Benjamin Bonte MD Interventional Pain Fellow Hudson Spine amp Pain Medicine 10112017 Cervical Spine Disorders Anatomy Cervical Spondylosis Facet pain Myofascial pain Cervical radiculopathy ID: 701133
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Slide1
Neck Pain: Treatment of Cervical Spine Pain
Benjamin Bonte, MD
Interventional Pain Fellow
Hudson Spine & Pain Medicine
10/11/2017Slide2
Cervical Spine Disorders
Anatomy
Cervical Spondylosis
Facet pain
Myofascial pain
Cervical radiculopathy
Cervical myelopathy
Modalities/other considerationsSlide3
Anatomy
7 cervical vertebrae
Atlas/axis, C3-7
Extension
Occipital C1 junction, C1/C2
Lateral bendingC3-5 levelsAxial rotationC1-2 levelSlide4
ALL
PLL
Ligamentum Flavum
Interspinous ligament (midline)
Supraspinous ligamentSlide5Slide6
C2/3 – Third occipital nerve
C3 to T1Slide7
Cervical Spondylosis
Characterized by disc height loss, endplate spurring,
uncoverterbral
joint hypertrophy, facet joint hypertrophy and ligamentum hypertrophy
Most common at C5-6 levelSlide8
Facet joint pain
Pain related to synovial capsule nociceptors
Imaging may show facet hypertrophy, MRI with synovial capsule enlargement*Slide9
Medial Branch BlocksSlide10
Medial Branch Blocks
Targets at articular pillar
C7 – apex of SAP
C2/3 –multiple locations needed for blockingSlide11
Cervical RFASlide12
Evidence?
Significant benefit over sham
Length to 50% return in pain?
8 vs 263 d.Slide13
Cervical Radiculopathy
Hx
, PE (reflexes, strength testing, sensation)
Spurling’s maneuver is most sensitive and specific test
Butler test (SLR of the upper limb)
Rule out imitatorsSlide14
Dynatomal
maps (referred pain)Slide15
Cervical Radiculopathy
Foraminal stenosis due to facet hypertrophy or disc herniation.
MRI – axial view is more useful due to oblique angle of exit.
EMG – assists with localizing lesionSlide16Slide17
C7-T1 has largest epidural space relative to the dura and spinal cord.
Ligamentum flavum has lower failure to fuse rate a this level
Lateral view may be impossible due to shoulder
Contralateral oblique can be used to assess depthSlide18
Cervical TFESI
Bad publicity
Avoid particulate steroid
inj
into feeder vessels of VA or ASA (use dexamethasone)
Hit anterior SAP then walk off, stay posterior, inferior.Digital subtraction angiography strongly advisedSlide19
Evidence?
PT
Saal&Saal
study
Observational trial
24/26 patients with radiculopathy and neurologic loss who underwent nonsurgical treatment (sensation+)
20/24 had good or excellent outcome.
Medications
NSAIDS
Oral steroids
Very little evidence for efficacy in cervical
Kaiser study shows good evidence in lumbar
radiculopathyies
for functional improvement but not in terms of pain.Slide20
Evidence?
ILESI and TFESI both have evidence for treating radiculopathy.
ILESI has RCTs to support this, whereas TFESI has descriptive studies.
Stav
1993
Better pain reduction in ESI group than local anesthetic
inj
Better outcomes at 1 year and 1 year.
Both ILESI and TFESI have limited evidence in treatment of axial neck pain.Slide21
Cervical Myofascial Pain
Can give referral patterns similar to facet joint referral patterns
X-ray may show straightening of cervical spineSlide22
Trigger points
Tender point that causes referred pain
Nelemans
PJ, de
Bie
RA, de Vet HCW, et al: Injection therapy for subacute and chronic benign low-back pain (Cochrane review),
Cochrane Database
Syst
Rev
(2), 2000, CD001824.
When targeting trigger points, Dry needling, lido, lido + steroid all superior to placebo injectionsSlide23
Cervical Myelopathy
Insidious weakness, bowel/bladder changes
PE: test for Hoffman’s sign, spasticity, clonus, Babinski.
Risk factors: cervical stenosis - congenital, degenerative, HNP.
MRI is test of choice – assess for spinal fluid around cord.
Torg
ratio (diameter of canal to vertebral body) on XR is out of favor. Although sensitive, it has low predictive value for symptomatic cervical stenosis.
Laminectomy indicated for
Multilevel
spondylotic
myelopathy
Spondylotic
myelopathy with congenital canal stenosis.Slide24
Stingers
Neurapraxia of the brachial plexus
usually after sport injury causing transient stretching.
Younger athletes – presents similar to brachial plexopathy, generally involving upper trunk/C5
Older athletes – may present similar to nerve root
impingment
Generally self-resolvesSlide25
Special Considerations
Cervical Manipulation
Stroke associated with VA dissection – 275 cases in literature since 1925
No reliable risk factor to identify those at risk from spine manipulation
Risk for VA dissection in general: Migraine, hypertension, OCP, smoking
Lack of ROM testing prior, and use of high-amplitude, high-velocity, high force thrust associated with all accidents in a German studySlide26
Special Considerations
Cervical Traction
Head in 20-30 degrees of flexion, 25
lbs
of force applied.
Some evidence that this can treat cervical radiculopathies.Evidence does not support/efficacy is unknown for axial neck pain.Slide27
Special Considerations
Massage
Very difficult to study due to different techniques and lack of a standardized sham treatment.
At least one large RCT supports the use of massage
in the treatment of
Anxiety/stress
Arthritis
Fibromyalgia
Lymphedema
Whiplash
Sleep disorders
Contraindications – area of malignancy, cellulitis, trauma, bleeding, DVT/atherosclerotic plaques
Caution – anticoagulation/bleeding disorder, osteoporosis, low BP,
hx
physical abuse