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Non-Operative Management of Cervical Radiculopathy

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Presentation on theme: "Non-Operative Management of Cervical Radiculopathy"— Presentation transcript:

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

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