Approaching Neck Pain MCP IPA LBP Task Force

Approaching Neck Pain MCP IPA LBP Task Force

MCPIPA Spinal Pain Task Force Committee Members – Neck Pain
Doug Speedie MD Ellen Mead PT John Gustavson PhD KC Lewis MD Mike Dohm MD Britt Smith PT Ellen Price DO Todd Hegstrom MD Cindy Holst Consulted: Susan Hemley MD, Mike Reeder DO

Disclosure Statement Dr. D.K. Speedie is a full time employee of Rocky Mountain HMC He is not on any outside Speakers Bureau However, given that he had two kids in college AGAIN, he is willing to entertain any offer The information in this presentation has been evaluated by the Committee for accuracy Speedie, however has not Fortunately, little of this talk is opinion

Spinal Pain Task Force Mission
To create Evidence Based Clinical Pathways that promotes the effective, efficient and quality care of neck & low back pain patients To recognize those individuals with Red Flag Diagnoses And treat them appropriately

Spinal Pain Task Force Mission
To recognize those individuals with non-specific neck pain or low back pain and treat them according to evidence based guidelines To appropriately treat other forms of neck pain and low back pain according to evidence-based guidelines, where available. Finally, to improve care which is likely to reduce overall health costs to the community

Neck Pain Definitions Several distinct types and the evaluation and treatment is often different. Types include Neck Pain with Headache Neck Pain with Radiculopathy Neck Pain with Myelopathy Neck Pain Mechanical Neck Disorder Whiplash-Associated Disorders Vertebral-Basilar Dissection

Neck Pain Prevalence 12 Month Prevalence of 30-50%
Lifetime Prevalence of 70% Point Prevalence of 22% Estimated Incidence of 213 per 1000 per years Accounts for 25% of chiropractic visits, 15% of PT visits, 2% to family physicians, and 70% of musculoskeletal disease seen by rheumatologists relates to neck pain

Neck Anatomy The cervical spine consists of seven vertebrae denoted as C1 through C7. The bony anatomy of the atlas (C1) and axis (C2) are unique, whereas C3 through C7 have fairly consistent anatomy

Neck Anatomy The atlas is a ring, consisting of anterior and posterior arches with two lateral masses and no vertebral body.

Neck Anatomy The lateral masses articulate with the skull through the occipital condyles and form the atlanto-occipital joints supported further by occipital membranes. The atlanto-occipital joint is responsible for approximately 50% of total flexion and extension in the neck

Neck Anatomy The axis consists of two lamina, a spinous process, two lateral masses, two pedicles, a vertebral body, and the dens or odontoid peg

Neck Anatomy There is no intervertebral disk between the atlanto-occipital joint and atlantoaxial joint Without the stability conferred by a disk, the area is often involved by destructive inflammatory arthritides, which may result in instability. The axis articulates with the vertebra above and below through the superior and inferior facets

Neck Anatomy Posteriorly, the axis has a large spinous process, which can be easily palpated just below the occiput. The atlantoaxial articulation also provides approximately 50% of rotatory motion of the cervical motion.

Neck Anatomy C3 through C7 vertebrae all have fairly similar anatomy.
Each vertebra consists of a body, two interconnecting pedicles, two lateral masses, two transverse processes, two laminae, and a spinous process. The transverse and spinous processes project outward, providing attachment for ligaments and muscles and creating a moment arm to facilitate motion.

Neck Anatomy

Neck Anatomy The spinous processes of C3 through C6 are bifid, whereas the C7 spinous process usually is not. The C7 spinous process is large, however, and the next most prominent and easily palpable spinous process below C2.

Neck Anatomy There are five articulations between each vertebra from C2 through C7, including the intervertebral disk, two uncovertebral joints, and two facet joints.

Neck Anatomy Uncovertebral joints are formed between uncinate process above, and uncus below Two lips project upward from the superior surface of the vertebral body below, and one projects downward from the inferior surface of vertebral body above This is not a synovial joint.

Uncovertebral joints

Cervical Nerves The first cervical nerve emerges from the vertebral canal between the occipital bone and the atlas, sometimes called the suboccipital nerve

Cervical Nerves There are eight cervical nerves (C1-C8). All nerves except C8 emerge above their corresponding vertebrae, while the C8 nerve emerges below the C7 vertebra. (In the other portions of the spine, the nerve emerges below the vertebra with the same name.)

Basic Principles of Neck Pain Management
History and physical exam to exclude ‘Red Flag’ symptoms Physical exam for neurologic screening Diagnostic triage into broad categories mentioned previously Judicious use of diagnostic imaging Use interventions with proven efficacy Non-invasive approaches for most Neck Pain

What are the Red Flags? Fever or Chills Unintentional weight loss
History of osteoporosis or cancer with high risk of metastasis Increasing neurological deficit I V Drug Use Inflammatory arthritis, RA or Ankylosing Spondylitis Intractable pain

Neck Disorder with Headache (NDH)
It has recently been accepted that cervical spine structures, particularly those innervated by the upper three cervical nerves, have the capacity to refer pain into the head and cause neck pain and headache.

Neck Disorder with Headache
The possible sources of cervicogenic headache are the joints, ligaments, muscles, dura, and arteries innervated by the upper three cervical nerves There is no evidence that specific MRI findings are associated with neck pain, cervicogenic headache, or whiplash exposure

NDH Treatment Multimodal therapy for NDH has the most benefit including Mobilization/ Manipulation, Stretching exercise and coordination and strengthening exercise Should be done by physical therapists At-home treatment is not of significant benefit.

NDH Treatment Exercise alone, medication, massage, acupuncture and orthopedic pillows have some benefit. Botox, home exercise, manipulation alone, static traction and have not been shown to be of any benefit. Surgery has no place in the treatment of NDH

Neck Pain with Radiculopathy
Cervical radiculopathy is characterized by dysfunction of a cervical spinal nerve, the roots of the nerve, or both. Patients present with pain in the neck and one arm, with a possible combination of sensory loss, loss of motor function, or reflex changes in the affected nerve-root distribution

Annual incidence rate of per 100,000 for men and 63.5 per 100,000 for women, Peak at 50 to 54 years of age. History of physical exertion or trauma preceded the onset of symptoms in only 15 percent of cases.

Study from Rochester MN-- 26 percent of 561 patients with cervical radiculopathy underwent surgery within three months of the diagnosis Recurrence, (reappearance of symptoms of radiculopathy after a symptom-free interval of at least 6 months) occurred in 32 percent of patients during a median follow-up of 4.9 years.

90 percent of the patients had normal findings or were only mildly incapacitated owing to cervical radiculopathy. Most common cause (in 70 to 75 percent of cases) is foraminal encroachment of the spinal nerve including decreased disc height and degenerative changes of the uncovertebral joints anteriorly and facet joints posteriorly

In contrast to disorders of the lumbar spine, herniation of the disc is responsible for only 20 to 25 percent of cases Other causes, including tumors of the spine and spinal infections, are infrequent. The nerve root that is most frequently affected is the C7, followed by the C6.

Spurling’s Maneuver Spurling’s Maneuver: Spine extended with head rotated to affected shoulder while axially loaded Sensitivity ~30-50%, but specificity 92-95%

MRI is the imaging approach of choice No clear guidelines as to when imaging is warranted. Reasonable indications include the presence of symptoms or signs of myelopathy, significant neurologic loss, or Red flags suggestive of tumor or infection, or the presence of progressive neurologic deficits It is appropriate to limit the use of MRI to those who remain symptomatic after four to six weeks of nonsurgical treatment

As with Low Back Pain, there is a high frequency of abnormalities detected on MRI in asymptomatic adults Disk herniation or bulging (57 percent of cases) Spinal cord impingement (26 percent) Cord compression (7 percent) Carette, NEJM, 2005

Radiculopathy Treatment
Multimodal therapy including Mobilization, Manipulation, Stretching exercise and Coordination and Strengthening exercise Epidural Steroids Injections (ESI) Medication, acupuncture and orthopedic pillows have some benefit Traction has little benefit

ESI ASIPP states that the level of evidence for cervical intralaminar epidural steroid injections is level II-1 (controlled trials w/o randomization) and the recommendation for its use is 1C strong. The Bone and Joint Task Force agrees that there is evidence supporting short-term symptomatic improvement of radicular symptoms in patient's when treatment involves a short course of epidural or selective root injections with corticosteroids

Radiculopathy Treatment -Surgery
It is not clear that long-term outcomes are improved with surgical treatment of cervical radiculopathy compared to non-operative measures However, relatively rapid and substantial pain and impairment relief after surgical treatment seems to be reliably achieved.

Radiculopathy Treatment - Surgery
Most surgeries for disc disease in the neck are accompanied by fusion as removing the disc in the neck typically results in native fusion. Fusion results in adjacent joint arthritis and further limits ROM Results from cervical disc arthroplasty for radicular symptoms seem to show outcomes similar to discectomy and fusion but long-term viability has not been demonstrated

Radiculopathy Treatment - Surgery
The PRESTIGE® Cervical Disc is a metal-on-metal design (stainless steel). Concern with the artificial cervical discs is that they may have to be in place 40+ years and the longest studies to date are at 2 years. Ongoing studies are taking place out to 7 years. RMHP does not cover

Prodisc -C More difficult revision with keeled device
Persistent or recurrent neural compression because osteophytes do not resorb as they do with fusion Sagittal splitting vertebral fracture

Neck Pain with Myelopathy
Dysfunction of the spinal cord is termed myelopathy. The usual sources of this dysfunction include cervical stenosis from osteoarthritis and herniated discs Occasionally, an acute disc can herniate centrally and cause a myelopathy. If left untreated, the effects can be irreversible.

Neck Pain with Myelopathy

Cervical Spondylotic Myelopathy
Cervical spondylotic (osteoarthritic) myelopathy (CSM) is the most common spinal cord disorder in persons more than 55 years of age There are three important pathophysiologic factors in the development of CSM: (1) Static mechanical; Static mechanical factors result in the reduction of spinal canal diameter and spinal cord compression. (2) Dynamic mechanical; and (3) Spinal cord ischemia

Static mechanical: disc hardening and degeneration, osteophytic spurring and the ligamentum flavum may stiffen and buckle into the spinal canal Dynamic Mechanical Factors: with flexion, the spinal cord lengthens, thus stretching over ventral osteophytic ridges.

Dynamic Mechanical Factors: During extension, the ligamentum flavum may buckle into the spinal cord causing a reduction of available space for the spinal cord Spinal cord ischemia: probably plays a role in the development of CSM, particularly in later stages Other associated factors include heavy labor, posture and genetic predisposition

Cervical Spondylotic Myelopathy (CSM) Symptoms
In the early stages of CSM, complaints of neck stiffness are common because of the presence of advanced cervical spondylosis Other symptoms include crepitus in the neck with movement Stabbing pain in the arm, elbow, wrist or fingers; or a dull "achy" feeling in the arm; and numbness or tingling in the hands.

Cervical Spondylotic Myelopathy Symptoms
The hallmark symptom of CSM is weakness or stiffness in the legs Symptoms may be asymmetric particularly in the legs Unsteadiness of gait Weakness or clumsiness of the hands Slight hesitancy on urination

Cervical Spondylotic Myelopathy Signs
Atrophy of the hand musculature Hyperreflexia Lhermitte's sign (electric shock-like sensation down the center of the back following flexion of the neck) Sensory loss: particularly proprioception or vibratory in the extremities; may be asymmetrical Gait abnormalities Hoffman and Babinski reflexes should also be assessed.

Hoffman’s sign The test involves tapping the nail or flicking the terminal phalanx of the third or fourth finger. A positive response is seen with flexion of the terminal phalanx of the thumb Often considered the upper limb equivalent of the Babinski's sign

Neck Pain with Myelopathy Diagnostic Testing
MRI of the cervical spine is the procedure of choice during the initial screening process of patients with suspected myelopathy. Electrical testing is rarely useful in most patients with myelopathy; however, it may help in the exclusion of specific syndromes such as peripheral neuropathy

Cervical Spondylotic Myelopathy Natural History
Evaluating the efficacy of any particular treatment strategy for CSM is difficult As many as 18 percent of patients with CSM will improve spontaneously 40 percent will stabilize Approximately 40 percent will deteriorate if no treatment is given. No way to predict

Myelopathy – Surgical Indications
Multilevel spondylotic myelopathy, as evidenced by ANY ONE of the following Clinical symptoms of myelopathy; examples include: Clumsiness of hands Urinary urgency Bowel or bladder incontinence Frequent falls

Myelopathy – Surgical Indications
Clinical signs of myelopathy; examples include: Hyperreflexia Hoffmann sign Increased tone or spasticity Loss of thenar or hypothenar eminence Gait abnormality Positive Babinski sign

Mechanical Neck Pain Muscle strain is the most common cause of neck pain followed by ligamentous sprain Like the Low Back, these probably account for 85% of cases presenting in the office Acute muscle-mediated pain can be subdivided into delayed onset muscle soreness (DOMS) and muscle contusion, which occur after direct tissue trauma.

Mechanical Neck Pain Almost everyone will experience DOMS at some time in their life. Usually occurs after unusual physical activity.

Mechanical Neck Pain . The symptoms usually appear 24 to 48 hours after such activity and abate completely within several days The mechanism of this type of muscle injury consists of excessive eccentric muscular contraction

Mechanical Neck Pain When a direct and forceful compression is applied to a muscle, as occurs commonly during sports participation, muscle contusion may develop. The trauma produces local tissue necrosis, cellular death, extravasation of blood into the tissues, and secondary inflammatory response Uncommon cause of neck pain. More typical of extremities

Mechanical Neck Pain Likewise, ligamentous injury not only is limited to pathologic elongation (sprain) but also can be classified further as a partial or a complete tear. Ligamentous sprains are produced by forceful, passive stretching beyond the physiologic range or with strong muscular contractions If there are no Red Flags, there is no reason to image these people

Mechanical Neck Pain - Treatment
None; or Multimodal therapy including Mobilization, Manipulation, Stretching exercise and Coordination and Strengthening exercise Massage, Electrotherapy, Low-level laser therapy, Orthotic pillow, Acupuncture all have some evidence Surgery is not indicated

Whiplash Associated Disorder (WAD)
Whiplash is defined as an acceleration-deceleration mechanism of energy transfer to the neck. The current model of injury → body’s inertial response causing the head & neck to undergo large amounts of displacement without any direct impact. The most recent data from the US suggest that this injury costs 29 billion yearly.

Rear end impact → patient's torso is rapidly carried forward. Movement → development of the S shaped cervical curve forcing C-spine into an abnormal, non-physiologic motion of lower extension and upper flexion

The reverse occurs with a front end impact. Motion has been shown to produce elongation and failure strain of the facet capsule and ligaments at the C6-7 level during the initial S-shaped phase. May be facet joint spearing of the superior facet on the inferior articular facet as well as stretching of the anterior ligamentous tissues

May be a variety of unique injuries involving the spinal dorsal ganglia, and intervertebral disks. Location of the dorsal root ganglia and nerve roots and render them vulnerable to excessive stretching There may be hemarthrosis, capsular tears, articular cartilage damage, joint fractures and capsular rupture.

Ligamentous injuries in the mid and lower cervical segments may also contribute to development of the persistent symptoms. There may be strains in the superficial posterior neck muscles.

Mechanical tissue injury has been shown to create local and systemic inflammation → profound changes in muscle tissue. There are a may also be denervation contributing to the muscular degeneration.

Most individuals recover within two to 3 weeks A number of individuals with this injury will sustain longer problems with the injury. Symptoms of whiplash injury may include pain, dizziness, visual and auditory disturbances, photophobia, fatigue, cognitive difficulties such as concentration and memory loss, anxiety, insomnia and depression.

WAD The Québec Task Force categorizes WAD into 4 groups:
WAD I: Stiffness or tenderness in the neck; no physical signs of a injury; WAD II: Stiffness or tenderness, some physical signs of injuries such as point tenderness or trouble turning the head WAD III: stiffness or tenderness and neurologic signs WAD IV: fracture or dislocation of the neck. The problem with his classification scheme is that virtually everyone requiring treatment will be a WAD II.

Proposed classification Physical/Psychological Impairment WAD 0 WAD I
No complaint about neck pain No physical signs WAD I Neck pain, complaints of pain/stiffness/tenderness only WAD II A Neck pain Motor Impair: ↓ ROM, Altered Muscle recruitment (CCFT) Sensory Impair: Local cervical mechanical hyperalgesia WAD II B Psych. Impair: ↑ Psychological distress (GHQ-28, TAMPA)

Proposed classification Physical/psychological Impairment WAD II C
Neck pain Motor Impair: ↓ ROM, Altered muscle recruitment → Cranio-cervical flexion test (CCFT), ↑ Joint position error (JPE) Sensory Impair: Local cervical mechanical hyperalgesia, Generalized sensory hypersensitivity (mechanical, thermal, (BPPT)) Some may show Sympathetic Nervous System (SNS) disturbances Psych. Impair: ↑ Psychological distress (GHQ-28, TAMPA), ↑ Elevated levels of acute post-traumatic stress → Impact of Event Scale (IES) WAD III Motor Impair: ↓ ROM, Altered muscle recruitment (CCFT) ↑ JPE Sensory Impair: Local cervical mechanical hyperalgesia, Generalized sensory hypersensitivity (mechanical, thermal, BPPT) Some may show SNS disturbances Psych. Impair: ↑ psychological distress (GHQ-28, TAMPA), ↑ Elevated levels of acute post-traumatic stress (IES) Neurological signs of conduction loss: ↓ DTRs, muscle weakness, Sensory deficits brachial plexus provocation test (BPPT)

Fracture or dislocation
Proposed Classification Physical & Psych. Impairments present WAD IV Fracture or dislocation

Significant presenting findings include loss of active cervical ROM Measurements of ROM discriminate between patients with persistent whiplash associated disorder compared to those with no further problems → sensitivity of 86.2%, specificity of 95.3%.

Loss of balance and disturbed neck influenced eye-movement control are present in chronic WAD Vestibular control mechanisms utilize neck musculature for balance and the mechanisms may be damaged by the whiplash injury

Whiplash injuries may also present with widespread sensory hypersensitivity to a variety of stimuli including pressure and thermal. Hypersensitive responses suggest augmented central pain processing mechanisms. Cold hyperalgesia in sympathetic nervous system changes could also indicate peripheral nerve injury/involvement.

Initial pain and functional disability levels → useful in the prediction of those at risk for transitioning from acute to chronic. High pain and disability levels with physical and psychological factors, including early presence of ↓cervical movement, cold temperature hyperalgesia, and PTSD symptoms are all strong predictors of poor outcome.

There may be significant psychological factors in chronic whiplash pain including affective disturbances, anxiety, depression, and behavioral abnormalities such as fear of movement. Some of the psychological factors and mental function abnormalities may be the result of traumatic brain injury.

Though there is typically no direct blunt force trauma to the head, the acceleration deceleration portion of the injury may cause a coup-contrecoup phenomenon.

Without the direct blunt force trauma, TBI may not be as readily apparent. Given that these may be severe accidents, there may be significant risk of posttraumatic stress disorder as well which has been shown to increase the risk of chronic WAD

Clinical evaluation should aim to identify the presence of physical and psychological impairments Measure cervical active range of motion Specific sensory assessments → no current consensus about the most appropriate testing mechanisms. MRI is not useful

Whiplash Associated Disorder (WAD) Treatment
Physical rehabilitation Psychological support and possibly neuropsychological evaluation Pharmacological pain management Surgical intervention not useful

Vertebral-Basilar Dissection
Often presents as strictly neck pain making diagnosis challenging, however, if the following symptoms occur – consider immediate referral. Female to male ratio 3:1, average age 40 Dizziness (vertigo) and Disequilibrium Dysesthesia, (facial) Dysphagia Diplopia Dysarthria

Handouts Algorithm: The Committee’s recommended approach to neck pain presenting in the office Template: The Committee’s recommended approach to the History and Physical. Can be used in a paper chart or the basis of a template for an EMR.

Physical Exam Gait abnormality _________________ Palpation for spinal tenderness _________ Complete with % of Normal ROM: Flexion_____Extension_____ R Rotation_____L Rotation_____

Physical Exam Strength Testing R L Handgrip Finger Abduction
Wrist Extension Biceps Triceps Deltoid Inspection for Atrophy R L Biceps Triceps Deltoid Hand Forearm

Physical Exam Reflexes Biceps R L Triceps R L Hoffman’s Babinski’s
Spurling’s sign

Handouts Physical Findings Associated with Specific Cervical Radiculopathy: Reference for the specific findings of the various levels that are seen with cervical radiculopathy. Dermatome Map: Reference for the specific dermatomes Neck Disability Index: Essentially the Oswestry for the neck. Useful in assessing for Yellow flags as well as following progress in the neck pain patient

Approaching Neck Pain MCP IPA LBP Task Force The END

Approaching Neck Pain MCP IPA LBP Task Force

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