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Neck Pain, Myelopathy and Radiculopathy Clinical Assessment and Management

Neck Pain, Myelopathy and Radiculopathy Clinical Assessment and Management. Mr. David Bell London Neurosurgery Partnership. Introduction. Consultant neurosurgeon Subspecialty - complex spine surgery NHS base at Kings College Hospital Part of London Neurosurgery Partnership

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Neck Pain, Myelopathy and Radiculopathy Clinical Assessment and Management

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  1. Neck Pain, Myelopathy and RadiculopathyClinical Assessment and Management Mr. David Bell London Neurosurgery Partnership

  2. Introduction • Consultant neurosurgeon • Subspecialty - complex spine surgery • NHS base at Kings College Hospital • Part of London Neurosurgery Partnership • 11 consultant group treating all disorders of the brain and spinal cord

  3. Aims To discuss common clinical scenarios To explain common diagnoses and treatment To identify how to investigate and who to refer

  4. Definitions Mechanical neck pain -Pain felt within the neck and shoulders/trapezius exacerbated by movement Radiculopathy – Clinical syndrome of arm pain, weakness or numbness caused by nerve root irritation Myelopathy – clinical syndrome of loss of dexterity and gait disturbance due to spinal cord compression

  5. Red Flags Fever Weight loss History of cancer Progressive neurological deficit Nocturnal pain Severe pain requiring opiates

  6. Investigation of Neck Pain No need for imaging or blood tests initially No role for plain x-rays If red flags then needs cross-sectional imaging Usually MRI or CT

  7. Incidence of MRI Abnormalities • 30 asymptomatic subjects • 22 (73%) bulging discs • 15 (50%) focal disc protrusions • 1 extrusion • 4 (13%) cord compression • 100 asymptomatic subjects • 40-55 y o: disc protrusions in 20% • 64+ y o: 57% • Cord compression 7%

  8. Management of Neck pain Reassurance NSAIDS Add opiates as required Physiotherapy Acupuncture/Dry needling

  9. Surgery for Neck Pain Unusual for degenerative neck pain Instability due to tumour/infection/trauma responds well to surgery Occasional fusion for degenerative disease

  10. Cervical Radiculopathy Less common than simple neck pain Neuralgic pain radiating down arm Sensory disturbance in distribution of affected nerve Rarely motor deficits Usually accompanied by neck pain

  11. Foraminal Narrowing • Progressive narrowing of exit foramina occurs with normal ageing • Typically asymptomatic

  12. Localisation

  13. Differential Diagnosis Shoulder/Elbow pathology If sensory disturbance it has to be neural Thoracic outlet syndrome Brachial neuritis Entrapment neuropathy – median/ulnar

  14. Investigation MRI cervical spine Nerve conduction studies Brachial plexus imaging

  15. Cervical Root compression

  16. Natural History Spontaneous resolution within 6-12 weeks occurs in 90% of attacks Investigate urgently/refer those with severe pain or progressive motor deficits

  17. Treatment of Radiculopathy Physical therapies Acupuncture Analgesics Ibuprofen/codeine Opiates Pregabalin/Gabapentin/Amitriptyline

  18. Escalation Injections Surgery

  19. Cervical Nerve root injections • ?risk of paraplegia • Interscalene block • Temporary • Local anaesthetic/ steroid

  20. Surgery for Radiculopathy Anterior cervical discectomy Cervical disc replacement Posterior foraminotomy

  21. Discectomy/Replacement Bloodless plane to spine Removal of compression without manipulation of spinal cord Preservation of normal motion/reduce adjacent segment disease 90% relief from arm pain

  22. Cervical Total Disc Replacement • Preserve motion • Reduce stresses on adjacent disc • Prevent adjacent segment disease • Popular • Lack of evidence of efficacy at current time • Expensive

  23. Risks 1 in 1000 risk of paralysis 1% risk of vocal cord paresis Transient hoarseness/dysphagia common

  24. Posterior Foraminotomy Posterior approach Microscopic No risk to oesophagus/trachea Some neck pain 90% effective

  25. Cervical Myelopathy • Clinical syndrome of spinal cord irritation/compression • Insidious loss of fine finger movement • Gait ataxia • Urinary hesitancy

  26. Myelopathy • Increased tone • Spastic reflexes • Rombergs positive • Unable to heel-toe walk • L’Hemitte’s phenomenon

  27. Myelopathy - Causes • Most commonly degenerative • Disc-osteophyte bars • OPLL • Tumour

  28. Natural History • Limited data • Some non –progressive • Most slowly progressive • Occasional rapidly progressive

  29. Myelopathy Treatment • Observational • Supportive - OT/physio • Surgery – Anterior cervical discectomy/corpectomy • Posterior cervical laminectomy +/- fusion

  30. Outcome • 50% notice improvement in hand/leg function • Others arrest progression • 1% continue to deteriorate • 1 in 1000 risk of paralysis • 1 in 10,000 risk of death

  31. Any Questions?

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