Non-Operative Management of Cervical Radiculopathy

1. Non-Operative Management of Cervical Radiculopathy Matthew R. Doyle, MS, ATC, LAT

2. Why this topic? • Wrestling and Neck Injuries • In the past a lack of quality information on managing Cervical Radiculopathy (CR)

3. 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

4. College Time Loss Injuries Body Sites of Wrestling Injuries

5. 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

6. 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

7. 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

8. 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

9. 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

10. 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

11. 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

12. 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

13. 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

14. 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) • 18 lbs, 30 sec on and 12 lbs, 10 sec • Strengthening • 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

15. Multi-modal Intervention Approach • Case series of CR patients • 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

16. 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

17. Treatment • Natural history, favorable prognosis long term • Non-operative Management is effective • Little high quality evidence on the best non-operative therapy for CR • Multimodal approach may alleviate symptoms

18. Interventions for CR • Some but few RCT, systematic reviews • Largely case studies and anecdotal experience • Clinical Practice Guidelines

19. 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?

20. 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

23. 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

24. 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

25. 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

26. 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

27. 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.

28. 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

29. 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

30. 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

31. 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

32. 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

33. 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