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