symptoms of cervicothoracic bursitis completely. Ultrasound needle guidance may help improve the accuracy of needle placement and decrease the incidence of needle-related complications.
The proximity to the spinal cord and exiting nerve roots makes it imperative that this procedure be performed only by clinicians well versed in the regional anatomy and experienced in performing injection techniques.
The proximity to the vertebral artery combined with the vascular nature of this anatomical region makes the potential for intravascular injection high. Even small amounts of a local anesthetic injected into the vertebral arteries result in seizures.
Given the proximity of the brain and brainstem, ataxia after trigger point injection as a result of vascular uptake of local anesthetic is common. Many patients also complain of a transient increase in pain after injection in this anatomical area. If long needles are used, pneumothorax also may occur.
Because of the proximity of the epidural, subdural, and subarachnoid space, placement of a needle too deeply could result in inadvertent neuraxial block.
Failure to recognize inadvertent epidural, subdural, or dural puncture can result in significant motor and sensory block with the potential for associated loss of consciousness, hypotension, and apnea.
If subdural placement is unrecognized, and the previously mentioned doses of local anesthetics are administered, the signs and symptoms are similar to those of subarachnoid injection, although the resulting motor and sensory block may be spotty.
The aforementioned injection technique is extremely effective in the treatment of cervicothoracic bursitis. This technique is a safe procedure if careful attention is paid to the clinically relevant anatomy in the areas to be injected.
Care must be taken to use sterile technique to avoid infection and universal precautions to avoid risk to the operator. Most side effects of the injection technique for cervicothoracic bursitis are related to needle-induced trauma to the injection site and underlying tissues.
The incidence of ecchymosis and hematoma formation can be decreased if pressure is placed on the injection site immediately after injection.
The avoidance of overly long needles helps decrease the incidence of trauma to underlying structures. Special care must be taken to avoid pneumothorax given the proximity to the underlying pleural space.
The use of physical modalities, including local heat and gentle stretching exercises, should be introduced several days after the patient undergoes this injection technique for cervicothoracic bursitis.
Vigorous exercises should be avoided because they would exacerbate the symptoms. Cognitive functional therapy may provide symptom relief in some patients. Simple analgesics, NSAIDs, and antimyotonic agents such as tizanidine may be used concurrently with this injection technique.