Neck pain myelopathy and radiculopathy clinical assessment and management
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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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Neck Pain, Myelopathy and RadiculopathyClinical 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

  • 11 consultant group treating all disorders of the brain and spinal cord


Aims

To discuss common clinical scenarios

To explain common diagnoses and treatment

To identify how to investigate and who to refer


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


Red Flags

Fever

Weight loss

History of cancer

Progressive neurological deficit

Nocturnal pain

Severe pain requiring opiates


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


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%


Management of Neck pain

Reassurance

NSAIDS

Add opiates as required

Physiotherapy

Acupuncture/Dry needling


Surgery for Neck Pain

Unusual for degenerative neck pain

Instability due to tumour/infection/trauma responds well to surgery

Occasional fusion for degenerative disease


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


Foraminal Narrowing

  • Progressive narrowing of exit foramina occurs with normal ageing

  • Typically asymptomatic


Localisation


Differential Diagnosis

Shoulder/Elbow pathology

If sensory disturbance it has to be neural

Thoracic outlet syndrome

Brachial neuritis

Entrapment neuropathy – median/ulnar


Investigation

MRI cervical spine

Nerve conduction studies

Brachial plexus imaging


Cervical Root compression


Natural History

Spontaneous resolution within 6-12 weeks occurs in 90% of attacks

Investigate urgently/refer those with severe pain or progressive motor deficits


Treatment of Radiculopathy

Physical therapies

Acupuncture

Analgesics

Ibuprofen/codeine

Opiates

Pregabalin/Gabapentin/Amitriptyline


Escalation

Injections

Surgery


Cervical Nerve root injections

  • ?risk of paraplegia

  • Interscalene block

  • Temporary

  • Local anaesthetic/ steroid


Surgery for Radiculopathy

Anterior cervical discectomy

Cervical disc replacement

Posterior foraminotomy


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


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


Risks

1 in 1000 risk of paralysis

1% risk of vocal cord paresis

Transient hoarseness/dysphagia common


Posterior Foraminotomy

Posterior approach

Microscopic

No risk to oesophagus/trachea

Some neck pain

90% effective


Cervical Myelopathy

  • Clinical syndrome of spinal cord irritation/compression

  • Insidious loss of fine finger movement

  • Gait ataxia

  • Urinary hesitancy


Myelopathy

  • Increased tone

  • Spastic reflexes

  • Rombergs positive

  • Unable to heel-toe walk

  • L’Hemitte’s phenomenon


Myelopathy - Causes

  • Most commonly degenerative

  • Disc-osteophyte bars

  • OPLL

  • Tumour


Natural History

  • Limited data

  • Some non –progressive

  • Most slowly progressive

  • Occasional rapidly progressive


Myelopathy Treatment

  • Observational

  • Supportive - OT/physio

  • Surgery – Anterior cervical discectomy/corpectomy

  • Posterior cervical laminectomy +/- fusion


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


Any Questions?


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