Neck Pain: Help! Eric M. Massicotte, MD, MSc, MBA, FRCSC Associate Professor University of Toronto

Neck Pain: Help! Eric M. Massicotte, MD, MSc, MBA, FRCSC Associate Professor University of Toronto

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Objectives Develop first line treatment for neck pain based on evidence based medicine Indications for ordering imaging of the spine Indication for neurosurgical consultation

Outline Different clinical presentations Looking for Red Flags Definition of conservation management Indications for imaging Indications for neurosurgical consultation

Presentation I. Radiculopathy Nerve root compression II. Myelopathy Spinal cord compression III. Combination IV. Axial neck pain

Clinical Presentation

Clinico-anatomical Correlation

Clinico-anatomical Correlation

1. Heavy lifting 2. Immobilization 3. Vibration 4. Trauma 5. Smoking 6. Diabetes 7. Genetic 8. Infection Pathological Process Factors Implicated In Causing Intervertebral Disc Degeneration 30 year-old 90 year-old

Cervical Spondylotic Myelopathy (CSM) Natural History Variable clinical courses Mild protracted state 1995 Stepwise deterioration Relentless progression 2001

Symptoms Myelopathy Pain, numbness, weakness Presentation Signs Sensory deficits Motor deficits Reflexes -hyper-reflexia -Pathological reflexes (Hoffman plantar reflex) Spasticity Sphincter dysfunction (bowel/bladder incontinence, sexual dysfunction)

Case Illustration 76 Yr-Old Male 10 year history 2 yr decline in function Florid spastic gait Generalized quadriparesis ASIA C C1-2 stenosis atlanto- subluxation axial Procedure: PCDF C1/2 laminectomy occiput to C2 reconstruction

Case Illustration Baseline 6 Months 12 Months Nurick (0-5) 5 4 4 MJOA (0-18) 7 11 11 BBS (0-56) 6 26 28 30 MWT Cadence/Seco nds Dynamometry Kg/F 0/0 60/51 sec 10 22 24 60/46 sec

Literature Support

What are the sources of neck pain? 1. Anatomical sources of pain Disc Facet joints (includes capsule) Muscle Tendon Ligament Vessels Bone Referred pain Organs 2. Pathological Causes Trauma Genetic influences Infection Degenerative change Inflammation Disease Psychosomatic** 3. Biomechanical reasons Hyperlaxity Joint dysfunction Excessive aberrant **Probably strength/flexibility-related components** Postural decompensation

Red Flags Progressive neurologic deficit Recent bowel or bladder dysfunction Unsteady gait Traumatic event Age young (< 50) Cancer history Constitutional symptoms (e.g. fever, weight loss) Hx UTI/other infection, IV drug use, TB exposure Immune suppression, Steroid use history Previous surgery Scientific approach to the assessment and managementof activity-related spinal disorders. A monograph for clinicians. Report of the Quebec Task Force on Spinal Disorders. Spine 1987; 12(7 Suppl):S1 S59

Conservative Treatment For Neck Pain Conclusion: Our best evidence synthesis suggests that therapy involving exercise and educational interventions are more effective than alternative strategies for patients with neck pain;

Internal Carotid Artery Dissection Following Chiropractic Manipulation Associated With Small Cortical Infarct

Definition of Conservative Management Ask the patient EXACTLY what their therapy was like. If therapy didn t consist of active participation on the part of the patient, they haven t really failed conservative management. Direct the therapist and don t accept

Plain Films Imaging Studies easy and fast, can rule out fracture, bony destruction from neoplasia, identify non-specific degenerative processes allows assessment of disc height CT- allows axial assessment of disc and relation to spinal canal and foramen MRI- much improved soft tissue resolution

Imaging Studies

Neuro-Anatomy

Bozzao et al 69 non operated pts Repeat scan on average at 11months 70% in 48% 30-70% in 15% No change in 29% Increased in 8% Imaging Studies: MRI Natural History Larger herniation more likely to regress Clinical changes occurred prior to radiographic

Case Illustration Cervical Application 52 year old female 2 year history of neck and arm pain normal myotomal strength, except for right hand weakness + Hoffman s, brisk reflexes Diagnosis: Spondylosis, causing cord compression Procedure: ACDF C5/6 C6/7 discectomy C6 corpectomy Instrumented fusion

Case Illustration Cervical Application Base line 6 Months 12 Months Nurick (0-5) 1 1 1 MJOA (0-18) 17 18 18 BBS (0-56) 56 56 56 30 MWT Cadence/Seconds 39/17 34/15 37/16 Dynamometry Kg/F 20 24 28

Case Illustration Cervical Application Clinical Details: 42 yr-old executive 10 mth hx of left arm pain with neck pain Numbness in middle finger of left hand

Case Illustration Cephalad Cephalad Medial Medial Cephalad Disc Disc

Take Home Messages 1- Look for Red Flags 2- Neurological deficits dictate indications for imaging & consultation 3- Not all treatment algorithms end with surgery 4- Surgical intervention for a select group of patients is very effective

Questions? Thank you.