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Download 14 Manayan - CervicalDiscSyndrome
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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 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 fever and chills nuchal rigidity 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 MRIC5-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: • • • • 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#
