Approaching Neck Pain MCP IPA LBP Task Force

1
Approaching Neck Pain MCP IPA LBP Task Force

• 2009-10

2
MCPIPA Spinal Pain Task ForceCommittee Members
Neck Pain

• Doug Speedie MD Ellen Mead PT
• John Gustavson PhD KC Lewis MD
• Mike Dohm MD Britt Smith PT
• Ellen Price DO Todd Hegstrom MD Cindy Holst
• Consulted Susan Hemley MD, Mike Reeder DO

3
Disclosure Statement

• Dr. D.K. Speedie is a full time employee of Rocky
  Mountain HMC
• He is not on any outside Speakers Bureau
• However, given that he had two kids in college
  AGAIN, he is willing to entertain any offer
• The information in this presentation has been
  evaluated by the Committee for accuracy
• Speedie, however has not

4
Spinal Pain Task Force Mission

• To create Evidence Based Clinical Pathways that
  promotes the effective, efficient and quality
  care of neck low back pain patients
• To recognize those individuals with Red Flag
  Diagnoses

5
Spinal Pain Task Force Mission

• To recognize those individuals with non-specific
  neck pain or low back pain and treat them
  according to evidence based guidelines
• To appropriately treat other forms of neck pain
  and low back pain according to evidence-based
  guidelines, where available.
• Finally, to improve care which is likely to
  reduce overall health costs to the community

6
(No Transcript)
7
Neck Pain Definitions

• Several distinct types and the evaluation and
  treatment is often different. Types include
• Neck Pain with Headache
• Neck Pain with Radiculopathy
• Neck Pain with Myelopathy
• Neck Pain
• Mechanical Neck Disorder
• Whiplash-Associated Disorders
• Vertebral-Basilar Dissection

8
Neck Pain Prevalence

• 12 Month Prevalence of 30-50
• Lifetime Prevalence of 70
• Point Prevalence of 22
• Estimated Incidence of 213 per 1000 per years
• Accounts for 25 of chiropractic visits, 15 of
  PT visits, 2 to family physicians, and 70 of
  musculoskeletal disease seen by rheumatologists
  relates to neck pain

9
Neck Anatomy

• The cervical spine consists of seven vertebrae
  denoted as C1 through C7. The bony anatomy of the
  atlas (C1) and axis (C2) are unique, whereas C3
  through C7 have fairly consistent anatomy

10
Neck Anatomy

• The atlas is a ring, consisting of anterior and
  posterior arches with two lateral masses and
• no vertebral body.

11
Neck Anatomy

• The lateral masses articulate with the skull
  through the occipital condyles and form the
  atlanto-occipital joints supported further by
  occipital membranes.
• The atlanto-occipital joint is responsible for
  approximately 50 of total flexion and extension
  in the neck

12
Neck Anatomy

• The axis consists of two lamina, a spinous
  process, two lateral masses, two pedicles, a
  vertebral body, and the dens or odontoid peg

13
Neck Anatomy

• There is no intervertebral disk between the
  atlanto-occipital joint and atlantoaxial joint
• Without the stability conferred by a disk, the
  area is often involved by destructive
  inflammatory arthritides, which may result in
  instability.
• The axis articulates with the vertebra above and
  below through the superior and inferior facets

14
Neck Anatomy

• Posteriorly, the axis has a large spinous
  process, which can be easily palpated just below
  the occiput.
• The atlantoaxial articulation also provides
  approximately 50 of rotatory motion of the
  cervical motion.

15
Neck Anatomy

• C3 through C7 vertebrae all have fairly similar
  anatomy.
• Each vertebra consists of a body, two
  interconnecting pedicles, two lateral masses, two
  transverse processes, two laminae, and a spinous
  process.
• The transverse and spinous processes project
  outward, providing attachment for ligaments and
  muscles and creating a moment arm to facilitate
  motion.

16
Neck Anatomy
17
Neck Anatomy

• The spinous processes of C3 through C6 are bifid,
  whereas the C7 spinous process usually is not.
• The C7 spinous process is large, however, and the
  next most prominent and easily palpable spinous
  process below C2.

18
Neck Anatomy

• There are five articulations between each
  vertebra from C2 through C7, including the
  intervertebral disk, two uncovertebral joints,
  and two facet joints.

19
Neck Anatomy

• Uncovertebral joints are formed between uncinate
  process above, and uncus below
• Two lips project upward from the superior surface
  of the vertebral body below, and one projects
  downward from the inferior surface of vertebral
  body above
• This is not a synovial joint.

20
Uncovertebral joints
21
Cervical Nerves

• The first cervical nerve emerges from the
  vertebral canal between the occipital bone and
  the atlas, sometimes called the suboccipital nerve

22
Cervical Nerves

• There are eight cervical nerves (C1-C8). All
  nerves except C8 emerge above their corresponding
  vertebrae, while the C8 nerve emerges below the
  C7 vertebra. (In the other portions of the spine,
  the nerve emerges below the vertebra with the
  same name.)

23
Basic Principles of Neck Pain Management

• History and physical exam to exclude Red Flag
  symptoms
• Physical exam for neurologic screening
• Diagnostic triage into broad categories mentioned
  previously
• Judicious use of diagnostic imaging
• Use interventions with proven efficacy
• Non-invasive approaches for most Neck Pain

24
What are the Red Flags?

• Fever or Chills
• Unintentional weight loss
• History of osteoporosis or cancer with high risk
  of metastasis
• Increasing neurological deficit
• I V Drug Use
• Inflammatory arthritis, RA or Ankylosing
  Spondylitis
• Intractable pain

25
Neck Disorder with Headache (NDH)

• It has recently been accepted that cervical spine
  structures, particularly those innervated by the
  upper three cervical nerves, have the capacity to
  refer pain into the head and cause neck pain and
  headache.

26
Neck Disorder with Headache

• The possible sources of cervicogenic headache are
  the joints, ligaments, muscles, dura, and
  arteries innervated by the upper three cervical
  nerves
• There is no evidence that specific MRI findings
  are associated with neck pain, cervicogenic
  headache, or whiplash exposure

27
NDH Treatment

• Multimodal therapy for NDH has the most benefit
  including Mobilization/ Manipulation, Stretching
  exercise and coordination and strengthening
  exercise
• Should be done by physical therapists
• At-home treatment is not of significant benefit.

28
NDH Treatment

• Exercise alone, medication, massage, acupuncture
  and orthopedic pillows have some benefit.
• Botox, home exercise, manipulation alone, static
  traction and have not been shown to be of any
  benefit.
• Surgery has no place in the treatment of NDH

29
Neck Pain with Radiculopathy

• Cervical radiculopathy is characterized by
  dysfunction of a cervical spinal nerve, the roots
  of the nerve, or both.
• Patients present with pain in the neck and one
  arm, with a possible combination of sensory loss,
  loss of motor function, or reflex changes in the
  affected nerve-root distribution

30
Neck Pain with Radiculopathy

• Annual incidence rate of 107.3 per 100,000 for
  men and 63.5 per 100,000 for women,
• Peak at 50 to 54 years of age.
• History of physical exertion or trauma preceded
  the onset of symptoms in only 15 percent of
  cases.

31
Neck Pain with Radiculopathy

• Study from Rochester MN-- 26 percent of 561
  patients with cervical radiculopathy underwent
  surgery within three months of the diagnosis
• Recurrence, (reappearance of symptoms of
  radiculopathy after a symptom-free interval of at
  least 6 months) occurred in 32 percent of
  patients during a median follow-up of 4.9 years.

32
Neck Pain with Radiculopathy

• 90 percent of the patients had normal findings or
  were only mildly incapacitated owing to cervical
  radiculopathy.
• Most common cause (in 70 to 75 percent of cases)
  is foraminal encroachment of the spinal nerve
  including decreased disc height and degenerative
  changes of the uncovertebral joints anteriorly
  and facet joints posteriorly

33
(No Transcript)
34
Neck Pain with Radiculopathy

• In contrast to disorders of the lumbar spine,
  herniation of the disc is responsible for only 20
  to 25 percent of cases
• Other causes, including tumors of the spine and
  spinal infections, are infrequent.
• The nerve root that is most frequently affected
  is the C7, followed by the C6.

35
(No Transcript)
36
Spurlings Maneuver

• Spurlings Maneuver Spine extended with head
  rotated to affected shoulder while axially loaded
  
• Sensitivity 30-50, but specificity 92-95

37
Neck Pain with Radiculopathy

• MRI is the imaging approach of choice
• No clear guidelines as to when imaging is
  warranted.
• Reasonable indications include the presence of
  symptoms or signs of myelopathy, significant
  neurologic loss, or
• Red flags suggestive of tumor or infection, or
  the presence of progressive neurologic deficits
• It is appropriate to limit the use of MRI to
  those who remain symptomatic after four to six
  weeks of nonsurgical treatment

38
Neck Pain with Radiculopathy

• As with Low Back Pain, there is a high frequency
  of abnormalities detected on MRI in asymptomatic
  adults
• Disk herniation or bulging (57 percent of cases)
• Spinal cord impingement (26 percent)
• Cord compression (7 percent)
• Carette, NEJM, 2005

39
Radiculopathy Treatment

• Multimodal therapy including Mobilization,
  Manipulation, Stretching exercise and
  Coordination and Strengthening exercise
• Epidural Steroids Injections (ESI)
• Medication, acupuncture and orthopedic pillows
  have some benefit
• Traction has little benefit

40
ESI

• ASIPP states that the level of evidence for
  cervical intralaminar epidural steroid injections
  is level II-1 (controlled trials w/o
  randomization) and the recommendation for its use
  is 1C strong.
• The Bone and Joint Task Force agrees that there
  is evidence supporting short-term symptomatic
  improvement of radicular symptoms in patient's
  when treatment involves a short course of
  epidural or selective root injections with
  corticosteroids

41
Radiculopathy Treatment -Surgery

• It is not clear that long-term outcomes are
  improved with surgical treatment of cervical
  radiculopathy compared to non-operative measures
• However, relatively rapid and substantial pain
  and impairment relief after surgical treatment
  seems to be reliably achieved.

42
Radiculopathy Treatment - Surgery

• Most surgeries for disc disease in the neck are
  accompanied by fusion as removing the disc in the
  neck typically results in native fusion.
• Fusion results in adjacent joint arthritis and
  further limits ROM
• Results from cervical disc arthroplasty for
  radicular symptoms seem to show outcomes similar
  to discectomy and fusion but long-term viability
  has not been demonstrated

43
Radiculopathy Treatment - Surgery

• The PRESTIGE Cervical Disc is a metal-on-metal
  design (stainless steel).
• Concern with the artificial cervical discs is
  that they may have to be in place 40 years and
  the longest studies to date are at 2 years.
  Ongoing studies are taking place out to 7 years.
  RMHP does not cover

44
Prodisc -C

• More difficult revision with keeled device
• Persistent or recurrent neural compression
  because osteophytes do not resorb as they do with
  fusion
• Sagittal splitting vertebral fracture

45
Neck Pain with Myelopathy

• Dysfunction of the spinal cord is termed
  myelopathy.  The usual sources of this
  dysfunction include cervical stenosis from
  osteoarthritis and herniated discs
• Occasionally, an acute disc can herniate
  centrally and cause a myelopathy. If left
  untreated, the effects can be irreversible.

46
Neck Pain with Myelopathy
47
Cervical Spondylotic Myelopathy

• Cervical spondylotic (osteoarthritic) myelopathy
  (CSM) is the most common spinal cord disorder in
  persons more than 55 years of age
• There are three important pathophysiologic
  factors in the development of CSM (1) Static
  mechanical Static mechanical factors result in
  the reduction of spinal canal diameter and spinal
  cord compression. (2) Dynamic mechanical and (3)
  Spinal cord ischemia

48
Cervical Spondylotic Myelopathy

• Static mechanical disc hardening and
  degeneration, osteophytic spurring and the
  ligamentum flavum may stiffen and buckle into the
  spinal canal
• Dynamic Mechanical Factors with flexion, the
  spinal cord lengthens, thus stretching over
  ventral osteophytic ridges.

49
Cervical Spondylotic Myelopathy

• Dynamic Mechanical Factors During extension, the
  ligamentum flavum may buckle into the spinal cord
  causing a reduction of available space for the
  spinal cord
• Spinal cord ischemia probably plays a role in
  the development of CSM, particularly in later
  stages
• Other associated factors include heavy labor,
  posture and genetic predisposition

50
Cervical Spondylotic Myelopathy
51
Cervical Spondylotic Myelopathy (CSM) Symptoms

• In the early stages of CSM, complaints of neck
  stiffness are common because of the presence of
  advanced cervical spondylosis
• Other symptoms include crepitus in the neck with
  movement
• Stabbing pain in the arm, elbow, wrist or
  fingers or a dull "achy" feeling in the arm and
  numbness or tingling in the hands.

52
Cervical Spondylotic Myelopathy Symptoms

• The hallmark symptom of CSM is weakness or
  stiffness in the legs
• Symptoms may be asymmetric particularly in the
  legs
• Unsteadiness of gait
• Weakness or clumsiness of the hands
• Slight hesitancy on urination

53
Cervical Spondylotic Myelopathy Signs

• Atrophy of the hand musculature
• Hyperreflexia
• Lhermitte's sign (electric shock-like sensation
  down the center of the back following flexion of
  the neck)
• Sensory loss particularly proprioception or
  vibratory in the extremities may be asymmetrical
• Gait abnormalities
• Hoffman and Babinski reflexes should also be
  assessed.

54
Hoffmans sign

• The test involves tapping the nail or flicking
  the terminal phalanx of the third or fourth
  finger. A positive response is seen with flexion
  of the terminal phalanx of the thumb
• Often considered the upper limb equivalent of the
  Babinski's sign

55
Neck Pain with MyelopathyDiagnostic Testing

• MRI of the cervical spine is the procedure of
  choice during the initial screening process of
  patients with suspected myelopathy.
• Electrical testing is rarely useful in most
  patients with myelopathy however, it may help in
  the exclusion of specific syndromes such as
  peripheral neuropathy

56
Cervical Spondylotic MyelopathyNatural History

• Evaluating the efficacy of any particular
  treatment strategy for CSM is difficult
• As many as 18 percent of patients with CSM will
  improve spontaneously
• 40 percent will stabilize
• Approximately 40 percent will deteriorate if no
  treatment is given.
• No way to predict

57
Myelopathy Surgical Indications

• Multilevel spondylotic myelopathy, as evidenced
  by ANY ONE of the following
• Clinical symptoms of myelopathy examples
  include
• Clumsiness of hands
• Urinary urgency
• Bowel or bladder incontinence
• Frequent falls

58
Myelopathy Surgical Indications

• Clinical signs of myelopathy examples include
• Hyperreflexia
• Hoffmann sign
• Increased tone or spasticity
• Loss of thenar or hypothenar eminence
• Gait abnormality
• Positive Babinski sign

59
Mechanical Neck Pain

• Muscle strain is the most common cause of neck
  pain followed by ligamentous sprain
• Like the Low Back, these probably account for 85
  of cases presenting in the office
• Acute muscle-mediated pain can be subdivided into
  delayed onset muscle soreness (DOMS) and muscle
  contusion, which occur after direct tissue
  trauma.

60
Mechanical Neck Pain

• Almost everyone will experience DOMS at some time
  in their life.
• Usually occurs after unusual physical activity.

61
Mechanical Neck Pain
.

• The symptoms usually appear 24 to 48 hours after
  such activity and abate completely within several
  days
• The mechanism of this type of muscle injury
  consists of excessive eccentric muscular
  contraction

62
Mechanical Neck Pain

• When a direct and forceful compression is applied
  to a muscle, as occurs commonly during sports
  participation, muscle contusion may develop.
• The trauma produces local tissue necrosis,
  cellular death, extravasation of blood into the
  tissues, and secondary inflammatory response
• Uncommon cause of neck pain. More typical of
  extremities

63
Mechanical Neck Pain

• Likewise, ligamentous injury not only is limited
  to pathologic elongation (sprain) but also can be
  classified further as a partial or a complete
  tear.
• Ligamentous sprains are produced by forceful,
  passive stretching beyond the physiologic range
  or with strong muscular contractions
• If there are no Red Flags, there is no reason to
  image these people

64
Mechanical Neck Pain - Treatment

• None or
• Multimodal therapy including Mobilization,
  Manipulation, Stretching exercise and
  Coordination and Strengthening exercise
• Massage, Electrotherapy, Low-level laser therapy,
  Orthotic pillow, Acupuncture all have some
  evidence
• Surgery is not indicated

65
Whiplash Associated Disorder (WAD)

• Whiplash is defined as an acceleration-deceleratio
  n mechanism of energy transfer to the neck.
• The current model of injury ? bodys inertial
  response causing the head neck to undergo large
  amounts of displacement without any direct
  impact.
• The most recent data from the US suggest that
  this injury costs 29 billion yearly.

66
Whiplash Associated Disorder (WAD)

• Rear end impact ? patient's torso is rapidly
  carried forward.
• Movement ? development of the S shaped cervical
  curve forcing C-spine into an abnormal,
  non-physiologic motion of lower extension and
  upper flexion

67
Whiplash Associated Disorder (WAD)

• The reverse occurs with a front end impact.
• Motion has been shown to produce elongation and
  failure strain of the facet capsule and ligaments
  at the C6-7 level during the initial S-shaped
  phase.
• May be facet joint spearing of the superior facet
  on the inferior articular facet as well as
  stretching of the anterior ligamentous tissues

68
Whiplash Associated Disorder (WAD)

• May be a variety of unique injuries involving the
  spinal dorsal ganglia, and intervertebral disks.
• Location of the dorsal root ganglia and nerve
  roots and render them vulnerable to excessive
  stretching
• There may be hemarthrosis, capsular tears,
  articular cartilage damage, joint fractures and
  capsular rupture.

69
Whiplash Associated Disorder (WAD)

• Ligamentous injuries in the mid and lower
  cervical segments may also contribute to
  development of the persistent symptoms.
• There may be strains in the superficial posterior
  neck muscles.

70
Whiplash Associated Disorder (WAD)

• Mechanical tissue injury has been shown to create
  local and systemic inflammation ? profound
  changes in muscle tissue.
• There are a may also be denervation contributing
  to the muscular degeneration.

71
Whiplash Associated Disorder (WAD)

• Most individuals recover within two to 3 weeks
• A number of individuals with this injury will
  sustain longer problems with the injury.
• Symptoms of whiplash injury may include pain,
  dizziness, visual and auditory disturbances,
  photophobia, fatigue, cognitive difficulties such
  as concentration and memory loss, anxiety,
  insomnia and depression.

72
WAD

• The Québec Task Force categorizes WAD into 4
  groups
• WAD I Stiffness or tenderness in the neck no
  physical signs of a injury
• WAD II Stiffness or tenderness, some physical
  signs of injuries such as point tenderness or
  trouble turning the head
• WAD III stiffness or tenderness and neurologic
  signs
• WAD IV fracture or dislocation of the neck.
• The problem with his classification scheme is
  that virtually everyone requiring treatment will
  be a WAD II.

73
Proposed classification Physical/Psychological Impairment
WAD 0 No complaint about neck pain No physical signs
WAD I Neck pain, complaints of pain/stiffness/tenderness only No physical signs
WAD II A Neck pain Motor Impair ? ROM, Altered Muscle recruitment (CCFT) Sensory Impair Local cervical mechanical hyperalgesia
WAD II B Neck pain Motor Impair ? ROM, Altered Muscle recruitment (CCFT) Sensory Impair Local cervical mechanical hyperalgesia Psych. Impair ? Psychological distress (GHQ-28, TAMPA)
74
Proposed classification Physical/psychological Impairment
WAD II C Neck pain Motor Impair ? ROM, Altered muscle recruitment ? Cranio-cervical flexion test (CCFT), ? Joint position error (JPE) Sensory Impair Local cervical mechanical hyperalgesia, Generalized sensory hypersensitivity (mechanical, thermal, (BPPT)) Some may show Sympathetic Nervous System (SNS) disturbances Psych. Impair ? Psychological distress (GHQ-28, TAMPA), ? Elevated levels of acute post-traumatic stress ? Impact of Event Scale (IES)
WAD III Motor Impair ? ROM, Altered muscle recruitment (CCFT) ? JPE Sensory Impair Local cervical mechanical hyperalgesia, Generalized sensory hypersensitivity (mechanical, thermal, BPPT) Some may show SNS disturbances Psych. Impair ? psychological distress (GHQ-28, TAMPA), ? Elevated levels of acute post-traumatic stress (IES) Neurological signs of conduction loss ? DTRs, muscle weakness, Sensory deficits
75
Proposed Classification Physical Psych. Impairments present
WAD IV Fracture or dislocation
76
Whiplash Associated Disorder (WAD)

• Significant presenting findings include loss of
  active cervical ROM
• Measurements of ROM discriminate between patients
  with persistent whiplash associated disorder
  compared to those with no further problems ?
  sensitivity of 86.2, specificity of 95.3.

77
Whiplash Associated Disorder (WAD)

• Loss of balance and disturbed neck influenced
  eye-movement control are present in chronic WAD
• Vestibular control mechanisms utilize neck
  musculature for balance and the mechanisms may be
  damaged by the whiplash injury

78
Whiplash Associated Disorder (WAD)

• Whiplash injuries may also present with
  widespread sensory hypersensitivity to a variety
  of stimuli including pressure and thermal.
• Hypersensitive responses suggest augmented
  central pain processing mechanisms.
• Cold hyperalgesia in sympathetic nervous system
  changes could also indicate peripheral nerve
  injury/involvement.

79
Whiplash Associated Disorder (WAD)

• Initial pain and functional disability levels ?
  useful in the prediction of those at risk for
  transitioning from acute to chronic.
• High pain and disability levels with physical and
  psychological factors, including early presence
  of ?cervical movement, cold temperature
  hyperalgesia, and PTSD symptoms are all strong
  predictors of poor outcome.

80
Whiplash Associated Disorder (WAD)

• There may be significant psychological factors in
  chronic whiplash pain including affective
  disturbances, anxiety, depression, and behavioral
  abnormalities such as fear of movement.
• Some of the psychological factors and mental
  function abnormalities may be the result of
  traumatic brain injury.

81
Whiplash Associated Disorder (WAD)

• Though there is typically no direct blunt force
  trauma to the head, the acceleration
  deceleration portion of the injury may cause a
  coup-contrecoup phenomenon.

82
Whiplash Associated Disorder (WAD)

• Without the direct blunt force trauma, TBI may
  not be as readily apparent.
• Given that these may be severe accidents, there
  may be significant risk of posttraumatic stress
  disorder as well which has been shown to increase
  the risk of chronic WAD

83
Whiplash Associated Disorder (WAD)

• Clinical evaluation should aim to identify the
  presence of physical and psychological
  impairments
• Measure cervical active range of motion
• Specific sensory assessments ? no current
  consensus about the most appropriate testing
  mechanisms.
• MRI is not useful

84
Whiplash Associated Disorder (WAD) Treatment

• Physical rehabilitation
• Psychological support and possibly
  neuropsychological evaluation
• Pharmacological pain management
• Surgical intervention not useful

85
Vertebral-Basilar Dissection

• Often presents as strictly neck pain making
  diagnosis challenging, however, if the following
  symptoms occur consider immediate referral.
  Female to male ratio 31, average age 40
• Dizziness (vertigo) and Disequilibrium
• Dysesthesia, (facial)
• Dysphagia
• Diplopia
• Dysarthria

86
Handouts

• Algorithm The Committees recommended approach
  to neck pain presenting in the office
• Template The Committees recommended approach
  to the History and Physical. Can be used in a
  paper chart or the basis of a template for an
  EMR.

87
Physical Exam

• Gait abnormality _________________ Palpation
  for spinal tenderness _________
• Complete with of Normal
• ROM Flexion_____Extension_____
• R Rotation_____L Rotation_____

88
Physical Exam

• Strength Testing
• R L
• Handgrip
• Finger Abduction
• Wrist Extension  
• Biceps
• Triceps
• Deltoid

• Inspection for Atrophy
• R L 
• Biceps
• Triceps
• Deltoid
• Hand
• Forearm

89
Physical Exam

• Reflexes
• Biceps R L Triceps R L
• Hoffmans
• Babinskis
• Spurlings sign

90
Handouts

• Physical Findings Associated with Specific
  Cervical Radiculopathy Reference for the
  specific findings of the various levels that are
  seen with cervical radiculopathy.
• Dermatome Map Reference for the specific
  dermatomes
• Neck Disability Index Essentially the Oswestry
  for the neck. Useful in assessing for Yellow
  flags as well as following progress in the neck
  pain patient

91
Approaching Neck Pain MCP IPA LBP Task
ForceThe END

• 2009-10