1. Neck Pain, Myelopathy and Radiculopathy Clinical Assessment and Management Mr. David Bell London Neurosurgery Partnership

2. Introduction Consultant neurosurgeon Subspecialty - complex spine surgery NHS base at Kings College Hospital Part of London Neurosurgery Partnership 11 consultant group treating all disorders of the brain and spinal cord

3. Aims To discuss common clinical scenarios To explain common diagnoses and treatment To identify how to investigate and who to refer

4. Definitions Mechanical neck pain -Pain felt within the neck and shoulders/trapezius exacerbated by movement Radiculopathy – Clinical syndrome of arm pain, weakness or numbness caused by nerve root irritation Myelopathy – clinical syndrome of loss of dexterity and gait disturbance due to spinal cord compression

5. Red Flags Fever Weight loss History of cancer Progressive neurological deficit Nocturnal pain Severe pain requiring opiates

6. Investigation of Neck Pain No need for imaging or blood tests initially No role for plain x-rays If red flags then needs cross-sectional imaging Usually MRI or CT

7. Incidence of MRI Abnormalities 30 asymptomatic subjects – 22 (73%) bulging discs – 15 (50%) focal disc protrusions – 1 extrusion – 4 (13%) cord compression 100 asymptomatic subjects – 40-55 y o: disc protrusions in 20% – 64+ y o: 57% – Cord compression 7%

8. Management of Neck pain Reassurance NSAIDS Add opiates as required Physiotherapy Acupuncture/Dry needling

9. Surgery for Neck Pain Unusual for degenerative neck pain Instability due to tumour/infection/trauma responds well to surgery Occasional fusion for degenerative disease

10. Cervical Radiculopathy Less common than simple neck pain Neuralgic pain radiating down arm Sensory disturbance in distribution of affected nerve Rarely motor deficits Usually accompanied by neck pain

11. Foraminal Narrowing Progressive narrowing of exit foramina occurs with normal ageing Typically asymptomatic

13. Localisation RootC5C6C7C8T1 Sensory LossUpper arm ThumbMiddle finger Little finger Inner arm Motor lossShoulder abduction Elbow flexion Elbow/ wrist extension Long finger flexors Lumbrical PainShoulderForearm Upper arm/chest ReflexBicepsBiceps/ supinator TricepsNone

14. Differential Diagnosis Shoulder/Elbow pathology If sensory disturbance it has to be neural Thoracic outlet syndrome Brachial neuritis Entrapment neuropathy – median/ulnar

15. Investigation MRI cervical spine Nerve conduction studies Brachial plexus imaging

16. Cervical Root compression

18. Natural History Spontaneous resolution within 6-12 weeks occurs in 90% of attacks Investigate urgently/refer those with severe pain or progressive motor deficits

19. Treatment of Radiculopathy Physical therapies Acupuncture Analgesics Ibuprofen/codeine Opiates Pregabalin/Gabapentin/Amitriptyline

20. Escalation Injections Surgery

21. Cervical Nerve root injections ?risk of paraplegia Interscalene block Temporary Local anaesthetic/ steroid

22. Surgery for Radiculopathy Anterior cervical discectomy Cervical disc replacement Posterior foraminotomy

23. Discectomy/Replacement Bloodless plane to spine Removal of compression without manipulation of spinal cord Preservation of normal motion/reduce adjacent segment disease 90% relief from arm pain

26. Cervical Total Disc Replacement Preserve motion Reduce stresses on adjacent disc Prevent adjacent segment disease Popular Lack of evidence of efficacy at current time Expensive

28. Risks 1 in 1000 risk of paralysis 1% risk of vocal cord paresis Transient hoarseness/dysphagia common

29. Posterior Foraminotomy Posterior approach Microscopic No risk to oesophagus/trachea Some neck pain 90% effective

31. Cervical Myelopathy Clinical syndrome of spinal cord irritation/compression Insidious loss of fine finger movement Gait ataxia Urinary hesitancy

32. Myelopathy Increased tone Spastic reflexes Rombergs positive Unable to heel-toe walk L’Hemitte’s phenomenon

33. Myelopathy - Causes Most commonly degenerative Disc-osteophyte bars OPLL Tumour

35. Natural History Limited data Some non –progressive Most slowly progressive Occasional rapidly progressive

36. Myelopathy Treatment Observational Supportive - OT/physio Surgery – Anterior cervical discectomy/corpectomy Posterior cervical laminectomy +/- fusion

38. Outcome 50% notice improvement in hand/leg function Others arrest progression 1% continue to deteriorate 1 in 1000 risk of paralysis 1 in 10,000 risk of death

39. Any Questions?