Non-operative Management of Neck Pain and Cervical Radiculopathy: What treatment protocol is rational and effective?

W. Porter McRoberts MD www.internationalhouseofpain.com

•Interventional physiatrist •Director Holy Cross interventional Pain, Spine and Neurosurgery •Researcher, Writer, Scientist, Husband, Father. •Student of the game

Disclosures: McRoberts • Research – St. Jude, Vertiflex, Medtronic, Nevro, Flowonix, Mesoblast, Bioness, SPR, Sanofi-Aventis, Main-Stay, Neuros.

• Consulting • St. Jude, Vertiflex, Medtronic, Nevro, Flowonix, Nalu, Bioness, Boston Scientific, SPR, Guidepoint, Gore Industries.

• I have received no financial compensation for any portion of this lecture. • There will be off label discussion during this talk.

Objectives: 1. To understand the structures which contribute to both axial neck pain and cervical radicular pain 2. To understand the stepwise approach to evaluation of the above sources of pain. 3. To understand the EBM and approaches to treatment of cervical axial and radicular pain. • The above, free of commercial bias.

Causes of Pain AXIAL vs RADICULAR • Axial Neck Pain • High Pain – AA Joint, AO Joint – High Cervical Facets(common) – High Cervical Discs(rare) • Luschka Joints

– Ondontoid/Alar – Chiari

The distribution of pain in normal volunteers after stimulation of the zygapophysial joints indicated. (From Cooper G, Bailey B, Bogduk N. Cervical zygapophysial joint pain maps. Pain Med 2007;8:344–53.)

The distribution of pain relieved in patients with neck pain, after anesthetization of the synovial joints indicated, using controlled diagnostic blocks. The density of shading is proportional to the number of patients whose pain extended into the area indicated. (From Cooper G, Bailey B, Bogduk N. Cervical zygapophysial joint pain maps. Pain Med 2007;8:344–53.)

Causes of Axial Pain • Mid and Low Pain – – – –

Discs Facets Muscle Ligaments

• Taxes, Ex’s, Hangovers

Causes of Axial neck pain – TON, GON, LON (C2 Mediated) – Muscle/Ligament – CSF Leak – CA/Infxn/Fx/Other

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Rare: Vertrbral tumors Discitis Septic Arthritis Osteomyleitis Meningitis RA/AS/ CA-Gout/Fx

Causes of Radicular Pain • Radiculopathy is a disease of neural irritation and or compression.

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Disc: Protrusion/Herniation/ Ostophytic compresison Z-Joint: Ospeophyte/Ganglion/Tumor/RA/Gout/AS/Fx V-Body:Tumor/Paget’s, Fx, Osteomyelitis Meninges: Cysts/Mengioma/cysts/Epidural abcess/Hematoma Nerve Sheath: Neurofibroma/Schwannoma Nerve: Glioblastoma/Ganglioneuroma

Epidemiology of Neck Pain • • • • • • •

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2000-2010 Task Force on Neck Pain and Its Associated Disorders performed a systematic search and critical review of literature published between 1980 and 2006 to assemble the best evidence on neck pain. 469 studies 249 to be scientifically admissible; 101 articles related to the burden and determinants of neck pain in the general population. Incidence ranged from 0.055 per 1000 person years(disc herniation with radiculopathy) to 213 per 1000 persons (self-reported neck pain). Incidence of neck injuries during competitive sports ranged from 0.02 to 21 per 1000 exposures. The 12-month prevalence of pain typically ranged between 30% and 50%; the 12month prevalence of activity-limiting pain was 1.7% to 11.5%. Neck pain was more prevalent among women and prevalence peaked in middle age. Risk factors for neck pain included genetics, poor psychological health, and exposure to tobacco. Disc degeneration was not identified as a risk factor. The use of sporting gear (helmets, face shields) to prevent other types of injury was not associated with increased neck injuries in bicycling, hockey, or skiing. European Spine JournalApril 2008, Volume 17, Supplement 1, pp 39-51

Prevalence of Cervical Axial Pain of zygopophyseal origin • Prospective study of 318 patients with intractable neck pain • Provocation discography, Z-Joint blocks. • Z-joints: 38% suffered zygapophyseal pain Aprill C, Bogduk N, The Prevalence of Cervical Zygapophyseal Joint Pain; A First Approximation. PhDSpine (Phila Pa 1976). 1992 Jul;17(7):744-7.

Summary: Controlled studies: facet or zygapophysial joint pain in 36% to 67% of these patients, when disc herniation, radiculitis, and discogenic are not pathognomic. Falco FJ1, Manchikanti L, Datta S, Wargo BW, Geffert S, Bryce DA, Atluri S, Singh V, Benyamin RM, Sehgal N, Ward SP, Helm S 2nd, Gupta S, Boswell MV., Systematic review of the therapeutic effectiveness of cervical facet joint interventions: an update. Pain Physician. 2012 NovDec;15(6):E839-68.

Diagnosis of Cervical Axial Pain •

Consecutive patients, seen between January 2003 and January 2005, in whom a diagnosis of neck pain was made. MBB/F-IAI vs Disco vs AA/AO

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Pain Med. 2008 Mar;9(2):196-203. doi: 10.1111/j.1526-4637.2007.00369.x.The nature of neck pain in a private pain clinic in the United States.Yin W, Bogduk N.

Z/Facet Joint Pain Treatment •Having failed PT/other conservative measures: •Diagnostic Medical Branch Block of the Dorsal Primary Ramus: “MBB or FJNB” •Dual Block Paradigm

Z/Facet Joint Pain Treatment • Facet Joint Nerve Ablation • FJNA • Typically 6-18 months of relief

Z/Facet Joint Pain Treatment

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The median time that elapsed before the pain returned to at least 50 percent of the preoperative level was 263 days in the active-treatment group and 8 days in the control group (P = 0.04). At 27 weeks, seven patients in the active-treatment group and one patient in the control group were free of pain. Five patients in the active-treatment group had numbness in the territory of the treated nerves, but none considered it troubling.

Z/Facet Joint Pain Treatment

Z/Facet Joint Pain Treatment

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Retrospective.Objective. To assess the incidence of complications associated with fluoroscopically guided percutaneous radiofrequency denervation of the lumbar facet joints. facet joint radiofrequency denervation procedures performed at the Mayo Clinic in Jacksonville during a 5-year period. Ninety-two patients received a total of 616 radiofrequency lesions during 116 separate denervation procedures. An average of 5 ± 3 lesions were performed during each radiofrequency denervation procedure. Six minor complications were identified, yielding a 1.0% overall incidence of minor complications per radiofrequency site. Complications included: 3 cases of localized pain lasting more than 2 weeks (0.5%) and 3 cases of neuritic pain lasting less than 2 weeks (0.5%). No cases of infection, new motor deficits, or new sensory deficits were identified. Conclusions. Fluoroscopically guided percutaneous radiofrequency denervation of the lumbar facets is associated with an overall 1.0% incidence of minor complications per lesion site.

Cervical Degenerative Disc Disease (C-DDD) 1998

Abstract: Cervical MRI 497 ASYMPTOMATIC subjects • five disc levels from C2–C3 to C6–C7 were evaluated. • The frequency of all degenerative findings increased linearly with age. • Disc degeneration was the most common observation • 20s 17% of discs of men 12% of those of women • 60< 86% and 89% of discs of both men and women • demonstrable compression of the spinal cord, was observed in 7.6% of subjects, mostly over 50 years of age. • “Our results should be taken into account when interpreting the MRI findings in patients with symptomatic disorders of the cervical spine.”

Cervical Degenerative Disc Disease (C-DDD)

•89 asymptomatic volunteers aged 9 to 63 years. •The degree of DD (disc darkening on T2*-weighted images), disc protrusions and prolapses, narrowing of disc spaces, dorsal osteophytes and spinal canal stenosis were assessed. •Abnormalities were commoner in older subjects, •62% of being seen in those over 40 •subjects aged less than 30 years there were virtually no abnormalities. •DD was the most common abnormality, seen in 10% of discs; • 57% DD was in subjects aged over 40. •DD at the C5/6 level was the most common finding. •No differences in abnormal findings between males and females was observed

Cervical Degenerative Disc Disease (C-DDD) E. J. of Spine, 2002

•“Role of pathology visualized by magnetic resonance imaging (MRI) remains unclear.” •The study aimed to determine whether subjects with persistent or recurrent neck and shoulder pain were more likely to have abnormal MRI findings of cervical spine than those without neck and shoulder pain. •Random 826 high-school students investigated 17–19 years and AGAIN 24–26 years of age. 87% initial participation, 76% took part in follow-up. •Nordic Musculoskeletal Questionnaire was used to collect data about neck and shoulder symptoms. •Two groups: G1::reported no neck and shoulder symptoms in either of the inquirie • G2:: suffering from neck and shoulder symptoms once a week or more often •.The study found that abnormal MRI findings were common in both study groups. •Disc herniation was the only MRI finding that was significantly associated with neck pain.

When Is C-DDD Clinically significant? (C-DDD)

Results: A systematic review of the literature demonstrated that cervical discography plays a significant role in selecting surgical candidates and improving outcomes, despite concerns regarding the false-positive rate, lack of standardization, and assorted potential confounding factors. Based on the studies utilizing the International Association for the Study of Pain (IASP) criteria, the data show a prevalence rate ranging between 16% and 20%. Based on the 3 studies that utilized IASP criteria during the performance of cervical discography, the evidence derived from studies evaluating the diagnostic validity of the procedure, the indicated level of evidence is Level II-2 based on modified U.S. Preventive Services Task Force (USPSTF) criteria.

•Beyond the debate regarding its efficacy in identifying the site of cervical symptomatology and directing appropriate intervention are the potential morbidity and mortality associated with this diagnostic procedure. •Discitis, subdural empyema, spinal cord injury, vascular injury, and prevertebral abscess have all been reported as complications of diagnostic cervical disc injection. •Retrospective: 4400 cervical disc injections in 1357 patients performed by an experienced radiologist between 1988 and 1993 to define the morbidity and mortality associated with discography. •In addition, we reviewed the extant medical literature on the complications of this controversial procedure. • This study demonstrates significant complications from diagnostic discography procedures occurring in less than 0.6% of the patients and 0.16% of the cervical disc injections.

Why I rarely do Cervical Discography: • Excluding facetogenic pain, rare to find purely axial, non-tender pain that is NOT C-DDD • What's the literature reveal on cervical fusion and replacement? • Pretty good outcomes.

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Medicine (Baltimore). 2016 Jan;95(4):e2568. doi: 10.1097/MD.0000000000002568.Comparison of Clinical Efficacy Between Interlaminar and Transforaminal Epidural Injection in Patients With Axial Pain due to Cervical Disc Herniation.

• Axial neck pain is originated from sinuvertebral nerve located in ventral epidural spaces, which has been described to be related to central or paramedian disc herniation. • 108 patients who underwent IL and TF epidural injections, axial neck/interscapular pain due to central or paramedian cervical disc herniation were included. • Successful pain relief was defined if a 50% or more reduction of NRS score was achieved in comparison with pretreatment one. • Overall, 79 (73.1%) and 57 (52.8%) 2 and 8 weeks, respectively. Seventy-six (70.4%) and 52 (48.1%) had successful functional improvement at 2 and 8 weeks, Cervical epidural injection showed favorable results in 2 weeks and moderate results in 8 weeks in patients with axial pain due to cervical disc herniation.

Epidemiology of Cervical Radiculopathy • 561 patients (332 males and 229 females). • 13 to 91 years; the mean age ±SD was 47.6±13.1 years for males and 48.2±13.8 years for females. • A history of trauma preceding= 14.8% of cases. • A past history of lumbar radiculopathy was present in 41%. • A monoradiculopathy involving C7 nerve root was the most frequent, followed by C6. • A confirmed disc protrusion was responsible for cervical radiculopathy in 21.9% of patients;

Epidemiology of Cervical Radiculopathy • 68.4% were related to spondylosis, disc or both. • During the median duration of follow-up of 4.9 years, recurrence of the condition occurred in 31.7%, and 26% underwent surgery for cervical radiculopathy. • At last follow-up 90% of our population-based patients were asymptomatic or only mildly incapacitated due to cervical radiculopathy • Annual incidence rates per 100k

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– 83.2 for the total, – 107.3 for males and – 63.5 for females The age-specific annual incidence rate per 100 000 population reached a peak of 202.9 for the age group 50–54 years. Kurupath Radhakrishnan, William J. Litchy, W. Michael O'Fallon, Leonard T. Kurland, Epidemiology of cervical radiculopathy A population-based study from Rochester, Minnesota, 1976 through 1990, BrainA Journal of Neurology

Cervical Radiculopathy

Cervical Radiculopathy • Common etiologies: • Cervical Disc Herniation • Lateral recess stenosis – Disc/Luschka vs ligament

• Foraminal stenosis – Facet vs Luschka

Cervical Radiculopathy

C-Radic: Non-operative Management • “The axons of these nerves are either compressed directly or are rendered ischemic by compression of their blood supply. Symptoms of sensory or motor loss arise as a result of block of conduction along the affected axons. The features of cervical radiculopathy, therefore, are essentially negative in nature; they reflect loss of function. In contrast, pain is a positive feature, not caused by loss of nerve function. • For this reason cervical radicular pain cannot be summarily attributed to the same causes as those of radiculopathy. Compression of axons does not elicit pain. If compression is to be invoked as a mechanism for pain it must explicitly relate to compression of a dorsal root ganglion.“ • -Nikolai Bogduk • Phys Med Rehabil Clin N Am. 2011 Aug;22(3):367-82, vii. doi: 10.1016/j.pmr.2011.03.008.The anatomy and pathophysiology of neck pain.Bogduk N1.

Cervical Radiculopathy •

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“As opposed to compression, there are growing contentions that cervical radicular pain may be caused by inflammation of the cervical nerve roots. This mechanism might be applicable to radicular pain caused by disc protrusions, because inflammatory exudates have now been isolated from cervical disc material. However, inflammation cannot be invoked as the mechanism of radicular pain caused by noninflammatory lesions such as tumors, cysts, and osteophytes. For these conditions, compression of the dorsal root ganglion is the only mechanism for which there is experimental evidence. However, none of these considerations bear on the causes and mechanisms of neck pain. Whatever its cause, and whatever its mechanism, cervical radicular pain is perceived in the upper limb. -Nikolai Bogduk Phys Med Rehabil Clin N Am. 2011 Aug;22(3):367-82, vii. doi: 10.1016/j.pmr.2011.03.008.The anatomy and pathophysiology of neck pain.Bogduk N1.

• The Nerve Moves- Porter McRoberts.

Cervical Radiculopathy Non-operative treatment • Non-operative treatment – Physical therapy – Chiropractic – Traction – Epidural steroid injections

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This prospective study with independent clinical review was set up to monitor the clinical outcome of patients when using serial periradicular/epidural corticosteroid injection techniques in managing cervical radiculopathy. Over a 10 year period, between 1986 and 1995, a consecutive series of 68 secondary referral patients presenting with cervical radiculopathy were entered into the study. Of the 64 patients (94%) who under-went imaging, relevant pathology thought to correlate with the clinical presentation was demonstrated in all but one patient. Serial periradicular/epidural corticosteroid injections were used to control pain; an average of 2.5 injections was administered per patient (range 1–6). Patients underwent a final clinical examination when their pain had remained satisfactorily under control for an average of 7 months (range 1–23 months). They subsequently were reassessed, by an independent clinician, at an average of 39 months (range 4–112 months) after initial presentation, via a telephone interview. Despite the fact that all 68 patients were potential surgical candidates, they all made a satisfactory recovery without the need for surgical intervention. Forty-eight patients (76%) did not experience any arm pain, and of the 15 patients (24%) who did, this improved from 10 to an average of 2 (range 1–4) on a 10-point pain scale. Thus, patients with cervical radiculopathy make a satisfactory recovery with serial periradicular/epidural corticosteroid injections without the need for surgical intervention.

• Complications of Cervical Epidural Nerve Blocks with Steroids: A Prospective Study of 790 Consecutive Blocks. WALDMAN, STEVEN D. M.D. May/June 1989 - Volume 14 - Issue 3pp: 99-159

790 consecutive cervical epidural nerve blocks were followed prospectively for a six-week period for early as well as delayed complications. • Two patients sustained unintentional dural puncture. Both patients ultimately required cervical epidural blood patch. • Three patients experienced vasovagal syncope during CSENB. They were easily resuscitated. • One late complication of superficial infection at the injection site was noted. The patient recovered without sequela. • From the above data, it appears that CSENB represents a safe modality in the treatment of a variety of painful conditions.

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Study Design. A prospective, concurrently controlled, randomized, multicenter trial of an anterior Bagby and Kuslich cervical fusion cage (BAK/C; Sulzer Spine-Tech, Minneapolis, MN) for treatment of degenerative disc disease of the cervical spine.Objectives. To report clinical results with maximum 24-month follow-up of fusions performed with the BAK/C fusion cage.Summary of Background Data. Threaded lumbar cages have been used during the past decade as a safe and effective surgical solution for chronic disabling low back pain. Threaded cages have now been developed for use in anterior cervical interbody fusions to obviate the need for allografts or autogenous bone grafting procedures while providing initial stability during the fusion process.Methods. Patients with symptomatic cervical discogenic radiculopathy were treated with either anterior cervical discectomy with uninstrumented bone-only fusion (ACDF) or BAK/C fusion cage(s). Independent radiographic assessment of fusion was made and patient-based outcome was assessed by visual analog pain scale and a Short Form (SF)-36 Health Status Questionnaire.Results. Data analysis included 344 patients at 1 year and 180 at 2 years. When the two cage groups (hydroxya, patite-coated or noncoated) were compared with the ACDF group, similar outcomes were noted for duration of surgery, hospital stay, improvements in neck pain and radicular pain in the affected limb, improvements in the SF-36 Physical Component subscale and Mental Component subscale, and the patients’ perception of overall surgical outcome. Symptom improvements were maintained at 2 years. A greater percentage of patients with ACDF needed an iliac crest bone harvest than did BAK/C patients (67%vs.— 3%). Successful fusion for one-level procedures at 12 months was 97.9% for the BAK/C groups and 89.7% for the ACDF group (P < 0.05).

The complication rate for the ACDF group was 20.4% compared with an overall complication rate of 11.8% with BAK/C.

Summary:

•Examine and read the patient. •Take course of highest safety with best outcome. •Many cases of cervicogenic pain recover without intervention •Evaluate the risk of your intervention BUT •ALSO EVALUATE THE RISK ASSOCIATED WITH NONTREATMENT. •INACTIVITY IN OLDER AGE GROUPS CAN BE DEVESTATING AND GREAT MORBIDITY AND MORTALITY IS ASSOCIATED WITH TORPOR.

“While this chapter seeks to investigate and present the available surgical options, the greater importance, already appreciated by many patients, may lie not on the selection of surgical method but rather on the selection of surgeon. “ •

McRoberts WP, Cairns KD, Current Surgical Options for the Treatment of Cervical and Lumbar Degenerative Disc Disease, IN: Kapural L (ed) Diagnosis, Management, & Treatment of Discogenic Pain, Elsevier, Philadelphia, 2011.

In Conclusion: Come Here for Help