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Causes and Treatments of Neck and Arm Pain Brian Ragel, MD Causes & treatments for neck & arm pain Expert: Brian Ragel, M.D. Acute arm or neck pain, tingling or loss of sensation is often caused by spine inflammation or injury. Hear more on the latest treatments and therapies that can dramatically decrease pain and increase function.

No conflicts of interest No disclosures I can never do less, I can always do more

Introduction Anatomy Definitions Cases Cervical spondylosis Herniated disc Cases Axial neck pain Radiculopathy Myelopathy

7 VB in neck 8 nerve roots -

Discs are taller ventrally than dorsally and responsible for lordotic posture of spine. Beginning in 3rd decade of life, progressive decline in water content of disc which continues with age. Center of disc, nucleus pulposes, starts at 90% water and decreases to 70% water at 80 yo. Results in disc which loses height and becomes less elastic VB drift towards one another ligamentum flavum buckles

Dermatomes

Dermatomes

Cervical Spondylosis “wear and tear” over time Facet arthropy “bone spurs” / osteophytes loss of disc height mineral deposition within ligaments and discs

Imaging: Cervical Spondylosis

Imaging: Cervical Spondylosis

Imaging: Cervical Spondylosis Degenerative changes that contribute to spinal cord/nerve root compression Degenerative changes that contribute to compression of spinal cord in cervical myelopathy

Axial Neck Pain Case 45 yo F Neck pain x 2 years, following MVC. Exam Mid-cervical spine pain Has tried everything. Exam Paraspinous tenderness Non-focal neuro exam Imaging X-rays: AP/lat/flex/ex, normal MRI: mild DDD at C6/7

Axial Neck Pain DFN: pain in neck and upper trapezius pain without radicular symptoms usually mechanical component 66% of all adults will suffer Imaging studies correlate poorly Sx ?pain generator? Nerve endings Disc Periosteum Facets Paraspinous muscles

Diagram: Nerve Endings for Axial Pain * * * Disc is innervated by sinuvertebral nerve formed by branches from ventral nerve root and sympathetic plexus, once formed the nerve turns back into intervertebral foramen along the posterior aspect of the disc Facet is innervated by dorsal rami of nerve *

Axial Neck Pain Imaging Indications: Imaging: h/o trauma h/o cancer progressive neck pain on-going neck pain > 2 months Imaging: X-ray (AP/lat/flex/ex) r/o fracture, instability, lytic/blastic lesion CT C-spine r/o fracture (h/o trauma) MRI r/o tumor, spinal cord compression 61 yo F w/ h/o breast cancer and progressive neck pain.

Axial Neck Pain Tx* Tx, limited success* Exercise: strengthen and stretch OTCs (Tylenol / NSAIDs) Talk therapy (cognitive specialist) Heat Sleeping right – back or side (change pillow, collar, bed) Physical therapy Acupuncture Chiropractor Tx, limited success* Injections (steroids ~3 mo; ablations ~1 yr) Surgery *Best Relief for Neck Pain, Consumer Reports, 2015 and 2016

Surgery for Axial Neck Pain Pain relief 21 – 45% Partial pain relief 25 – 55% No relief 22 – 32% Overall, for axial neck pain, surgery 50/50 at best, no good exam, no good imaging modality to define pain generator site. I utilize SPECT/CT in some cases. *Lees, Rothman, Deplama, Gore.

Axial Neck Pain Case 45 yo F, chronic neck pain after MVC. Imaging Failed conservative measures Imaging CT C-spin, no fracture Consider Hybrid SPECT/CT, metabolic study

Axial Neck Pain Arthritis can be persistent source of pain. Facet arthritis, 39% pts w/ neck pain. Hybrid SPECT/CT Single Positron Computed Tomography (SPECT) Nuclear study, Gamma emitting nucleotide IV 99mTc-medronic acid (phosphate derivative) Taken up by osteoblasts, Imaged w/ gamma camera CT scan screen merged w/ gamma counts Matar et. al., 72 patients, 25 cervical Identified potential pain generator sites in 92% and 86% of cervical and lumbar scans, respectively Can, focus treatments at areas high uptake

Axial Neck Pain Case 45 yo F, chronic neck pain after MVC. Imaging Failed conservative measures NSAIDs / PT / Chiro / Acupuncture Facet blocks Imaging Hybrid SPECT/CT, normal NO surgery offered. Next?: Encourage pain counseling ?Consider arthritic w/u? ?Refer for facet denervation procedure? ?Spinal cord stimulator? NO, not good for axial neck pain, best for arm pain F/u 1 year – re-image

Conclusion: Axial Neck Pain Imaging: r/o fracture, instability, tumor. Surgery: No good surgical option. Treatment: non-surgical! My practice: “Sorry, surgery won’t help.” In pts w/ little secondary gain and willing try – offer 1 yr f/u. I have performed ACDF’s for axial neck pain w/ mixed results. I have offered patients fusion w/ facet arthropathy on SPECT/CT surgery, 1 taker.

Cervical Radiculopathy Case 45 yo M Neck and right arm pain x 6 weeks Deltoid to bicep to lateral forearm to thumb Exam 4+/5 biceps diminished LT thumb

Cervical Radiculopathy Sx Sx’s in dermatomal distribution from compressed nerve root Example: C6 radiculopathy will produce pain/numbness in lateral biceps -> lateral forearm -> thumb Dx Sensory: ask patient to self diagram Motor: C5 deltoid, C6 biceps, C7 triceps MRI

Cervical Radiculopathy Tx, non-surgical OTCs Rx: Neurontin and Lyrica Physical therapy / cervical traction Goal: strength and stretch Epidural steroid injections Chiropractic I do not advise high velocity manipulation Acupuncture

Cervical Radiculopathy Surgical Indications Life-limiting pain Pain > 2 months Progressive motor deficit Tx, surgical Anterior Cervical Discectomy and Fusion (ACDF) Artificial Cervical Disc Replacement (ACR) Posterior Cervical Foraminotomy

Cervical Radiculopathy Case, F/U 2 months 45 yo M, weakness improved, but R C6 arm pain continues. NSAIDs, gabapentin, PT x 3 wks, ESI Exam: full strength diminished LT R C6 Decision: offered surgery, ACDF/ACR

Insurance: Surgery Authorization Criteria Molina utilizes McKesson InterQual - Evidence Based Clinical Criteria Surgery algorithms Example: Surgery approval algorithm for cervical disc herniation w/ unilateral symptoms

Insurance: Surgery Authorization Criteria X X

Insurance: Surgery Authorization Criteria X X

Insurance: Surgery Authorization Criteria X Pt w/ only 3 wks PT. Surgery denied? X X X

Insurance: Surgery Authorization Criteria X Pt w/ only 3 wks PT. Surgery denied? DENIED, until documented 6 wks home exercise. X X X X X X

Cervical Radiculopathy Outcomes: >80% pts w/ arm relief ACR/ACDF risks Dysphagia, ~5% hoarse voice, ~5% C5 or C6 nerve palsy, ~1% adjacent level breakdown, ~1-2%/yr (~25% pts sx in10 yr) ACR ACR ~20% undergo ACDF ACR ~30% fuse Recovery Return to work 2 – 4 wks

Cervical Radiculopathy Case, F/U 4 wks after C6/7 ACR 45 yo M R arm pain resolved intermittent tingling down arm discomfort b/w shoulder blades Exam: full strength diminished LT R C6 F/u 6 months, annually w/ x-rays Risks: symptomatic adjacent level disc disease ~1-2% yr, ~20% at decade.

270 ACDR vs. 219 ACDF Equivalent: Motion preserved >80% relief neck pain >80% relief arm pain Motion preserved Unclear if ACDR diminishes risk symptomatic adjacent level disc diseasae

Conclusion: Cervical Radiculopathy Surgical Indications Life-limiting pain Pain > 2 months Progressive motor deficit Surgery ACDF or ACDR excellent outcomes in neck and arm pain relief

Cervical Myelopathy Case 65 yo M Presents increasing falls, clumsy hands, and upper extremity tingling for past 2 years Exam: 4+/5 triceps and grip +Hoffman’s sign, up-going toes Mild ataxia w/ heel-to-toe walk

Cervical Myelopathy Sx Sx / Dx Sx’s N/T, clumsy hands, spastic gait, leg weakness due to spinal cord compression Sx / Dx Upper Motor Neuron signs (Myelopathy) Upgoing toes (Babinski) Finger flexor reflex (Hoffman’s sign) Spastic gait Imaging: MRI, damaged spinal cord (cord signal noted on T2WI)

Natural History of Cervical Myelopathy Lees and Turners usually stable non-progressive disability progressive deterioration exception Symon et al, 67% steady decline Nonrandomized MCT in 2000 20 surgery with improved function 23 non-op with decline in ADL MCT = multi center trial ADL = activity of daily living

Natural History of Mild Cervical Myelopathy Study, 60 patients w/ mild CM (JOA score >13) 30% decline in stair-step fashion 70% tolerate MCT = multi center trial ADL = activity of daily living

Cervical Myelopathy Surgical Goal: decompress spinal cord to halt progression of symptoms Surgical Indications: Progressive symptoms Cord signal on MRI Patient choice if mild Surgery: Anterior decompressive surgery for anterior compression / kyphosis Posterior decompression for degenerative / congenital stenosis

Cervical Myelopathy 65yo M w/ severe cervical myelopathy. MRI, severe anterior compression. Example: C4/5, C5/6 and C6/7 ACDF d/t anterior compression.

Cervical Myelopathy 82yo M w/ increasing gait disturbance. MRI, cord signal change. Example: Posterior laminoplasty w/ lateral mass expansion hardware for congenital stenosis with cervical myelopathy

Outcome: Cervical Myelopathy Short-term: Improved gait Return proximal strength Long-term complaints: c/o grip weakness c/o balance issues c/o UE Paresthesia's (gabapentin) Risk: 10% patients have neurologically worse following surgery

Summary Axial neck pain, no good surgical options. Cervical radiculopathy, excellent surgical options to relieve arm pain. Cervical stenosis with myelopathy, good surgical options to stop progressive neurologic decline.

Foundation Conference Save the Date! NW Surgical Research Foundation Conference March 2018 @ReboundMD facebook.com/ReboundMD/