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Cervical Spine Arthur Jason De Luigi, DO Program Director, Sports Medicine Fellowship Director, Sports Medicine Director, Interventional Pain MedStar National.

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Presentation on theme: "Cervical Spine Arthur Jason De Luigi, DO Program Director, Sports Medicine Fellowship Director, Sports Medicine Director, Interventional Pain MedStar National."— Presentation transcript:

1 Cervical Spine Arthur Jason De Luigi, DO Program Director, Sports Medicine Fellowship Director, Sports Medicine Director, Interventional Pain MedStar National Rehabilitation Hospital MedStar Georgetown University Hospital Medical Director and Head Team Physician US Paralympic Alpine Ski Team

2 Overview Cervical Anatomy Physical Examination Pathology Treatment

3 Cervical Spine Anatomy 3-joint complex 50% Flex-Ext – Atlanto-occipital 50% rotation – C1-C2 Center of motion – Flex C 5-6 – Ext C 6-7 C2 and C7 most prominent spinous processes

4 Anatomy Center of motion – Flex C 5-6 – Ext C 6-7 Normal lordodic curve helps absorb energy of blows to head and neck Lordosis 30 deg forward flexion

5 Cervical Nerves 8 cervical roots 8 cervical roots C1-C4 C1-C4 – Sensory C5-T1 C5-T1 – Brachial Plexus – Motor Branches

6 Cervical and Thoracic Nerve ROots Cervical Nerve Roots – Exit above the vertebral body for which they are named Thoracic Nerve Roots – Exit under the vertebral body and rib

7 Exam Overview C-Spine Exam Overview Inspection Inspection Palpation Palpation Range of Motion Range of Motion Strength Strength Neurovascular testing Neurovascular testing Special tests Special tests

8 Inspection Overall posture Overall posture Position of comfort Position of comfort ROM when walking, talking ROM when walking, talking Deformity, ecchymosis, swelling Deformity, ecchymosis, swelling (All marketed devices to improve posture)

9 Palpation Spinous processes Spinous processes – Bony TTP is a red-flag Paraspinal muscles Paraspinal muscles Anterior & lateral neck Anterior & lateral neck Upper back & scapula Upper back & scapula Arms if symptoms there Arms if symptoms there

10 Range of Motion Forward Flexion60 degrees Forward Flexion60 degrees Extension70 degrees Extension70 degrees Side bending45 degrees* Side bending45 degrees* Rotation80 degrees* Rotation80 degrees* Note mild/moderate/severe restriction *compare to opposite side

11 Motor Exam C5-Deltoid Elbow Flexion C6- Wrist Extension Elbow Flexion C7-Wrist flexion Elbow Extension Finger Extension C8- Finger flexors T1-Hand intrinsics Blocker Beggar Kisser Grabber Spock

12 Exam- Sensory C5-anterior brachium C6- thumb – Lateral arm C7- middle finger – Posterior arm C8-ulnar side hand – Posterior arm T1-inner brachium – Axilla

13 Deep Tendon Reflexes C5: Biceps C6: Brachioradialis C7: Triceps

14 Nerve Root Disc Level Pain/Sensory Loss Weak- ness DTR’s decr C1,2O-C2Occiput C3C2-3Post-Sup neck Ears and mastoid C4C3-4Post-Inf neck/shoulder C5C4-5Lat. neck and shoulder Ant. Arm Deltoid C6C5-6Post-Lat arm to Thumb, +/- index finger Biceps & Br-rad C7C6-7Post-Mid arm to mid fngr Triceps C8C7-8Post arm to ring/small fingr Grip T1T1-2Proximal inner arm/axilla Intrinsics

15 Special Tests Spurling Test Lhermitte’s Sign Hoffman’s Sign

16 Spurling Test Cervical etiology Cervical etiology – pinched nerve rt. Head is extended and rotated Head is extended and rotated – Slight axial load Practical Tip: Extend the pts head and then tell them to ”look in their back pocket.” If no symptoms then apply axial load.

17 Spurling Test Also known as – foraminal compression test – neck compression test – quadrant test

18 Spurling Test World War II Walter Reed General Hospital – Roy Greenwood Spurling Hospital's first Chief of Neurosurgery Organizer of neurosurgery for the entire Army – First noted this finding in patients of ruptured cervical discs. Spurling and Scoville – Demonstrated a positive test on 12 patients with presumed ruptured cervical discs – confirmed surgically in 1943 and reported their findings in 1944 The original description of the test – Head and neck will be tilted toward the painful side to reproduce the patient’s typical radicular symptoms – Pressure will then be placed on the top of the head to further intensify the symptoms – Whereas tilted the head away from the painful side will alleviate the symptoms

19 Spurling Test Validity and Reliability – Shah and Rajshekhar in surgical patients with findings on MRI – Sensitivity 92% – Specificity 95% – Positive predictive value 96.4% – Negative predictive value 90.9% Concluding that the Spurling’s test is the gold standard for evaluating cervical radiculopathy

20 Lhermitte’s Sign Also known as – Barber Shop Phenomenon 1920 – Jean Jacque Lhermitte patients with spinal cord concussion and later in other neurologic diagnoses Previously described 1917 – Marie and Chatelin Transient pins and needles sensations into the limbs on flexion of the neck 1918 – Babinski and Dubois Electric discharges into the limbs with head flexion, sneezing, or coughing in a patient with Brown-Sequard syndrome

21 Lhermitte’s sign Passive or Active Neck Flexion Pain/Electric sensation shooting down back or into legs – Myelopathy – Multiple Sclerosis

22 Lhermitte’s Sign Validity and Reliability – Malanga Review – Insufficient evidence of the inter-rater reliability, sensitivity, and specificity – Sandmark and Nissell Active flexion and extension test » resembles the Lhermitte’s sign and was found to – Specificity (90%) – Sensitivity (27%) – Negative predictive value of 75% – Positive predictive value of 55%.

23 Hoffman’s sign “Babinski of the Upper Extremity” Test for UMN lesion – Flick middle finger – Watch for reflexive flexion/adduction of thumb

24 Cervical Pathologies Cervical Strain/spasm Cervical Sprain Cervical Instability Stingers Spondylosis Stenosis HNP Cervical Cord Neuropraxia Fractures/subluxation

25 Cervical Strain & Spasm Usually minor trauma (or none) – “Slept Wrong” – Overuse/Posture – Sudden movement Minor muscle fiber tears, secondary spasm

26 Myofascial Pain Travell & Simon “Trigger Points” – Discrete hyperirritable spots located within taut muscle band – Often with chronic MSK disorder – Hypersensitive area or firmer than normal tissue, usually quarter-size area – Can result in decreased ROM in the affected muscles

27 Trigger Points Treatments – Spray and stretch – Ultrasound – Massage – Manipulation – Trigger point injection Injection material – 3cc lidocaine – +/- Corticosteroid – Dry needle (more post injection soreness) Disrupts the pain cycle – Stops hyper-responsive signals

28 Myofascial Pain Muscle Relaxants Cyclobenzaprine – Relieve skeletal muscle spasms and associated pain in acute musculoskeletal conditions. – 2RCTs Both found no significant differences between the treatment groups. – Another RCT evaluated the effect of cyclobenzaprine 12 in patients with jaw paiin No evidence favoring cyclobenzaprine over clonazepam or placebo. – Cochrane review nsufficient evidence to support its use due to a lack of high quality RCTs. 9 Tizanidine – Alpha2 adrenergic agonist – Two prospective trials (not RCT) evaluated tizanidine for MPS 14, 15. Manfredini et al., in 2004 – 78 patients with MPS, and noted only a slight improvement in pain. Malanga et al., in 2002 – 29 patients who were titrated on tizanidine for 3 weeks. – Significant decrease in VAS, disability and sleep improvement were noted – Two RCTs patients with acute low back pain showed a significant difference in pain reduction favoring tizanidine to placebo. – Review article Insufficient literature to support the use of tizanidine

29 Myofascial Pain Sedatives/Hypnotics Clonazepam – Benzodiazepinederivative with anticonvulsant, muscle relaxant, and anxiolytic properties. – Two RCTs 19, 20 evaluated the efficacy of clonazepam for MPS treatment Found it to be effective However, caution was advised due to side effects such as depression and liver function – Review article Better than placebo for MPS pain relief. – Analysis of the above literature Strongly supports the use of clonazepam, a traditional agent, in the treatment of MPS. Alprazolam and Diazepam – Potent benzodiazepines. – Review article alprazolam or diazepam in combination with ibuprofen is better than placebo. – RCT significant reduction of pain in both the diazepam and the diazepam with ibuprofen groups.

30 Myofascial Pain Anti-Depressants Amitriptyline and Nortriptyline – Amitriptyline TCA traditionally studied in the treatment of a wide variety of painful conditions including MPS – Nortriptyline Second generation TCA with less incidence of side effects compared to amitriptyline. – Two RCTs Bendsten and Jensen – Significant reduction in pain and myofascial tenderness. Plesh et al – Effective for myofascial pain

31 Myofascial Pain Topical Agents Topical Lidocaine Patch – Case report in 2002 did not demonstrate significant evidence for pain reduction – Open labeled non randomized trial Showed some relief of pain and improvement in quality of life in 27 patients – RCT topical lidocaine patch demonstrated a significant reduction of pain episodes, intensity of pain at rest and with activity, improvement of mood and quality of life as compared to a placebo patch. Topical Methyl Salicylate and Menthol Patches – Methyl Salicylate Rubefacient in deep heating liniments For myalgias and muscle spasms – Menthol Organic compound with local anesthetic and counterirritant qualities weak kappa opioid receptor agonist. – A single RCT demonstrated a significant global satisfaction and reduction of pain at rest and with movement compared to placebo Topical Diclofenac Patch and Solution – single RCT significant difference in pain, range of motion and disability scores compared to placebo – Lone RCT studying topical diclofenac solution no significant differences between the groups. Topical Thiocolchicoside Ointment – Muscle relaxant with anti-inflammatory and analgesic effects – Competitive GABA-A receptor antagonist and also inhibits glycine receptors – Single blind, RCT Significant improvement in pain and range of motion in all treatment groups.

32 Whiplash

33 Cervical Sprain Usually higher-energy trauma (MVA) Often d/t rapid or excessive ROM in one or more planes Ligamentous injury usually coupled with muscle strain/spasm Non-radicular neck/shoulder pain – worsened by neck motion Careful exam to r/o nerve injury Consider X-rays to r/o fracture & instability

34 Imaging No imaging required if patient meets all of the following… – No midline tenderness – No focal neuro sx – Normal LOC – No drugs/meds – No distracting injuries

35 Cervical Spine Trauma Imaging AP view Lateral view (must include entire C7) Odontoid view IF NORMAL, consider FLEX/EXT VIEWS IF NORMAL, consider FLEX/EXT VIEWS

36 Flexion & Extension Views

37 Cervical Sprain w/ Instability Can present subacutely – Persistent pain after appropriate time to recover Flex/Ex view criteria: – >3.5 mm AP displacement – >11 deg angulation IMMOBILIZE & REFER ASAP

38 Cervical Sprain w/o Instability Treatment: Analgesics, +/- muscle relaxer Analgesics, +/- muscle relaxer +/- Hard/Soft collar +/- Hard/Soft collar Relative rest; encourage resumption of ADL soon Relative rest; encourage resumption of ADL soon Early referral to PT Early referral to PT – ROM emphasized (decrease disability) – ROM emphasized (decrease risk disability) – Modalities

39 Strain/Spasm Treatment NSAID/Tylenol NSAID/Tylenol Muscle relaxer? Muscle relaxer? Trigger point injections? Trigger point injections? Soft collar (rarely) Soft collar (rarely) Relative rest & active stretching Relative rest & active stretching Usually improvement starts after 3-4 days Usually improvement starts after 3-4 days If recurrent refer to PT

40 Cervical Spondylosis Degeneration of discs and facets joints – Space narrowing – Osteophytes – Sclerosis

41 Cervical spondylosis s/sx Paramedian neck tenderness Paramedian neck tenderness Reduced ROM Reduced ROMGRADED Mild: HA’s, neck pain (limited to disc, ) Mild: HA’s, neck pain (limited to disc, facet jt) Moderate: radicular sxs (foramen) Moderate: radicular sxs (foramen) Severe: myelopathy (canal) Severe: myelopathy (canal) – gait, balance, bladder sx’s

42 Cervical Stenosis Narrowing of the AP diameter of the cervical canal – Developmental – Acquired: secondary to degenerative dz, HNP, etc. MRI for diagnosis EMG can reveal nerve damage

43 Tx of spondylosis/stenosis Analgesics +/- muscle relaxer Soft collar prn Relative rest from offending activity Physical Therapy if persistent Cervical Epidural if refractory Surgical indications: – Myelopathy – Radicular sxs not responding to tx Get MRI, talk to surgeon

44 Herniated Nucleus Pulposus (HNP) Acute Radiculopathy – Rupture of nucleus pulposus through tear in the annulus fibrosus Chronic Radiculopathy – Gradual Onset d/t disc degeneration, thinning, bulge, and osteophytes

45 HNP Neck pain with radiation into the shoulder/arm – Burning pain or weakness Sensory changes in a specific nerve root – Motor if C5-T1 involvement Spurling’s maneuver reproduces symptoms – Improved with distraction maneuvers No upper motor neuron deficits – Neg Hoffman, Babinski – No rigidity, gait dysfx, hyper-reflexia

46 HNP Treatment Conservative therapy: 40-80% respond by 6-12wk – Rest, NSAID, ROM ex’s, neck collar, cervical pillow – Consider oral steroids if severe radicular sx’s Physical therapy if poor response 1-2 wks – Traction, TENS Consider referral for invasive tx if: – Patient is ready – Progressive neurological symptoms – sxs persist despite tx – MRI, EMG/NCV

47 Epidural Steroid Injections Epidural steroid injections (ESI) commonly used intervention to treat radicular pain In the cervical and thoracic spine, this pain is most commonly caused by herniated disc and/or foraminal stenosis Mechanism of pain generation: mechanical compression and chemical inflammation Corticosteroids thought to reduce chemical inflammation and pain

48 Introduction - ESI 2 methods for delivering medication to the epidural space in the cervical and thoracic spine: – Interlaminar epidural steroid injection (ILESI) – Transforaminal epidural steroid injection (TFESI)

49 Cervical TFESI – ISIS Guidelines Pre-injection procedures – IV access – VS Monitoring: BP,HR,pulse-ox – Patient Positioning: supine, oblique, lateral decubitus position – Sterile Prep: antibacterial solution, sterile draping

50 Cervical TFESI – ISIS Guidelines Target Identification – Oblique View – Identify target foramen – Rotate C-arm to open foramen – Consider magnification

51 Cervical TFESI – ISIS Guidelines Within foramen: – Posterior Wall – Anterior surface of SAP

52 Cervical TFESI – ISIS Guidelines Puncture Point – Skin directly over target – Mark with sterile marker or small wheel of local anesthetic – +/- Local anesthetic (shallow) Needle Insertion – 25-guage needle (2.5 inch, SB) – Needle tip should lie directly over anterior part of SAP, not foramen (or can be over posterior foramen if checking A/P early and often) – Ideally, advance needle down the beam - “hubogram” – Once SAP is reached, adjust needle to pass into foramen – Subsequent insertion should not be more than a few mm in depth, and should never stray into anterior aspect of foramen

53 Cervical TFESI – ISIS Guidelines Needle Insertion – AP view: target is sagittal midline of articular pillar

54 Cervical TFESI – ISIS Guidelines Contrast injection: – Under real-time fluoro, inject non-ionic contrast – Contrast should disperse in intervertebral foramen, outlining spinal nerve and DRG

55 Big Red DRG SAP Big Red and his little friends

56 Epidural Veins DRG cord SAP DISC SPACE

57 What to watch out for DRG/Spinal Nerve Vascular flow: – Arterial Vertebral artery – rapid upward flow Radicular artery – narrow vessel with transverse flow medially toward cord ISIS recommends procedure aborted in this case – Venous (radicular and epidural veins): slow clearance of contrast – can reposition needle Subarachnoid flow – Rapid dilution of contrast – Can be from medial position, or lateral dilatation of dural root sleeve in foramen – Procedure should be aborted

58 Use Digital Subtraction Angiography in Cervical and Thoracic Spine

59 Digital Subtraction Angiography – Same patient

60 Cervical TFESI – ISIS Guidelines Medication Injection: once injection of contrast has identified acceptable needle position in 2 views, therapeutic solutions can be delivered – Corticosteroid: Dexamethasone (7.5-15mg) Betamethasone (3mg – 12mg) – Short-acting local anesthetic 1% Lidocaine ( ml) 0.5% Lidocaine ( ml) – Normal Saline

61 Cervical Cervical Interlaminar ESI (ILESI) Cervical epidural space much more narrow (1.5-2mm at C7 to less than 1mm at higher levels) compared to lumbar spine If less than 1 mm on MRI, avoid interlaminar Interlaminar approach: usually 2 cc celestone/dexamethasone, 2-3 cc of 1-1.5% lidocaine and 0-2 cc of saline for 4-7 cc total; usually at C6-7-T1

62 C5-6

63 C7-T1

64 Cervical ILESI Position patient prone with pillow under chest Sterile prep with betadine and drape Identify target interlaminar space (C6-7,7-1)

65 Cervical ILESI Target: superior border of inferior lamina at midline Mark and anesthetize (1% lidocaine) 18- or 20- gauge Touhy needle advanced using: – Frequent lateral imaging – Loss of resistance technique with normal saline

66 Cervical ILESI Once epidural space entered (based on LOR), inject non-ionic contrast (1cc) under live fluoro. Should see even spread of contrast, and lateral imaging should show posterior flow. If no vascular flow, no subarachnoid flow…inject medication (1-2 cc celestone / dexamethasone, 2-3 cc of % lidocaine and 0-2 cc of saline for a total of 4-7cc)

67 Cervical ESI - Complications Botwin 5/2003: 157 patients receiving a total of 345 cervical ILESI for cervical radicular pain caused by cervical spondylosis or HNP – All complications: 16.8%. All resolved without morbidity, and no patient required hospitalization: Transient increased neck pain (6.7%), transient headaches (4.6%), insomnia the night of injection (1.7%), Vasovagal reaction (1.7%), facial flushing (1.5%), Transient Fever 1(0.3%), Dural puncture: 1 (0.3%) Ma 8/2005: 844 patients, 1036 Extraforaminal Nerve Root Blocks (TFESI): – All complications: 1.66%. No death, paralysis, stroke, vertebral artery injury or infection recorded: Transient neuro deficit (pain or weakness): 6 pts, HA/Dizziness: 5 patients, Hypersensitivity rxn: 1 pt, Vasovagal rxn: 1 pt, Transient global amnesia, dizziness, nausea:1 pt (admitted to hospital overnight, neuro w/u negative, resolution of dizziness by 2 weeks), Injection at incorrect level: 2 pts, Inadvertent facet injection: 1 pt Case reports – cervical TFESI (Scanlon 2007): death, vertebrobasilar infarcts/TIA/RIND, cervical spinal cord infarcts, combined brain and SCI infarcts, high spinal anesthesia, Seizures, severe HA, brainstem edema with herniation, cortical blindness from air embolus, cervical epidural hematoma, paraspinal hematoma – Mechanism unclear, but thought to be related to particulate steroid causing vascular embolism – SCI, stroke, death – Safety measures: Small/no particulate steroid (dexamethasone) and DSA

68 Cervical ESI - Evidence Transforaminal ESI: No RCT’s, just descriptive studies, generally with positive short-term ( 6 weeks) results for radiculopathy. Limited evidence for axial neck pain. – Morvan 1988: 51 pts with radicular pain - 14% obtained complete and long lasting relief, 86% derived incomplete relief, transitory relief, or no relief – Bush 1996: 68 pts with radicular pain- Transforaminal +/- Interlaminar – 76% complete relief of arm pain (7 mos) – Slipman 2000: 20 pts with radicular pain – 60% success (pain reduction, return to FT work, decreased meds, patient satisfaction) at avg. 22 mos f/u – Vallee 2001: 32 pts with radicular pain - at 6 mos – 53% of patients had >75% pain relief – Cyteval 2004: CT guided TFESI – 30 pts with radicular pain – good pain relief in 60% of patients at 2 wks and 6 mos – Kolstad 2005: 21 surgical candidates (discectomy): significant decrease in radicular pain at 6 wks and 4 mos, 5 patients avoided surgery – Lin 2006: 70 surgical candidates (HNP): 63% had significant relief of symptoms and decided against surgery

69 Cervical ESI - Evidence Interlaminar ESI – 2 RCT for radiculopathy Castagnera 1994: Group 1 (14 pts: LA + Steroid) vs.. Group 2 (10 pts: LA + Steroid + Morphine) – no diff between groups, but good overall pain relief (>50mm decrease on VAS): – Initial: 96% – 1 Month: 75% – 3, 6 and 12 mos: 79% Stav 1993: Group 1 (25 pts: ESI) vs. Group 2 ( 17 pts: intramuscular LA + steroid). Significant outcomes (good-very good pain reduction, return to FT work, decreased meds, change in ROM) – 1 week: 76% group 1, 36% group 2 – 1 year: 68% group 1, 12% group 2 – Axial neck pain: limited evidence

70 Patient Selection for Cervical ESI Indications: – Cervical radicular pain +/- radiculopathy – Hx, PE and imaging c/w nerve root impingment/irritation – Failed conservative treatment (PT, meds, activity modification) >6weeks Contraindications (ABCDEFGHIJK) Absolute:Relative: – Coagulopathy (Bleeding)-Allergy – Local Infection(Fever)-Hx steroid psychosis (Krazy) – Spinal Malignancy (CA)-CHF (decreased EF) – Uncontrolled DM-Pregnancy (Gravid) – Pt. unable to lie still -Systemic infection (Fever) (“Jimmy legs”)-Heart/Respiratory issues – -Immunosupression

71 Stingers (Burners) Transient UE neuropraxia of root or brachial plexus – Traction  plexus – Compression  root Burning in arm Weakness in C5 and C6 distribution – Deltoid, biceps, RC, wrist extensors, pronator teres +/- Positive Spurling’s

72 Stingers Treatment – Protection – Rest until asymptomatic May Return to Play when: – Full cervical ROM w/o pain – Normal sensory, motor exam – Negative Spurling

73 Cervical Cord Neurapraxia Sxs or neuro findings in ≥2 limbs – Axial load with hyperextension or flexion – Cervical cord “pinch” Sx last 10 min-48 hrs – Burning Hands Syndrome – Transient Quadraparesis

74 C-spine Injury On-Field Management Assess LOC and simple neuro exam by question without moving athlete Stabilize C-spine and log- roll if necessary to move athlete to back “Leave helmet on” – Helmet & shoulder pads Manage airway by removing face mask

75 Immediate Transport for… Unconscious athlete Neuro symptoms in ≥2 limbs Spinous process tenderness with concerning MOI Any distracting injuries

76 References Abdi S, et al. Epidural Steroids in the Management of Chronic Spinal Pain: A systematic review. Pain Physician 2007; 10: International Spine Intervention Society: Practice Guidelines – Spinal Diagnostic and Treatment Procedures ISIS Manchikanti, et al. Evidence-Based Practice Guidelines for Interventional Techniques in the Management fo Chronic Spinal Pain. Pain Physician 2003;6:3-81 Rathmal JP, et al. Cervical Transforaminal Injections of Steroids. Anesthesiology 2004; 100: Fenton, DS and Czervionke LF: Image-Guided Spine Intervention. Saunders 2003 Botwin KP, et al. Adverse Effects of Fluoroscopically Guided Interlaminar Thoracic Epidural Steroid Injections. AJPMR 1/06

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