1. NW Surgical Research Foundation Conference
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NW Surgical Research Foundation Conference
March 2018
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2. 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.

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

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

5. 7 VB in neck
8 nerve roots -

6. 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

7. Dermatomes

8. Dermatomes

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

10. Imaging: Cervical Spondylosis

11. Imaging: Cervical Spondylosis

12. 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

13. 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

14. 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

15. 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 *

16. 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.

17. 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

18. 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.

19. 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

20. 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

21. 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

22. 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.

23. 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

25. Cervical RadiculopathySx
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

28. 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

29. 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

30. 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

31. 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

32. Insurance: Surgery Authorization CriteriaX X

33. Insurance: Surgery Authorization CriteriaX X

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

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

36. 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

37. 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.

38. 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

39. 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

40. 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

41. 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)

42. 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

43. 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

44. 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

45. 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.

46. 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

47. 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

48. 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.

49. Foundation Conference
Save the Date!
NW Surgical Research
Foundation Conference
March 2018
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