non-operative management of cervical radiculopathy matthew r. doyle, ms, atc, lat
TRANSCRIPT
Non-Operative Management of Cervical RadiculopathyMatthew R. Doyle, MS, ATC, LAT
Why this topic?
Wrestling and Neck Injuries In the past a lack of quality information on
managing Cervical Radiculopathy (CR)
Goals
Update self, others on current evidence and best clinical practices Paper with Clark, Rosenquist, McKinley
Discuss amongst colleagues, gain consensus for future cases at Iowa, multi-disciplinary approach
Body Sites of Wrestling Injuries
Knee Shoulder Head/Face
Trunk Hip/Leg Ankle Neck0
5
10
15
20
25
30
Yard, 2008 AJSM
College Time Loss Injuries
Iowa Wrestling Cervical Disorders August 2002 to current 56 total problems and cases Minor= strains, sprains, facet syndrome,
mechanical neck pain 10 caused time loss of greater than one week 9 cervical radiculopathy, one brachial plexus
traction injury 3 cases to examine
Define the Problem
Neck Disorders classification problems
Childs, 2004
SIMS by anatomy List of diagnosis: facet syndromes, HNP, hard
disc, soft disc, Mechanical neck pain, CR, neuropraxia, brachial plexopathy, spondylosis, jammed neck, stingers, myelopathy, Spinal Cord Neuropraxia
Focus today on cervical radiculopathy
Cervical Radiculopathy
Disease process marked by spinal or nerve root compression or irritation
Numbness, sensory and reflex deficits, or motor dysfunction in affected nerve root distribution May be crossover between myotomes/dermatomes
Impingement may produce neck, upper trapezius, interscapular, shoulder girdle, and unilateral radiating arm pain
• Combination of above and changes in acute to chronic
Pathoanatomy
Inflammatory mediators, changes in vascular response, intraneural edema, hypoxia Cervical spondylosis (70-75% of cases)
decreased disc height space, degenerative changes at uncovertebral and facet joints
Herniated nucleus pulposus (20-25%) Tumors, infection
Clinical Diagnosis
No universally accepted criteria for the diagnosis of CR.
Wainner, 2000
Proposed guidelines to treat low back pain may be applied to neck pain and CR.
Carette, 2005
Match imaging to clinical signs
Cervical Radiculopathy
Clinical Diagnosis, unknown diagnostic accuracy
Can’t determine prognosis, risk factors, or effective interventions
Called for definitive diagnostic criteria and terms Homogeneous groups No evidence for any single intervention
Wainner, 2000 Literature review
Tx Cervical DDD
Pain generators, anatomical reference Mechanical Neck Pain (facet and disc joint) CR, myelopathy and stenosis
CR caused by disc herniations Rest, immobilization, NSAIDS, traction, Physical
Therapy Narayan, 2001 and Zmurko, 2003
Rehabilitation
Phased progression for syndromes Education, posture corrective exercises and
stretching Beazell, Magrum, 2003
Algorithm of progressive intervention Nonspecific treatments Included ESI, TENS, acupuncture
Saal, 1996
Clinical Prediction Rule
Test Item Cluster, 4 positive exam findings Spurling, upper limb tension, cervical
distraction tests >60 deg rotation toward symptomatic side
Wainner, 2003
Multi-modal Treatment Approach Case study of CR patients
Manual physical therapy Cervical lateral glide mob in upper limb neurodynamic position
Mechanical intermittent cervical traction (ICT) (15 min) 18 lbs, 30 sec on and 12 lbs, 10 sec
Strengthening Cervical Stabilization Exercises (deep neck flexor) scapulothoracic strengthening
Screened in using CPR Series suggests this tx approach may be appropriate for CR
patients
Cleland, et al. 2005
Multi-modal Intervention Approach
Case series of CR patients ICT, Thoracic thrust joint manipulation Cervical stabilization exercises and ROM Posture education Used Clinical Prediction Rule
Possible that this approach can improve symptoms and functional outcomes
Waldrop, 2006
Multi-modal Intervention
• RCT, MNP patients w and w/o unilateral UE symptoms Manual physical therapy targeted to
impairments Joint mobilization, thrust and non-thrust Muscle energy Stretching
Home exercise program, deep flexors and ROM Outcomes support previous RCT w/ MNP
Walker, Boyles, et al. 2008
Treatment
Natural history, favorable prognosis long term Non-operative Management is effective Little high quality evidence on the best non-
operative therapy for CR Multimodal approach may alleviate
symptoms
Interventions for CR
Some but few RCT, systematic reviews Largely case studies and anecdotal
experience Clinical Practice Guidelines
Nonsurgical Management
Pharmacotherapy for tx low back Analgesics, NSAIDS, muscle relaxants,
antidepressants, anticonvulsants for CR anecdotal, no RCT Effexor, ultram, oral steroids
Epidural injections of corticosteroids (ESI) Retro and prospective cohort studies reporting
favorable results, complications?
Nonsurgical Management
Education –may help some, systematic review says no benefit.
Haynes 2009.
Short term immobilization, soft collar Cervical Traction Exercise therapy seems appropriate, not
supported Modalities may be beneficial Manual Therapies, manipulation and
mobilization
Cochrane Reviews
Exercises for mechanical neck disorders, 2009 Unclear, strength, stretch Strong evidence for multi-modal care
Patient education for neck pain, 2009 Unclear
Mechanical traction for neck pain, 2010 Doesn’t support or refute
Electrotherapy for neck pain, 2010 Very low quality of evidence TENS effective
Acupuncture for neck disorders, 2010 Moderate evidence of effect MNP and chronic CR
Massage for mechanical neck disorders, 2007 (not Cochrane)(systematic review in Spine) No recommendations
Case Study 1
College Wrestler (2nd yr) reports neck pain while strength training in September Tx with e-stim, ice, heat, massage, traction, joint
mobilization, isometric strengthening, 4 way neck strengthening, soft collar, gradual functional progression
Lumbar Disc Bulge the next season (3rd yr) December of 4th season treated for facet sprain
Heat, traction, joint mobilization, ice massage, protection with soft collar and partner selection
Seeks chiropractic care January
C-7 Nerve Radiculopathy
April of same year while wrestling noticed pain and weakness in his left arm
Tricep weakness and hand was tingly, neck/scapular pain
MRI multilevel degenerative changes in discs disc osteophyte complex at C6-C7 level on left
side causing moderate narrowing of neural foramen
Cervical Herniated Disc
Acute treatment with ice, heat, e-stim, NSAIDs Referred to Pain Clinic for epidural steroid
injection mid-April No wrestling, stiff collar for machine strength
training 10 lbs restriction to lift with no valsalva Aqua therapy, non-impact cardio Address UE weakness with specific resistance
exercises, t-bands, machines, dumbells
Summer Break
May no pain in left arm, no neck pain, no
numbness or tingling Dramatically improved strength in triceps Negative Spurling, full neck ROM No additional ESI Weight lifting restriction to 20 lbs.
Summer Training
June Asymptomatic and allowed to resume
strength training with no weight restrictions Begins gradual, progressive functional return Plan to resume live wrestling in 6 weeks Aug 28 cleared to full return
Case Study 2
22 y.o. college wrestler has stinger while wrestling
Reports event several days later Reports mild neck pain, normal cervical
ROM, wants to continue wrestling but notices arm weakness
No previous neck problems Treated with activity modifications
Case 2
4 weeks later has 4/5 tricep strength MRI to evaluate for disc affecting C7 nerve
root Impression: No evidence of cervical spine
injury or acute abnormality Short pedicles present resulting in congenital
narrow AP dimension of the central canal
Case 3
College Wrestler (2nd yr) with two year history of repeated stingers
Current episode with neck extension, compression, lateral flexion
Causing acute radiating pain into right trap, shoulder and distally past elbow to hand
Previous tx activity modification, protection, strengthening, modalities, gradual return
Case 3
Normal myotome exam within minutes Following acute phase normal neck motion Neurodynamic testing revealed increased
sensitivity and decreased right upper extremity ROM in median, radial, and ulnar nerve tracts
3 sets of 30 reps and instructions for self mobilization
Remainder of career 2 more episodes
Case 3
MRI during junior year Posterolateral disk osteophyte complexes
bilaterally at C3-4 Right side at C4-5 Neural foraminal narrowing on right at both
intervals
Managed with activity modification, modalities, neuromobilization, and ESI