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Dr Peter Heppner Consultant Neurosurgeon Auckland City Hospital Starship Childrens Hospital Ascot Hospital

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Dr Peter Heppner Consultant Neurosurgeon Auckland City Hospital Starship Childrens Hospital Ascot Hospital Dr Peter Heppner Consultant Neurosurgeon Auckland City Hospital Starship Childrens Hospital Ascot Hospital 14:00 - 14:55 WS #55: Case Studies on Managing Cervical Radiculopathy 15:05 - 16:00 WS #67: Case Studies on Managing Cervical Radiculopathy (Repeated) Case Studies on Managing Cervical Radiculopathy: Peter Heppner Neurosurgeon Auckland City Hospital Starship Childrens Hospital Ascot Private Hospital www.neurosurgeon.org.nz DISCLOSURES I have no actual or potential conflict of interest in relation to this presentation WHAT ARE THE TAKE HOME POINTS? Evidence relating to cervical radiculopathy management is poor Natural history is generally very good In the absence of red flags, initial management with analgesia and physiotherapy appropriate NRIs can be a useful therapeutic and diagnostic tool Surgery ideally considered between 3-6 months from onset Either anterior or posterior surgical approaches can be selected depending on specifics of the case CASE 1 58 yr old lady 2 weeks radiating left arm pain (?after pilates) Taking paracetamol and NSAID Mild parasthesia in thumb Neuro exam normal Neck Disability Index 28% (mild) Clinically: Mild C6 radiculopathy of short duration CERVICAL RADICULOPATHY Radiating arm pain in a nerve distribution due to mechanical compression/chemical irritation of the nerve root Referred pain to inter-scapular and lateral neck common Weakness usually mild Pain or parasthesia non-dermatomal in almost half of patients Reduced reflex best predictor of imaging findings>motor weakness>sensory change Rarely painless SPONDYLOSIS Note: Significant cervical spondylosis (including foraminal stenosis) common in >40yrs without sx Correlate clinical with radiological findings Spondylosis a combination of wear, trauma and genetics (relative contribution unknown) RED FLAGS History of fall or trauma to head and neck Unexplained weight loss Severe intractable pain or severe local tenderness Cervical lymphadenopathy Unexplained fever Hx of cancer Hx of chronic steroid use DIFFERENTIAL Peripheral nerve entrapment Shoulder pathology Shingles Parsonage-Turner syndrome (brachial neuritis) Intra and extra spinal tumours Thoracic outlet Case 1 Given short duration and no red flags Conservative treatment and imaging in 6 week if not settling Natural history Poor data 80-90% settle: reassurance important! 75% in first 4-6 weeks Can take 1-2 yrs Is it going to come back? 20% recurrence over 2-3yrs Typically not as bad WHAT CONSERVATIVE TREATMENT? Physical therapy Literature limited by variation in therapy, duration and intensity and lack of control group BMJ: Physio including posture correction, stretching and active ROM exercises NASS: No studies adequately address issue Recommended Traction Improvement in pain in uncontrolled series Option in BMJ guidelines. Cochrane: no evidence Option Manipulation Cochrane/NASS: No benefit proven however small risk of significant complication (eg vertebral dissection) Gentle dissuasion Collar immobilisation Little evidence supporting More than 1-2 weeks can decondition neck muscles Gentle dissuasion Accupuncture May help alleviate pain but no evidence of efficacy ?risk of complication Option CONSERVATIVE TREATMENT Not convinced any conservative treatment alters the natural history of the condition but may provide some relief from discomfort along the way Best evidence for physical therapy Usually happy for patients to try anything that does not put them at risk CASE 2 47 YR OLD MAN 6 weeks ago lifted a bin Severe right neck and radiating arm pain Pain in triceps Pins and needles in index and middle finger No myelopathic sx Taking Paracetamol, Voltaren, Tramadol Moderate triceps weakness and absent triceps reflex NDI 56% (Severe) WHEN SHOULD SPECIALIST REFERRAL OCCUR? Failure of pain to improve in 4-6 weeks Severe uncontrollable pain (may consider early NRI) Severe or progressive motor deficit Red flag symptoms (get x-ray first) OPTIONS FOR TREATMENT Physical therapy Medication No studies on pharmacological rx of cervical radiculopathy Analgesic stepladder (NSAIDs, Tramadol, Gabapentin/Pregabalin) Short course of oral steroids (little evidence) Prednisone 60-80g daily for 2-3 days then taper over 10 days NRI Surgery Rx Gabapentin CT guided C7 nerve root injection 6 weeks later Pain resolved Minor ongoing parasthesia Mild weakness only NERVE ROOT INJECTION Indications Pain relief: around 60% Duration variable Clarify cause of pain if multi-level compression on MRI and syndrome not diagnostic Confirm symptomatic level in patient with discordant clinical and radiological findings Not without risk Neuro deficit, TIA, cord injury, spinal anaethesia, death Incidence low but not known NERVE CONDUCTION STUDIES/EMG Main use is to diagnose another condition such peripheral entrapment or focal mononeuropathy Sensitivity for diagnosing CR MRI 93% NPS 42% Ie NCS more likely than not to miss diagnosis In pts with clinical and MRI evidence of cervical radiculopathy, NCS has little additional diagnostic value SPECIFIC OUTCOME SCORES NDI, SF-36, SF-12 and VAS recommended for assessing treatment (NASS) NDI Self reported questionnaire indicating how symptoms affect QOL (like ODI)… 0-8% None 10-28% Mild 30-48% Moderate 50-68% Severe >70% Complete I use NDI Gain understanding on impact of symptoms on QAL Assess improvement with time or treatment Guide to if there is an indication for surgery CASE 3 37 yr old man 4 mths prior, hurt neck doing sit ups Presistent C6 distribution pain Rx Voltaren Saw sports physician who ordered MRI and arranged NRI NDI 42% (moderate) OPTIONS FOR TREATMENT Physical therapy Medication NRI Surgery Indications for surgery No consensus as to appropriate duration of conservative treatment Studies 1: Surgery <60 days had better HRQOL and QALY than >60 (but some may have got better by themselves). 2: Surgery < 6 mths had better outcomes (arm pain) than >6 mths 3: RCT: Surgery vs physio vs hard collar. Surgery better at 3 months but results similar at 1 yr (small sample size) Progressive motor weakness Note mild to moderate weakness at presentation can be treated conservatively Intractable severe pain that can not be controlled OUTCOMES OF SURGERY Good or excellent resolution of arm pain, neck pain, scapular pain and headache in 90-95% Residual deficit Sensory 20% Motor 2% If regularly operating before 2-3 months, you are probably operating on people who don’t need it CASE 4 59 yr old Vicar 7 weeks pain right neck and shoulder running into arm No symptoms in hand Sensation impaired in C5 distribution Exam otherwise normal ?C5 radiculopathy due to C4/5 foraminal stenosis NDI 50% (severe) ?Post fixed plexus Trialled a CT guided steroid injection with good relief of pain Pain recurred 1 month later What operation Preserved lordosis Foraminal compression Needs to project voice for 45 minute sermons Posterior foraminotomy Posterior Anterior advantages advantages No fusion Direct decompression Easier to expose multiple Access to medial levels compression Any level (above C3 and Restore alignment if below T1) irrespective of kyphotic habitus Bilateral foraminal Good for smokers, decompression athletes and singers ?Helps axial neck pain Avoid Approach morbidity Trach/Oes/Carotid/RLN Less painful Avoid fusion complications Pseudoarthrosis Adjacent segment disease (symptomatic in 25% at 10 yrs after ACDF) CASE 5 33yr old lady Avid gym attender 6 weeks of left sided neck pain radiating down the back of the arm and forearm Sensory change middle finger Mildly weak elbow flexion and reduced biceps reflex NDI 58% (severe) Saw back at 2.5 months: still symptomatic Recommended surgery ACDF or ACDR ARTIFICIAL CERVICAL DISCS Theory Maintaining motion will reduce the strain on adjacent levels hence adjacent level degeneration Results out to 10 yrs In well selected patients Osteoporosis, significant kyphosis, instability, >50% loss of disc height, facet arthropathy, OPLL, inflam arthropathy, multilevel. Clinical outcome as good if not better than ACDF Neck disability score, neurological recovery, cost/QALY, less revision surg and ?ALD ?Degeneration of the devices over time ACD is an option in well selected patients CONCLUSION Cervical radiculopathy common Typically good natural history Watch for red flags Consider NSAIDs, Tramadol, nerve stabilisers and short course oral steroid Physio may be beneficial Early referral for red flags, severe pain or weakness NRI may help dx and rx Surgery can help speed up resolution Thank you www.neurosurgeon.org.nz References https://bestpractice.bmj.com/topics/en- gb/577/evidence North American Spine Society. Evidence based clinical guidelines for multidisciplinary spine care: diagnosis and treatment of cervical radiculopathy from degenerative disorders Cervical radiculopathy: Cur Rev Musculoskelet Med (2016) 9: 272-280.
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