Neck Pain and Arm Pain : Cervical Radiculopathy by Pablo Pazmino MD

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This video explains Cervical Radiculopathy and Cervical Herniations. When herniations begins to affect the nerves and spinal cord this is called Cervical Radiculopathy. This video highlights the history, epidemiology, and treatment options both conservative and surgical. If you or someone you know needs to be seen in regards to Cervical Herniation/Radiculopathy feel free to look us up online www.beverlyspine.com or www.santamonicaspine.com OR call toll free 1-8SPINECAL-1

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Neck Pain and Arm Pain : Cervical Radiculopathy by Pablo Pazmino MD

  1. 1. Pablo Pazmi ño, MD
  2. 2. Orthopaedic Surgery American Academy of Orthopaedic Surgeons Clinical Faculty Olympia Medical Center Cedars Sinai Medical Center Century City Doctors Hospital <ul><li>Education </li></ul><ul><ul><li>The University of California, Los Angeles </li></ul></ul><ul><ul><li>The University of Michigan, Ann Arbor </li></ul></ul>
  3. 3. <ul><li>Radiculopathy is not a specific condition, but rather a description of a problem in which one or more nerves are affected and do not work properly </li></ul><ul><li>The emphasis is on the nerve root (“Radix&quot; = &quot;root“ ). </li></ul><ul><li>This can result in radicular pain, weakness, numbness, or difficulty controlling specific muscles. </li></ul>
  4. 4. <ul><li>History </li></ul><ul><li>Epidemiology, Natural History </li></ul><ul><li>Pathophysiology </li></ul><ul><li>Diagnosis </li></ul><ul><ul><li>Symptoms </li></ul></ul><ul><ul><li>Exam Findings </li></ul></ul><ul><li>Studies </li></ul><ul><li>Treatment </li></ul><ul><ul><li>Non Operative </li></ul></ul><ul><ul><li>Decision Making Process </li></ul></ul><ul><ul><li>Operative </li></ul></ul><ul><li>7 . Cases </li></ul>Dr. V.A.H. Horsley (1857-1916)
  5. 5. <ul><li>Neck related problems date back to Egyptian ruins dated 1700 B.C. </li></ul><ul><li>References are found in the Ayurveda, Indian medical textbooks 3500 B.C. </li></ul>
  6. 6. <ul><li>Cervical Spondylosis: Progressive degenerative changes that develop slowly over time, this alters the spinal biomechanics from the loss of shock absorption properties of intervertebral discs. This leads to secondary changes in surrounding structures. </li></ul><ul><li>Dysfunction  Instability  Stabilization (Marginal Osteophytes) </li></ul>
  7. 7. Three distinct clinical syndromes can result: Type I: Cervical Radiculopathy: Cmprsn +Inflammation of Spinal Nerve with symptoms that correspond to the level involved Type II: Cervical Myelopathy: Cord involvement Type III: Axial Joint Pain (Mechanical neck pain, “discogenic pain”, facet syndrome, painful instability
  8. 8. <ul><li>Sex: Radiographic changes are more severe in men than in women. </li></ul><ul><li>Cervical Spondylosis present in 50% of population at 50 years of age. Kellgren Ann Rheum Dz 1958 </li></ul><ul><li>Irvine et al defined the prevalence of Spondylosis using radiographic evidence. Lancet 1965 </li></ul><ul><ul><li>♂ prevalence was 13% in the third decade  100% by age 70 years. </li></ul></ul><ul><ul><li>♀ prevalence ranged from 5% in the fourth  96% > 70 years. </li></ul></ul><ul><ul><li>In 1992, Rahim and Stambough noted that spondylotic changes are most common in those older than 40 years. Eventually, more than 70% of men and women are affected Orthop Clin North Am 1992 </li></ul></ul><ul><ul><li>By age 60-65 95% of nonsymptomatic men and 70% of asymptomatic women develop at least one degenerative change on Xray Gore Spine 1986 </li></ul></ul><ul><li>Moore and Blumhardt series, 23.6% of patients presenting with nontraumatic myelopathic symptoms had CSM. Spinal Cord 1997 </li></ul><ul><li>CSM is the most common cause of nontraumatic spastic paraparesis and quadriparesis. </li></ul>
  9. 9. <ul><li>No patient ever returned to normal state </li></ul><ul><li>75% Had episodic worsening/progression </li></ul><ul><li>20% Slow steady progression </li></ul><ul><li>5% Rapid onset followed by lengthy disability </li></ul><ul><li>Motor changes tended to persist and progress with time </li></ul><ul><li>Sensory/bladder changes were transient </li></ul><ul><li>Soft collar improved gait and Nroot syx for 50% pts </li></ul><ul><ul><ul><li>Clark E, Robinson PK Cervical Myelopathy: a complication of cervical spondylosis Brain 56:79:483-70 (120 patients) </li></ul></ul></ul><ul><li>Stepwise degeneration with periods of stability between exacerbations. </li></ul><ul><li>45% of patients with nonmyelopathic symptoms have good resolution after onset, the remaining 55% continue to have moderate long term morbidity </li></ul><ul><ul><ul><li>Lees Turner BMJ 63:2:1607 (44pts/ CSM 3-40yrs) </li></ul></ul></ul>
  10. 10. <ul><li>Cervical Spine Research Society </li></ul><ul><li>Multicenter, Nonrandomized study </li></ul><ul><li>Poor outcome of Nonsurgical Mgmt of CSM </li></ul><ul><li>43pts </li></ul><ul><li>23 Medical treatment: Decrease in ability to perform ADLs, worsening of Neurologic symptoms </li></ul><ul><li>20 Surgical treatment: Decreased neurologic symptoms,overall pain, and improved functional status </li></ul><ul><li>Sampath P et al Spine 2000: 25:670 </li></ul>
  11. 11. <ul><li>Gowers (1892) “Vertebral Exostoses” were exceedingly rare and their chief characteristic was chronicity. </li></ul><ul><li>“ Concluded exostoses constituted a more promising field for the surgeon than other kinds “ </li></ul>
  12. 12. October 24,1892 20 YO “builder who under the influence of alcohol, fell off his van on to the road striking his right shoulder.” Over the next 2months he gradually lost control of legs and sphincters Dr Horsley performs the first Laminectomy of 6 th Cervical Vertebra. The Spinal cord was found to be compressed by a transverse ridge projecting backwards from the body of the vertebra. Complete recovery by September of that year
  13. 13. <ul><li>1892 First Laminectomy for Cervical sponylotic myelopathy …………………… </li></ul><ul><li>B M McCormack and P R Weinstei </li></ul><ul><li>West J Med. 1996 Jul–Aug; 165(1-2): 43–51. </li></ul><ul><li>Cervical spondylosis. An update. </li></ul><ul><li>January 1895, Viennese newspapers heralded Professor Röntgen's new “ray,” which would become the basis for the science of roentgenography. </li></ul>
  14. 14. <ul><li>Cervical spondylosis and cord impingement was originally described by Stookey in 1928 </li></ul><ul><li>He attributed compression of the cord by “extradural chondromas” cartilaginous nodules , which they thought were the same findings as some people had on their ears </li></ul><ul><li>1934 Peet, MM and Echols, DH showed “chondromas” were disc protrusions </li></ul>Lord Brain, F.R.S., D.M., F.R.C.P. (1895-1966)
  15. 15. <ul><li>In 1952 Lord Brain is the first person who actually recognized myelopathy and radiculopathy as a clinical disorder </li></ul>
  16. 16. <ul><li>T he Cervical discs themselves have been shown to account for consistent patterns of neck pain </li></ul><ul><li>Grubb Spine 25: 1382-1389, 2000 </li></ul>
  17. 17. <ul><li>The facet joints themselves can account for significant neck pain. </li></ul><ul><li>The facet joint capsules have free nerve endings which send referred pain into these specific distributions. </li></ul><ul><li>This is why many of the patients we see every day have neck/ shoulder/scapular pains. </li></ul>Dwyer Spine 15: 453-7, 1990.
  18. 18. <ul><li>With my background as a Third grade teacher I always make it a point to build a foundation concept before moving on to complex ideas. </li></ul><ul><li>As a Spine surgeon I want the most vantage points on an object, this gives me a frame of reference and helps to construct the anatomy in my mind. </li></ul>
  19. 19. Here is what I mean by a foundation concept. You will see side view images and top down images throughout this presentation and on your MRIs. This can be hard to grasp unless we stop and point a few things out initially The Sagittal view is also called the lateral view and this is pictured here it displays the spine as viewed from the SIDE. The Axial view is a top down view of the spine. This image repsents a slice obtained as if an Axe were to chop you, therefore the name Axial view.
  20. 20. <ul><li>Next we will review some basic anatomy </li></ul><ul><li>Some images will be in the Sagittal plane </li></ul>
  21. 21. <ul><li>Others will be in the Axial Plane </li></ul>
  22. 22. <ul><li>There are seven bones which make up the cervical spine. Each vertebral body ( these look like blocks) are separated by intervertebral discs which function as shock absorbers. </li></ul>1 2 3 4 5 6 7
  23. 24. <ul><li>A Herniated disc A herniated disc (sometimes called a slipped disc) is the most common cause of sciatica. Discs are the cushions between the bones in the back. They act like &quot;shock absorbers&quot; when we move, bend, and lift. </li></ul>
  24. 25. <ul><ul><li>There is a tough ring around the outside called the Annulus Fibrosus , and a thick almost crabmeat like center inside called the Nucleus pulposus. </li></ul></ul>
  25. 26. <ul><ul><li>If the outer edge of the disc ruptures, the center can push through and put pressure on the exiting nerve, leading to the pain of sciatica (referred to as a Herniated nucleus pulposus or disc herniation). </li></ul></ul>
  26. 27. <ul><li>Are located posteriorly, these are the joints of the spine and are essential for control of normal motion and based on their orientation </li></ul><ul><li>Compromised facets will alter the distribution of mechanical forces throughout the spine </li></ul>
  27. 28. Joint Facet Nucleus Pulposus Right Nerve Root Left Nerve Root As you can see here on MRI and CT scans the Facet joints end up looking like the buns of a hamburger. Its just the way the happen to look when they are sliced in this plane. We will show you this on some examples later Annulus Fibrosus Axial View of the Disc and Neural elements
  28. 29. Joint Facet Disc Right Nerve Root Left Nerve Root Axial View
  29. 30. <ul><li>The pain is not improving after several days or seems to be getting worse. </li></ul><ul><li>You are younger than 20 or older than 55 years and are having sciatica for the first time. </li></ul><ul><li>You presently have cancer or have a history of cancer. </li></ul><ul><li>You have lost a large amount of weight recently or have unexplained chills and fever with back pain. </li></ul><ul><li>You continue to have trouble bending forward after more than a week or two. </li></ul><ul><li>You notice weakness is getting more pronounced over time. </li></ul><ul><li>You develop any new onset weakness, such as a drop foot. </li></ul><ul><li>You are dropping items, have noticed a loss of dexterity, difficulty opening jars. </li></ul>
  30. 31. <ul><li>The pain is unbearable, despite trying first aid methods , NSAIDs, rest, relaxation, and bedrest. </li></ul><ul><li>The pain follows a violent injury, such as a fall from a ladder or an automobile crash. </li></ul><ul><li>The pain is in the back of your chest. </li></ul><ul><li>You are unable to move or feel your legs or feet. </li></ul><ul><li>You lose control of your bowels or bladder or have numbness in your genitals. </li></ul><ul><li>You have a high temperature (over 101°F). </li></ul>
  31. 32. <ul><li>Radiographs </li></ul><ul><li>CT: Computed Tomography </li></ul><ul><li>MRI: Magnetic Resonance Imgaing </li></ul>
  32. 33. <ul><li>Radiographs usually reveal findings consistent with degeneration of the lumbar spine, such as </li></ul><ul><li>Disc space narrowing </li></ul><ul><li>Endplate sclerosis </li></ul><ul><li>Formation of osteophytes </li></ul><ul><li>Facet joint hypertrophy and arthritis </li></ul><ul><li>Degenerative scoliosis or spondylolisthesis </li></ul><ul><li>Settling of spinous processes </li></ul><ul><li>Instability </li></ul>
  33. 34. <ul><li>CT&MRI </li></ul><ul><li>1. Identify location, degree of stenosis (15% trefoil) </li></ul><ul><li>2. Absolute stenosis lateral recess diameter <3mm, relative 3-5mm </li></ul><ul><li>3. Sagittal absolute <10 , relative <12 </li></ul><ul><li>Ciric JNeurosurgery ’80:5 </li></ul><ul><li>Verbeist JBJS B’77:59 </li></ul><ul><li>4. Cross sectional area <100mm2 absolute stenosis </li></ul><ul><ul><li>Bolender JBJS ‘85: 67A </li></ul></ul><ul><ul><li>5. The critical height of the intervertebral foramen is believed to be 15 mm and posterior disc height of 3 mm. N Root compression 80% when below </li></ul></ul>
  34. 35. Joint Facet Disc Right Nerve Root Left Nerve Root Axial View
  35. 36. Joint Facet Disc Right Nerve Root Left Nerve Root Next I will show you some MRIs You will see this is a patient with a left sided herniation pinching off her exiting left nerve root
  36. 37. Joint Facet Disc Right Nerve Root Left Nerve Root Axial Scans:
  37. 38. Cervical 7 Spinous Process Nerves 2-3 Disc 3-4 Disc 4-5 Disc 5-6 Disc 6-7 Disc
  38. 39. <ul><li>Early stages intermittent symptoms (neural inflammation) </li></ul><ul><li>Activity modification </li></ul><ul><li>Staying in shape physically/aerobically </li></ul><ul><li>Bedrest 2-3 days: Avoid longterm bedrest </li></ul><ul><li>Avoid certain activities : bending,twisting, lifting, unnecessary walking…..Usually eases pain </li></ul><ul><li>PTherapy: stretching and isometrically strengthening atrophied muscles </li></ul><ul><li>Modalities: heat, U/S, Whirlpool, massage </li></ul>
  39. 40. <ul><li>Avoid Narcotic medications and muscle relaxants (depression/sedation) </li></ul><ul><li>Anti-inflammatory meds </li></ul><ul><li>Bracing </li></ul><ul><li>Epidural steroids and oral steroid ‘dose packs’ relieve pain and inflammation and allow aerobic conditioning and incr fcn </li></ul><ul><li>All temporary not a cure for stenosis, and gives indication of severity </li></ul>
  40. 41. <ul><li>Surgery should be a last resort, when conservatives measures fail. </li></ul><ul><li>In some cases surgery needs to be done sooner than later, or even urgently, depending on the physical exam, history, neural deficits, and size of the herniation. </li></ul>
  41. 43. <ul><li>All our procedures are peformed </li></ul><ul><li>in a minimally invasive manner. </li></ul><ul><li>All discectomies are performed as a microdiscectomy as opposed to the traditional open discectomy. </li></ul><ul><li>All patients receive a plastics closure and are followed closely afterwards </li></ul>
  42. 44. <ul><li>Thank you for your time. </li></ul><ul><li>If you know someone who could benefit from a consultation for Neck Pain please refer them to our online website or call toll free to schedule an appointment </li></ul><ul><li>1-8SPINECAL-1 </li></ul><ul><li>www.beverlyspine.com </li></ul><ul><li>www.santamonicaspine.com </li></ul>

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