How to manage cervical spondylosis?

Question

Hello doctor,

For the last few days, I have been experiencing left-sided pain in my shoulder, upper arm, the front area near the shoulder, breast, both outer sides of my neck, and collarbone area. Occasionally, there is pain in the back as well. I can feel the pain when I press on the affected areas, and it worsens with pressure. There is no accompanying shortness of breath or sweating. Please note that the pain may not be present in all areas at the same time. At this moment, I only have very mild discomfort in the front area near my shoulder and breast.

Here are some points to consider for diagnosis: I am hypertensive; however, my blood pressure is well-controlled (110/80) with Metoprolol and Amlodipine. I also take Atorvastatin 10 mg for cholesterol, but I have been asked to stop this medication. I have been on these medications for the past year. All my tests from one year ago are normal, including EKG, chest X-ray, brain CT scan, pulmonary embolism assessment, and all blood work. I also had a 48-hour Holter monitor, and there were no murmurs or gallops noted, with normal arterial oxygen levels and troponin levels. My recent blood work from two months ago—such as lipid profiles, kidney function tests, complete blood profile, liver function tests, HbA1c, vitamin profiles (vitamin D, B12, calcium, iron), sodium, potassium, and urine exam—are all normal.

I walk daily for 20 to 30 minutes, occasionally run, and do not experience any pain. I can take stairs without any shortness of breath or pain. Last year, I experienced a different variant of chest pain, for which I underwent EKG, TMT, and 2D echo, all showing normal findings. It was diagnosed as non-cardiac pain. I also have mild to moderate generalized anxiety disorder (GAD) and am uncertain if the pain I am experiencing is psychosomatic.

I dislocated my left shoulder about 20 years ago, and it has been dislocated almost seven to eight times since, with four instances requiring non-surgical intervention at the hospital. The last dislocation was quite some time ago, and I am unsure if my current pain is related to that. I did not consistently follow the instructions regarding wearing a sling and often went without it soon after the shoulder was relocated. While I never had any significant problems with my left shoulder or arm, I did experience mild pain intermittently in my shoulder and upper arm. My left hand is fully functional, although I am cautious about rotating it 360 degrees due to fear of dislocation. Currently, I do not have any acidity, so I believe the pain is not related to GERD.

Since my 2D echo and TMT were done just one year ago and returned normal, do I need to repeat these tests? I believe my condition has improved since then, as I have made significant lifestyle and dietary changes. My blood pressure remains well-controlled at 110/80, with a resting heart rate of 70 to 80 BPM. My lipid profile is normal: LDL (73), HDL (46), and total (145). If this is musculoskeletal pain, could you please suggest some medication? I am looking for something that does not affect my blood pressure or heart rate. Is a combination of Tramadol and Acetaminophen a good option? Please suggest a potent and safe medication that can relieve the pain and relax the muscles.

One of the doctors I consulted in person suggested that my symptoms may be psychosomatic and prescribed a combination of Flupentixol and Escitalopram. However, I am concerned about the potential side effects, such as thrombosis and QT prolongation, and have not started it yet. What is your opinion on this combination drug? Is it safe to try it for four months and then wean off over the next two months? Can you recommend any other anti-anxiety medications with a safer cardio-metabolic profile?

Please advise.

Answer 1

Hello,

Welcome to icliniq.com.

Firstly, this is not related to the heart. Cardiac pain typically increases with exertion and alleviates with rest; it does not worsen with pressing or arm movement. You do not need to repeat any tests. Regarding potential causes, psychosomatic factors are certainly a possibility, but given the location of the pain, there is also a chance of a cervical spine issue. Do you experience any tingling, numbness in your arm, neck stiffness, increased pain with neck movements, or have a history of neck trauma? If so, this may suggest the possibility of cervical spondylosis. I believe it would be worthwhile to get an X-ray of the cervical spine, either anteroposterior or lateral view. Additionally, during a CT scan of the head, the neck region may sometimes be included. If that’s the case, then an X-ray may not be necessary.

Regarding medications, Tramadol is the safest option in terms of blood pressure, but it may not be very effective. You might try taking Naproxen 250 mg twice a day after meals. The only concern with this medication is that, in some patients, it may slightly raise blood pressure, but this typically normalizes once the medication is discontinued. Therefore, I think it is worth trying. Additionally, you could take the muscle relaxant Thiocolchicoside 4 mg as needed, up to three times a day, and monitor your response. If you experience a positive response, you can complete a five-day course. This should not cause any significant cardiac issues for you.

As for anti-anxiety medication, I believe there is no need for Flupentixol and it would be better to avoid it. However, Escitalopram is commonly used and is considered quite safe. Side effects like QT prolongation are very rare, so it may be appropriate for you. It is available in combination with Etizolam, which is a good anti-anxiety medication to take at bedtime for about a week or so.

Regards.

Answer 2

Hello,

Welcome back to icliniq.com.

You should take Naproxen for five days. For muscle relaxation, I recommend Thiocolchicoside 4 mg. For local application, you can use Diclofenac gel.

All the best!