1. Julian Price MD Athens Orthopedic Clinic 8/23/2017
Neck Pain
Julian Price MD
Athens Orthopedic Clinic
8/23/2017

2. Disclosures Globus Medical: a,b Stryker Spine: a Choice Spine: a,b
Amendia, Inc.: b
a: consulting
b: royalties

3. Anatomy
7 Cervical
12 Thoracic
5 Lumbar
Sacrum/Coccyx

4. ANATOMY Seven Cervical Vertebrae: C1-2: rotation
C3-C7: flx/ext + side bending
Spinal Motion Unit: disc + 2 facet joints
Cervical Lordosis: normal is 20-40⁰

5. Anatomy Uncovertebral Joint Intervertebral Disc Vertebral Body
Vertebral Artery
Nerve Root

6. Anatomy Intervertebral Disc Nerve Root Spinal Canal / Cord
Vertebral Artery
Facet Joints
Posterior Longitudinal Ligament

7. Anatomy

8. Anatomy 1. Myelopathy (Cord compromise)
2. Radiculopathy (Nerve Root impingement)

9. Anatomy
Anterior
Posterior
J Bone Joint Surg Am. 2007;89:

10. Presentation Causes: Degenerative Disc Spondylosis Sprain/Strain
Disc herniation
Trauma/Fracture
Tumor/Malignancy
Infection

11. Presentation Neck pain Stiffness Arm pain Referred pain
Numbness/Tingling
Weakness
Occipital headaches
Crepitance

12. Presentation Facetogenic Pain Patterns Discogenic Pain Patterns
J Bone Joint Surg Am. 2007;89:

13. Presentation Radiculopathy Myelopathy Neck pain Arm pain Referred pain
Numbness/Tingling
Weakness
Decreased motion
Myelopathy
Same as radiculopathy, but often less specific
Balance changes
Bowel/Bladder changes
Dexterity changes
Gait changes

14. Presentation
J Bone Joint Surg Am. 2007;89:

15. Examination ROM TTP Strength Sensation DTR’s Long tract signs
Vascular/skin changes

16. Examination Radiculopathy Myelopathy Dermatomal pain
Dermatomal numbness
Myotomal weakness
Decreased DTR
Spurling’s sign
Hand on head (C7 mostly)
Myelopathy
Often nondermatomal pattern pain/numbness
+/- weakness
Increased reflexes
Rhomberg
Broad based gait
Hoffman’s sign
Clonus/Babinski
Finger escape, inverted radial reflex
Shoulder abduction sign: decrease tension nn root, lift DRG away from compression, decompress epidural vv

17. Imaging
X-rays: note end-plate sclerosis, disc collapse, facet arthrosis, fracture, lytic lesions, malalignment in sagittal and\or coronal planes
AP, LAT; flexion & extension views to assess sagittal instability
(Caution: flexion / extension views should be avoided in acute trauma until CT Scan has ruled out injury leading to instability)
Gives clues/ideas of which levels have advanced degeneration; does not show disc or neurologic structures

18. Imaging

19. Imaging
MRI: -optimal method to assess spinal cord, nerve roots, disc integrity 1. spinal cord deformation, cord edema 2. decreased neuroforamen volume 3. evaluation of cord in acute injury -ability to depict soft tissue structures causing stenosis: 1. ligament flavum hypertrophy 2. facet capsule hypertrophy 3. disk herniation

20. Imaging

21. Imaging
CT: -optimal method to assess osseous structures -can create 3-dimensional images to link degenerative disease to neural structures -best study for acute trauma to evaluate the bony structures for fracture / dislocation CT myelogram: -allows erect position for gravity’s effect on spinal segments (stressful position) to assess dynamic changes -helpful in patient with previous instrumentation

22. Imaging

23. Imaging
EMG/NCV
Good for ruling out (or in) peripheral entrapment syndromes
Carpal Tunnel, Cubital Tunnel, Suprascapular nerve impingement
EMG
2 muscles same root, different peripheral nerve = radiulopathy
High specificity, low sensitivity
NCV
Only for peripheral entrapment syndromes

24. Treatment: Conservative
Activity Modification: avoid heavy lifting, repetitive push/pull and overhead activity
Physical Therapy: ROM, low impact aerobic conditioning, isometrics, traction, modalities
NSAIDS: reduce inflammation, edema
ESI: decrease inflammation, decrease pain
Others: chiropractic, massage therapy, accupuncture
Bracing: no role due to muscle deconditioning

25. CERVICAL SPRAIN/STRAIN
Neck pain w/o arm s/s
Stiffness/spasms
Decreased ROM
XR: loss of lordosis
NSAIDs, heat/ice, ROM

26. Fracture/Dislocation
Imaging
Stable, no neuro involvement: immobilization x 6-12 weeks
Unstable or neuro involvement: surgery
All C- spine fractures should have orthopedic or neurosurgery evaluation

27. Treatment: Surgical Indications:
HNP/spondylosis with radiculopathy: S/S >6-12 weeks* and failure of conservative treatment
Progressive neurologic deficit
Myelopathy
Significant/persistent motor deficit
Severe pain, inability ADL’s/work, + tension
Infection
Malignancy
Instability (fracture and/or ligamentous injury)

28. Treatment: Surgical
Approach is based on where the pathology is and if there is deformity present
Options: anterior, posterior, A/P
In general, if kyphotic deformity, go anterior
If mulitilevel*, consider A/P for additional biomechanical support

29. Treatment: Surgical Anterior Posterior ACDF Corpectomy
Disc arthroplasty
Posterior
Laminoplasty
Laminectomy
Laminectomy and fusion
laminoforaminotomy

30. Complications Anterior Posterior Dysphagia Dysphonia Sore throat
Pseudarthrosis
Horner’s syndrome
Adjacent level degeneration
Infection
Nerve injury
Spinal cord injury
Posterior
Wound complications
Infections
Neck pain
Pseudarthrosis
Adjacent level degeneration
Nerve injury*
Spinal cord injury

31. Complications Esophageal injury: 50% mortality
Recurrent laryngeal nerve: dysphonia
Superior laryngeal nerve: gag reflex, dysphonia, voice fatigue
Sympathetics: Horner’s syndrome (meosis, ptosis, anhydrosis)

32. Outcomes Dependent on levels of involvement, pathology, etc
In general, less levels involved equals higher success rate
In general, improvement of radicular s/s higher success than axial pain

33. Case Example 40 yo female Neck and LUE pain
Dorsal forearm and thumb/index
+Numbness, +Weakness
- B/B, balance, dexterity
Failed 6 week cons tx including ESI

34. Case example Postop pain and N/T, weakness resolved
No narcotics at 6 week checkup
Back to work full-time

35. Alternative: Disc Athroplasty

36. Case Example 46 yo female Previous ACDF C5-6 in 2001
Neck pain and BUE pain lateral arm
+ N/T, weakness
- B/B, balance, dexterity
Failed non-op tx including ESI’s

37. Case Example
6 weeks post-op
Off narcotics
RTW full time

38. Case Example 60 yo female Neck + BUE pain BUE N/T, weakness
+ balance, dexterity changes
- B/B changes

39. Case Example 6 weeks post op
Hands increased feeling, decreased weakness
Balance improving
Start PT for gait training, proprioception, and BUE strengthening

40. Case Example 68 yo female Presents for LBP Denies neck pain
Some dexterity, balance changes
No B/B changes
Exam: hyperreflexia, hoffman

41. Case Example 6 months post op No B/B, balance or dexterity changes
Primary complaint: lumbar

42. Case Example 72 yo male ground level fall ~3 weeks prior
Neck pain + R arm pain/N+T/weakness
No bowel or bladder, dexterity or gait changes
h/o 3 level ACDF by outside MD 6 years prior
Chin forward position with fixed thoracic hyperkyphosis
RUE: 3/5 triceps, 1/5 grip, 1/5 intrinsics
Decreased C7, C8 sensation

46. Quartex
Quartex

47. Take Home Pearls Radiculopathy Myelopathy Neck pain Arm pain
Referred pain
Numbness/Tingling
Weakness
Decreased motion
Myelopathy
Same as radiculopathy, but often less specific
Balance changes
Bowel/Bladder changes
Dexterity changes
Gait changes

48. QUESTIONS?