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Cervical Spine Pain - Dr S L Yadav

Cervical Spine Pain
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Cervical Spine Pain - Dr S L Yadav

  1. 1. Management of Cervical Pain Dr S L Yadav, MD Department of Physical Medicine & Rehabilitation All India Institute of Medical Sciences, New Delhi
  2. 2. Neck pain is generally defined as pain and /or stiffness felt dorsally in the cervical region 95% of patients with neck pain – Benign clinical diagnosis (Neck sprain, mechanical neck pain, muscular neck pain, postural neck pain, Myofascial pain syndrome) Patients often search for a more definitive diagnosis Cervical Pain Gore D.R. Medscape General Medicine 1999; Ferrari R Best practice & Research Clinical Rheumatology 2003; 17(1): 57 - 70
  3. 3. • Neck pain – Acute ( < 6 weeks) or Chronic (> 6 weeks) • 80% of all acute neck pain resolves within days to weeks • Common problem – Second only to Low back pain • Population studies – prevalence of 13.8% (Norway) • Slightly more common in Females (M:F :: 9.5% :13.5%) • 10% of population – Neck pain on at least 7 days/month • Neck pain occurs in 80% population at some time in their life Cervical Pain – Epidemiology Gore D.R. Medscape General Medicine 1999; Ferrari R Best practice & Research Clinical Rheumatology 2003; 17(1): 57 - 70
  4. 4. Epidemiology •Prevalence : 9-18% of general population. •Workplace : 20-30% < 30 yrs age 50% over 45 yrs. •Cervical pain- 2 types. –Axial pain – pain occuring from inferior occiput to superior interscapular region, localising to midline or just paramidline. –Radicular pain – pain involving shoulder girdle & distally, manifests as pain in UE. Equating cervical axial & cervical radicular pain can result in misdiagnosis, inappropriate investigation & suboptimal treatment.
  5. 5. Biomechanics of Cervical Spine • Support & stabilizes head: allowing movt. in all planes. • Protect spinal cord, nerve roots, vertebral artery. • Atlanto-occipital (C0-1): 10 o flexion & 25 o extn. • C1-2: 40-50% of all cervical rotation. • Below C2-3 level, lat flexion coupled with rotation in same direction. This motion is due to 45 o sagital inclination of zygapophyseal jt. • Greatest flexion at C4-5 & C5-6 • Greatest lateral bending at C3-4 & C4-5.
  6. 6. Neck pain Three categories • Uncomplicated -joints, ligaments and muscles • Associated with Radiculopathy [Single nerve root ] • Associated with Myelopathy [Spinal cord lesion, stenosis or compression ]
  7. 7. Acute neck pain • What Causes Acute Neck Pain? – In most cases it is not possible to pinpoint the cause of the neck pain, or it may be the result of an injury. – In either case, it is necessary to have a specific diagnosis of the cause in order to manage the pain effectively. – There is a less than 1% chance that the pain is due to a serious medical condition. http://www.nhmrc.gov.au/_files_nhmrc/publications/attachments/cp94c.pdf
  8. 8. Chronic axial neck pain (Structures & Causes) • Discogenic • Facet joint • Neural • Musculoligamentous • Postural/ sagittal balance issues • Trauma and biomechanics injuries • Degeneration • Inflammation (arthritis) • Infection (e.g., discitis, meningitis, and epidural abscess) • Infiltration (e.g., metastatic cancer and spinal cord tumors) • Compression (e.g., epidural hematoma and abscess).
  9. 9. Differential Diagnosis for Neck pain • Mechanical – Non-Traumatic • Neck strain • Spondylosis* • Myelopathy* • Cervical fracture* (see neoplasm) – Traumatic • Whiplash syndromes* • Disc herniation* • Cervical fracture* • Neck sprain • Sports (stinger)* • Non-mechanical – Rheumatological/ inflammatory • Rheumatoid arthritis • Ankylosing spondylitis/ Reiter’s syndrome/ Psoriatic arthritis. • Fibromyalgia/ PMR – Neoplastic • Metastasis • Osteoblastoma/ osteochondroma/ giant cell tumour – Infectious • Osteomyelitis/ discitis • Meningitis/ Herpes Zoster/ Lyme disease – Neurological • Peripheral entrapment/ Brachial plexitis/ Neuropathies/ CRPS – Referred • Thoracic outlet syndrome/ Pancoast tumour/ Oesophagitis/ Angina/ Vascular dissection/ carotidynia • Miscellaneous – Sarcoidosis/ Paget’s disease/ AV malformations, syringomyelia. * With or without radiculopathy https://www.inkling.com/read/essentials-family-medicine-philip-sloane-6th/chapter-37/table-37-1 Metabolic – osteoporosis, osteomalacia, PTH disorder, pagets disease
  10. 10. How to differentiate the source of Cervical pain Pain from nerve roots or the spinal cord  c/o root pain  Sharp, intense often burning pain  Radiates to trapezi, interscapular areas or down the arm Numbness & motor weakness in a myotomal distribution  Headache may occur with upper root involvement  Symptoms aggravated by neck hyperextension. Pain from joints ligaments/muscles  c/o pain & stiffness  Deep, dull aching & often episodic pain  h/o excessive/unaccustomed activity or of sustaining an awkward posture  No h/o injury  Localized asymmetric pain  Upper cervical pain is referred to the head, lower cervical to the arm  Aggravated by movement, relieved by rest
  11. 11. Clinical Evaluation • History • Pain – Character/ location/ mechanism and timing of onset/ duration/ clinical course • Associated symptoms – Radiation/ neurological symptoms/ functional limitations/ psychosocial stresses etc. • Examination – Appearance/ posture/ stance/ gait – Range of movement – Neurological examination – Specific tests • Spurling test • Axial cervical distraction test • Arm abduction test
  12. 12. Red Flags • Bowel/ bladder of sexual dysfunction: – consider cervical myelopathy • Unexplained fever/ symptoms of infection – Consider infection related to recent previous neck surgery, immunosuppressed patient, intravenous drug use, or prolonged steroid use • Unexplained weight loss – Consider malignancy/ metastatic lesion • Yellow flags: – Non-physiological pain distribution, non-organic physical signs, repetitive neck injuries, multiple failed treatment, litigation and or disability claims, apparent secondary pain, substance abuse, depression or other psychiatric diagnosis. Carette S et. al. N Engl J Med 2005;353:392-9.
  13. 13. Physical Examination • Cervical +shoulder ROM, Find out whether movement causes pain , and pain is felt locally or radiating to UL. • Neurologic examination - sensory and motor + reflexes is vital. • Shoulder girdle, arm, forearm & hand examination for atrophy / fasciculation. • Extrinsic causes of neck pain – ear, throat conditions. • Flexion :80° • Extension :50° • Lateral flexion :45° • Rotation :80° to either side
  14. 14. Neurological exam • C1-C4 involvement will show no motor weakness or reflex changes clinically C5 C6 C7 C8 Sensory Lateral arm Thumb Middle finger Little finger Motor Deltoid Wrst extensors Tricep Finger flexion Disc C4-C5 C5-C6 C6-C7 C7-T1 Reflex Bicep Brachioradialis Tricep
  15. 15. Common Cervical Rediculopathy Patterns Root Symptoms Motor Reflex C2 Posterior occipital headaches, temporal pain - - C3 Occipital headache, retro-orbital or retroauricular pain - - C4 Base of neck, trapezial pain - - C5 Lateral arm Deltoid Biceps C6 Radial firearm, thumb and index fingers Biceps, wrist extension Brachioradialis C7 Middle finger Triceps, wrist flexion Triceps C8 Ring and little fingers Finger flexors - T1 Ulnar forearm Hand intrinsics -
  16. 16. Referred Pain Pattern • Occiput: C1-2, C2-3 (Headache: C3-4, C4-5, C5-6) • Face: C1-2, C2-3, C3-4 • Posterior Neck: C3-4 & C4-5 • Supraspinatus fossa of scapula: C5-6 • Periscapular / trapezi: C4,5 • Lower end of scapula: C6-7, C7,8. • To Arm: C5 • To forearm & hand: C6,7,8.
  17. 17. Investigations • Short lived neck pain and no red flags – no tests needed • Systemic disease – Rheumatology screen – Metabolic screen • Ca/ Phosphate/ ALP – Infection/ inflammatory screen • ESR/ CRP/ FBC/ cultures • Neurological symptoms/ signs – NCS/ EMG • Radiological – X-ray; dynamic views (as long as stable) – CT scan; – MRI scan; – Bone scan/ CT-SPECT scan – Shoulder and upper limb investigations • X-ray/ Ultrasound/ MRI – TOS investigations • Doppler studies
  18. 18. X-RAY • Plain radiographs evaluate chronic degenerative changes, metastatic disease, infection, spinal deformity, and stability. • Use 7 views – Flexion-extension views identify subluxations or cervical spine instability. – Open-mouth views evaluate the odontoid process and C1-C2 stability. – AP views identify tumors, osteophytes, and fractures. – Lateral views assess stability and spondylosis (ie, spurring, disc space narrowing). – Oblique views reveal DDD, as well as foraminal encroachment by uncovertebral or z-joint osteophytes.
  19. 19. Computed Tomography • Delineates cervical spine fracture and is used extensively in trauma cases. • CT-myelography – A myelogram followed by CT scan may be obtained prior to cervical decompressive spinal cord or nerve root surgery. – This study evaluates the spinal canal, its relationship to the spinal cord, and nerve root impingement from disc, spur, or foraminal encroachment. – CT-myelography, still the criterion standard, remains superior to MRI in detecting lateral and foraminal encroachment, despite greater expense and morbidity. Consequently, CT-myelography is not the initial imaging study to evaluate cervical spine and is reserved for complicated cases.
  20. 20. MRI • MRI remains the imaging modality of choice to evaluate cervical disk disease due to its low morbidity. – Advantages include soft tissue definition (eg, cervical discs, spinal cord), cerebrospinal fluid visualization, noninvasiveness, and lack of patient radiation exposure. – disadvantages include expense, inability of claustrophobic patients to tolerate the procedure, dependence on patient cooperation to minimize artifact, high false-positive rate, and insensitivity compared to CT scan in evaluating bony structures. – MRI appears inferior in differentiating cervical disc prolapse (ie, soft cervical disc) from spondylitic osteophytic compression (ie, hard cervical disc). • Contraindications to MRI include patients with embedded metallic objects, such as pacemakers, surgical clips, spinal cord stimulators, or prosthetic heart valves that may be dislodged by MRI magnets
  21. 21. MRI
  22. 22. ELECTRODIAGNOSTIC STUDIES • Electrodiagnostic studies continue to be standard for evaluating neurologic function of the cervical spine. – Needle EMG: detect acute and chronic radicular features. – A diagnosis of radiculopathy is apparent when needle EMG reveals abnormal spontaneous potentials and/or certain changes in motor unit action potentials, in 2 or more muscles innervated by the same nerve root but different peripheral nerves. Ideally, EMG abnormalities also should be demonstrated in the paraspinal muscles to confirm the diagnosis of radiculopathy. – CMAP amplitude drop of 50% or more indicates significant axonal loss. – NCS/EMG is especially helpful to differentiate cervical radiculopathy from confounding neuropathic conditions (eg, ulnar nerve entrapment, carpal tunnel syndrome, peripheral neuropathy, plexopathy). Can J Neurol Sci. Hassan A et al, 2013 Mar;40(2):219-24. Clinical predictors of EMG-confirmed cervical and lumbosacral radiculopathy.
  23. 23. Clinical Maneuvers • Spurling’s maneuver - Axial loading of the neck while the head is extended and rotated will often provoke radicular pain. • Abduction Relief sign - Placing the affected hand on top of the head takes stretch off of the affected nerve root and may decrease or relieve radicular symptoms • Lhermitte sign - An electric shock sensation down the center of the back after neck flexion is indicative of cervical spinal cord pathology such as cervical myelopathy.
  24. 24. Spurling’s Maneuver 90% specific, 45% sensitive.
  25. 25. Abduction relief sign
  26. 26. Lhermitte sign (Barber chair phenomenon)
  27. 27. Clinical Tests • Adson’s test – for thoracic outlet syndrome. • Roos test – done in surrender position, to r/o thoracic outlet syndrome.. • Hoffmann’s test – rapidly extend distal phalanx of middle finger by flicking its ant surface. Test is +ve if it results in flx of IP jts of thumb & index finger. • Dynamic Hoffmann’s test – rpt while the pt flx / ext neck, which often facilitates the response. • Inverted radial reflex - +ve if fingers flex during brachioradial reflex.
  28. 28. Signs of Thoracic Outlet Obstruction
  29. 29. Roos Test Indication: All types of TOS
  30. 30. Hoffmann’s test
  31. 31. Inverted radial reflex
  32. 32. Hand: Clinical signs are useful in detecting subtle myelopathy in the upper extremities
  33. 33. Patient Outcome Assessment • Disability • Neck Disability Index (NDI) • Neck and Arm Pain • NRS • Function - HRQol • SF-12®V2
  34. 34. Each section is scored on a 0–5 scale, 5 representing the greatest disability. (Vernon H, Mior S. "The Neck Disability Index: a study of reliability and validity." J Manipulative Physiol Ther. 1991 Sep;14(7):409-15.)
  35. 35. RTA & Whiplash • Whiplash is an acceleration-deceleration mechanism of energy transfer to the neck. It may result from “...motor vehicle collisions...”. The impact may result in bony or soft tissue injuries which in turn may lead to a variety of clinical manifestations (Whiplash-associated disorders). Spitzer WO, Skovron ML, Salmi LR, Cassidy JD, Duranceau J, Suissa S, et al. Scientific Monograph of the Quebec Task Force on Whiplash-Associated Disorders, Redefining Whiplash and its Management. Spine 1995;20(8 Suppl):1S-73S. • 62% of RTA victims have whiplash • 33-66% develop symptoms within 24 hours • 30-42% have intermittent pain at 1 year • 6% have continuous pain at 1 year • 28% have chronic pain
  36. 36. Specific….. – Myelopathy • LMN signs in the upper limbs at the level of compression (flaccid paralysis, muscle atrophy, absent reflexes) • UMN signs below the level of the lesion, mainly evident in the lower limbs. (hypertonicity, hyperreflexia, clonus, Babinskis sign) • Sensory deficit is non dermatomal involving large areas e.g. whole arm/forearm/wrist • Bladder involvement may be present • Funicular pain (burning pain)
  37. 37. Other signs of myelopathy • Hoffman's test/dynamic Hoffmann's test • Lhermittes sign • Inverted supinator jerk/inverted radial reflex • Clonus • Myelopathy hand • Gait abnormalities such as ataxic broad based shuffling gait
  38. 38. Anatomy of compression • Anterior compression-IVDP/osteophytes • Anterolateral compression-joints of Luschka • Lateral compression- facet joints • Posterior compression- ligamentum flavum
  39. 39. UNCOVERTEBRAL JOINT • Lower cervical vertebrae (C3-7) have unique synovial joint-like articulations called uncovertebral joint or joints of Luschka • These joints commonly develop OA changes • Proximity of UV joint to spinal nerve roots can cause compression due to degenerative change.
  40. 40. Neck Pain or injury Immediate cervical radiographs indicate diagnosis? Red Flags present? Cervical injury risk factors ? Diagnosis life-threatening or requiring referral Referral to specialist Begin diagnostic workup it surgery would be considered Cervical films negative or show spondylosis? Symptomatic treatment 4 more weeks Continued pain and disability? Evaluate for complications or occult disease (Basic lab tests) Unsure of diagnostic course of action? Referral to specialist Treatment successful? No further Treatment Chronic neck pain Confirming or unsure Cervical films as needed: MRI Cervical spine CT Cervical spine Myelogram or Electromyelography Symptomatic treatment 2 more weeks Continued pain and Disability? Symptomatic treatment for 2 weeks Continued pain and Disability? Cervical radiculopathy or myelopathy Cervical neck strain, or cervical spondylosis Radicular pain and/or pattern? Yes No Yes Yes Yes Yes No No Diagnosis Yes Yes OR Yes No No No Yes No No No No
  41. 41. Management • Non-operative –Many options –Little evidence to support • Operative –Many options –Little evidence to support Carette S et. al. N Engl J Med 2005;353:392-9.
  42. 42. Acute Neck pain • NSAIDs • Exercise groups performed better compared to Rest groups (Rest makes Rusty) Chronic Neck pain • Educational efforts & exercise rehabilitation programme helped majority of patients in relieving psychological distress, pain and helped patients to return to work • Drug therapy may not be very useful in non specific chronic neck pain • Limited evidence of efficacy of Radiofrequency neurotomy for facet joint pain Neck Pain – Treatment Ferrari R Best practice & Research Clinical Rheumatology 2003; 17(1): 57 - 70
  43. 43. Treatment Options • Medications – NSAID, COX-2 inhibiters – Muscle relaxants – used to aid sleep if disrupted by muscular guarding. – Tricyclic antidepressants like amitryptiline / nortryptiline prescribed at 10-25mg at bedtime can be beneficial in relieving pain. – Gabapentin & pregabalin 300-900mg/ day can be effective in modulating pain. – Other drugs are tiagabine, oxcarbamazepine , opiate analgesics for resistant cases. • Surgery: – Diskectomy, Laminoforaminectomy, cervical arthroplasty
  44. 44. Radiculopathy: Medical vs. Surgical management Carette S et. al. N Engl J Med 2005;353:392-9. • Few good-quality studies comparing surgical and non-surgical treatments for cervical radiculopathy • A significantly greater reduction in pain at 3 months in surgical group than the patients who were assigned to receive physiotherapy or who underwent immobilization in a hard collar (reductions in VAS for pain: 42 %, 18 % & 2 %, respectively). • No difference among the 3 treatment groups in any of the outcomes measured, including pain, function, and mood at 1 year follow up.
  45. 45. Neck Pain : Algorithm for management History / physical examination Whiplash associated disorder Radiculopathy Axial Neck pain Suspected infection / neoplasm Suspected myelopathy X-ray MRI/Labs Confirmed NSAID ± Muscle Relaxant + early return to usual activities GIII/IV GI/II If -ve If -ve Consultation Grade IV confirmed Immobilize / Consultation Opioid, Anticonvulsant or antidepressant If not resolved Investigate further If not resolved * Douglass AB et. al. J. Am. Board Fam Pract 2004;17: S13-22
  46. 46. Recommendations for Diagnosis and Imaging • RECOMMENDATION: It is suggested that the diagnosis of cervical radiculopathy be considered in patients with arm pain, neck pain, scapular or periscapular pain, and paresthesias, numbness and sensory changes, weakness, or abnormal deep tendon reflexes in the arm. These are the most common clinical findings seen in patients with cervical radiculopathy. Grade of Recommendation: B • RECOMMENDATION: It is suggested that the diagnosis of cervical radiculopathy be considered in patients with atypical findings such as deltoid weakness, scapular winging, weakness of the intrinsic muscles of the hand, chest or deep breast pain, and headaches. Atypical symptoms and signs are often present in patients with cervical radiculopathy, and can improve with treatment. Grade of Recommendation: B • RECOMMENDATION: Provocative tests including the shoulder abduction and Spurling’s tests may be considered in evaluating patients with clinical signs and symptoms consistent with the diagnosis of cervical radiculopathy. Grade of Recommendation: C • RECOMMENDATION: Because dermatomal arm pain alone is not specific in identifying the pathologic level in patients with cervical radiculopathy, further evaluation including CT, CT myelography, or MRI is suggested prior to surgical decompression. Grade of Recommendation: B North American Spine Society Evidence-Based Clinical Guidelines for Multidisciplinary Spine Care 2010
  47. 47. Recommendations for Diagnosis and Imaging • RECOMMENDATION: MRI is suggested for the confirmation of correlative compressive lesions (disc herniation and spondylosis) in cervical spine patients who have failed a course of conservative therapy and who may be candidates for interventional or surgical treatment. Grade of Recommendation: B • RECOMMENDATION: CT myelography is suggested for the evaluation of patients with clinical symptoms or signs that are discordant with MRI findings (eg, foraminal compression that may not be identified on MRI). CT myelography is also suggested in patients who have a contraindication to MRI. Grade of Recommendation: B • RECOMMENDATION: In the absence of reliable evidence, it is the work group’s opinion that CT may be considered as the initial study to confirm a correlative compressive lesion (disc herniation or spondylosis) in cervical spine patients who have failed a course of conservative therapy, who may be candidates for interventional or surgical treatment and who have a contraindication to MRI. Work Group Consensus Statement North American Spine Society Evidence-Based Clinical Guidelines for Multidisciplinary Spine Care 2010
  48. 48. Outcome Measures for Medical/Interventional and Surgical Treatment • RECOMMENDATION: The Neck Disability Index (NDI), SF- 36, SF-12 and VAS are recommended outcome measures for assessing treatment of cervical radiculopathy from degenerative disorders. Grade of Recommendation: A • RECOMMENDATION: The Modified Prolo, Patient Specific Functional Scale (PSFS), Health Status Questionnaire, Sickness Impact Profile, Modified Million Index, McGill Pain Scores and Modified Oswestry Disability Index are suggested outcome measures for assessing treatment of cervical radiculopathy from degenerative disorders. GRADE OF RECOMMENDATION: B North American Spine Society Evidence-Based Clinical Guidelines for Multidisciplinary Spine Care 2010
  49. 49. Medical and Interventional Treatment • RECOMMENDATION: Emotional and cognitive factors (e.g., job dissatisfaction) should be considered when addressing surgical or medical/interventional treatment for patients with cervical radiculopathy from degenerative disorders. GRADE OF RECOMMENDATION: I (Insufficient Evidence) • RECOMMENDATION: As the efficacy of manipulation in the treatment of cervical radiculopathy from degenerative disorders is unknown, careful consideration should be given to evidence suggesting that manipulation may lead to worsened symptoms or significant complications when considering this therapy. Pre-manipulation imaging may reduce the risk of complications. Work Group Consensus Statement • RECOMMENDATION: Transforaminal epidural steroid injections using fluoroscopic or CT guidance may be considered when developing a medical/interventional treatment plan for patients with cervical radiculopathy from degenerative disorders. Due consideration should be given to the potential complications. GRADE OF RECOMMENDATION: C • RECOMMENDATION: Ozone injections, cervical halter traction and combinations of medications, physical therapy, injections and traction have been associated with improvements in patient reported pain in uncontrolled case series. Such modalities may be considered recognizing that no improvement relative to the natural history of cervical radiculopathy has been demonstrated. Work Group Consensus Statement North American Spine Society Evidence-Based Clinical Guidelines for Multidisciplinary Spine Care 2010
  50. 50. EBM of Acute Cervical Pain • There is both a lack of evidence (i.e. few or no scientific studies conducted) and a lack of high quality studies on pain- relieving treatments in this area • Not effective – There is scientific evidence that collars are not effective for acute neck pain • Effective Measures • Measures that are effective for relieving acute neck pain are: – Staying active and keeping the neck moving; – gentle neck exercises (these can be started soon after the pain starts); – combined (or ‘multi-modal’) treatments involving cervical passive mobilisation with exercises, or – exercises with other types of treatments; – and pulsed electromagnetic therapy (reduces pain in the short term). www.nhmrc.gov.au
  51. 51. EBM of Acute cervical Pain • Inconclusive Studies on – TENS, – electrotherapy and – micro-breaks (small breaks from computer work) for acute neck pain • have not tested these treatments against placebo. • No studies done to prove is work or not • There are no studies that have looked at: – acupuncture, – pain-relieving medication (analgesics), anti-inflammatory drugs (NSAIDs), – Cervical manipulation, cervical passive mobilisation, – multi-disciplinary treatment in the workplace, – Muscle relaxants, – neck school, – patient education, – spray and stretch therapy and – traction for the treatment of acute neck pain. www.nhmrc.gov.au
  52. 52. Neck pain with radiculopathy • There is little credible evidence to support one best course of treatment for neck pain with radiculopathy • One non-blinded randomized trial of patients with more than 3 months of radicular pain compared surgery with physical therapy or immobilization in a collar. The long-term result was no difference in pain, although the surgery group had a greater short- term reduction in pain, and a large proportion of patients in all groups eventually had surgery • One very real problem in the study of the treatment of radicular symptoms is that the natural history of symptomatic radiculopathy is not known. The belief that untreated patients will develop progressive disability is not supported by reliable evidence. The reported death rates from surgical procedures are 0% to 1.8%, and the rate of non-fatal complications is reported as 1% to 8% . Therefore, there are no clear indications for which patients with neck pain and radiculopathy should be referred for surgery and the choice of surgical procedure has not been established by appropriately designed studies. www.nhmrc.gov.au
  53. 53. Pain Physician. Kaye AD et al; 2015 Nov;18(6):E939-1004. Efficacy of Epidural Injections in Managing Chronic Spinal Pain: A Best Evidence Synthesis. CONCLUSION: This systematic review, with an assessment of the quality of manuscripts and outcome parameters, shows the efficacy of epidural injections in managing a multitude of chronic spinal conditions. Data sources included relevant literature identified through searches of PubMed for a period starting in 1966 through August 2015; Cochrane reviews; and manual searches of the bibliographies of known primary and review articles. A systematic review of randomized controlled trials of epidural injections in managing chronic spinal pain.
  54. 54. Strong Evidence of Treatment Effect Moderate Evidence of Treatment Effect (2) 1. Gross AR, Hoving JL, Haines TA, Goldsmith CH, Kay T, Aker P, Bronfort G, Cervical overview group, The Cochrane Collaboration. Manipulation and mobilization for mechanical neck disorders (Review). 2. Gross AR, Goldsmith, C, Hoving, JL, Haines T, Peloso P, Aker P, Santaguida P, Myers C, and the Cervical Overview Group. Con-servative Management of Mechanical Neck Disorders: A Systematic Review. The Journal of Rheumatology 2007; 34:3, 1083-102. 3. Gross AR, McLaughlin L, Cervical Overview Group. Lecture notes from HaNSA meeting, McMaster University, 2008. 4.Sterling M, Jull G, Wright A. Cervical Mobilisation: concurrent effects on pain, sympathetic nervous system activity, and motor activ-ity. Manual Therapy 2001 6(2), p.72-81.
  55. 55. Gross A, Kay TM, Paquin J, Blanchette S, Lalonde P, Christie T, Dupont G, Graham N, Burnie SJ, Gelley G, Goldsmith CH, Forget M, Hoving JL, Brønfort G, Santaguida PL; 28 January 2015 Cochrane No high quality evidence was found, indicating that there is still uncertainty about the effectiveness of exercise for neck pain. Using specific strengthening exercises as a part of routine practice for chronic neck pain, cervicogenic headache and radiculopathy may be beneficial. Research showed the use of strengthening and endurance exercises for the cervico-scapulothoracic and shoulder may be beneficial in reducing pain and improving function. However, when only stretching exercises were used no beneficial effects may be expected. Future research should explore optimal dosage.
  56. 56. ISRN Pain. Pia Damgaard et al,Volume 2013 (2013), 23 pages; Evidence of Physiotherapy Interventions for Patients with Chronic Neck Pain: A Systematic Review of Randomised Controlled Trials Review Article Only exercise therapy, focusing on strength and endurance training, and multimodal physiotherapy, cognitive-behavioural interventions, massage, manipulations, laser therapy, and to some extent also TNS appear to have an effect on CNP. However, sufficient evidence for application of a specific physiotherapy modality or aiming at a specific patient subgroup is not available.
  57. 57. Take home message… • Thorough evaluation and assessment is essential for proper diagnosis & management • Significant patients are looking around for specific diagnosis which may reduce their anxiety • The clinical picture is often non-specific • Beware of alerts in evaluation & treatment
  58. 58. Thank You Questions?

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