Julian Price MD Athens Orthopedic Clinic 8/23/2017 Neck Pain Julian Price MD Athens Orthopedic Clinic 8/23/2017

Disclosures Globus Medical: a,b Stryker Spine: a Choice Spine: a,b Amendia, Inc.: b a: consulting b: royalties

Anatomy 7 Cervical 12 Thoracic 5 Lumbar Sacrum/Coccyx

ANATOMY Seven Cervical Vertebrae: C1-2: rotation C3-C7: flx/ext + side bending Spinal Motion Unit: disc + 2 facet joints Cervical Lordosis: normal is 20-40⁰

Anatomy Uncovertebral Joint Intervertebral Disc Vertebral Body Vertebral Artery Nerve Root

Anatomy Intervertebral Disc Nerve Root Spinal Canal / Cord Vertebral Artery Facet Joints Posterior Longitudinal Ligament

Anatomy

Anatomy 1. Myelopathy (Cord compromise) 2. Radiculopathy (Nerve Root impingement)

Anatomy Anterior Posterior J Bone Joint Surg Am. 2007;89:1360-1378.

Presentation Causes: Degenerative Disc Spondylosis Sprain/Strain Disc herniation Trauma/Fracture Tumor/Malignancy Infection

Presentation Neck pain Stiffness Arm pain Referred pain Numbness/Tingling Weakness Occipital headaches Crepitance

Presentation Facetogenic Pain Patterns Discogenic Pain Patterns J Bone Joint Surg Am. 2007;89:1360-1378.

Presentation Radiculopathy Myelopathy Neck pain Arm pain Referred pain Numbness/Tingling Weakness Decreased motion Myelopathy Same as radiculopathy, but often less specific Balance changes Bowel/Bladder changes Dexterity changes Gait changes

Presentation J Bone Joint Surg Am. 2007;89:1360-1378.

Examination ROM TTP Strength Sensation DTR’s Long tract signs Vascular/skin changes

Examination Radiculopathy Myelopathy Dermatomal pain Dermatomal numbness Myotomal weakness Decreased DTR Spurling’s sign Hand on head (C7 mostly) Myelopathy Often nondermatomal pattern pain/numbness +/- weakness Increased reflexes Rhomberg Broad based gait Hoffman’s sign Clonus/Babinski Finger escape, inverted radial reflex Shoulder abduction sign: decrease tension nn root, lift DRG away from compression, decompress epidural vv

Imaging X-rays: note end-plate sclerosis, disc collapse, facet arthrosis, fracture, lytic lesions, malalignment in sagittal and\or coronal planes AP, LAT; flexion & extension views to assess sagittal instability (Caution: flexion / extension views should be avoided in acute trauma until CT Scan has ruled out injury leading to instability) Gives clues/ideas of which levels have advanced degeneration; does not show disc or neurologic structures

Imaging

Imaging MRI: -optimal method to assess spinal cord, nerve roots, disc integrity 1. spinal cord deformation, cord edema 2. decreased neuroforamen volume 3. evaluation of cord in acute injury -ability to depict soft tissue structures causing stenosis: 1. ligament flavum hypertrophy 2. facet capsule hypertrophy 3. disk herniation

Imaging

Imaging CT: -optimal method to assess osseous structures -can create 3-dimensional images to link degenerative disease to neural structures -best study for acute trauma to evaluate the bony structures for fracture / dislocation CT myelogram: -allows erect position for gravity’s effect on spinal segments (stressful position) to assess dynamic changes -helpful in patient with previous instrumentation

Imaging

Imaging EMG/NCV Good for ruling out (or in) peripheral entrapment syndromes Carpal Tunnel, Cubital Tunnel, Suprascapular nerve impingement EMG 2 muscles same root, different peripheral nerve = radiulopathy High specificity, low sensitivity NCV Only for peripheral entrapment syndromes

Treatment: Conservative Activity Modification: avoid heavy lifting, repetitive push/pull and overhead activity Physical Therapy: ROM, low impact aerobic conditioning, isometrics, traction, modalities NSAIDS: reduce inflammation, edema ESI: decrease inflammation, decrease pain Others: chiropractic, massage therapy, accupuncture Bracing: no role due to muscle deconditioning

CERVICAL SPRAIN/STRAIN Neck pain w/o arm s/s Stiffness/spasms Decreased ROM XR: loss of lordosis NSAIDs, heat/ice, ROM

Fracture/Dislocation Imaging Stable, no neuro involvement: immobilization x 6-12 weeks Unstable or neuro involvement: surgery All C- spine fractures should have orthopedic or neurosurgery evaluation

Treatment: Surgical Indications: HNP/spondylosis with radiculopathy: S/S >6-12 weeks* and failure of conservative treatment Progressive neurologic deficit Myelopathy Significant/persistent motor deficit Severe pain, inability ADL’s/work, + tension Infection Malignancy Instability (fracture and/or ligamentous injury)

Treatment: Surgical Approach is based on where the pathology is and if there is deformity present Options: anterior, posterior, A/P In general, if kyphotic deformity, go anterior If mulitilevel*, consider A/P for additional biomechanical support

Treatment: Surgical Anterior Posterior ACDF Corpectomy Disc arthroplasty Posterior Laminoplasty Laminectomy Laminectomy and fusion laminoforaminotomy

Complications Anterior Posterior Dysphagia Dysphonia Sore throat Pseudarthrosis Horner’s syndrome Adjacent level degeneration Infection Nerve injury Spinal cord injury Posterior Wound complications Infections Neck pain Pseudarthrosis Adjacent level degeneration Nerve injury* Spinal cord injury

Complications Esophageal injury: 50% mortality Recurrent laryngeal nerve: dysphonia Superior laryngeal nerve: gag reflex, dysphonia, voice fatigue Sympathetics: Horner’s syndrome (meosis, ptosis, anhydrosis)

Outcomes Dependent on levels of involvement, pathology, etc In general, less levels involved equals higher success rate In general, improvement of radicular s/s higher success than axial pain

Case Example 40 yo female Neck and LUE pain Dorsal forearm and thumb/index +Numbness, +Weakness - B/B, balance, dexterity Failed 6 week cons tx including ESI

Case example Postop pain and N/T, weakness resolved No narcotics at 6 week checkup Back to work full-time

Alternative: Disc Athroplasty

Case Example 46 yo female Previous ACDF C5-6 in 2001 Neck pain and BUE pain lateral arm + N/T, weakness - B/B, balance, dexterity Failed non-op tx including ESI’s

Case Example 6 weeks post-op Off narcotics RTW full time

Case Example 60 yo female Neck + BUE pain BUE N/T, weakness + balance, dexterity changes - B/B changes

Case Example 6 weeks post op Hands increased feeling, decreased weakness Balance improving Start PT for gait training, proprioception, and BUE strengthening

Case Example 68 yo female Presents for LBP Denies neck pain Some dexterity, balance changes No B/B changes Exam: hyperreflexia, hoffman

Case Example 6 months post op No B/B, balance or dexterity changes Primary complaint: lumbar

Case Example 72 yo male ground level fall ~3 weeks prior Neck pain + R arm pain/N+T/weakness No bowel or bladder, dexterity or gait changes h/o 3 level ACDF by outside MD 6 years prior Chin forward position with fixed thoracic hyperkyphosis RUE: 3/5 triceps, 1/5 grip, 1/5 intrinsics Decreased C7, C8 sensation

Quartex Quartex

Take Home Pearls Radiculopathy Myelopathy Neck pain Arm pain Referred pain Numbness/Tingling Weakness Decreased motion Myelopathy Same as radiculopathy, but often less specific Balance changes Bowel/Bladder changes Dexterity changes Gait changes

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