Transcript 14 Manayan - CervicalDiscSyndromex

By Talar Manayan
Brief review
• Cervical spinal bones run from the
base of the skull to the upper back
• Intervertebral discs facilitate spinal
movement and absorb shocks.
• Discs are composed of a gel-like
substance called the nucleus
pulposus.
• The nucleus pulposus is encased in
a tough fibrous outer material called
the annulus fibrosis.
(Sponamore, 2013)
What happens in Cervical Disc Syndrome?
• An intervertebral disc gets
displaced & bulges out
• Sometimes the nucleus pulposus
can extrude through a tear in the
annulus fibrosis.
• Either one of these two scenarios
leads to irritation and pressure on
an exiting spinal nerve causing
dysfunction of that nerve root. This
is called radiculopathy.
(Sponamore, 2013)
What happens in Cervical Disc Syndrome? (cont’d)
• Less frequently, herniation at
the cervical or thoracic levels
can compress the spinal cord
itself.
• This is referred to as disc
herniation with myelopathy
and represents a critical
problem.
What happens in Cervical Disc Syndrome? (cont’d)
• Radiculopathy most often
occurs in the setting of
existing degenerative disc
disease or spondylosis
• The most common reason for
myelopathy amongst adults
55 years or older is again
spinal spondylosis
(Sponamore, 2013)
By their 5th decade, most individuals already have degenerative
changes often still asymptomatic.
Cervical Disc Syndrome
Disc syndrome is neurologically
more complex at the cervical level
than thoracic, lumbar and sacral
Cervical Disc Syndrome is more
common at the C5, C6 and C7
levels.
(Sponamore, 2013)
Etiologies
Trauma (most common)
Spondylosis (common)
Spinal stenosis
Spinal abnormalities the accompany achondroplastic
dwarfism or other diseases
Incidence is highest in the 4th-6th decade of life
More common in males
More common in individuals with a history of trauma.
Signs & Symptoms
Initially
 neck stiffness
 splinting of the neck muscles
 pain at the medial side of the scapula
As the nerve roots get compressed, other symptoms arise (most often one sided)
 neck pain
 radicular pain
 Paresthesias and sensory loss in the arm and hand
 Muscle weakness in the arm
 Muscle atrophy in the arm if prolonged period
Signs & Symptoms (cont’d)
Root Affected
Muscles
Affected
Area of pain &
Sensory Loss
Reflex
diminished
C5
Deltoid, Biceps
Shoulder,
anterior arm,
radial forearm
Biceps
C6
Biceps
Thumb
Biceps
C7
Triceps, wrist
extensors, and
pectoral muscles
Thumb, index and Triceps
middle fingers
C8
Intrinsic hand
muscles
Index, fourth, and
fifth fingers
Triceps
Signs & Symptoms (cont’d)
 Patients with myelopathy may or may not experience symptoms of
radiculopathy
 Patients with myelopathy would exhibit neurological dysfunction in lower
extremities as well as possible bowel or bladder control impairment
 Patients exhibiting symptoms of vertigo, syncope, blurred vision, tinnitus or
pain behind the eyes in conjunction of radicular or myelopathy symptoms
may have compromised blood supply to the brainstem and brain due to
compression on the vertebral artery
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A detailed description of the
pain is needed.
Severity of pain
Onset: sudden or gradual
Location
Duration
Timing: whether the pain is
worse at night or in the
morning
Aggravating & alleviating
factors: lying down, moving the
neck, raising the arm
History of playing sports
Recent trauma
Diagnosis of cancer
Diagnosis of osteoporosis
Family history of spinal
stenosis or other genetic
diseases
 Previous spinal disc disease, if
yes, how it was treated
 Previous spinal surgery
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 fever and chills
 nuchal rigidity
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syncope
dizziness
disturbances in gait
neck pain
clumsiness or difficulty using arms or legs
muscle weakness
Paresthesias in the arms or legs
Pain in the arms or legs
Loss of bladder or bowel control
Sexual dysfunction
 Observe for any gait disturbance
 Observe the neck, thorax, and upper extremities for symmetry, deformity or any
unusual characteristics
 Palpation of the spine may help localize the point of tenderness. Severe pain upon
palpation may indicate spinal fracture
 Spurling maneuver is the neck compression test that is performed by extending and
rotating the neck towards the affected side and then applying downward pressure on
the head. The test is positive for radiculopathy if limb pain and paresthesias are
reproduced; neck pain alone is inconclusive
 A careful bilateral assessment and comparison of both arms
 ROM, loss of sensations, paresthesias and muscle weakness of the arms Hyporeflexia in
the area corresponding to the affected nerve root needs to be checked
 Hyperreflexia
 Babinski reflex
 A jolt down the spine may result upon neck flexion
 ROM, loss of sensations, paresthesias and muscle weakness of BOTH legs
Differential Diagnoses
 Supraspinatus tendinitis
 Acromioclavicular joint arthritis
 Rotator cuff tears  Red Flag
 Tumors that compress the nerves or spinal cord Red Flag
 Subdural abscess Red Flag
 Entrapment neuropathy of the median, ulnar nerves
 Brachial plexus neuritis
 Spinal fracture Red Flag
 Spondylosis
 Rheumatoid arthritis
 Neck strain and whiplash injuries
 MRI  preferred diagnostic test for CDS, can
identify spinal cord and/or nerve root compression
 X-ray  views of bony structures
 Needle EMG  to confirm radiculopathy &
identify the affected nerve
 Myelography  detects spinal stenosis
 CT  when MRI is contraindicated
 Lab tests  only to rule out infection & other
etiologies
MRIC5-C6 disc herniation,
(Rowland, Pedley, & Merritt, 2010)
Primary care providers need to distinguish surgical candidates from
those who qualify for conservative management.
 Patients presenting with severe neurological deficits or any
suspicion of myelopathy  immediate referral
 Muscles supplied by C5 & C8 rapidly atrophy; delays in
decompressing these nerves may result in irreversible shoulderarm-hand disorders  refer
 Patients with persistent symptoms, those with only limited
improvement after six weeks of conservative therapy, or those who
get worse  refer
Consider conservative management in the following patients:
 C6 or C7 involvement. These nerves supply larger muscles and can tolerate more compressive
pressure before irreversible damage occurs.
 Mild to moderate radiculopathy in the absence of myelopathy
 Non-surgical candidates
A reasonable approach:
 2-3 days of rest
 F/U visit
 Start activity using soft neck collar to limit mobilization of the cervical spine
 F/U visit after 2 weeks make sure the patient’s condition still calls for
conservative management
 Working patients may return at the earlier possible time on light duty.
 Medications:
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Start analgesics: acetaminophen or aspirin as a first line of
therapy;
NSAIDs: ibuprofen or naproxen could be started but with caution
Muscle relaxers such as cyclobenzaprine
Narcotics (tramadol, hydrocodone, oxycodone)
 Cervical epidural steroid injections may be considered for
radiculopathy alone. 60% achieve sustained pain relief
 Patient should also start physical therapy.
 Cervical traction: the evidence is of inadequate quality to make an
objective determination
A cochrane review performed by Nikolaidis, Fouyas,
Sandercock and Statham published in 2010.
 surgical intervention vs. conservative management in
radiculopathy alone and in myelopathy
 2 RCTs only
 limited research available
Conclusion: surgical intervention did alleviate the pain in the
short term, however, long term results were comparable.
Dependent on:
 the initial level of involvement
 duration of symptoms
 presence of myelopathy
 Complete recovery is rare with myelopathy
 Natural course of the disease
 Available treatment options
 Medication side effects
 When to seek medical attention
 Set realistic expectations for patients
References
Al-Shatoury, H. A., Galhom, A. A. (2014). Cervical spondylosis clinical presentation. Medscape. Retrieved March 18, 2016 from
http://emedicine.medscape.com/article/306036-clinical
Cervical Spine and Low Back Pain Task Force. (2014). Cervical spine injury medical treatment guidelines. Colorado Division of
Workers' Compensation.
Fouyas, I. P., Sandercock, P. A. G., Statham, P. F. X., & Nikolaidis, I. (2010). How beneficial is surgery for cervical radiculopathy
and myelopathy? BMJ (Clinical Research Ed.), 341(jul13 2), c3108-c3108. doi:10.1136/bmj.c3108
Goroll, A. H., & Mulley, A. G. (2014). Primary care medicine: Office evaluation and management of the adult patient (7th ed.)
(pp.1206-1212). Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins.
Nikolaidis, I., Fouyas, I. P., Sandercock, P. A., & Statham, P. F. (2010). Surgery for cervical radiculopathy or myelopathy. The
Cochrane Database of Systematic Reviews, (1), CD001466.
Robinson, J., & Kothary, M. J. (2016). Clinical features and diagnosis of cervical radiculopathy. Up to Date. Retrieved on March 18,
2016 from http://www.uptodate.com/contents/clinical-features-and-diagnosis-of-cervical-radiculopathy?source=see_link#H17
Rowland, L. P., Pedley, T. A., & Merritt, H. H. (2010). Merritt's neurology (12th ed.) (pp. 532-538). Philadelphia, PA: Lippincott
Williams & Wilkins.
Sponamore, M.,J. (2013). Radiculopathy. University of South Carolina. Shwarm Interactive Incorporation. Retrieved on March 20 2016
from http://www.uscspine.com/conditions/radiculopathy.cfm#