Dr Jim Borowczyk. Dr John Robinson. Dr Peter McKenzie. Dr John MacVicar

Transcription

1 Dr Jim Borowczyk Musculoskeletal Physician Christchurch Dr Peter McKenzie Musculoskeletal Physician Nelson Dr John Robinson General Practitioner Otumoetai Doctors Tauranga Dr John MacVicar Medical Director Musculoskeletal Medicine Specialist Southern Rehab Christchurch 8:30-10:30 WS #1: Musculoskeletal Workshop Part 1 11:00 13:00 WS #7: Musculoskeletal Workshop Part 2

2 EVIDENCE-BASED INTERVENTIONS Part 1 Neck Pain John MacVicar SouthernRehab Christchurch, NZ South GP CME 2017 South GP CME 2017 meeting 10 th August 2017

3 CONSIDERATIONS Cause trauma red flags Acute/chronic Natural history Specificity/sensitivity of imaging

4 DEFINITIONS Somatic pain zygapophysial joints muscles ligaments intervertebral discs

5 DEFINITIONS Somatic pain zygapophysial joints muscles ligaments intervertebral discs dura mater vertebral arteries

6 DEFINITIONS Radicular pain Referred to forearm and hand (accompanied by radiculopathy?) Somatic referred pain Upper cervical spine Lower cervical spine head shoulder, arm

7 RED FLAGS Severe worsening pain, especially at night or when lying down Significant trauma Weight loss, history of cancer, fever Use of intravenous drugs or steroids Patient over 50 years old Investigate with Blood tests MRI

8 TRAUMA

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10 TRAUMA What imaging? Plain x-rays CT scan (ACR 2 ) (in patients with neurologic signs or symptoms whose plain films are normal) in patients whose screening films suggest injury at the occiput to C2 levels SPECT scan 3 1. Stiell IG et al. The Candian C-Spine Rule versus the NEXUS Low-Risk Criteria in patients with trauma. N Engl J Med 2003;349: Kathol MH. Cervical Spine Trauma. What is new? Radiol Clin North Am 1997;35: Seitz JP, Unguez CE, Corbus HF, Wooten WW. SPECT of the cervical spine in the evaluation of neck pain after trauma. Clin Nucl Med 1995;20:

11 NATURAL HISTORY 205 patients (121 had neck pain after an injury) 1 seen at least ten years previously 43% of patients recovered fully 25% of patients continued to have moderate symptoms 7% remained, or became, severely disabled 51 patients 2 reviewed between two and 19 years after onset of symptoms 44% had no symptoms 29% had mild or intermittent symptoms 28% had troublesome symptoms or moderate disability. 1. Gore DR, Sepic SB, Gardner GM, et al. Neck pain: A long-term follow-up of 205 patients. Spine 1997;12: Lees F, Turner JWA. Natural history and prognosis of cervical spondylosis. Br Med J 1963; 2:

12 NATURAL HISTORY Acute neck pain after whiplash, n = 117 Fully recovered: by 3 months - 56% by 6 months- 70% by 1 year - 76% by 2 years - 82% Mild or moderate symptoms: by 3 months - 38% by 6 months- 26% by 1 year - 20% by 2 years 14% Radanov BP, Sturzenegger M, Di Stefano G. Long term outcome after whiplash injury: a 2 year follow-up considering features of injury mechanism and somatic, radiologic, and psychosocial findings. Medicine 1995; 74:

13 IMAGING - SPECIFICITY/SENSITIVITY

14 IMAGING - SPECIFICITY/SENSITIVITY

15 IMAGING SENSITIVITY

16 DEGENERATIVE JOINT DISEASE CERVICAL SPONDYLOSIS Radiographic features occur with increasing frequency with increasing age in asymptomatic individuals. 1,2 Age changes most commonly affect the C5-6 and C6-7 segments. In some studies cervical spondylosis occurs slightly more commonly in symptomatic individuals than in asymptomatic individuals, 3,4 but the odds ratios for disc degeneration or osteoarthrosis as predictors of neck pain are only 1.1 and 0.97 respectively for women, and 1.7 and 1.8 for men. 4 In other studies, the prevalence of disc degeneration at individual segments of the neck is not significantly different between symptomatic patients and asymptomatic controls. 5 Indeed, uncovertebral osteophytes and osteoarthrosis were found to be less prevalent in symptomatic individuals. 5

17 DEGENERATIVE JOINT DISEASE CERVICAL SPONDYLOSIS Spondylosis and osteoarthrosis, or degenerative joint disease, are regularly listed as causes of neck pain, but the evidence expressly refutes this association. Source: Bogduk N, McGuirk B. Management of Acute and chronic neck pain. An Evidence Based Approach. Elslvier 2006 References: 1. Gore DR, Sepic SB, Gardner GM. Roentgenographic findings of the cervical spine in asymptomatic people. Spine 1986; 1: Elias F. Roentgen findings in the asymptomatic cervical spine. NY State J Med 1958; 58: Heller CA, Stanley P, Lewis-Jones B, Heller RF. Value of X-ray examinations of the cervical spine. Brit Med J 1983; 287: Van der Donk J, Schouten ISAG, Passchier J, van Romunde LKJ, Valkenburg HA. The associations of neck pain with radiological abnormalities of the cervical spine and personality traits in a general population. J Rheumatol 1991; 18: Fridenberg ZB, Miller WT. Degenerative disc disease of the cervical spine: a comparative study of asymptomatic and symptomatic patients. J Bone Joint Surg Am 1963; 45A:

18 MRI CERVICAL SPINE 30 asymptomatic volunteers Age 19-69, median age 44 Disc degeneration: Mild - 50% (age <30) 75% (age 31-45) 100% (age>45) Severe - 55% (age 41-60) 100% (age >60) Bulging discs: 73% - 50% (age <30) 100% (age >45 ) Protrusion: 50% Annular tear: 36.7% Extrusion: 3.3% Ernst, C W. Stadnik, T W. Peeters, E. Breucq, C. Osteaux, M J C. Prevalence of annular tears and disc herniations on MR images of the cervical spine in symptom free volunteers.. European Journal of Radiology. 55(3):409-14, 2005 Sep.

19 MRI CERVICAL SPINE 30 asymptomatic volunteers Age 19-69, median age 44 Disc degeneration: Mild - 50% (age <30) 75% (age 31-45) 100% (age>45) Severe - 55% (age 41-60) 100% (age >60) Bulging discs: 73% - 50% (age <30) 100% (age >45 ) Protrusion: 50% Annular tear: 36.7% Extrusion: 3.3% Ernst, C W. Stadnik, T W. Peeters, E. Breucq, C. Osteaux, M J C. Prevalence of annular tears and disc herniations on MR images of the cervical spine in symptom free volunteers.. European Journal of Radiology. 55(3):409-14, 2005 Sep.

20 IMAGING SPECIFICITY

21 PREVALENCE CERVICAL ZYGAPOPHYSIAL JOINT PAIN

22 Whiplash - postmortem findings Nerve-root lesions Rim-lesions to the intervertebral discs Cervical zygapophysial joint lesions: intra-articular haemorrhages fractures affecting articular cartilage, subchondral bone, or entire articular processes joint capsule tears 1. Jónsson H, Bring G, Rauschning W, et al. Hidden cervical spine injuries in traffic accident victims with skull fractures. J Spinal Disord 1991 ; 4 : Taylor JR, Twomey LT. Acute injuries to cervical joints: an autopsy study of neck sprain. Spine 1993 ; 9 : Taylor JR, Taylor MM. Cervical spinal injuries: an autopsy study of 109 blunt injuries. J Musculoskeletal Pain 1996 ; 4 : Clemens HJ, Burow K. Experimental investigation on injury mechanisms of cervical spine at frontal and rear-frontal vehicle impacts. Proceedings of the 16th Stapp Car Crash Conference, Detroit, MI ;1972 : Yoganandan N, Cusick JF, Pintar FA, et al. Whiplash injury determination with conventional spine imaging and cryomicrotomy. Spine 2001 ; 26 :

23 RADIOLOGICAL IMAGING CERVICAL SPINE

24 RADIOLOGICAL IMAGING CERVICAL SPINE

25 RADIOLOGICAL IMAGING CERVICAL SPINE

26 PRECISION DIAGNOSIS OF CERVICAL ZYGAPOPHYSIAL JOINT PAIN

27 PRECISION DIAGNOSIS OF CERVICAL ZYGAPOPHYSIAL JOINT PAIN

28 PRECISION DIAGNOSIS OF CERVICAL ZYGAPOPHYSIAL JOINT PAIN

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31 Third occipital nerve A B

32 PRECISION DIAGNOSIS OF CERVICAL ZYGAPOPHYSIAL JOINT PAIN INTRA-ARTICULAR BLOCKS OR MEDIAL BRANCH BLOCKS? Medial branch blocks: are easier to perform can always be performed are safer are more easily subjected to controls if positive, can be followed by radiofrequency neurotomy. Medial branch blocks, therefore, have therapeutic utility and predictive validity. Bogduk N. Editor: Practice guidelines for spinal diagnostic and treatment procedures. 2 nd Ed. San Francisco (CA): International Spine Intervention Society (ISIS); 2013.

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38 C5,6 MEDIAL BRANCH BLOCKS

39 C5,6 MEDIAL BRANCH BLOCKS

40 THIRD OCCIPITAL NERVE BLOCK

41 WHICH LEVEL? No correlation between clinical examination findings and the response to controlled blocks Manual examination 1 Tenderness 2 1. King W, Lau P, Lees R, Bogduk N. The validity of manual examination in assessing patients with neck pain. The Spine Journal 2007;7: Siegenthaler A, Eichenberger U, Schmidlin K, Arendt-Nielsen L, Curatolo M. Anesth Analg. What does local tenderness say about the origin of pain? An investigation of cervical zygapophysial joint pain Mar 1;110(3):923-7.

42 Dwyer A, Aprill C, Bogduk N. Cervical zygapophyseal joint pain patterns I: a study in normal volunteers. Spine 1990;15: Aprill C, Dwyer A, Bogduk N. Cervical zygapophyseal joint pain patterns II: a clinical evaluation. Spine 1990; 15:

43 Schellhas KP, Smith MD, Gundry CR, PolleiSR. Cervical discogenic pain. Prospective correlation of magnetic resonance imaging and discography in asymptomatic subjects and pain sufferers. Spine 1996; 21: Grubb SA, Kelly CK. Cervical discography: clinical implications from 12 years of experience. Spine 2000; 25:

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48 Cooper G, Bailey B, Bogduk, N. Cervical Zygapophysial Joint Pain Maps. Pain Medicine 2007; 8:(4),

49 ASSESSING THE RESPONSE

50 REAL TIME ASSESSMENT Description of index pain Current pain/pain drawing Visual analogue scale (NRS): - Worst pain ever experienced - Worst ever index pain - Index pain today Four activities that aggravate pain, and that can be tested after the procedure

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53 RADIOLOGICAL IMAGING CERVICAL SPINE

54 1. Barnsley L, Lord SM, Wallis BJ, Bogduk N. The prevalence of chronic cervical zygapophysial joint pain after whiplash. Spine 1995; 20: Lord S, Barnsley L, Wallis BJ, Bogduk N. Chronic cervical zygapophysial joint pain after whiplash: a placebo-controlled prevalence study. Spine 1996; 21: Speldewinde GC, Bashford GM, Davidson IR. Diagnostic cervical zygapophysial joint blocks for chronic cervical pain. Med J Aust 2001; 174: Manchikanti L, Singh V, Rivera J, Pampati V. Prevalence of cervical facet joint pain in chronic neck pain. Pain Physician 2002;5: Yin W, Bogduk N. The nature of neck pain in a private pain clinic in the United States. Pain Med 2008; 9:

55 1. Barnsley L, Lord SM, Wallis BJ, Bogduk N. The prevalence of chronic cervical zygapophysial joint pain after whiplash. Spine 1995; 20: Lord S, Barnsley L, Wallis BJ, Bogduk N. Chronic cervical zygapophysial joint pain after whiplash: a placebo-controlled prevalence study. Spine 1996; 21: Speldewinde GC, Bashford GM, Davidson IR. Diagnostic cervical zygapophysial joint blocks for chronic cervical pain. Med J Aust 2001; 174: Manchikanti L, Singh V, Rivera J, Pampati V. Prevalence of cervical facet joint pain in chronic neck pain. Pain Physician 2002;5: Yin W, Bogduk N. The nature of neck pain in a private pain clinic in the United States. Pain Med 2008; 9: Gibson T, Bogduk N, Macpherson J, McIntosh A. Crash characteristics of whiplash associated chronic neck pain. J Musculoskeletal Pain 2000; 8:87-95.

56 VALIDITY Cervical medial branch blocks False positive rate 27% Barnsley L, Lord S, Wallis B, Bogduk N. False-positive rates of cervical zygapophysial joint blocks. Clin J Pain 1993; 9: Placebo-controlled cervical medial branch blocks Concordant responses sensitivity 54% specificity 88% Discordant responses sensitivity 100% specificity 65% Lord SM, Barnsley L, Bogduk N. The utility of comparative local anaesthetic blocks versus placebo-controlled blocks for the diagnosis of cervical zygapophysial joint pain. Clin J Pain 1995; 11:

57 LATERAL ATLANTOAXIAL JOINT BLOCK

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60 dural sac

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63 g. dural sac

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76 CERVICAL DISCOGRAPHY

77 CERVICAL DISCOGRAPHY

78 CERVICAL DISCOGRAPHY International Spinal Intervention Society diagnostic criteria provocation of the target disc reproduces the patient s pain the pain that is reproduced is 7/10 provocation of adjacent discs does not reproduce pain. stimulation of adjacent discs does not reproduce the patient s pain. Schellhas KP, Smith MD, Gundry CR, PolleiSR. Cervical discogenic pain. Prospective correlation of magnetic resonance imaging and discography in asymptomatic subjects and pain sufferers. Spine 1996; 21:

79 CERVICAL DISCOGRAPHY International Spinal Intervention Society diagnostic criteria provocation of the target disc reproduces the patient s pain the pain that is reproduced is 7/10 provocation of adjacent discs does not reproduce pain. stimulation of adjacent discs does not reproduce the patient s pain. Positive cervical discography in 34/56 patients (61%) False positive in 23 patients (41%) whose pain was relieved by z-joint blocks. Clearly positive in only 11 (20%). These figures suggest a false-positive rate of 23/32 (72%) Schellhas KP, Smith MD, Gundry CR, PolleiSR. Cervical discogenic pain. Prospective correlation of magnetic resonance imaging and discography in asymptomatic subjects and pain sufferers. Spine 1996; 21: Bogduk N, Aprill C. On the nature of neck pain, discography and cervical zygapophysial joint blocks. Pain 1993;54:

80 CERVICAL DISCOGRAPHY International Spinal Intervention Society diagnostic criteria provocation of the target disc reproduces the patient s pain the pain that is reproduced is 7/10 provocation of adjacent discs does not reproduce pain. stimulation of adjacent discs does not reproduce the patient s pain. cervical zygapophysial joint pain has been excluded at the segments being investigated. Schellhas KP, Smith MD, Gundry CR, PolleiSR. Cervical discogenic pain. Prospective correlation of magnetic resonance imaging and discography in asymptomatic subjects and pain sufferers. Spine 1996; 21: Bogduk N, Aprill C. On the nature of neck pain, discography and cervical zygapophysial joint blocks. Pain 1993;54:

81 SOMATIC CERVICAL SPINAL PAIN INVESTIGATION summary Radiological imaging required to investigate red flags Trauma Canadian C-spine rule Otherwise: For acute pain, provide reassurance Imaging not helpful Precision diagnostic procedures required

82 SOMATIC CERVICAL SPINAL PAIN INVESTIGATION summary Radiological imaging required to investigate red flags Trauma Canadian C-spine rule Otherwise: For acute pain, provide reassurance Imaging not helpful it leads to inappropriate intervention Precision diagnostic procedures required