Non-Operative Management of Cervical Radiculopathy Matthew 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 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 Mechanisms of radicular pain poorly understood

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