Diagnosis of Neck & Upper Extremity Pain
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1 Diagnosis of Neck & Upper Extremity Pain David B. Bumpass, MD Assistant Professor, Spine Surgery UAMS Depts. of Orthopaedic Surgery & Neurosurgery May 12, 2018
2 Disclosures Medtronic Spine speaking fees
3 Objectives 1. Identify common causes of neck/upper extremity pain in a general practice population. 2. Review current literature and practice guidelines on imaging and diagnostic strategies for neck/upper extremity pain. 3. Review options for initial non-operative management of neck/upper extremity pain, knowing when patients need referral for further specialist evaluation.
4
5 Differential Diagnosis Cervical spine Radiculopathy Myelopathy Shoulder Subacromial bursitis Rotator cuff tendonitis Rotator cuff tear Biceps tendonitis Glenohumeral arthritis Acromioclavicular arthritis Adhesive capsulitis
6 Differential Diagnosis Brachial plexus Thoracic outlet syndrome Parsonage-Turner syndrome Elbow Lateral/medial epicondylitis Peripheral nerve entrapment Carpal tunnel syndrome Cubital tunnel syndrome
7 Differential Diagnosis Neurologic Multiple sclerosis ALS Peripheral neuropathy
8 Osseous Anatomy Uncovertebral joint Zygoapophyseal joint SOURCE:
9 Neural Anatomy 8 cervical nerve roots C1 is clinically unimportant C8 emerges at C7-T1 interspace Slide Courtesy of D. Riew, MD
10 History Location Duration Exacerbation Handedness Occupation
11 Cervical Radiculopathy Pain Burning Deep ache Tingling Excruciating Headaches Occipital, retroauricular Ponnappan et al. JAAOS 2015 Often relieved by placing hand on head
12 Cervical Spine Physical Exam Motor exam C5 biceps C6 wrist extensors C7 wrist flexors C8 finger flexors T1 - interossei
13 Cervical Spine Physical Exam Exam Motor and sensory extremity testing Reflexes Spurling test Romberg test Heel-toe gait CERVICAL MYELOPATHY Hoffman sign Clonus
14 Spurling Test Narrows foramina on side head tilts towards
15 Shoulder Physical Exam Hawkins Test = bursitis/tendonitis Jobe/ Empty Can Test = supraspinatus
16 Shoulder Physical Exam Lift-Off Test = subscapularis External Rotation Test = infraspinatus
17 Workup Cervical radiographs AP, lateral views Swimmer s view if cannot see C7-T1 Cervical MRI Without contrast unless previous surgery, concern for tumor/infection EMG/nerve conduction study Gold standard to differentiate cervical radiculopathy vs. peripheral nerve pathology
18 Cervical Radiographs SOURCE:
19 Cervical MRI Non-contrast (except for infection/tumor) Evaluate for disk herniation Central canal Foramina Myelomalacia Cord signal change, particularly on STIR sequence
20 Radiographic Findings of Spondylosis Disk space narrowing Listhesis Loss of lordosis Anterior body osteophytes Uncovertebral narrowing/osteophytes (on AP) Foraminal stenosis Central stenosis Less than 13mm A-P diameter
21 Non-Operative Management Physical therapy NSAIDs Injections Central epidural Trans-foraminal
22 Corticosteroid Injections Level II evidence for effectiveness But, number of high-quality studies low (only 7 qualifying studies) Majority of evidence for use in disk herniation
23 Operative Indications Persistent radicular pain not responsive to conservative management Persistent/progressive radicular numbness Radicular motor deficit Myelopathy Myelomalacia on MRI
24 Anterior Cervical Diskectomy/Fusion (ACDF) Gold standard for 1-level or 2-level pathology Much less pain and shorter recovery than posterior approach Most common post-op complaint is sore throat for several days
25 ACDF Outcomes Cost/QALY 1 Year: $105,000 2 Years: $53,000 3 Years: $38,000 4 Years: $28,000 5 Years: $23,000 Spine 2013
26 Cervical Disk Arthroplasty (CDA) Indications Radiculopathy caused by disk herniation NOT caused by osteophyte impingement Contraindications Rheumatoid arthritis Myelopathy NEED PRE-OP CT SCAN
27 CDA Options Jeon et al JKMA 2011
28 CDA Outcomes CDA had better Neck Disability Index scores and neurologic improvement at 7 years vs. ACDF CDA maintained 6-7 degrees of segmental motion CDA was superior in terms of subsequent adjacent-level surgery (4.6% vs. 11.9%, p=0.008)
29 CDA Outcomes Burkus et al. J Neurosurg Spine 2014
30 Laminoplasty Advantages vs. Fusion Preserves motion No risk of pseudarthrosis Can be utilized for myelopathic smokers
31 Treatment Non-operative Ergonomics Observation Night splints Corticosteroid injection Operative Carpal tunnel release
32 Thank You
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