dr keith laubscher mr dean mistry katy street north/sun_room2_0815_mistry_neck...dr keith laubscher...
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Dr Keith LaubscherPain Specialist
Director, PainCare
Auckland
8:15 - 9:10 WS #189: Managing Neck Pain
9:20 - 10:15 WS #201: Managing Neck Pain (Repeated)
Mr Dean MistryOrthopaedic Spine Surgeon
Auckland
Katy StreetPhysiotherapist
Auckland Physiotherapy
Middlemore Hospital
Auckland
Neck Pain
Keith Laubscher, Dean Mistry, Katy Street
Introduction
• Neck pain is very common
– Yearly incidence ~40%
• Neck pain with disability is less common
– ~10%
Introduction
• Neck pain is very common
– Yearly incidence ~40%
• Neck pain with disability is less common
– ~10%
The challenge of neck pain
• Difficult to have an exact anatomical diagnosis
• Often takes far longer to resolve than most patients expect
• Often some ongoing pain/disability
• Expectations of further investigations
Presentation
• 3 groups of sx
1. Axial Neck Pain
2. Radicular Symptoms
3. Myelopathic sx
Pain terminology
Stage influences options
Acute 0 to 6 weeks
Subacute6 to 12 weeks
Chronic> 12 weeks
Types of pain
• Nociceptive = stimulation of peripheral nociceptors– Somatic, referred somatic
• Neuropathic = lesion or disease of the somatosensory nervous system+ Signs of neurological dysfunction+ Demonstration of lesion (MRI, NCS)
Eg Radicular pain/RadiculopathyMyelopathy
• Visceral
Axial Symptoms
• Distribution– Occipit down to mid thoracic spine
– Posterior shoulder girdle commonly involved
– Not anterior
– Associations• Headaches
– DD Migraine
• Dizzyness
Axial Symptoms
• Distribution– Occipit down to mid thoracic spine
– Posterior shoulder girdle commonly involved
– Not anterior
– Associations• Headaches
– DD Migraine
• Dizzyness
• Differentiate between migraine, tension headache and cervicogenic – patient history
• Flexion / rotation test Sn 91%, Sp 90%
• Palpation upper cervical spine
Zygapophysial joint (facet) “pain maps” -headache
Axial Symptoms – Pain Generators
Specific pain sources
• Zygapophysial joint -55%
• Discogenic pain -16%
• Lateral atlanto-axial joint -9%.
The nature of neck pain in a private pain clinic in the United States. Pain Med. 2008 Mar;9(2):196-203. Yin W, Bogduk N.
Whiplash Diagram of injuries identified
Partial avulsions of discs
from vertebral bodies, in
extension
Facet
haemarthroses
with # of C7
Bruising of
vascular
synovial folds
Haematoma
around C2
Distraction injuries Compression injuries
Radicular Symptoms
• Pain/PN shooting down arm
• May be associated weakness or numbness
• Can be confused with– Shoulder issues: Shoulder problems
tend to get worse with abduction. Cervical better.
– Peripheral neuropathies: Cubital/Carpal Tunnel syndromes
Radicular sx
• Pain distribution
– Sensory changes are a more accurate guide than pain
• If Thumb/IF DD: Carpal Tunnel Syndrome
• If Little Finger DD: Cubital Tunnel
Aetilogy
Aetilogy
• Acute Disc Herniation
• Foraminal Stenosis
Aetilogy
• Acute Disc Herniation
– Acute herniation of soft disc
– Younger age group, <40y
– Can still be superimposed on top of pre-existing degenerative change/osteophytes
Aetilogy
• Acute Disc Herniation
– Acute herniation of soft disc
– Younger age group, <40y
– Can still be superimposed on top of pre-existing degenerative change/osteophytes
Aetilogy
• Degenerative foraminal stenosis
– Due to a combination of• Disc height loss
• Osteophyte formation
– More common in older age group
– Often have multilevel pathology
Aetilogy
Myelopathic Symptoms
• Loss of fine motor ability
– Dropping cups/plates
– Difficulty with buttons/laces
– Handwriting
• Gait abnormality
– Unsteadiness, particularly rough ground or low lighting
• Sphincter disturbance
– Late sign!
Cervical Spine Exam• Look
• Feel
• Move
• Neuro– Sensation– Power– Reflexes– Test for Myelopathy– Peripheral Neuro
Look
• From the front• From the side• From the back
Feel
• Can check for lumps
• Utility of discrete tenderness is low
Movement
• Stand in front of the patient so you can seewhen it hurts
• Flexion (L’hermitte’s)
• Lateral Rotation
• Extension
• Extension and rotation (Spurling’s Test)
Neuro - Sensory
• C4 – Point of shoulder
• C5 – Lateral Elbow
• C6 – Thumb
• C7 – Middle Finger
• C8 – Little Finger
• T1 – Medial Elbow
Neuro - Motor
• C4 – Shoulder Shrug
• C5 – Deltoid/Biceps
• C6 – Wrist Extension
• C7 – Triceps
• C8 – Finger Extension
• T1 – Finger ABduction
Deltoid and elbw
Neuro - Motor
• C4 – n/a
• C5 – Deltoid/Biceps
• C6 – Wrist Extension
• C7 – Triceps
• C8 – Finger Extension
• T1 – Finger ABduction
Wrist extension
Neuro - Motor
• C4 – n/a
• C5 – Deltoid/Biceps
• C6 – Wrist Extension
• C7 – Triceps
• C8 – Finger Extension
• T1 – Finger ABduction
Finger Extension
Neuro - Motor
• C4 – n/a
• C5 – Deltoid/Biceps
• C6 – Wrist Extension
• C7 – Triceps
• C8 – Finger Extension
• T1 – Finger ABduction
Finger Abduction
Neuro - Reflexes
C5 –Biceps
C6 – Brachoradialis
C7 – Triceps
Neuro - Myelopathy
Inverted Radial (aka Inverted Supinator) Reflex
Hoffman’s Sign
Finger Escape
Grip and Release Test
Neuro - Myelopathy
Gait - Ataxia
Rhomberg’s Test
Babinski
Clonus
Other
• Tinel’s over cubital tunnel
• Flexion compression of carpal tunnel
Investigations
• Blood Tests
– Inflammatory arthritides
– Infection
– Tumour
• Xrays– 3 shot C-spine series
– Oblique views: foraminal stenosis
– Flex/extension views
• Indications– Trauma
– Tumour
– Infection
– Limited use in axial neck pain and radiculopathy
• High Tech Imaging
– MRI• Exclude dangerous pathologies
• Radiculopathy or myelopathy
• Limited use in axial neck pain
• SPECT/CT
– Can highlight pain generators
– Identify targets for interventional treatments
Diagnostic Blocks
• Local anaesthetic block of nerves to facet-joint
• Under Xray guidance
• Low volume - 0.3ml
• Controlled – different LA
• Independent assessment
• Positive = VAS 0/10
Gold standard
Management
GROUP 1:
REFER IMMEDIATELY
GROUP 2:
SPECIALIST REFERRAL
GROUP 3: TRIAL OF TREATMENT
+ INVESTIGATIONS
GROUP 4:
TRIAL OF TREATMENT
GROUP 4:
TRIAL OF TREATMENT
GROUP 2:EXPIDITIOUS
SPECIALIST REFERRAL
GROUP 3: TRIAL OF TREATMENT
+ INVESTIGATIONS
GROUP 1: REFER IMMEDIATELY
Risk FactorsSevere, worsening painSepticemia – febrile, neck painCatastrophic neurological changes
Sphincter lossSaddle/perianal anaesthesiaProgressive neurological deterioration
High energy trauma or trauma with neurological sx
Pathologies Infection with systemic toxemiaHigh likelihood of spinal tumourUnstable Fractures/Spinal Cord InjuryCarotid artery dissection
GROUP 1:
REFER IMMEDIATELY
GROUP 2:
SPECIALIST REFERRAL
GROUP 3: TRIAL OF TREATMENT
+ INVESTIGATIONS
GROUP 4:
TRIAL OF TREATMENT
GROUP 1:
REFER IMMEDIATELY
GROUP 3: TRIAL OF TREATMENT
+ INVESTIGATIONS
GROUP 4:
TRIAL OF TREATMENT
GROUP 2: EXPIDITIOUS SPECIALIST REFERRAL
Intermediate risk signs forSpinal Mets/Tumour
Age greater than 50 years, history of cancer, unexplained weight loss, failure to improve with conservative therapy
Low energy trauma
Progressive myelopathy
Severe radicular pain
GROUP 1:
REFER IMMEDIATELY
GROUP 3: TRIAL OF TREATMENT
+ INVESTIGATIONS
GROUP 4:
TRIAL OF TREATMENT
GROUP 2: EXPIDITIOUS SPECIALIST REFERRAL
When to add in Xrays?If you suspect fracture, tumour, or +/- infectionNOT routinely
When to add in Blds?If you suspect infection, or tumourFBC/ESR/CRPALP, LFT’s, Ca/Phosphate
GROUP 1:
REFER IMMEDIATELY
GROUP 2:
SPECIALIST REFERRAL
GROUP 3: TRIAL OF TREATMENT
+ INVESTIGATIONS
GROUP 4:
TRIAL OF TREATMENT
GROUP 1:
REFER IMMEDIATELY
GROUP 2:EXPIDITIOUS
SPECIALIST REFERRAL
GROUP 3: TRIAL OF TREATMENT
+ INVESTIGATIONS
GROUP 4:
TRIAL OF TREATMENT
GROUP 3: TRIAL OF Tx + INVESTIGATIONS
Trial of Tx = 4 weeks of adequate conservative treatment
For Acute Neck Pain with weak risk factorsManageable radicular pain
Xrays = fracture, tumour, or infectionBlds = infection, or tumour
FAILURE OF TRIAL OR INVESTIGATIONS +VE REFER
TEMPORISING GROUP – FOLLOWING Ix or TOT SHOULD MOVE INTO GP 1/2/4
GROUP 1:
REFER IMMEDIATELY
GROUP 2:
SPECIALIST REFERRAL
GROUP 3: TRIAL OF TREATMENT
+ INVESTIGATIONS
GROUP 4:
TRIAL OF TREATMENT
GROUP 1:
REFER IMMEDIATELY
GROUP 2:EXPIDITIOUS
SPECIALIST REFERRAL
GROUP 3: TRIAL OF TREATMENT
+ INVESTIGATIONS
GROUP 4: TRIAL OF TREATMENT
Trial of Tx = 4 weeks of adequate conservative treatment
Acute musculoskeletal neck pain that is • manageable with analgesia• can mobilise• with no risk factors
Adequate non-operative therapy • Education• Physical Therapy
• Manipulation• Tailored Exercises
IF FAILURE OF TRIAL (NO IMPROVEMENT) REFER
Management
Initial pain management
Medication, exercise/manual therapy, education, vocational, lifestyle, psychological strategies
Interventional Treatments
• Joint injection
• Radiologically guided interventions
– Nerve blocks
– Radiofrequency denervation
• Surgery
Non-interventional treatment
• Exercise• Education / cognitive behavioural therapy• Ergonomics• Electrotherapy• McKenzie manual diagnosis and therapy• Manipulation/mobilisation• Massage• Cervical collar• Acupuncture• Traction
Evidence… What works?
• Exercise and Manual Therapies– Consistent strong evidence that exercise may be effective in preventing neck and
back pain– Strong evidence for combining exercise and mobs/manips for subacute/chronic
population at short & long term F/U– Manipulation should be preceded by examination for myelopathy and discussion
of risks
• McKenzie therapy– ↑ pain relief & reduction in disability vs comparison (NSAIDs, educational
booklet, back massage & advice, strength training & spinal mobs and general exercise) at short term F/U
Evidence..what doesn’t work?
• Acupuncture– No good quality trails showing effect in cute or subacute populations– Moderate evidence that acupuncture is more effective for pain relief than sham treatment or
wait list control at short term F/U
• Massage– Massage alone showed inconsistent results– Other trials used massage as part of a multimodal intervention and the role of massage was
unclear– 12/19 studies were low quality
• Education alone– Strong evidence that education alone is not effective– Education, advice on stress coping skills or ‘neck school’ not better than no treatment
• Mechanical traction– No evidence with low bias that supports or refutes the use of continuous or intermittent
traction
Evidence…what doesn’t work?
• Ergonmics– Poor quality of evidence on effectiveness
• Electrotherapy– Underpowered low quality trials– Conflicting/limited evidence for direct/modulated galvanic current,
iontophoresis, TENS, EMS, PEMF & permanent magnets
• MDT biopsychosocial rehab– Limited evidence
• Cervical collar– Initially minimizing ROM can ↓ nerve irritation but limited evidence– Longer use may have adverse effects eg. Atrophy of paraspinal muscles
Management of headaches
• Treatment involves postural correction, assessment of workplace ergonomics, manual therapy (Watson, Mulligan) and home exercises for neck / scapular strengthening and exercises to relieve headaches – self traction or self mobilisation
Take home message
• Strong evidence to support multimodal therapy approach –exercise combined with mobilisation +/- manipulation if indicated
• Strong evidence to support exercise
• Limited evidence for massage, cervical collar, education alone.
Management - Medication
• Paracetamol - ?effectiveness
• NSAID - more effective
Side effects: 25 admissions, 5 deaths / 100 000
• Muscle relaxants: Orphenadrine- weak evidence in acute pain
• Tramadol – variable response
• Codeine - ?effectiveness
• Opioids: for acute with usual precautions
• Chronic pain – controversial (lack of efficacy, tolerance, dependence, addiction, hyperalgesia, immune, endocrine)
An evidence base for WHO ”essential analgesics”
Wiffen P. Pain Clinical Updates March 2000.
Medication for neuropathic pain
1. Antidepressants: TCA – Amitriptyline, Nortriptyline, (Duloxetine)
2. Anti-epileptics: Gabapentin, (Pregabalin)
3. Diazepam: evidence more against (Cochrane)
4. Corticosteroid ~ placebo
• Some are useful in neuropathic pain
• May help sleep or spasm
• Sedative effects
Interventional
Cervical facet joint
• Facet joint single most common focus – axial pain
• Somatic /referred pain pattern
• No specific clinical or radiological feature
• Easily tested - controlled double blind local anaesthetic nerve block (MBB)
Cervical radiofrequency neurotomy
Technical
• Heating course of nerve to joint
• Under fluoroscopy
• Local anaesthetic
• Specific electrode
• 80 -850 C 2 – 6 lesions 90 sec each
• 1-2 hours
Cervical Radiofrequency Neurotomy
Radiofrequency outcomes
65% Successful– Complete relief > 6 months,
– Complete restoration of ADL
– No need further health care
– Return to work.
80% pts experience 80% reduction in pain
Cervical facet joint – Intra-articular injection
• Under Xray
• LA and corticosteroid
• Short term benefit
• Maybe useful acute and failed medical mx
Cervical epidural corticosteroid injection
• For radicular pain
• Under Xray
• LA and corticosteroid
Interlaminar epidural corticosteroid injection
Poor Evidence available
Effectiveness defined as 50% relief or more, +/- 50% improvement in function
Disc Herniation-1-3 injection; 70% patients good or very good relief –
for 1 year
Manchikanti, L., Nampiaparampil, D. E., Candido, K. D., Bakshi, S., Grider, J. S., Falco, F. J., ... & Hirsch, J. A. (2015). Do cervical epidural injections provide long-term relief in neck and upper extremity pain? A systematic review.
Transforaminal epidural corticosteroid injection
Effectiveness:• 50% patients - 50% relief 1 month; 30% patients by 12 months• Surgery avoided approx 50% in 2 separate studies
Controversies:• 23 reported serious side effects• Recent move away from particulate local anaesthetics
Take Home Message• Useful pain relief for 50% of patients• Second injection dependant on effect of 1st injection• Not a long term repeat therapy
Engel, A., King, W., & MacVicar, J. (2014). The effectiveness and risks of fluoroscopically guided cervical transforaminal injections of steroids: A systematic review with comprehensive analysis of the published data. Pain Medicine, 15(3), 386-402
Surgical Treatment
TREATMENT – CERVICAL DISCECTOMY
• Excellent for rapid relief of severe radicular pain, or symptoms not settling with conservative care
• Trends towards better average resolution of neck and arm pain than conservative treatment
• Gold Standard: ACDF
Anterior Cervical Discectomy and Fusion
• 90% success rate for relieving arm pain
• Traditionally held to be less effective at relieving neck pain
Anterior Cervical Discectomy and Fusion
• 90% success rate for relieving arm pain
• Traditionally held to be less effective at relieving neck pain, but…
ANTERIOR CERVICAL DISCECTOMY AND FUSION TECHNIQUE
• Goal is to remove disc and osteophyte impinging on the foraminal part of the nerve root
• 4-6cm skin incision with dissection through a plane between the midline structures (airway, oesophagus) and the carotid vessels
• Disc is removed and the PLL at the back of the disc space visualised
C4 BODYC5 BODY
POSTERIORLONGITUDINAL LIGAMENT
• PLL taken down
• Dura visable
• Dissection carried out laterally until nerve visualised and free of compression from bone or disc
• Graft inserted
• Plate inserted
• Graft inserted
• Plate inserted
Outcomes
• Rapid relief of radicular pain
• Surgical pain/swelling usually settles quickly
• No noticeable loss of movement for single level.
• Robust procedure – can get back to sedentary work within 2-4 weeks
When to call a patients surgeon
• Wound
– Redness extending further than the immediate wound line
– Expressible Pus/clear fluid
– Fever
• Cauda Equina – call ambulance
• Recurrent or progressive neurology – analgesia and call rooms
CASES
KS Case 1• 48 year old female –
– 4 weeks ago at round about drove into the back of a car
– left / central lower cervical pain with frontal headache that lasts all day
– Type: constant pain, worse at night, aching, occasional sharp pains
• Aggravated: gardening, digging, sitting using computer, rotation
• Eases: heat, massage, analgesia
– VAS 4-7/10
– Nausea with headaches
• No other red flags
• PMHx - Type 2 diabetes, depression/anxiety
• Examination– Cervical ROM - minimal loss right rotation with end range stiffness, end range pain flex, full extension, minimal loss right lateral
flexion - limited by tightness left side
– Palpation right C2/3 reproduced nausea, also tender CT junction
– Normal neurological examination
KS Case 1• 48 year old female –
– 4 weeks ago at round about drove into the back of a car
– left / central lower cervical pain with frontal headache that lasts all day
– Type: constant pain, worse at night, aching, occasional sharp pains
• Aggravated: gardening, digging, sitting using computer, rotation
• Eases: heat, massage, analgesia
– VAS 4-7/10
– Nausea with headaches
• No other red flags
• PMHx - Type 2 diabetes, depression/anxiety
• Examination– Cervical ROM - minimal loss right rotation with end range stiffness, end range pain flex, full extension, minimal loss right lateral
flexion - limited by tightness left side
– Palpation right C2/3 reproduced nausea, also tender CT junction
– Normal neurological examination
GROUP 1:
REFER IMMEDIATELY
GROUP 2:
SPECIALIST REFERRAL
GROUP 3: TRIAL OF TREATMENT
+ INVESTIGATIONS
GROUP 4:
TRIAL OF TREATMENT
GROUP 1:
REFER IMMEDIATELY
GROUP 2:
SPECIALIST REFERRAL
GROUP 3: TRIAL OF TREATMENT
+ INVESTIGATIONS
GROUP 4:
TRIAL OF TREATMENT
KS Case 1• Impression:
– Whiplash injury with referred head pain– mild loss of ROM but normal neurology
• therefore okay to proceed with conservative management
• Treatment
• Education, reassurance• Home exercises – self mobilisation with movement, self traction
– Assisted by mobilisation CT junction right rotation decreased pain / stiffness, mobilisation C2/3 with right rotation increased to full ROM
• 1 week follow up – only one headache which resolved with exercises, ROM improved, only mild stiffness
• 2 week follow up - headaches and stiffness completely resolved – Full ROM painfree –discharged
KL Case 1 - Axial cervical pain and headache
• 53 yr prison officer• Flexion/extension injury assault
2011
• Cervical pain and suboccipital headache
• VAS 3 -10/10; ave 5/10
• Light duties, Poor sleep, ↓ Exercise, ↓Mood
GROUP 1:
REFER IMMEDIATELY
GROUP 2:
SPECIALIST REFERRAL
GROUP 3: TRIAL OF TREATMENT
+ INVESTIGATIONS
GROUP 4:
TRIAL OF TREATMENT
GROUP 1:
REFER IMMEDIATELY
GROUP 2:
SPECIALIST REFERRAL
GROUP 3: TRIAL OF TREATMENT
+ INVESTIGATIONS
GROUP 4:
TRIAL OF TREATMENT
Axial cervical pain and headache
• 53 yr prison officer• Flexion/extension injury assault 2011
• Cervical pain and suboccipital headache• VAS 3 -10/10; ave 5/10
• Light duties, Poor sleep, ↓ Exercise, ↓Mood
• Physical therapies, Panadol, Ibuprofen, Tramadol• Imaging normal
• Not Improving – Now what?
GROUP 1:
REFER IMMEDIATELY
GROUP 2:
SPECIALIST REFERRAL
GROUP 3: TRIAL OF TREATMENT
+ INVESTIGATIONS
GROUP 4:
TRIAL OF TREATMENT
Axial cervical pain and headache
• Diagnostic blocks positive for right C2/3 and C3/4 combined
• RFN Nov 2014
Axial cervical pain and headache
• Stop analgesics, return to full duties• Sustained 16 months;
• Repeat RFN April 2016
DM Case 1
• 44m IT worker
• 2 months hx– Sudden flexion and rotation force across neck when drying back of head with a
towel– Left neck/shoulder pain radiating to dorsum of hand. PN three middle fingers.
VAS 4-7.– No red flags
• Exam: – Mild sensory disturbance Left C7 distribution
GROUP 1:
REFER IMMEDIATELY
GROUP 2:EXPIDITIOUS
SPECIALIST REFERRAL
GROUP 3: TRIAL OF TREATMENT
+ INVESTIGATIONS
GROUP 4:
TRIAL OF TREATMENT
GROUP 1:
REFER IMMEDIATELY
GROUP 2:EXPIDITIOUS
SPECIALIST REFERRAL
GROUP 3: TRIAL OF TREATMENT
+ INVESTIGATIONS
GROUP 4:
TRIAL OF TREATMENT
• Tx:
– Education
– Physio
– Analgesia
• 6 weeks later
– Still symptomatic
GROUP 1:
REFER IMMEDIATELY
GROUP 2:
SPECIALIST REFERRAL
GROUP 3: TRIAL OF TREATMENT
+ INVESTIGATIONS
GROUP 4:
TRIAL OF TREATMENT
GROUP 1:
REFER IMMEDIATELY
GROUP 2:
SPECIALIST REFERRAL
GROUP 3: TRIAL OF TREATMENT
+ INVESTIGATIONS
GROUP 4:
TRIAL OF TREATMENT
• TFI
– Temporary relief of sx only
• Proceeded to ACDF after 7 months of sx
• Postop
– Good relief of neck and arm pain
– Fused well
– Back to work in 4 weeks
– Back to bouncing on trampoline with children at 6 months
DM Case 2
• 61M Mechanic
• 3 months
– Loss of fine motor abilities
– PN both hands
– Gait disturbance
– Minimal neck pain
GROUP 1:
REFER IMMEDIATELY
GROUP 2:
SPECIALIST REFERRAL
GROUP 3: TRIAL OF TREATMENT
+ INVESTIGATIONS
GROUP 4:
TRIAL OF TREATMENT
GROUP 1:
REFER IMMEDIATELY
GROUP 2:
SPECIALIST REFERRAL
GROUP 3: TRIAL OF TREATMENT
+ INVESTIGATIONS
GROUP 4:
TRIAL OF TREATMENT
• 6 weeks post op
– Back at work
– No neck pain
– Better R.O.M
– Improving sensation in hand
– Improved fine motor ability
Thank you