1. PC3: Positional Cervical Cord Compression October 9, 2015
Andrew J. Holman, MD
Associate Clinical Professor of Medicine
University of Washington
Pacific Rheumatology Associates
Pacific Rheumatology Research
Renton, WA USA

2. Overview
Dynamic MR imaging of the degenerative cervical spine reveals spinal cord compression.
Spinal cord compression among patients with fibromyalgia.
Neurological deficits among patients with fibromyalgia
Treatment of cervical spinal cord compression (PC3).
Implications for fibromyalgia diagnostic criteria.

5. 81 patients with different stages (I-IV) of degenerative disease of the cervical spine.
Neutral
Flexion (maximal)
Extension (maximal)
Conclusion: Regardless of stage or grade of spinal stenosis in neutral position, cervical spinal motion may contribute to the development of cervical spondylitic myelopathy.
Muhle C, Metzner J, Weinert D et al. Clasification system based on kinematic MR imagng in cervical spondylitis myelopathy. Am J Neuroradiol. 1998;19:

6. Muhle C, Metzner J, Weinert D et al
Muhle C, Metzner J, Weinert D et al. Classification system based on kinematic MR imaging in cervical spondylitis myelopathy. Am J Neuroradiol. 1998;19:

7. Muhle C, Metzner J, Weinert D et al
Muhle C, Metzner J, Weinert D et al. Classification system based on kinematic MR imaging in cervical spondylitis myelopathy. Am J Neuroradiol. 1998;19:

8. Muhle C, Metzner J, Weinert D et al
Muhle C, Metzner J, Weinert D et al. Classification system based on kinematic MR imaging in cervical spondylitis myelopathy. Am J Neuroradiol. 1998;19:

9. Implications Accurate diagnosis Appropriately targeted surgery
Novel pain generator
Novel autonomic nervous system (ANS) sympathetic arousal

10. Cervical spinal cord and fibromyalgia
In animal models, intermittent light abutment of the cervical cord is a potent autonomic arousal.
Karlsson AK. Autonomic dysfunction in spinal cord injury: clinical presentation of symptoms and signs. Prog Brain Res. 2006;152:1-8.
Cervical trauma (remote) is common among FM patients.
Staud R. Long-term outcome of fibromyalgia related to cervical spine injury is worse in women than in men. Curr Rheumatol Rep Aug;6(4):
Reduction of cervical compression in patients with FM reduces FM symptoms.
Heffez DS et al. Clinical evidence for cervical myelopathy due to Chiari malformation and spinal stenosis in a non-randomized group of patients with the diagnosis of fibromyalgia. Eur Spine J. 2004;13(6):

11. Positional Cervical Cord Compression (PC3) (January-February 2006)
Review all referred consultation to one provider at suburban rheumatology clinic.
Evaluate myelopathy screening questions and exam.
107 consultations reviewed
Segregate diagnoses
CTD or enthesitis / bursitis w/o FM FM
Unexplained widespread pain
Holman AJ. J Pain 2008;9(7):

12. Definition for PC3.
Visual evidence in the midline sagittal view of abutment or flattening of the spinal cord AND narrowing of the spinal canal to less than 10 mm in flexion, neutral or extension position.
Degenerative findings not considered.
Holman AJ. J Pain 2008;9(7):

20. Patient characteristics
CTD FMS CWP
Age
Yrs of FMS
MHAQ
Function (0-10)
Psych (0-9.9)
10 cm VAS Pain
AM Stiffness (min)
10 cm VAS Fatigue
10 cm VAS Global

21. Patient characteristics
CTD (32) FM (53) CWP(22)
Subjects 14M/18F 4M/49F 3M/19F
Disabled (34%) (5%)
Trauma (13%) 4 (18%)
Sink Pain (3%) 36 (68%) 13 (59%)
Dentist Chair 2 (6%) 34 (64%) 8 (36%)
Dizzy 6 (19%) 16 (30%) 5 (23%)
Unsteady Gait 2 (6%) 6 (11%) (5%)
Positive Romberg 3 (9%) 37 (70%) 14 (67%)
Abnormal Grip 6 (19%) 14 (26%) (32%)
Extension Pain 3 (9%) 36 (68%) 15 (67%)
Holman AJ. J Pain 2008;9(7):

22. MRI RESULTS CTD FM CWP Had MRI 1 (3%) 49 (92%) 20 (91%)
Subjects
Had MRI 1 (3%) 49 (92%) 20 (91%)
Abnormal MRI (71%) 17 (85%)
New Views required of 35 (71%) of 17 (71%)
Chiari
Flat cord (9%) 5 (23%)
Radiculopathy 5 (9%) 2 (9%)
Multiple Sclerosis
Multiple Myeloma
Holman AJ. J Pain 2008;9(7):

23. Results FM CW Subjects 53 22 C2-3 6%) 0% C3-4 26% 36% C4-5 35% 41%
Sink % %
Dentist % %
Romberg 70% %
Extension % %

24. MYOPAIN 2010 Toledo, Spain OHSU corroborates Seattle findings
129 patients (2007)
57.4% FM patients tested had PC3
48% of FM+PC3+ had OSA.
CWP not evaluated
Unique PT reproduced and also helpful
Surgical outcomes similar

25. 166 Patients with FM 66 Pain-free controls IX, X 42% 8%
Sensory 65% 25%
Motor 33% %
Gait 28% %
Photophobia 70% %
Poor balance 63% %
Weakness 58% %
Tingling 54% %
Watson FW, Buchwald D, Goldberg J et al. Neurological signs and symptoms in fibromyalgia. Arthritis Rheum 2009;60(9):

26. FM and the cervical spinal cord
[FOR DIAGNOSIS]
“Taken together, these studies suggest that neurologic findings are common in fibromyalgia and may, in some cases, have a neuroanatomical basis.”
[FOR THERAPY]
“…highlights the need for carefully designed, rigorously blinded and controlled studies of craniocervical neuroanatomy in fibromyalgia.”1
1.Watson FW, Buchwald D, Goldberg J et al. Neurological signs and symptoms in fibromyalgia. Arthritis Rheum 2009;60(9):

27. PC3 and ANS Comparing PC3 with asymptomatic controls (2015)
PC3+FM+ vs. PC3-FM+
Indistinguishable except for ANS
PC3+FM- (pain free)
Normal ANS despite cord abutment

28. PC3 Treatment Physical therapy Medications (all off label)
Unique program
Depends on degree of narrowing
DVD available
Medications (all off label)
pregabalin, duloxetine, milnacipran
Analgesics, corticosteroids
RLS meds (lorazepam, clonazepam)
Manipulation
Surgery (<15% since 2003)

29. The 1990 ACR Classification Criteria for FM Has Limited Use
25% of FM patients do not satisfy the 1990 ACR criteria1
Originally developed as a research tool2
Relies on patient’s self-report of symptoms3
No objective clinical findings, radiographic abnormalities, or routinely used laboratory tests2,3
Localized or regional pain may precede the advent of widespread pain3
Tender point examination increasingly considered optional1,4
1Wolfe F, et al. Arthritis Care Res. 2010;62: Navarro RP. Am J Manag Care. 2009;15(suppl):S197-S218.
3Lawson K. Neuropsychiatr Dis Treat. 2008;4: Häuser W, et al. Dtsch Arztebl Int. 2009;106:

30. Diagnostic Workup for FM
History of CWP for ≥ 3 months
Consider other diagnoses that may present with CWP
History, general physical,
musculoskeletal and neurological examination,
selected laboratory testing
Confirm presence of pain
at ≥ 11 of 18 tender points
“Fibromyalgia”
< 11 of 18 tender points, but presence
of other core symptoms
(eg, fatigue, sleep disturbance, dyscognition,
mood disorder, decreased function)
“Probable Fibromyalgia”
Goldenberg DL. Am J Med. 2009;122(suppl):S14-S21.

31. Fibromyalgia Tender Points
Wolfe et al Arthritis and Rheumatism 33(2): (1990)

32. Widespread pain index and symptom severity scoring
WPI
In how many areas has the patient had pain (over the last week)? Score 0-19
Shoulder girdle*
Upper arm, lower arm*
Hip (buttock, trochanter)*
Upper leg, lower leg*
Jaw*
Chest
Abdomen
Upper back, lower back
Neck
SS scale score
Fatigue, waking unrefreshed, cognitive symptoms
Plus general somatic symptoms
Scoring
0 (no problem)
1 (slight/mild)
2 (moderate)
3 (severe)
*Left, right
Wolfe F, et al. Arthritis Care Res. 2010;62:

33. New ACR Diagnostic Criteria for FM and Measurement of Symptom Severity
Widespread pain index (WPI) ≥ 7 and symptom severity (SS) scale score ≥ 5
or WPI 3-6 and SS scale score ≥ 9
Symptoms have been present at a similar level for at least 3 months
The patient does not have another disorder that would otherwise explain the pain
No physical examination necessary
Can be self-administered
Probably more sensitive to change than ACR criteria
Wolfe F, et al. Arthritis Care Res. 2010;62:

34. Summary
Positional cervical cord compression (PC3) is common among patients with degenerative cervical disease.
PC3 is a common co-morbidity among patients with FM.
PC3 may account for neurological deficits and autonomic nervous system (ANS) arousal among patients with FM.
Treatment of PC3 is predominantly PT based with spinal cord active medications, but may also require surgery.
Future studies are required to explain how ANS arousal and pain may be linked and how PC3 may be incorporated into diagnostic criteria for widespread pain states.