Dr Keith Laubscher Mr Dean Mistry Katy Street Pain Specialist - - PowerPoint PPT Presentation

Dr Keith Laubscher

Pain 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 Mistry

Orthopaedic Spine Surgeon Auckland

Katy Street

Physiotherapist 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 Subacute 6 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/Radiculopathy Myelopathy

• 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 see when 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 Factors Severe, worsening pain Septicemia – febrile, neck pain Catastrophic neurological changes Sphincter loss Saddle/perianal anaesthesia Progressive neurological deterioration High energy trauma or trauma with neurological sx Pathologies Infection with systemic toxemia High likelihood of spinal tumour Unstable Fractures/Spinal Cord Injury Carotid 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 for Spinal 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 +/- infection NOT routinely When to add in Blds? If you suspect infection, or tumour FBC/ESR/CRP ALP, 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 factors Manageable radicular pain Xrays = fracture, tumour, or infection Blds = 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

• f 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
• steophyte impinging on the

foraminal part of the nerve root

• 4-6cm skin incision with dissection

through a plane between the midline structures (airway,

• esophagus) and the carotid vessels
• Disc is removed and the PLL at the

back of the disc space visualised

C4 BODY C5 BODY POSTERIOR LONGITUDINAL 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