Neck & Arm Pain : When is Surgery Appropriate?

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Many of us suffer from aches & pains, particularly in the back and neck, but when is it time to call your doctor? Springfield Clinic Orthopedic specialist, Dr. Ra'Kerry K. Rahman, leads the discussion on back and neck pain, covering the full spectrum of care from diagnosis to treatment. Learn about the treatment options available and the advances in medicine that have improved the management of pain in the back and neck.

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  • Patient positioning for SCNRB on the left side. A, The chin is rotated approximately 30° to the right, away from the side to be studied. To prevent sudden movements during needle placement/manipulation, we used 1¼-inch paper adhesive tape. B, Note how the patient's neck is rotated and slightly extended. C, A metal clamp is used to help identify the optimal axis of fluoroscopy.
  • Sequential fluoroscopic images demonstrate optimal needle placement (A and B) and contrast injection (C and D). A, Approximately 45° oblique projection, with slight caudal-to-cephalad orientation of the fluoroscopy axis, is centered on the lower lateral aspect of right C5–6 foramen. Needle tip (arrow) is in contact with the posterior wall of nerve root canal. B, AP image shows the needle tip (arrow) optimally positioned in the lower lateral aspect of right C5–6 neural foramen, with the needle tip contacting bone. C and D, Approximately 45° oblique (C) and AP (D) images obtained after injection of approximately 1.5 mL of contrast. The right C5 nerve root is outlined by contrast. Epidural reflux at C5 (small arrow) and C6 (larger arrow) is clearly demonstrated in D. This case represents an optimal degree of opacification for a therapeutic blockade, in which epidural reflux is desired.
  • Optimal right C7 nerve root opacification before therapeutic injection. AP projection shows contrast surrounding the right C7 nerve root and ganglion, with epidural reflux above and below (arrows).
  • Venous opacification observed during contrast injection into the lower lateral aspect of the right C6–7 nerve root canal, along the C7 nerve root. A, AP projection revealing prominent venous opacification (arrows) below the site of injection. Such venous opacification would not be visible on thin-sectioned CT, being out of the plane of data acquisition. B, After needle manipulation, repeat injection shows improved opacification of the C7 nerve sheath (curved arrows), but new venous filling above the nerve root (arrow).
  • Neck & Arm Pain : When is Surgery Appropriate?

    1. 1. Neck & Arm Pain: When is surgery appropriate? Ra'Kerry K. Rahman MD Cervical Spine & Scoliosis Surgeon Springfield Clinic Clinical Asst. Professor SIU SOM
    2. 2. www.SpringfieldClinic.com/DoctorIsIn
    3. 3. Cervical Spine Pathology • Cervical Strain or Sprain • Whiplash • Cervical Radiculopathy • Cervical Myelopathy & Myeloradiculopathy • Cervical Pseudarthrosis • Adjacent Segment Disease • Cervical Masqueraders ( Rotator cuff dz, carpal tunnel, cubital tunnel, anxiety)
    4. 4. You’re the doctor?? • 44 yo woman involved in a MVC whereby she describes hitting her head on the steering wheel. No major injuries. Exam, reveals pain with neck range of motion and firm paraspinal muscles with palpation; otherwise normal 1. Order XRs 2. She’ll be okay send her home with appt to follow up 3. MRI 4. Rest, Ice/Heat, anti-inflammatories
    5. 5. Whiplash Injury • Neck injury resulting from sudden acceleration – deceleration…example rear-end collision while stationary. • Soft tissues such as ligaments, facet capsules, and muscles can be damaged • Treatment: Rest, NSAIDs, muscle relaxants, soft collar (limited) • Surgery: Yes or No
    6. 6. Cervical Strain or Sprain • Neck Strains vs. Sprains – injury occurring at musculo- tendinous junctions vs facet capsule or ligament bone interface • Cause: Forceful neck motions which are strong enough for injury but not strong enough to generate instability • Treatment: Rest, NSAIDs, muscle relaxants • Surgery: Yes or No
    7. 7. • 62 yo woman presents complaining of neck & left arm pain, radiates down the back of the arm as well into the ring and pinky fingers. Associated symptoms include numbness & tingling of those fingers. 1. Order XRs 2. She’ll be okay send her home with a follow up appt 3. MRI 4. EMG You’re the doctor??
    8. 8. Adjacent Level Disease
    9. 9. • Occurs after cervical fusion - 3% of patients…..25% at 10 yrs postop • Pathoanatomy vs. Natural Hx causes some controversy • Proposed theory: Increased degeneration at adjacent level due to increased biomechanical stress from fusion • What’s most common level for ACDF?
    10. 10. This case illustrates a second diagnosis! Left C7 cervical radiculopathy secondary to adjacent level disease
    11. 11. Cervical Radiculopathy • Pathoanatomy: nerve root compression – Biochemical & Mechanical Interplay • Altered sensation, Pain, or Weakness in corresponding dermatome/myotome • Surgery appropriate: Yes or No Depends!!
    12. 12. This patient tells you that her daughter is getting married and she cannot undergo surgery at this time, despite having tremendous pain. What could you offer her? Cervical Selective Nerve Root Block
    13. 13. Cervical Nerve Root Blocks • Very helpful for refining diagnosis • Has a reasonable chance of helping patient avoid surgery • Gives time for natural hx to win • Goal: Modulate inflammatory response • Concerns: Sudden paraplegia after injection (Use Dexamethasone)
    14. 14. Patient positioning for SCNRB on the left side. Schellhas K et al. AJNR Am J Neuroradiol 2007;28:1909-1914 ©2007 by American Society of Neuroradiology
    15. 15. Sequential fluoroscopic images demonstrate optimal needle placement (A and B) and contrast injection (C and D). Schellhas K et al. AJNR Am J Neuroradiol 2007;28:1909-1914 ©2007 by American Society of Neuroradiology
    16. 16. Optimal right C7 nerve root opacification before therapeutic injection. Schellhas K et al. AJNR Am J Neuroradiol 2007;28:1909-1914 ©2007 by American Society of Neuroradiology
    17. 17. Venous opacification observed during contrast injection into the lower lateral aspect of the right C6–7 nerve root canal, along the C7 nerve root. Schellhas K et al. AJNR Am J Neuroradiol 2007;28:1909-1914 ©2007 by American Society of Neuroradiology
    18. 18. After wedding, she returns… ROI and C6-7 ACDF
    19. 19. Pre-surgical Considerations • Help cervical radiculopathy pts with conservative care until all options exhausted unless neurological symptoms that are not improving or worsening OR symptoms unacceptable to patient if symptoms became permanent. • 6-12 weeks of conservative care is reasonable before referral
    20. 20. You’re the doctor!! • 42 yo with balance difficulties, changes in handwriting, positive Romberg {can’t stand with eyes closed}, positive Hoffman’s bilaterally {primitive reflexes present}, “heavy” arms. Pt underwent decompressive surgery and fusion. Felt good for 8 months. One day she heard a pop and now has severe neck pain. • 1. Order XRs • 2. She’ll be okay send her home with a follow up appt • 3. MRI • 4. EMG
    21. 21. T2 Sagittal MRI
    22. 22. Post Op after Revision
    23. 23. Cervical Pseudarthrosis
    24. 24. Etiology of Revision Anterior Cervical Spine Surgery Ra’Kerry K. Rahman MD, Nisha R. Raja-Rahman MD, Moon Soo Park MD, K. Daniel Riew MD
    25. 25. • When surgery does not result in a bony union of desired area • Clinically: – neck pain – “Pain free interval” – radicular symptoms (+/-) • ?? Adequate decompression ?? • Indirect decompression
    26. 26. Example
    27. 27. Pre-surgical Issues 1) Be alert for problems in postsurgical pts with a pain free interval or persistent radicular symptoms despite surgical treatment 2) Order CT scan – Without contrast if “neck pain only” – With contrast (CT myelogram) if persistence of radicular symptoms 3) Send back to surgeon if imaging reveals a pseudarthrosis: Treatment = Revision Surgery 4) Okay to try conservative modalities
    28. 28. What will the surgeon do? 1) Redo/Revise the surgery 2) Augment index surgery with opposite column fixation 3) Both of the above 4) Iliac crest bone graft
    29. 29. You’re the Doctor!! 63 yo male c Balance problems, tripping, difficulty with fine motor activities present for years, but acute decline 6 months prior to presentation; onset of mild neck pain •Early fatigue with yardwork and distance walking +neurogenic claudication •PE: + Hoffman, broad-based gait, inability to perform tandem gait; +hyperreflexic b/l UE & LE •5/5 strength UE & LE; normal sensation 1. Order XRs 2. She’ll be okay send her home with a follow up appt 3. MRI 4. EMG
    30. 30. XRAYS
    31. 31. CT
    32. 32. C3-4
    33. 33. C4-5 C5-6 C6 C6-7
    34. 34. IMMEDIATELY POSTOP
    35. 35. Cervical Myelopathy
    36. 36. Cervical Myelopathy • Clinical diagnosis of spinal cord dysfunction (upper motor neuron lesion, long-tract sign) • Intrinsic cord lesion or extrinsic cord compression • MC. Cause: cervical spondylosis (CSM) – Disc herniation, bony overgrowth – Abnormal alignment – Ligamentous hypertrophy – Segmental instability – OPLL – Medical conditions
    37. 37. Cervical Spondylotic Myelopathy • Definition of CSM “ Spinal cord dysfunction secondary to extrinsic compression of the cord or its vascular supply, or both, that is caused by degenerative disease of the cervical spine” AAOS Instructional Course Lecture 1995
    38. 38. Epidemiology of CSM • Age: 40-60 years, M = F • “Cervical spondylosis” : more than half of the causes of cervical myelopathy. • The most common cause of spinal cord dysfunction in the patients > 55 years. • The most serious sequelae of cervical spondylosis. • MC. level: C5-6, C4-5, C6-7, C3-4 disc • Increased risk: Congenital spinal stenosis
    39. 39. Natural History • Symptomatic Myelopathy • Progressive worsening • Stepise deterioration • Rare acute deterioration
    40. 40. Cadaveric Section of Neck
    41. 41. More Anatomy
    42. 42. Pathoanatomy & Pathogenesis • Cervical spondylosis with stenosis – Stenosis of the central spinal canal & inter-vertebral foramina • Instability – Compensatory subluxation • Cervical kyphosis • Initial size of the spinal canal • OPLL
    43. 43. Pre-surgical Considerations • Recognize cervical myelopathy as a patient that requires early referral to spine surgeon. No PT, meds, etc. • Place elderly patients with poor balance in a soft collar to protect them unto surgical appt. • Pt are at risk for central cord syndrome and transient/permanent quadriplegia
    44. 44. Cervical Spine Masqueraders
    45. 45. • Rotator cuff disease (C4/5 radiculopathy) – Jobe’s – Resisted Abducted External Rotation • Carpal tunnel (C6 radic) – Phalen’s test can help distinguish from a C6 radiculopathy • Cubital Tunnel Syndrome (C7 radic) – “Pain with holding phone” – Reproduced symptoms with prolonged elbow flexion (~60 secs) EMG HELPFUL
    46. 46. • 20 -30 % of disk herniations can cause cervicogenic headaches • Cervical DDD/Black disk disease – historically does not respond well to surgery. Maximize conservative modalities • Be alert for posterior auricular pain reproduced by Spurling’s as a possible high cervical radiculopathy
    47. 47. THANK YOU!!

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