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Julian Price MD Athens Orthopedic Clinic 8/23/2017
Neck Pain Julian Price MD Athens Orthopedic Clinic 8/23/2017
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Disclosures Globus Medical: a,b Stryker Spine: a Choice Spine: a,b
Amendia, Inc.: b a: consulting b: royalties
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Anatomy 7 Cervical 12 Thoracic 5 Lumbar Sacrum/Coccyx
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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
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Anatomy Uncovertebral Joint Intervertebral Disc Vertebral Body
Vertebral Artery Nerve Root
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Anatomy Intervertebral Disc Nerve Root Spinal Canal / Cord
Vertebral Artery Facet Joints Posterior Longitudinal Ligament
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Anatomy
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Anatomy 1. Myelopathy (Cord compromise)
2. Radiculopathy (Nerve Root impingement)
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Anatomy Anterior Posterior J Bone Joint Surg Am. 2007;89:
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Presentation Causes: Degenerative Disc Spondylosis Sprain/Strain
Disc herniation Trauma/Fracture Tumor/Malignancy Infection
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Presentation Neck pain Stiffness Arm pain Referred pain
Numbness/Tingling Weakness Occipital headaches Crepitance
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Presentation Facetogenic Pain Patterns Discogenic Pain Patterns
J Bone Joint Surg Am. 2007;89:
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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
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Presentation J Bone Joint Surg Am. 2007;89:
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Examination ROM TTP Strength Sensation DTR’s Long tract signs
Vascular/skin changes
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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
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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
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Imaging
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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
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Imaging
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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
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Imaging
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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
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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
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CERVICAL SPRAIN/STRAIN
Neck pain w/o arm s/s Stiffness/spasms Decreased ROM XR: loss of lordosis NSAIDs, heat/ice, ROM
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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
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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)
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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
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Treatment: Surgical Anterior Posterior ACDF Corpectomy
Disc arthroplasty Posterior Laminoplasty Laminectomy Laminectomy and fusion laminoforaminotomy
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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
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Complications Esophageal injury: 50% mortality
Recurrent laryngeal nerve: dysphonia Superior laryngeal nerve: gag reflex, dysphonia, voice fatigue Sympathetics: Horner’s syndrome (meosis, ptosis, anhydrosis)
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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
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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
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Case example Postop pain and N/T, weakness resolved
No narcotics at 6 week checkup Back to work full-time
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Alternative: Disc Athroplasty
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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
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Case Example 6 weeks post-op Off narcotics RTW full time
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Case Example 60 yo female Neck + BUE pain BUE N/T, weakness
+ balance, dexterity changes - B/B changes
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Case Example 6 weeks post op
Hands increased feeling, decreased weakness Balance improving Start PT for gait training, proprioception, and BUE strengthening
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Case Example 68 yo female Presents for LBP Denies neck pain
Some dexterity, balance changes No B/B changes Exam: hyperreflexia, hoffman
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Case Example 6 months post op No B/B, balance or dexterity changes
Primary complaint: lumbar
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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
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Quartex Quartex
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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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QUESTIONS?
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