Transcript Fibromyalgia and the cervical spinal cord: more than just a pain in

PC3: Positional Cervical Cord Compression
October 9, 2015
Andrew J. Holman, MD
Associate Clinical Professor of Medicine
University of Washington
Pacific Rheumatology Associates
Pacific Rheumatology Research
Renton, WA USA
Overview
 Dynamic MR imaging of the degenerative cervical
spine reveals spinal cord compression.
 Spinal cord compression among patients with
fibromyalgia.
 Neurological deficits among patients with fibromyalgia
 Treatment of cervical spinal cord compression (PC3).
 Implications for fibromyalgia diagnostic criteria.
81 patients with different
stages (I-IV) of
degenerative disease of the
cervical spine.
Neutral
Flexion (maximal)
Extension (maximal)
Conclusion: Regardless of
stage or grade of spinal
stenosis in neutral
position, cervical spinal
motion may contribute to
the development of
cervical spondylitic
myelopathy.
Muhle C, Metzner J, Weinert D et al. Clasification system based on kinematic MR imagng in cervical spondylitis myelopathy. Am J
Neuroradiol. 1998;19:1763-1771.
Muhle C, Metzner J, Weinert D et al. Classification system based on kinematic MR imaging in cervical spondylitis myelopathy. Am J
Neuroradiol. 1998;19:1763-1771.
Muhle C, Metzner J, Weinert D et al. Classification system based on kinematic MR imaging in cervical spondylitis myelopathy. Am J
Neuroradiol. 1998;19:1763-1771.
Muhle C, Metzner J, Weinert D et al. Classification system based on kinematic MR imaging in cervical spondylitis myelopathy. Am J
Neuroradiol. 1998;19:1763-1771.
Implications
 Accurate diagnosis
 Appropriately targeted surgery
 Novel pain generator
 Novel autonomic nervous system (ANS) sympathetic
arousal
Cervical spinal cord and
fibromyalgia
• In animal models, intermittent light abutment of the cervical
cord is a potent autonomic arousal.
Karlsson AK. Autonomic dysfunction in spinal cord injury: clinical presentation of
symptoms and signs. Prog Brain Res. 2006;152:1-8.
• Cervical trauma (remote) is common among FM patients.
Staud R. Long-term outcome of fibromyalgia related to cervical spine injury is
worse in women than in men. Curr Rheumatol Rep. 2004 Aug;6(4):259-60.
• Reduction of cervical compression in patients with FM
reduces FM symptoms.
Heffez DS et al. Clinical evidence for cervical myelopathy due to Chiari
malformation and spinal stenosis in a non-randomized group of patients with
the diagnosis of fibromyalgia. Eur Spine J. 2004;13(6):516-23.
Positional Cervical Cord Compression (PC3)
(January-February 2006)
• Review all referred consultation to one provider at suburban
rheumatology clinic.
• Evaluate myelopathy screening questions and exam.
• 107 consultations reviewed
– Segregate diagnoses
• CTD or enthesitis / bursitis w/o FM
• FM
• Unexplained widespread pain
Holman AJ. J Pain 2008;9(7):613-22.
Definition for PC3.
Visual evidence in the midline sagittal view
of abutment or flattening of the spinal cord
AND narrowing of the spinal canal to less
than 10 mm in flexion, neutral or extension
position.
Degenerative findings not considered.
Holman AJ. J Pain 2008;9(7):613-22.
Patient characteristics
CTD
FMS
CWP
Age
50
49
52
Yrs of FMS
---
10.3
---
Function(0-10)
1.98
2.86
2.31
Psych (0-9.9)
2.44
5.18
2.32
10 cm VAS Pain
4.19
6.05
5.18
AM Stiffness (min)
37
88
79
10 cm VAS Fatigue
3.46
7.46
5.70
10 cm VAS Global
4.28
6.43
5.95
MHAQ
Patient characteristics
CTD (32)
FM (53)
CWP(22)
Subjects
14M/18F
4M/49F
3M/19F
Disabled
0
18 (34%)
1 (5%)
Trauma
0
7 (13%)
4 (18%)
Sink Pain
1 (3%)
36 (68%)
13 (59%)
Dentist Chair
2 (6%)
34 (64%)
8 (36%)
Dizzy
6 (19%)
16 (30%)
5 (23%)
Unsteady Gait
2 (6%)
6 (11%)
1 (5%)
Positive Romberg
3 (9%)
37 (70%)
14 (67%)
Abnormal Grip
6 (19%)
14 (26%)
7 (32%)
Extension Pain
3 (9%)
36 (68%)
15 (67%)
Holman AJ. J Pain 2008;9(7):613-22.
MRI RESULTS
CTD
FM
CWP
Subjects
32
53
22
Had MRI
1 (3%)
49 (92%)
20 (91%)
Abnormal MRI
New Views required
0
35 (71%)
25 of 35 (71%)
17 (85%)
12 of 17 (71%)
Chiari
2
0
Flat cord
5 (9%)
5 (23%)
Radiculopathy
5 (9%)
2 (9%)
Multiple Sclerosis
0
1
Multiple Myeloma
0
1
Holman AJ. J Pain 2008;9(7):613-22.
Results
Subjects
FM
53
CW
22
C2-3
C3-4
C4-5
C5-6
C6-7
C7-T1
6%)
26%
35%
56%
42%
11%
0%
36%
41%
50%
50%
9%
Sink
Dentist
Romberg
Extension
64%
68%
70%
68%
36%
59%
67%
67%
MYOPAIN 2010
Toledo, Spain
• OHSU corroborates Seattle findings
– 129 patients (2007)
– 57.4% FM patients tested had PC3
– 48% of FM+PC3+ had OSA.
– CWP not evaluated
• Unique PT reproduced and also helpful
• Surgical outcomes similar
IX, X
Sensory
Motor
Gait
Photophobia
Poor balance
Weakness
Tingling
166 Patients with FM
42%
65%
33%
28%
70%
63%
58%
54%
66 Pain-free controls
8%
25%
3%
7%
6%
4%
2%
4%
Watson FW, Buchwald D, Goldberg J et al. Neurological signs and symptoms in fibromyalgia. Arthritis Rheum 2009;60(9):2839-2844.
FM and the cervical spinal cord
[FOR DIAGNOSIS]
“Taken together, these studies suggest that
neurologic findings are common in fibromyalgia
and may, in some cases, have a neuroanatomical
basis.”
[FOR THERAPY]
“…highlights the need for carefully designed,
rigorously blinded and controlled studies of
craniocervical neuroanatomy in fibromyalgia.”1
1.Watson FW, Buchwald D, Goldberg J et al. Neurological signs and symptoms in fibromyalgia. Arthritis Rheum 2009;60(9):2839-2844.
PC3 and ANS
• Comparing PC3 with asymptomatic controls
(2015)
– PC3+FM+ vs. PC3-FM+
• Indistinguishable except for ANS
– PC3+FM- (pain free)
• Normal ANS despite cord abutment
PC3 Treatment
• Physical therapy
– Unique program
– Depends on degree of narrowing
– DVD available
• Medications (all off label)
– pregabalin, duloxetine, milnacipran
– Analgesics, corticosteroids
– RLS meds (lorazepam, clonazepam)
• Manipulation
• Surgery (<15% since 2003)
The 1990 ACR Classification Criteria for
FM Has Limited Use
• 25% of FM patients do not satisfy the 1990 ACR criteria1
– Originally developed as a research tool2
– Relies on patient’s self-report of symptoms3
– No objective clinical findings, radiographic abnormalities,
or routinely used laboratory tests2,3
– Localized or regional pain may precede the advent of
widespread pain3
• Tender point examination increasingly considered optional1,4
1Wolfe
F, et al. Arthritis Care Res. 2010;62:600-610. 2Navarro RP. Am J Manag Care. 2009;15(suppl):S197-S218.
K. Neuropsychiatr Dis Treat. 2008;4:1059-1071. 4Häuser W, et al. Dtsch Arztebl Int. 2009;106:383-391.
3Lawson
Diagnostic Workup for FM
History of CWP for ≥ 3 months
Consider other diagnoses that may present with CWP
History, general physical,
musculoskeletal and neurological examination,
selected laboratory testing
Confirm presence of pain
at ≥ 11 of 18 tender points
“Fibromyalgia”
< 11 of 18 tender points, but presence
of other core symptoms
(eg, fatigue, sleep disturbance, dyscognition,
mood disorder, decreased function)
“Probable Fibromyalgia”
Goldenberg DL. Am J Med. 2009;122(suppl):S14-S21.
Fibromyalgia Tender Points
Wolfe et al Arthritis and Rheumatism 33(2):160-172 (1990)
Widespread pain index and
symptom severity scoring
• WPI
• In how many areas has the
patient had pain (over the
last week)? Score 0-19
–
–
–
–
–
–
–
–
–
*Left, right
Shoulder girdle*
Upper arm, lower arm*
Hip (buttock, trochanter)*
Upper leg, lower leg*
Jaw*
Chest
Abdomen
Upper back, lower back
Neck
• SS scale score
– Fatigue, waking unrefreshed,
cognitive symptoms
– Plus general somatic symptoms
– Scoring
•
•
•
•
0 (no problem)
1 (slight/mild)
2 (moderate)
3 (severe)
Wolfe F, et al. Arthritis Care Res. 2010;62:600-610.
New ACR Diagnostic Criteria for FM and Measurement of
Symptom Severity
• Widespread pain index (WPI) ≥ 7 and
symptom severity (SS) scale score ≥ 5
or WPI 3-6 and SS scale score ≥ 9
• Symptoms have been present at a similar level for at
least 3 months
• The patient does not have another disorder that would
otherwise explain the pain
No physical examination necessary
Can be self-administered
Probably more sensitive to change than ACR criteria
Wolfe F, et al. Arthritis Care Res. 2010;62:600-610.
Summary
 Positional cervical cord compression (PC3) is common
among patients with degenerative cervical disease.
 PC3 is a common co-morbidity among patients with FM.
 PC3 may account for neurological deficits and autonomic
nervous system (ANS) arousal among patients with FM.
 Treatment of PC3 is predominantly PT based with spinal
cord active medications, but may also require surgery.
 Future studies are required to explain how ANS arousal
and pain may be linked and how PC3 may be incorporated
into diagnostic criteria for widespread pain states.