Save the Date! NW Surgical Research Foundation Conference March 2018

1. Save the Date! NW Surgical Research Foundation Conference March 2018 @ReboundMD facebook.com/ReboundMD/

2. Causes and Treatmentsof Neck and Arm Pain Brian Ragel, MD

3. No conflicts of interest • No disclosures • I can never do less, I can always do more

4. Introduction • Anatomy • Definitions • Cervical spondylosis • Herniated disc • Cases • Axial neck pain • Radiculopathy • Myelopathy

9. Cervical Spondylosis • “wear and tear” over time • Facet arthropy • “bone spurs” / osteophytes • loss of disc height • mineral deposition within ligaments and discs

10. Imaging: Cervical Spondylosis

11. Imaging: Cervical Spondylosis

12. Imaging: Cervical Spondylosis Degenerative changes that contribute to spinal cord/nerve root compression

13. Axial Neck Pain Case • 45 yo F • Neck pain x 2 years, following MVC. • Mid-cervical spine pain • Has tried everything. • Exam • Paraspinous tenderness • Non-focal neuro exam • Imaging • X-rays: AP/lat/flex/ex, normal • MRI: mild DDD at C6/7

14. Axial Neck Pain • DFN: pain in neck and upper trapezius pain without radicular symptoms • usually mechanical component • 66% of all adults will suffer • Imaging studies correlate poorly • Sx?pain generator? • Nerve endings • Disc • Periosteum • Facets • Paraspinous muscles

15. Diagram: Nerve Endings for Axial Pain * * * *

16. Axial Neck Pain • Imaging Indications: • h/o trauma • h/o cancer • progressive neck pain • on-going neck pain > 2 months • Imaging: • X-ray (AP/lat/flex/ex) r/o fracture, instability, lytic/blastic lesion • CT C-spine r/o fracture (h/o trauma) • MRI r/o tumor, spinal cord compression 61 yo F w/ h/o breast cancer and progressive neck pain.

17. Axial Neck Pain • Tx* • Exercise: strengthen and stretch • OTCs (Tylenol / NSAIDs) • Talk therapy (cognitive specialist) • Heat • Sleeping right – back or side (change pillow, collar, bed) • Physical therapy • Acupuncture • Chiropractor • Tx, limited success* • Injections (steroids ~3 mo; ablations ~1 yr) • Surgery *Best Relief for Neck Pain, Consumer Reports, 2015 and 2016

18. Surgery for Axial Neck Pain • Pain relief 21 – 45% • Partial pain relief 25 – 55% • No relief 22 – 32% • Overall, for axial neck pain, surgery 50/50 at best, no good exam, no good imaging modality to define pain generator site. • I utilize SPECT/CT in some cases. *Lees, Rothman, Deplama, Gore.

19. Axial Neck Pain Case • 45 yo F, chronic neck pain after MVC. • Failed conservative measures • Imaging • CT C-spin, no fracture • Consider Hybrid SPECT/CT, metabolic study

20. Axial Neck Pain • Arthritis can be persistent source of pain. • Facet arthritis, 39% pts w/ neck pain. • Hybrid SPECT/CT • Single Positron Computed Tomography (SPECT) • Nuclear study, Gamma emitting nucleotide • IV 99mTc-medronic acid (phosphate derivative) • Taken up by osteoblasts, • Imaged w/ gamma camera • CT scan screen merged w/ gamma counts • Matar et. al., 72 patients, 25 cervical • Identified potential pain generator sites in 92% and 86% of cervical and lumbar scans, respectively • Can, focus treatments at areas high uptake

21. Axial Neck Pain Case • 45 yo F, chronic neck pain after MVC. • Failed conservative measures • NSAIDs / PT / Chiro / Acupuncture • Facet blocks • Imaging • Hybrid SPECT/CT, normal • NO surgery offered. • Next?: • Encourage pain counseling • ?Consider arthritic w/u? • ?Refer for facet denervation procedure? • ?Spinal cord stimulator? NO, not good for axial neck pain, best for arm pain • F/u 1 year – re-image

22. Conclusion: Axial Neck Pain • Imaging: r/o fracture, instability, tumor. • Surgery: No good surgical option. • Treatment: non-surgical! • My practice: • “Sorry, surgery won’t help.” • In pts w/ little secondary gain and willing try – offer 1 yr f/u. • I have performed ACDF’s for axial neck pain w/ mixed results. • I have offered patients fusion w/ facet arthropathy on SPECT/CT surgery, 1 taker.

23. Cervical Radiculopathy Case • 45 yo M • Neck and right arm pain x 6 weeks • Deltoid to bicep to lateral forearm to thumb • Exam • 4+/5 biceps • diminished LT thumb

25. Cervical Radiculopathy • Sx • Sx’s in dermatomal distribution from compressed nerve root • Example: C6 radiculopathy will produce pain/numbness in lateral biceps -> lateral forearm -> thumb • Dx • Sensory: ask patient to self diagram • Motor: C5 deltoid, C6 biceps, C7 triceps • MRI

28. Cervical Radiculopathy • Tx, non-surgical • OTCs • Rx: Neurontin and Lyrica • Physical therapy / cervical traction • Goal: strength and stretch • Epidural steroid injections • Chiropractic • I do not advise high velocity manipulation • Acupuncture

29. Cervical Radiculopathy • Surgical Indications • Life-limiting pain • Pain > 2 months • Progressive motor deficit • Tx, surgical • Anterior Cervical Discectomy and Fusion (ACDF) • Artificial Cervical Disc Replacement (ACR) • Posterior Cervical Foraminotomy

30. Cervical Radiculopathy Case, F/U 2 months • 45 yo M, weakness improved, but R C6 arm pain continues. • NSAIDs, gabapentin, PT x 3 wks, ESI • Exam: • full strength • diminished LT R C6 • Decision: offered surgery, ACDF/ACR

31. Insurance: Surgery Authorization Criteria • Molina utilizes McKesson InterQual - Evidence Based Clinical Criteria • Surgery algorithms • Example: Surgery approval algorithm for cervical disc herniation w/ unilateral symptoms

32. Insurance: Surgery Authorization Criteria X X

33. Insurance: Surgery Authorization Criteria X X

34. Insurance: Surgery Authorization Criteria X Pt w/ only 3 wks PT. Surgery denied? X X X

35. Insurance: Surgery Authorization Criteria X Pt w/ only 3 wks PT. Surgery denied? DENIED, until documented 6 wks home exercise. X X X X X X

36. Cervical Radiculopathy • Outcomes: • >80% pts w/ arm relief • ACR/ACDF risks • Dysphagia, ~5% • hoarse voice, ~5% • C5 or C6 nerve palsy, ~1% • adjacent level breakdown, ~1-2%/yr (~25% pts sx in10 yr) • ACR • ACR ~20% undergo ACDF • ACR ~30% fuse • Recovery • Return to work 2 – 4 wks

37. Cervical Radiculopathy Case, F/U 4 wks after C6/7 ACR • 45 yo M • R arm pain resolved • intermittent tingling down arm • discomfort b/w shoulder blades • Exam: • full strength • diminished LT R C6 • F/u 6 months, annually w/ x-rays • Risks: symptomatic adjacent level disc disease ~1-2% yr, ~20% at decade.

38. 270 ACDR vs. 219 ACDF • Equivalent: • >80% relief neck pain • >80% relief arm pain • Motion preserved • Unclear if ACDR diminishes risk symptomatic adjacent level disc diseasae

39. Conclusion: Cervical Radiculopathy • Surgical Indications • Life-limiting pain • Pain > 2 months • Progressive motor deficit • Surgery • ACDF or ACDR excellent outcomes in neck and arm pain relief

40. Cervical Myelopathy Case • 65 yo M • Presents increasing falls, clumsy hands, and upper extremity tingling for past 2 years • Exam: • 4+/5 triceps and grip • +Hoffman’s sign, up-going toes • Mild ataxia w/ heel-to-toe walk

41. Cervical Myelopathy • Sx • Sx’s N/T, clumsy hands, spastic gait, leg weakness due to spinal cord compression • Sx / Dx • Upper Motor Neuron signs (Myelopathy) • Upgoing toes (Babinski) • Finger flexor reflex (Hoffman’s sign) • Spastic gait • Imaging: MRI, damaged spinal cord (cord signal noted on T2WI)

42. Natural History of Cervical Myelopathy • Lees and Turners • usually stable non-progressive disability • progressive deterioration exception • Symon et al, 67% steady decline • Nonrandomized MCT in 2000 • 20 surgery with improved function • 23 non-op with decline in ADL

43. Natural History of Mild Cervical Myelopathy • Study, 60 patients w/ mild CM (JOA score >13) • 30% decline in stair-step fashion • 70% tolerate

44. Cervical Myelopathy • Surgical Goal: decompress spinal cord to halt progression of symptoms • Surgical Indications: • Progressive symptoms • Cord signal on MRI • Patient choice if mild • Surgery: • Anterior decompressive surgery for anterior compression / kyphosis • Posterior decompression for degenerative / congenital stenosis

45. Cervical Myelopathy 65yo M w/ severe cervical myelopathy. MRI, severe anterior compression. Example: C4/5, C5/6 and C6/7 ACDF d/t anterior compression.

46. Cervical Myelopathy 82yo M w/ increasing gait disturbance. MRI, cord signal change. Example: Posterior laminoplasty w/ lateral mass expansion hardware for congenital stenosis with cervical myelopathy

47. Outcome: Cervical Myelopathy • Short-term: • Improved gait • Return proximal strength • Long-term complaints: • c/o grip weakness • c/o balance issues • c/o UE Paresthesia's (gabapentin) • Risk: 10% patients have neurologically worse following surgery

48. Summary • Axial neck pain, no good surgical options. • Cervical radiculopathy, excellent surgical options to relieve arm pain. • Cervical stenosis with myelopathy, good surgical options to stop progressive neurologic decline.

49. Save the Date! NW Surgical Research Foundation Conference March 2018 @ReboundMD facebook.com/ReboundMD/