Nerve root lesions in the neck are responsible for causing such extreme arm and shoulder pain that some patients wish they could cut off their arm. Typical presentation with this syndrome involves looking very tired from sleep loss, limited interaction and loss of sense of humour and the keeping of the arm in a guarded position. The exact nerve root implicated will determine which areas of the arm are most badly affected. The pain can surge through the arm in agonising waves and also appear incredibly sharp. Any stretching, or tension, forces applied to the nerve by movements of the neck or arm is followed by a worsening of the pain severity.

It is very hard for the patient to find a comfortable position for their arm and they may cradle it across the body or hold the hand on top of the head. Prescribing strong painkillers and anti-inflammatories is important as the joints and nerve need to settle and the pain mechanisms are difficult to reduce once they have been set up by severe incoming pain symptoms. Mechanical treatment needs to be careful as the irritability of the pain is very high, with careful pressure against the facet joint helping to relieve the local circulatory stasis and facilitate joint movement.

Nerve root lesions need therapeutic care as intervention is much more likely to aggravate this highly irritable condition than add anything to the natural resolving process. However, treatments such as neck traction, collar wearing, keeping the joint in the least painful position and mobilisation techniques can be useful to speed up or start the process. As the pathological process begins to ease the patient is relieved to sleep better, start neck motion and go back gradually to performing activities of daily living.

Therapeutic efforts can be intensified once the pain shows some sign of settling down but the therapist still needs to be aware of the potential for worsening with treatment. The neck can be gently restricted at night be wearing a soft collar and the patient encouraged to perform regular range of motion exercises within pain limits to increase mechanical inputs to the nervous system. The patient should continue to take painkillers for longer than they feel they need to initially as the syndrome relies on control of pain to settle and patients need to be able to do gradually more without too much pain.

If the arm pain does not settle after six weeks or so a referral to a spinal specialist may be useful. These kinds of syndromes almost always settle with time but the pain can be so severe that it is questionable in some cases whether we should wait for the length of time settling down might take. The examination will determine the history of the event, previous difficulties with the neck if any and the areas of symptoms and what aggravates or eases them. The physical examination is quite limited due to pain but consists of neck ranges of motion, muscle power, sensibility and reflex testing.

One nerve root is the most likely affected structure and this means that all the symptoms will be related to the functions which this nerve has. Reflex loss, loss of feeling, weakness of muscle groups and the distribution of the pain in the arm should all fit in terms of being attributable to the compression of this one nerve. If more than one root is affected the patient should be referred for a medical opinion.

After the examination the surgeon will have a clear idea of which nerve root is the likely culprit and will order an MRI scan to image the segment of the neck responsible. If a large disc protrusion is evident on the scan then a surgical removal of the disc prolapse is possible although this is less commonly performed than in the lumbar spine. After the recovery period it is useful for patients to keep themselves fit and try to return to as normal activity as possible in order to forestall any chances of developing consequences from the syndrome.