dr keith laubscher mr dean mistry katy street north/sun_room2_0815_mistry_neck...dr keith laubscher...

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%

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

• 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

• 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



• C7 – Triceps



Wrist extension

Neuro - Motor

• C4 – n/a



• C7 – Triceps



Finger Extension

Neuro - Motor

• C4 – n/a



• C7 – Triceps



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


+ 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


+ INVESTIGATIONS

GROUP 4:

TRIAL OF TREATMENT

GROUP 1:

REFER IMMEDIATELY


+ 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


+ 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


+ INVESTIGATIONS

GROUP 4:

TRIAL OF TREATMENT

GROUP 1:

REFER IMMEDIATELY

GROUP 2:EXPIDITIOUS

SPECIALIST REFERRAL


+ 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


+ INVESTIGATIONS

GROUP 4:

TRIAL OF TREATMENT

GROUP 1:

REFER IMMEDIATELY

GROUP 2:EXPIDITIOUS

SPECIALIST REFERRAL


+ INVESTIGATIONS


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

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

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


+ 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


+ 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


+ INVESTIGATIONS

GROUP 4:

TRIAL OF TREATMENT


• Diagnostic blocks positive for right C2/3 and C3/4 combined

• RFN Nov 2014


• 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


+ INVESTIGATIONS

GROUP 4:

TRIAL OF TREATMENT

• Tx:

– Education

– Physio

– Analgesia

• 6 weeks later

– Still symptomatic

GROUP 1:

REFER IMMEDIATELY

GROUP 2:

SPECIALIST REFERRAL


+ 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


+ 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

dr keith laubscher mr dean mistry katy street north/sun_room2_0815_mistry_neck...dr keith laubscher...

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