CLINICAL AND RADIOGRAPHIC CHARACTERISTICS OF PATIENTS WITH CERVICALGIA AFTER PREVIOUS INJURY TO THE PECTORAL GIRDLE

68 In the recent decade structural deformities and functional impairments of the spine have been deemed increasingly important as an underlying cause of both axial and peripheral pain syndromes. Biomechanically, the spine and the pectoral and pelvic girdles resemble an intricate rigging system [1, 2]; the spine, its central component, is a “mast” supported by “shrouds”, i.e. the pectoral girdle, pelvis, and spinal and limb muscles. In this biomechanical system, a change in the spatial orientation of one component will entail adaptive shifts or functional adjustments of others. Through such adaptation energy-efficient performance is achieved, meaning that the body can maintain its postural balance within the cone of 1 Кафедра травматологии, ортопедии и хирургии катастроф, лечебный факультет Первый Московский государственный медицинский университет им. И. М. Сеченова (Сеченовский университет), Москва

Fig. 1.The picture of the optimal standing posture of the human body as proposed by the "cone of economy" concept [3] Male Female economy, as described by Dubousset (Fig. 1) [3][4][5][6].Thus, functional statuses of the cervical spine (CS) and the shoulder girdle should be seen as interdependent [1,3,7,8].Injuries to the pectoral girdle are very common and nowadays account for 15% of all skeletal injuries [9].They are most often seen in young patients of working age and are a result of household, sport-related and road accidents.
Based on the analysis of treatment outcomes in patients with pectoral girdle injuries, we can isolate a group of patients with cervicalgia.This group is heterogenous and includes differently aged individuals who previously received operative or non-operative treatment for their condition.Of particular interest here are young and middle-aged patients who had no clinical signs of cervicalgia before the injury.Neck pain entails functional limitations and slows down rehabilitation, affecting its intensity; it also deteriorates the patient's quality of life [7].It is worth noting that there are no reliable data in the literature on the prevalence of cervicalgia in patients with previous injuries to the pectoral girdle or on its possible causes.
The aim of our study was to evaluate the condition of the cervical spine in patients with cervicalgia after a pectoral girdle injury based on radiographic and physical examinations.

METHODS
The study was conducted in 400 patients undergoing treatment at the facilities of the Trauma Unit (Вotkin City Clinical Hospital, Sechenov First Moscow State Medical University, Department of Traumatology, Orthopedics and Disaster Surgery) between 2015 and 2018.The study included male and female individuals aged from 18 to 59 years (mean age was 41.3 ± 1.1 years) with localized neck pain (suggestive of cervicalgia) and an isolated unilateral injury of the pectoral girdle received at least 6 weeks before the study.
Patients with clinical signs of cervical radiculopathy, any previous injury to the spine, the narrowing of the cervical spinal cord of any etiology and multiple injuries were excluded from the study.
Age-and sex-based distribution of patients is shown in Table 1.
Clinical evaluation of the orthopedic status was performed in all patients.Pain intensity was evaluated on the visual analog scale (VAS) [10,11].
The impact of neck pain on the patients' lives was assessed using the NDI-RU questionnaire [12][13][14].
CS radiography was performed in standard anteriorposterior and lateral projections (100%).Functional radiography of the cervical spine was not ordered: it would have provided no valuable information because of the pain syndrome the patients suffered from and because it would have been impossible to maintain identical conditions during each examination.
To understand the condition of intervertebral discs and to exclude cervical spinal stenosis, an MRI examination was ordered for all the patients (T1/T2-weighted and STIR scans in closed 1.5 Tesla machines with standard Pfirrmann grading) [21].

RESULTS
All patients complained of neck pain.Pain intensity on the VAS scale was mild in 18 patients (4.5%), moderate in 312 patients (78%), fairly severe and severe in 70 patients (17.5%).Average score for pain intensity was 5.6 ± 0.45 points.
Physical examinations were carried out to assess the overall condition of the spine, search for the abnormalities in the cervical spine, and estimate the range of motion in the latter (Table 2).
Radiography detected the following local symptoms (Table 3).
In the frontal plane the cervical spinal axis looked undeformed.
Table 4 shows the findings of postural digital radiography performed to assess cervical sagittal balance.
MRI scans were suggestive of intervertebral disc degeneration in the studied zone in all the patients (Pfirrmann's types I and II) [21]; their vertebral bodies were intact.No signs of cervical spinal stenosis were observed.

DISCUSSION
Our study was conducted in 400 patients with previous injury to the pectoral girdle who had developed clinical signs of cervicalgia in the post-injury period.The symptoms included local pain, myofascial pain, and the restricted range of motion in the cervical spine.Radiography did not detect severe degeneration or dystrophic changes in the spine.The sagittal balance profile obtained for 198 patients (49.5%) did not reveal severe biological or mechanical damage to the  Therefore, the changes detected in the cervical spine are not structural, but functional, implying static and dynamic impairments, such as hypermobility or hypomobility of spinal units, which can be interpreted as a functional dislocation within the facet joint syndrome [22,23].
Based on the static and dynamic changes detected, patients can be recommended an adequate plan of rehabilitation to alleviate cervical pain.However, further research is necessary to understand a correlation between those changes and different types of injuries to the pectoral girdle, types of surgical treatment applicable and other structural and functional impairments of the spine and pelvis.

CONCLUSIONS
Cervical spinal pain is a common problem in patients with previous injuries to the pectoral girdle.Girdle injuries can entail functional damage to the cervical spine, causing cervicalgia.Further exploration of cervical spine dysfunctions in patients with previous pectoral girdle injuries will help to develop methods for their prevention and elaborate adequate rehabilitation plans.

Table 1 .
Distribution of patients based on sex and age

Table 2 .
Results of clinical examinations