PC3: Positional Cervical Cord Compression

October 9, 2015

Andrew J. Holman, MD

Associate Clinical Professor of MedicineUniversity of Washington

Pacific Rheumatology AssociatesPacific Rheumatology Research

Renton, WA USA

Overview

Dynamic MR imaging of the degenerative cervical spine reveals spinal cord compression.

Spinal cord compression among patients with fibromyalgia.

Neurological deficits among patients with fibromyalgia

Treatment of cervical spinal cord compression (PC3).

Implications for fibromyalgia diagnostic criteria.

Muhle C, Metzner J, Weinert D et al. Clasification system based on kinematic MR imagng in cervical spondylitis myelopathy. Am J Neuroradiol. 1998;19:1763-1771.

81 patients with different stages (I-IV) of degenerative disease of the cervical spine.

NeutralFlexion (maximal)Extension (maximal)

Conclusion: Regardless of stage or grade of spinal stenosis in neutral position, cervical spinal motion may contribute to the development of cervical spondylitic myelopathy.

Muhle C, Metzner J, Weinert D et al. Classification system based on kinematic MR imaging in cervical spondylitis myelopathy. Am J Neuroradiol. 1998;19:1763-1771.

Muhle C, Metzner J, Weinert D et al. Classification system based on kinematic MR imaging in cervical spondylitis myelopathy. Am J Neuroradiol. 1998;19:1763-1771.

Muhle C, Metzner J, Weinert D et al. Classification system based on kinematic MR imaging in cervical spondylitis myelopathy. Am J Neuroradiol. 1998;19:1763-1771.

Implications

Accurate diagnosis

Appropriately targeted surgery

Novel pain generator

Novel autonomic nervous system (ANS) sympathetic

arousal

Cervical spinal cord and fibromyalgia

• In animal models, intermittent light abutment of the cervical cord is a potent autonomic arousal.

Karlsson AK. Autonomic dysfunction in spinal cord injury: clinical presentation of symptoms and signs. Prog Brain Res. 2006;152:1-8.

• Cervical trauma (remote) is common among FM patients.

Staud R. Long-term outcome of fibromyalgia related to cervical spine injury is worse in women than in men. Curr Rheumatol Rep. 2004 Aug;6(4):259-60.

• Reduction of cervical compression in patients with FM reduces FM symptoms.Heffez DS et al. Clinical evidence for cervical myelopathy due to Chiari

malformation and spinal stenosis in a non-randomized group of patients with the diagnosis of fibromyalgia. Eur Spine J. 2004;13(6):516-23.

Positional Cervical Cord Compression (PC3) (January-February 2006)

• Review all referred consultation to one provider at suburban rheumatology clinic.

• Evaluate myelopathy screening questions and exam.• 107 consultations reviewed

– Segregate diagnoses• CTD or enthesitis / bursitis w/o FM• FM• Unexplained widespread pain

Holman AJ. J Pain 2008;9(7):613-22.

Definition for PC3.

Visual evidence in the midline sagittal view of abutment or flattening of the spinal cord AND narrowing of the spinal canal to less than 10 mm in flexion, neutral or extension position.

Degenerative findings not considered.

Holman AJ. J Pain 2008;9(7):613-22.

Patient characteristicsCTD FMS CWP

Age 50 49 52

Yrs of FMS --- 10.3 ---

MHAQ

Function(0-10) 1.98 2.86 2.31

Psych (0-9.9) 2.44 5.18 2.32

10 cm VAS Pain 4.19 6.05 5.18

AM Stiffness (min) 37 88 79

10 cm VAS Fatigue 3.46 7.46 5.70

10 cm VAS Global 4.28 6.43 5.95

Patient characteristicsCTD (32) FM (53) CWP(22)

Subjects 14M/18F 4M/49F 3M/19F

Disabled 0 18 (34%) 1 (5%)

Trauma 0 7 (13%) 4 (18%)

Sink Pain 1 (3%) 36 (68%) 13 (59%)

Dentist Chair 2 (6%) 34 (64%) 8 (36%)

Dizzy 6 (19%) 16 (30%) 5 (23%)

Unsteady Gait 2 (6%) 6 (11%) 1 (5%)

Positive Romberg 3 (9%) 37 (70%) 14 (67%)

Abnormal Grip 6 (19%) 14 (26%) 7 (32%)

Extension Pain 3 (9%) 36 (68%) 15 (67%)

Holman AJ. J Pain 2008;9(7):613-22.

MRI RESULTSCTD FM CWP

Subjects 32 53 22

Had MRI 1 (3%) 49 (92%) 20 (91%)

Abnormal MRI 0 35 (71%) 17 (85%)New Views required 25 of 35 (71%) 12 of 17 (71%)

Chiari 2 0

Flat cord 5 (9%) 5 (23%)

Radiculopathy 5 (9%) 2 (9%)

Multiple Sclerosis 0 1

Multiple Myeloma 0 1

Holman AJ. J Pain 2008;9(7):613-22.

ResultsFM CW

Subjects 53 22

C2-3 6%) 0%C3-4 26% 36%C4-5 35% 41%C5-6 56% 50%C6-7 42% 50%C7-T1 11% 9%

Sink 64% 36%Dentist 68% 59%Romberg 70% 67%Extension 68% 67%

MYOPAIN 2010Toledo, Spain

• OHSU corroborates Seattle findings– 129 patients (2007)

– 57.4% FM patients tested had PC3

– 48% of FM+PC3+ had OSA.

– CWP not evaluated

• Unique PT reproduced and also helpful

• Surgical outcomes similar

166 Patients with FM 66 Pain-free controlsIX, X 42% 8%Sensory 65% 25%Motor 33% 3%Gait 28% 7%Photophobia 70% 6%Poor balance 63% 4%Weakness 58% 2%Tingling 54% 4%

Watson FW, Buchwald D, Goldberg J et al. Neurological signs and symptoms in fibromyalgia. Arthritis Rheum 2009;60(9):2839-2844.

1.Watson FW, Buchwald D, Goldberg J et al. Neurological signs and symptoms in fibromyalgia. Arthritis Rheum 2009;60(9):2839-2844.

[FOR DIAGNOSIS] “Taken together, these studies suggest that neurologic findings are common in fibromyalgia and may, in some cases, have a neuroanatomical basis.”

[FOR THERAPY]“…highlights the need for carefully designed, rigorously blinded and controlled studies of craniocervical neuroanatomy in fibromyalgia.”1

FM and the cervical spinal cord

PC3 and ANS

• Comparing PC3 with asymptomatic controls (2015)– PC3+FM+ vs. PC3-FM+

• Indistinguishable except for ANS

– PC3+FM- (pain free)• Normal ANS despite cord abutment

PC3 Treatment

• Physical therapy– Unique program

– Depends on degree of narrowing

– DVD available

• Medications (all off label) – pregabalin, duloxetine, milnacipran

– Analgesics, corticosteroids

– RLS meds (lorazepam, clonazepam)

• Manipulation

• Surgery (<15% since 2003)

The 1990 ACR Classification Criteria forFM Has Limited Use

• 25% of FM patients do not satisfy the 1990 ACR criteria1

– Originally developed as a research tool2

– Relies on patient’s self-report of symptoms3

– No objective clinical findings, radiographic abnormalities, or routinely used laboratory tests2,3

– Localized or regional pain may precede the advent of widespread pain3

• Tender point examination increasingly considered optional1,4

11Wolfe F, et al. Wolfe F, et al. Arthritis Care ResArthritis Care Res. 2010;62:600-610. . 2010;62:600-610. 22Navarro RP. Navarro RP. Am J Manag CareAm J Manag Care. 2009;15(suppl):S197-S218.. 2009;15(suppl):S197-S218.33Lawson K. Lawson K. Neuropsychiatr Dis TreatNeuropsychiatr Dis Treat. 2008;4:1059-1071. . 2008;4:1059-1071. 44Häuser W, et al. Häuser W, et al. Dtsch Arztebl IntDtsch Arztebl Int. 2009;106:383-391.. 2009;106:383-391.

Diagnostic Workup for FM History of CWP for ≥ 3 months

Consider other diagnoses that may present with CWP

History, general physical, musculoskeletal and neurological examination,

selected laboratory testing

Confirm presence of pain at ≥ 11 of 18 tender points

“Fibromyalgia”

< 11 of 18 tender points, but presence of other core symptoms

(eg, fatigue, sleep disturbance, dyscognition, mood disorder, decreased function)

“Probable Fibromyalgia”

Goldenberg DL. Goldenberg DL. Am J MedAm J Med. 2009;122(suppl):S14-S21.. 2009;122(suppl):S14-S21.

Fibromyalgia Tender Points

Wolfe et al Arthritis and Rheumatism 33(2):160-172 (1990)

Widespread pain index and symptom severity scoring

• WPI • In how many areas has the

patient had pain (over the last week)? Score 0-19– Shoulder girdle*– Upper arm, lower arm*– Hip (buttock, trochanter)* – Upper leg, lower leg* – Jaw*– Chest – Abdomen– Upper back, lower back– Neck

• SS scale score– Fatigue, waking unrefreshed,

cognitive symptoms– Plus general somatic symptoms– Scoring

• 0 (no problem)• 1 (slight/mild)• 2 (moderate)• 3 (severe)

Wolfe F, et al. Wolfe F, et al. Arthritis Care ResArthritis Care Res. 2010;62:600-610.. 2010;62:600-610.*Left, right*Left, right

New ACR Diagnostic Criteria for FM and Measurement of Symptom Severity

• Widespread pain index (WPI) ≥ 7 and symptom severity (SS) scale score ≥ 5

or WPI 3-6 and SS scale score ≥ 9

• Symptoms have been present at a similar level for at least 3 months

• The patient does not have another disorder that would otherwise explain the pain

No physical examination necessaryNo physical examination necessary

Can be self-administeredCan be self-administered

Probably more sensitive to change than ACR criteriaProbably more sensitive to change than ACR criteriaWolfe F, et al. Wolfe F, et al. Arthritis Care ResArthritis Care Res. 2010;62:600-610.. 2010;62:600-610.

Summary Positional cervical cord compression (PC3) is common among patients with degenerative cervical disease.

PC3 is a common co-morbidity among patients with FM.

PC3 may account for neurological deficits and autonomic nervous system (ANS) arousal among patients with FM.

Treatment of PC3 is predominantly PT based with spinal cord active medications, but may also require surgery.

Future studies are required to explain how ANS arousal and pain may be linked and how PC3 may be incorporated into diagnostic criteria for widespread pain states.