neck & arm pain : when is surgery appropriate?

Neck & Arm Pain: When is surgery appropriate?

Ra'Kerry K. Rahman MDCervical Spine & Scoliosis SurgeonSpringfield ClinicClinical Asst. Professor SIU SOM

www.SpringfieldClinic.com/DoctorIsIn

Cervical Spine Pathology• Cervical Strain or Sprain• Whiplash• Cervical Radiculopathy• Cervical Myelopathy & Myeloradiculopathy• Cervical Pseudarthrosis• Adjacent Segment Disease• Cervical Masqueraders ( Rotator cuff dz, carpal tunnel,

cubital tunnel, anxiety)

You’re the doctor??

• 44 yo woman involved in a MVC whereby she describes hitting her head on the steering wheel. No major injuries. Exam, reveals pain with neck range of motion and firm paraspinal muscles with palpation; otherwise normal1. Order XRs

2. She’ll be okay send her home with appt to follow up

3. MRI

4. Rest, Ice/Heat, anti-inflammatories

Whiplash Injury

• Neck injury resulting from sudden acceleration – deceleration…example rear-end collision while stationary.

• Soft tissues such as ligaments, facet capsules, and muscles can be damaged

• Treatment: Rest, NSAIDs, muscle relaxants, soft collar (limited)

• Surgery: Yes or No

Cervical Strain or Sprain

• Neck Strains vs. Sprains – injury occurring at musculo-tendinous junctions vs facet capsule or ligament bone interface

• Cause: Forceful neck motions which are strong enough for injury but not strong enough to generate instability

• Treatment: Rest, NSAIDs, muscle relaxants

• Surgery: Yes or No

• 62 yo woman presents complaining of neck & left arm pain, radiates down the back of the arm as well into the ring and pinky fingers. Associated symptoms include numbness & tingling of those fingers.1. Order XRs

2. She’ll be okay send her home with a follow up appt

3. MRI

4. EMG

You’re the doctor??

Adjacent Level Disease

• Occurs after cervical fusion - 3% of patients…..25% at 10 yrs postop

• Pathoanatomy vs. Natural Hx causes some controversy

• Proposed theory: Increased degeneration at adjacent level due to increased biomechanical stress from fusion

• What’s most common level for ACDF?

This case illustrates a second diagnosis!

Left C7 cervical radiculopathy secondary to adjacent level disease

Cervical Radiculopathy

• Pathoanatomy: nerve root compression– Biochemical & Mechanical Interplay

• Altered sensation, Pain, or Weakness in corresponding dermatome/myotome

• Surgery appropriate: Yes or NoDepends!!

This patient tells you that her daughter is getting married and she cannot undergo surgery at

this time, despite having tremendous pain. What could

you offer her?

Cervical Selective Nerve Root Block

Cervical Nerve Root Blocks• Very helpful for refining diagnosis• Has a reasonable chance of helping patient

avoid surgery • Gives time for natural hx to win • Goal: Modulate inflammatory response• Concerns: Sudden paraplegia after injection

(Use Dexamethasone)

Patient positioning for SCNRB on the left side.

Schellhas K et al. AJNR Am J Neuroradiol 2007;28:1909-1914

©2007 by American Society of Neuroradiology

Sequential fluoroscopic images demonstrate optimal needle placement (A and B) and contrast injection (C and D).

Schellhas K et al. AJNR Am J Neuroradiol 2007;28:1909-1914

©2007 by American Society of Neuroradiology

Optimal right C7 nerve root opacification before therapeutic injection.

Schellhas K et al. AJNR Am J Neuroradiol 2007;28:1909-1914©2007 by American Society of Neuroradiology

Venous opacification observed during contrast injection into the lower lateral aspect of the right C6–7 nerve root canal, along the

C7 nerve root.

Schellhas K et al. AJNR Am J Neuroradiol 2007;28:1909-1914©2007 by American Society of Neuroradiology

After wedding, she returns…ROI and C6-7 ACDF

Pre-surgical Considerations • Help cervical radiculopathy pts with conservative care

until all options exhausted unless neurological symptoms that are not improving or worsening OR symptoms unacceptable to patient if symptoms became permanent.

• 6-12 weeks of conservative care is reasonable before referral

You’re the doctor!!• 42 yo with balance difficulties, changes in handwriting,

positive Romberg {can’t stand with eyes closed}, positive Hoffman’s bilaterally {primitive reflexes present}, “heavy” arms. Pt underwent decompressive surgery and fusion. Felt good for 8 months. One day she heard a pop and now has severe neck pain.

• 1. Order XRs

• 2. She’ll be okay send her home with a follow up appt

• 3. MRI

• 4. EMG

T2 Sagittal MRI

Post Op after Revision

Cervical Pseudarthrosis

Etiology of Revision Anterior Cervical Spine SurgeryRa’Kerry K. Rahman MD, Nisha R. Raja-Rahman MD, Moon Soo Park MD, K. Daniel Riew MD

• When surgery does not result in a bony union of desired area

• Clinically: – neck pain – “Pain free interval”– radicular symptoms (+/-)

• ?? Adequate decompression ??• Indirect decompression

Example

Pre-surgical Issues1) Be alert for problems in postsurgical pts with a pain free interval or persistent radicular symptoms despite surgical treatment

2) Order CT scan– Without contrast if “neck pain only”– With contrast (CT myelogram) if persistence of radicular

symptoms

3) Send back to surgeon if imaging reveals a pseudarthrosis: Treatment = Revision Surgery

4) Okay to try conservative modalities

What will the surgeon do?

1) Redo/Revise the surgery

2) Augment index surgery with opposite column fixation

3) Both of the above

4) Iliac crest bone graft

You’re the Doctor!!63 yo male c Balance problems, tripping, difficulty with fine motor activities present for years, but acute decline 6 months prior to presentation; onset of mild neck pain•Early fatigue with yardwork and distance walking +neurogenic claudication•PE: + Hoffman, broad-based gait, inability to perform tandem gait; +hyperreflexic b/l UE & LE•5/5 strength UE & LE; normal sensation

1. Order XRs

2. She’ll be okay send her home with a follow up appt

3. MRI

4. EMG

XRAYS

CT

C3-4

C4-5

C5-6

C6

C6-7

IMMEDIATELY POSTOP

Cervical Myelopathy

Cervical Myelopathy• Clinical diagnosis of spinal cord dysfunction (upper motor

neuron lesion, long-tract sign)• Intrinsic cord lesion or extrinsic cord compression• MC. Cause: cervical spondylosis (CSM)

– Disc herniation, bony overgrowth– Abnormal alignment– Ligamentous hypertrophy– Segmental instability– OPLL– Medical conditions

Cervical Spondylotic Myelopathy

• Definition of CSM

“ Spinal cord dysfunction secondary to extrinsic compression of the cord or its vascular supply, or both, that is caused by degenerative disease of the cervical spine”

AAOS Instructional Course Lecture 1995

Epidemiology of CSM

• Age: 40-60 years, M = F• “Cervical spondylosis” : more than half of the causes of

cervical myelopathy.• The most common cause of spinal cord dysfunction in

the patients > 55 years.• The most serious sequelae of cervical spondylosis.• MC. level: C5-6, C4-5, C6-7, C3-4 disc• Increased risk: Congenital spinal stenosis

Natural History• Symptomatic Myelopathy

• Progressive worsening

• Stepise deterioration

• Rare acute deterioration

Cadaveric Section of Neck

More Anatomy

Pathoanatomy & Pathogenesis

• Cervical spondylosis with stenosis– Stenosis of the central spinal

canal & inter-vertebral foramina

• Instability– Compensatory subluxation

• Cervical kyphosis• Initial size of the spinal canal• OPLL

Pre-surgical Considerations

• Recognize cervical myelopathy as a patient that requires early referral to spine surgeon. No PT, meds, etc.

• Place elderly patients with poor balance in a soft collar to protect them unto surgical appt.

• Pt are at risk for central cord syndrome and transient/permanent quadriplegia

Cervical Spine Masqueraders

• Rotator cuff disease (C4/5 radiculopathy)

– Jobe’s

– Resisted Abducted External Rotation

• Carpal tunnel (C6 radic)

– Phalen’s test can help distinguish from a C6 radiculopathy

• Cubital Tunnel Syndrome (C7 radic)

– “Pain with holding phone”

– Reproduced symptoms with prolonged elbow flexion (~60 secs)

EMG HELPFUL

• 20 -30 % of disk herniations can cause cervicogenic headaches

• Cervical DDD/Black disk disease – historically does not respond well to surgery. Maximize conservative modalities

• Be alert for posterior auricular pain reproduced by Spurling’s as a possible high cervical radiculopathy

THANK YOU!!