1. Non-Operative Management of Cervical Radiculopathy
Matthew R. Doyle, MS, ATC, LAT

2. Why this topic? Wrestling and Neck Injuries
In the past a lack of quality information on managing Cervical Radiculopathy (CR)

3. 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

4. Body Sites of Wrestling Injuries
College Time Loss Injuries

5. 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

6. 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

7. 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

8. 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

9. 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

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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

16. 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

17. 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

18. Interventions for CR Some but few RCT, systematic reviews
Largely case studies and anecdotal experience
Clinical Practice Guidelines

19. 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?

20. 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

23. 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

24. 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

25. 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

26. 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

27. 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.

28. 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

29. 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

30. 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

31. 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

32. 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

33. 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