Conservative Management in Spondylosis ( Dr Pradip Mate )
-
Upload
dr-pradip-mate -
Category
Healthcare
-
view
229 -
download
0
Transcript of Conservative Management in Spondylosis ( Dr Pradip Mate )
Dr Pradip Mate(Masters In Pharmaceutical Medicine)
Introduction Cervical spondylosis is a common degenerative condition of the
cervical spine.
It is most likely caused by age-related changes in the intervertebral disks.
Clinically, several syndromes, both overlapping and distinct, are seen. These include
Neck and shoulder pain,
Suboccipital pain and headache,
Radicular symptoms
Cervical spondylotic myelopathy (CSM)
Cervical dermatomes
Schematic representation of the cervical and T1 dermatomes. There is no C1 dermatome. Patients with nerve root syndromes may have pain, paresthesias, and diminished sensation in the dermatome of the nerve that is involved.
Kerry Levin. Cervical spondylotic myelopathy. Up To Date. 2013
Progressive degenerative process
Cervical spondylosis refers to a progressive degenerative process affecting the cervical vertebral bodies and intervertebral discs.
This process can lead to narrowing (stenosis) of the central spinal canal, compressing the cervical spinal cord and producing a syndrome of spinal cord dysfunction known as cervical spondylotic myelopathy.
Myelopathy occurs in 5 to 10 percent of patients with symptomatic cervical spondylosis.
Other clinical syndromes associated with cervical spondylosis include neck pain and cervical radiculopathy
Kerry Levin. Cervical spondylotic myelopathy. Up To Date. 2013
A 48-year-old man presented with neck pain and predominantly left-sided radicular symptoms in the arm. The patient's symptoms resolved with conservative therapy. T2-weighted sagittal MRI shows ventral osteophytosis, most prominent between C4 and C7, with reduction of the ventral cerebrospinal fluid sleeve.
MRI cervical spondylosis
Kerry Levin. Cervical spondylotic myelopathy. Up To Date. 2013
Age Course Clinical features Diagnosis
Cervical spondyloticmyelopathy
Usually >60 yearsProgressive or stepwise course
Moderate-severe cases demonstrate gait and leg spasticity and amyotrophyof hand or arms
MRI cervical spine
Transverse myelitis Children, young adults Subacute Segmental cord syndrome MRI and CSF
Viral myelitis Any age Acute-subacutePure motor syndrome or Segmental cord syndrome
MRI and CSF
Epidural abscess Any ageSubacute; may worsen abruptly
Segmental cord syndrome MRI
Infarction Usually >60 years Abrupt onset Anterior cord syndromeMRI with diffusion weighted sequences
Vascular malformation>40 years (dural fistula)20's (intramedullary AVM)
Acute and/or stepwise Radicuomyelopathy MRI, spinal angiography
Subacute combined degeneration
Any age Slowly progressive Dorsal cord syndrome Vitamin B12 levels
Radiation Any ageSlowly progressive; beginning 6-12 months after radiation therapy
Segmental cord syndrome or Ventral cord syndrome
MRI, clinical history
Syringomyelia Children, young adults Slowly progressive Central cord syndrome MRI
Epidural metastasis Usually >50 yearsSubacute, may worsen abruptly
Segmental cord syndrome MRI
Intramedullary tumor Young adults Slowly progressive Central cord syndromeMRI with gadolinium enhancement
ALS Usually >60 years Slowly progressive Pure motor syndrome Electromyography
Important causes of spinal cord dysfunction
Kerry Levin. Cervical spondylotic myelopathy. Up To Date. 2013
Management
Conservative
Nonsteroidalanti-
inflammatory drugs (nsaids)
Physical modalities
Lifestyle modifications.
Surgery is occasionally performed.
Management
Medical treatments for cervical
spondylosis include
Neck immobilization,Pharmacologic
treatmentsLifestyle
modifications
Physical modalities (eg, traction,
manipulation, exercises)
No carefully controlled trials have compared these
modalities; therefore, these therapies are often initiated
based on a clinician's preference or specialty
Comparing the efficacy of these treatments against no treatment
is difficult
Cervical Spondylosis Treatment & Management. Available from URL: http://emedicine.medscape.com/article/1144952-treatment
Neck immobilization Neck immobilization (with a soft collar, Philadelphia collar, rigid orthoses,
Minerva jacket, or a molded cervical pillow for support) is a common,
nonoperative treatment for neck pain and/or suboccipital pain syndromes caused
by spondylosis and cervical radiculopathy.
Despite widespread use, soft collars are largely believed to work by placebo effect
because they do not appreciably limit motion of the cervical spine.
They have not been demonstrated to change long-term outcomes. If worn
properly, a soft collar maintains relative flexion.
The collar should be worn as long as possible during the day
Cervical Spondylosis Treatment & Management. Available from URL: http://emedicine.medscape.com/article/1144952-treatment
Neck immobilization As symptoms improve, the collar can be worn only during strenuous
activity.
Eventually, it can be discontinued.
More rigid collars and devices may better limit motion of the cervical spine, but they may reduce muscle tone and cause neck stiffness from disuse.
Implement a daily cervical exercise program to limit loss of muscle tone.
Cervical Spondylosis Treatment & Management. Available from URL: http://emedicine.medscape.com/article/1144952-treatment
Pharmacologic treatment includes several options. NSAIDs are the mainstay of pharmacologic treatment. They are effective in
reducing the biologic effects of inflammation and pain
Patients who experience more chronic pain symptoms may benefit from tricyclic
antidepressants (TCAs).
Muscle relaxants such as carisoprodol and cyclobenzaprine may also be beneficial
in patients with a spasm in the neck muscles (which can be related to spondylotic
changes).
Opioids could be considered in patients who have moderate-to-severe pain due to
significant structural spondylosis
Cervical Spondylosis Treatment & Management. Available from URL: http://emedicine.medscape.com/article/1144952-treatment
Lifestyle modificationsNeck schools
Instruction in body
mechanics
Relaxation techniques
Postural awareness
Ergonomics and/or
workplace modifications
Cervical Spondylosis Treatment & Management. Available from URL: http://emedicine.medscape.com/article/1144952-treatment
Lifestyle modifications Neck school is a form of small group therapy that provides techniques to patients
who are willing to actively work toward recovery.
Instruction in body mechanics focuses on low-load concepts.
These include ;
Avoiding forward bending and rotation of the neck,
Avoiding prolonged extension of the neck,
Avoiding prolonged sitting or standing
Selecting the proper chair.
Workplace modifications and ergonomics serve to reduce strenuous neck positions
during work and leisure.Cervical Spondylosis Treatment & Management. Available from URL: http://emedicine.medscape.com/article/1144952-treatment
Physical modalities Cervical mechanical traction, commonly used for cervical
radiculopathy.
Studies regarding its efficacy are conflicting, with intermittent
traction probably being more effective than static traction.
Initially, a weight of 10 lb is recommended, eventually increasing to 20
lb as tolerated
Cervical Spondylosis Treatment & Management. Available from URL: http://emedicine.medscape.com/article/1144952-treatment
It can be used at home 2-3 times daily for 15 minutes at a time.
It is contraindicated in patients who have myelopathy, a positive
Lhermitte sign, or rheumatoid arthritis with atlantoaxial subluxation.
A retrospective study found that cervical traction provided
symptomatic relief in 81% of the patients with mild-to-moderately
severe cervical spondylosis syndromes
Physical modalities
Cervical Spondylosis Treatment & Management. Available from URL: http://emedicine.medscape.com/article/1144952-treatment
Manipulation Manipulation, most commonly practiced by chiropractors and osteopathic physicians, was
described as early as 4000 years ago.
Techniques vary and include low-velocity, high-amplitude manipulation; high-velocity,
low-amplitude manipulation (eg, thrusting or impulse manipulation); and nonthrusting
maneuvers.
Contraindications to cervical manipulation include vertebral fractures, dislocations,
infections, malignancy, spondylolisthesis, myelopathy, various rheumatologic and
connective-tissue disorders, and the presence of objective signs of nerve root compromise
Cervical Spondylosis Treatment & Management. Available from URL: http://emedicine.medscape.com/article/1144952-treatment
Exercises designed for cervical pain
Isometric neck strengthening routines
Neck and shoulder stretching and flexibility exercises
Back strengthening exercises
Aerobic exercises
Cervical Spondylosis Treatment & Management. Available from URL: http://emedicine.medscape.com/article/1144952-treatment
Tilt your head to the right, trying to touch your ear to the tip of your shoulder. Place tension on the temple with your fingertips. Hold for a few seconds and return to the center. Repeat to the left.
Neck tilting Neck rotation
Slowly turn your head to the right. Place tension on your chin with your fingertips. Hold for a few seconds and return to the center. Repeat to the left.
Kerry Levin. Cervical spondylotic myelopathy. Up To Date. 2013
Other commonly used modalities for pain Heat
Cold
Acupuncture
Massage
Trigger-point injection
Transcutaneous electrical nerve stimulation
Low-power cold laser
Most of the passive modalities used for degenerative disease of the cervical spine are performed by physical therapists and are most efficacious in combination.
Cervical Spondylosis Treatment & Management. Available from URL: http://emedicine.medscape.com/article/1144952-treatment
IMMOBILIZATION
For patients with acute neck pain secondary to radiculopathy, a short course (one week) of neck immobilization may reduce symptoms in the inflammatory phase.
Although the effectiveness of immobilization with a cervical collar has not been proven to alter the course or intensity of the disease process, it may be beneficial in some patients.
Cervical Radiculopathy: Nonoperative Management of Neck Pain and Radicular Symptoms. http://www.aafp.org/afp/2010/0101/p33.html
TRACTION Home cervical traction units may decrease radicular symptoms.
In theory, traction distracts the neural foramen and decompresses the affected nerve root.
Typically, eight to 12 lb of traction is applied at an angle of approximately 24 degrees of flexion for 15- to 20-minute intervals.
Traction is most beneficial when acute muscular pain has subsided and should not be used in patients who have signs of myelopathy.
A recent systematic review of mechanical traction for neck pain of more than three months duration, with or without radicular symptoms, found insufficient evidence to recommend for or against its use in the management of chronic symptoms.
Cervical Radiculopathy: Nonoperative Management of Neck Pain and Radicular Symptoms. http://www.aafp.org/afp/2010/0101/p33.html
Algorithm for nonoperativetreatment of acute cervical radiculopathy.
Cervical Radiculopathy: Nonoperative Management of Neck Pain and Radicular Symptoms. http://www.aafp.org/afp/2010/0101/p33.html
Conservative measures Nonsurgical treatment often includes some form of cervical immobilization (soft
collar or brace), restriction of high-risk activities and environments (eg, slippery
surfaces, vigorous neck movement, heavy lifting, action sports), and pain
management.
Patients should also take precautions to avoid whiplash while in vehicle, by adjusting
the headrest to a position at the level of the occiput.
Although some regimens also include exercises and cervical traction, other clinicians
suggest that these are contraindicated in cervical spondylotic myelopathy .
Kerry Levin. Cervical spondylotic myelopathy. Up To Date. 2013
To anticipate symptomatic relief by conservative treatment, it should be carried out intensively in cases with a short disease duration.
Relationship between outcome and disease duration.
The Spine Journal 1 (2001) 269–273