Cervicothoracic Interspinous Bursitis

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.
• The pain with cervicothoracic interspinous busritis 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.
• In contrast to the pain of cervical strain, the pain of cervicothoracic interspinous bursitis often lessens with activity and worsens with rest.

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.

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.

Treatment

• 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.

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.

Summary

Cervicothoracic interspinous bursitis is a condition characterized by inflammation and irritation of the bursae located between the spinous processes of the cervical and thoracic vertebrae. Bursae are small fluid-filled sacs that act as cushions between bones, tendons, and muscles to reduce friction and facilitate smooth movement.

The specific cause of cervicothoracic interspinous bursitis may vary, but it is commonly associated with repetitive stress, overuse, or trauma to the neck and upper back region. Some potential causes and risk factors for this condition include:

1. Repetitive Movements: Activities or occupations that involve repetitive neck and upper back movements, such as excessive computer work or poor posture, can contribute to bursitis development.
2. Injury or Trauma: Accidents or injuries, such as falls or whiplash injuries, may lead to inflammation of the bursae in the cervicothoracic region.
3. Muscle Imbalance: Muscle imbalances or weakness in the neck and upper back muscles can lead to altered biomechanics and increased stress on the bursae.
4. Inflammatory Conditions: Underlying inflammatory conditions like rheumatoid arthritis or ankylosing spondylitis may predispose individuals to bursitis.
5. Infection: In rare cases, bursitis can be caused by infection of the bursa, leading to inflammation.

The typical symptoms of cervicothoracic interspinous bursitis include:

• Localized pain and tenderness at the back of the neck and upper back, especially between the spinous processes.
• Pain that worsens with movements of the neck or upper back.
• Limited range of motion in the neck and upper back.
• Swelling and warmth over the affected area.

The diagnosis of cervicothoracic interspinous bursitis is typically made based on a thorough clinical examination, medical history, and imaging studies, such as X-rays or MRI, to rule out other potential causes of the symptoms.

Treatment for cervicothoracic interspinous bursitis usually involves a combination of conservative measures, such as:

1. Rest and Activity Modification: Avoiding activities that exacerbate symptoms can help in the healing process.
2. Pain Relief: Nonsteroidal anti-inflammatory drugs (NSAIDs) or pain medications may be prescribed to reduce pain and inflammation.
3. Physical Therapy: Specific exercises and stretches to improve muscle strength, flexibility, and posture can be beneficial.
4. Hot and Cold Therapy: Applying heat or cold packs to the affected area can help alleviate pain and reduce inflammation.
5. Corticosteroid Injections: In some cases, corticosteroid injections may be recommended to reduce inflammation and provide relief.
6. Ergonomic Modifications: Adjusting workstations or activities to maintain proper posture and reduce strain on the neck and upper back.

Severe cases or those that do not respond to conservative measures may require further evaluation and treatment by a specialist, such as a pain management specialist or orthopedic surgeon. It is essential to seek medical advice for an accurate diagnosis and appropriate management of cervicothoracic interspinous bursitis.