Non-Operative Management of Cervical RadiculopathyMatthew R. Doyle, MS, ATC, LAT

Why this topic?

Wrestling and Neck Injuries In the past a lack of quality information on

managing Cervical Radiculopathy (CR)

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

Body Sites of Wrestling Injuries

Knee Shoulder Head/Face

Trunk Hip/Leg Ankle Neck0

5

10

15

20

25

30

Yard, 2008 AJSM

College Time Loss Injuries

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

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

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

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

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

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

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

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

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

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

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

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

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

Interventions for CR

Some but few RCT, systematic reviews Largely case studies and anecdotal

experience Clinical Practice Guidelines

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?

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

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

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

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

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

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.

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

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

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

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

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

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