Transcript Conservative Treatment of Cervical Radiculopathy

Non-Operative Management
of Cervical Radiculopathy
Matthew R. Doyle, MS, ATC, LAT
Why this topic?
 Wrestling and Neck Injuries
 In the past a lack of quality information on
managing Cervical Radiculopathy (CR)
Goals
 Update self, others on current evidence and
best clinical practices
 Paper with Clark, Rosenquist, McKinley
 Discuss amongst colleagues, gain consensus
for future cases at Iowa, multi-disciplinary
approach
College Time Loss Injuries
Yard, 2008 AJSM
30
25
20
15
10
5
0
Knee
Shoulder Head/Face
Trunk
Hip/Leg
Ankle
Neck
Iowa Wrestling Cervical Disorders
 August 2002 to current
 56 total problems and cases
 Minor= strains, sprains, facet syndrome,
mechanical neck pain
 10 caused time loss of greater than one week
 9 cervical radiculopathy, one brachial plexus
traction injury
 3 cases to examine
Define the Problem
 Neck Disorders
 classification problems
 Childs, 2004
 SIMS by anatomy
 List of diagnosis: facet syndromes, HNP, hard
disc, soft disc, Mechanical neck pain, CR,
neuropraxia, brachial plexopathy, spondylosis,
jammed neck, stingers, myelopathy, Spinal Cord
Neuropraxia
 Focus today on cervical radiculopathy
Cervical Radiculopathy
 Disease process marked by spinal or nerve root
compression or irritation
 Numbness, sensory and reflex deficits, or motor
dysfunction in affected nerve root distribution
 May be crossover between myotomes/dermatomes
 Impingement may produce neck, upper
trapezius, interscapular, shoulder girdle, and
unilateral radiating arm pain
• Combination of above and changes in acute to chronic
Pathoanatomy
 Inflammatory mediators, changes in vascular
response, intraneural edema, hypoxia
 Cervical spondylosis (70-75% of cases)
 decreased disc height space, degenerative changes at
uncovertebral and facet joints
 Herniated nucleus pulposus (20-25%)
 Tumors, infection
Clinical Diagnosis
 No universally accepted criteria for the
diagnosis of CR.
 Wainner, 2000
 Proposed guidelines to treat low back pain
may be applied to neck pain and CR.
 Carette, 2005
 Match imaging to clinical signs
Cervical Radiculopathy
 Clinical Diagnosis, unknown diagnostic
accuracy
 Can’t determine prognosis, risk factors, or
effective interventions
 Called for definitive diagnostic criteria and
terms
 Homogeneous groups
 No evidence for any single intervention
 Wainner, 2000
 Literature review
Tx Cervical DDD
 Pain generators, anatomical reference
 Mechanical Neck Pain (facet and disc joint)
 CR, myelopathy and stenosis
 CR caused by disc herniations
 Rest, immobilization, NSAIDS, traction, Physical
Therapy
 Narayan, 2001 and Zmurko, 2003
Rehabilitation
 Phased progression for syndromes
 Education, posture corrective exercises and
stretching
 Beazell, Magrum, 2003
 Algorithm of progressive intervention
 Nonspecific treatments
 Included ESI, TENS, acupuncture
 Saal, 1996
Clinical Prediction Rule
 Test Item Cluster, 4 positive exam findings
 Spurling, upper limb tension, cervical
distraction tests
 >60 deg rotation toward symptomatic side
 Wainner, 2003
Multi-modal Treatment Approach
 Case study of CR patients
 Manual physical therapy

Cervical lateral glide mob in upper limb neurodynamic position
 Mechanical intermittent cervical traction (ICT) (15 min)
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18 lbs, 30 sec on and 12 lbs, 10 sec
Strengthening
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Cervical Stabilization Exercises (deep neck flexor)
scapulothoracic strengthening
 Screened in using CPR
 Series suggests this tx approach may be appropriate for
CR patients
 Cleland, et al. 2005
Multi-modal Intervention Approach
 Case series of CR patients
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ICT, Thoracic thrust joint manipulation
Cervical stabilization exercises and ROM
Posture education
Used Clinical Prediction Rule
 Possible that this approach can improve
symptoms and functional outcomes
 Waldrop, 2006
Multi-modal Intervention
• RCT, MNP patients w and w/o unilateral
UE symptoms
 Manual physical therapy targeted to
impairments
 Joint mobilization, thrust and non-thrust
 Muscle energy
 Stretching
 Home exercise program, deep flexors and
ROM
 Outcomes support previous RCT w/ MNP
 Walker, Boyles, et al. 2008
Treatment
 Natural history, favorable prognosis long term
 Non-operative Management is effective
 Little high quality evidence on the best nonoperative therapy for CR
 Multimodal approach may alleviate symptoms
Interventions for CR
 Some but few RCT, systematic reviews
 Largely case studies and anecdotal
experience
 Clinical Practice Guidelines
Nonsurgical Management
 Pharmacotherapy for tx low back
 Analgesics, NSAIDS, muscle relaxants,
antidepressants, anticonvulsants for CR
 anecdotal, no RCT
 Effexor, ultram, oral steroids
 Epidural injections of corticosteroids (ESI)
 Retro and prospective cohort studies reporting
favorable results, complications?
Nonsurgical Management
 Education –may help some, systematic review
says no benefit.
 Haynes 2009.
 Short term immobilization, soft collar
 Cervical Traction
 Exercise therapy seems appropriate, not
supported
 Modalities may be beneficial
 Manual Therapies, manipulation and
mobilization
Cochrane Reviews
 Exercises for mechanical neck disorders, 2009
 Unclear, strength, stretch
 Strong evidence for multi-modal care
 Patient education for neck pain, 2009
 Unclear
 Mechanical traction for neck pain, 2010
 Doesn’t support or refute
 Electrotherapy for neck pain, 2010
 Very low quality of evidence TENS effective
 Acupuncture for neck disorders, 2010
 Moderate evidence of effect MNP and chronic CR
 Massage for mechanical neck disorders, 2007 (not
Cochrane)(systematic review in Spine)
 No recommendations
Case Study 1
 College Wrestler (2nd yr) reports neck pain while
strength training in September
 Tx with e-stim, ice, heat, massage, traction, joint
mobilization, isometric strengthening, 4 way neck
strengthening, soft collar, gradual functional
progression
 Lumbar Disc Bulge the next season (3rd yr)
 December of 4th season treated for facet sprain
 Heat, traction, joint mobilization, ice massage,
protection with soft collar and partner selection
 Seeks chiropractic care January
C-7 Nerve Radiculopathy
 April of same year while wrestling noticed
pain and weakness in his left arm
 Tricep weakness and hand was tingly,
neck/scapular pain
 MRI
 multilevel degenerative changes in discs
 disc osteophyte complex at C6-C7 level on left
side causing moderate narrowing of neural
foramen
Cervical Herniated Disc
 Acute treatment with ice, heat, e-stim, NSAIDs
 Referred to Pain Clinic for epidural steroid
injection mid-April
 No wrestling, stiff collar for machine strength
training
 10 lbs restriction to lift with no valsalva
 Aqua therapy, non-impact cardio
 Address UE weakness with specific resistance
exercises, t-bands, machines, dumbells
Summer Break
 May
 no pain in left arm, no neck pain, no
numbness or tingling
 Dramatically improved strength in triceps
 Negative Spurling, full neck ROM
 No additional ESI
 Weight lifting restriction to 20 lbs.
Summer Training
 June
 Asymptomatic and allowed to resume
strength training with no weight restrictions
 Begins gradual, progressive functional return
 Plan to resume live wrestling in 6 weeks
 Aug 28 cleared to full return
Case Study 2
 22 y.o. college wrestler has stinger while
wrestling
 Reports event several days later
 Reports mild neck pain, normal cervical
ROM, wants to continue wrestling but notices
arm weakness
 No previous neck problems
 Treated with activity modifications
Case 2
 4 weeks later has 4/5 tricep strength
 MRI to evaluate for disc affecting C7 nerve
root
 Impression: No evidence of cervical spine
injury or acute abnormality
 Short pedicles present resulting in congenital
narrow AP dimension of the central canal
Case 3
 College Wrestler (2nd yr) with two year history
of repeated stingers
 Current episode with neck extension,
compression, lateral flexion
 Causing acute radiating pain into right trap,
shoulder and distally past elbow to hand
 Previous tx activity modification, protection,
strengthening, modalities, gradual return
Case 3
 Normal myotome exam within minutes
 Following acute phase normal neck motion
 Neurodynamic testing revealed increased
sensitivity and decreased right upper
extremity ROM in median, radial, and ulnar
nerve tracts
 3 sets of 30 reps and instructions for self
mobilization
 Remainder of career 2 more episodes
Case 3
 MRI during junior year
 Posterolateral disk osteophyte complexes
 bilaterally at C3-4
 Right side at C4-5
 Neural foraminal narrowing on right at both
intervals
 Managed with activity modification,
modalities, neuromobilization, and ESI