Management Initial pain management Medication, exercise/manual therapy, education, vocational, lifestyle, psychological strategies Interventional Treatments • Joint injection • Radiologically guided interventions – Nerve blocks – Radiofrequency denervation • Surgery
Non-interventional treatment • Exercise • Education / cognitive behavioural therapy • Ergonomics • Electrotherapy • McKenzie manual diagnosis and therapy • Manipulation/mobilisation • Massage • Cervical collar • Acupuncture • Traction
Evidence… What works? • Exercise and Manual Therapies – Consistent strong evidence that exercise may be effective in preventing neck and back pain – Strong evidence for combining exercise and mobs/manips for subacute/chronic population at short & long term F/U – Manipulation should be preceded by examination for myelopathy and discussion of risks • McKenzie therapy – ↑ pain relief & reduction in disability vs comparison (NSAIDs, educational booklet, back massage & advice, strength training & spinal mobs and general exercise) at short term F/U
Evidence..what doesn’t work? • Acupuncture – No good quality trails showing effect in cute or subacute populations – Moderate evidence that acupuncture is more effective for pain relief than sham treatment or wait list control at short term F/U • Massage – Massage alone showed inconsistent results – Other trials used massage as part of a multimodal intervention and the role of massage was unclear – 12/19 studies were low quality • Education alone – Strong evidence that education alone is not effective – Education, advice on stress coping skills or ‘ neck school ’ not better than no treatment • Mechanical traction – No evidence with low bias that supports or refutes the use of continuous or intermittent traction
Evidence…what doesn’t work? • Ergonmics – Poor quality of evidence on effectiveness • Electrotherapy – Underpowered low quality trials – Conflicting/limited evidence for direct/modulated galvanic current, iontophoresis, TENS, EMS, PEMF & permanent magnets • MDT biopsychosocial rehab – Limited evidence • Cervical collar – Initially minimizing ROM can ↓ nerve irritation but limited evidence – Longer use may have adverse effects eg. Atrophy of paraspinal muscles
Management of headaches • Treatment involves postural correction, assessment of workplace ergonomics, manual therapy (Watson, Mulligan) and home exercises for neck / scapular strengthening and exercises to relieve headaches – self traction or self mobilisation
Take home message • Strong evidence to support multimodal therapy approach – exercise combined with mobilisation +/- manipulation if indicated • Strong evidence to support exercise • Limited evidence for massage, cervical collar, education alone.
Management - Medication • Paracetamol - ?effectiveness • NSAID - more effective Side effects: 25 admissions, 5 deaths / 100 000 • Muscle relaxants: Orphenadrine- weak evidence in acute pain • Tramadol – variable response • Codeine - ?effectiveness • Opioids: for acute with usual precautions • Chronic pain – controversial (lack of efficacy, tolerance, dependence, addiction, hyperalgesia, immune, endocrine) An evidence base for WHO ”essential analgesics” Wiffen P. Pain Clinical Updates March 2000.
Medication for neuropathic pain 1. Antidepressants: TCA – Amitriptyline, Nortriptyline, (Duloxetine) 2. Anti-epileptics: Gabapentin, (Pregabalin) 3. Diazepam: evidence more against (Cochrane) 4. Corticosteroid ~ placebo • Some are useful in neuropathic pain • May help sleep or spasm • Sedative effects
Interventional
Cervical facet joint • Facet joint single most common focus – axial pain • Somatic /referred pain pattern • No specific clinical or radiological feature • Easily tested - controlled double blind local anaesthetic nerve block (MBB)
Cervical radiofrequency neurotomy Technical • Heating course of nerve to joint • Under fluoroscopy • Local anaesthetic • Specific electrode • 80 -85 0 C 2 – 6 lesions 90 sec each • 1-2 hours
Cervical Radiofrequency Neurotomy
Radiofrequency outcomes 65% Successful 80% pts experience 80% reduction in pain – Complete relief > 6 months, – Complete restoration of ADL – No need further health care – Return to work.
Cervical facet joint – Intra-articular injection • Under Xray • LA and corticosteroid • Short term benefit • Maybe useful acute and failed medical mx
Cervical epidural corticosteroid injection • For radicular pain • Under Xray • LA and corticosteroid
Interlaminar epidural corticosteroid injection Poor Evidence available Effectiveness defined as 50% relief or more, +/- 50% improvement in function Disc Herniation -1-3 injection; 70% patients good or very good relief – for 1 year Manchikanti, L., Nampiaparampil, D. E., Candido, K. D., Bakshi, S., Grider, J. S., Falco, F. J., ... & Hirsch, J. A. (2015). Do cervical epidural injections provide long-term relief in neck and upper extremity pain? A systematic review.
Transforaminal epidural corticosteroid injection Effectiveness: • 50% patients - 50% relief 1 month; 30% patients by 12 months • Surgery avoided approx 50% in 2 separate studies Controversies: • 23 reported serious side effects • Recent move away from particulate local anaesthetics Take Home Message • Useful pain relief for 50% of patients Second injection dependant on effect of 1 st injection • • Not a long term repeat therapy Engel, A., King, W., & MacVicar, J. (2014). The effectiveness and risks of fluoroscopically guided cervical transforaminal injections of steroids: A systematic review with comprehensive analysis of the published data. Pain Medicine, 15(3), 386-402
Surgical Treatment
T REATMENT – C ERVICAL D ISCECTOMY • Excellent for rapid relief of severe radicular pain, or symptoms not settling with conservative care • Trends towards better average resolution of neck and arm pain than conservative treatment • Gold Standard: ACDF
Anterior Cervical Discectomy and Fusion • 90% success rate for relieving arm pain • Traditionally held to be less effective at relieving neck pain
Anterior Cervical Discectomy and Fusion • 90% success rate for relieving arm pain • Traditionally held to be less effective at relieving neck pain, but…
A NTERIOR C ERVICAL D ISCECTOMY AND F USION T ECHNIQUE • Goal is to remove disc and osteophyte impinging on the foraminal part of the nerve root • 4-6cm skin incision with dissection through a plane between the midline structures (airway, oesophagus) and the carotid vessels • Disc is removed and the PLL at the back of the disc space visualised
C4 BODY C5 BODY POSTERIOR LONGITUDINAL LIGAMENT
• PLL taken down • Dura visable
• Dissection carried out laterally until nerve visualised and free of compression from bone or disc
• Graft inserted • Plate inserted
• Graft inserted • Plate inserted
Outcomes • Rapid relief of radicular pain • Surgical pain/swelling usually settles quickly • No noticeable loss of movement for single level. • Robust procedure – can get back to sedentary work within 2-4 weeks
When to call a patients surgeon • Wound – Redness extending further than the immediate wound line – Expressible Pus/clear fluid – Fever • Cauda Equina – call ambulance • Recurrent or progressive neurology – analgesia and call rooms
C ASES
KS Case 1 • 48 year old female – – 4 weeks ago at round about drove into the back of a car – left / central lower cervical pain with frontal headache that lasts all day – Type: constant pain, worse at night, aching, occasional sharp pains • Aggravated: gardening, digging, sitting using computer, rotation • Eases: heat, massage, analgesia – VAS 4-7/10 – Nausea with headaches • No other red flags • PMHx - Type 2 diabetes, depression/anxiety • Examination – Cervical ROM - minimal loss right rotation with end range stiffness, end range pain flex, full extension, minimal loss right lateral flexion - limited by tightness left side – Palpation right C2/3 reproduced nausea, also tender CT junction – Normal neurological examination
KS Case 1 • 48 year old female – – 4 weeks ago at round about drove into the back of a car – left / central lower cervical pain with frontal headache that lasts all day – Type: constant pain, worse at night, aching, occasional sharp pains • Aggravated: gardening, digging, sitting using computer, rotation • Eases: heat, massage, analgesia – VAS 4-7/10 – Nausea with headaches • No other red flags • PMHx - Type 2 diabetes, depression/anxiety • Examination – Cervical ROM - minimal loss right rotation with end range stiffness, end range pain flex, full extension, minimal loss right lateral flexion - limited by tightness left side – Palpation right C2/3 reproduced nausea, also tender CT junction – Normal neurological examination
GROUP 1: GROUP 2: REFER IMMEDIATELY SPECIALIST REFERRAL GROUP 3: TRIAL OF GROUP 4: TREATMENT + INVESTIGATIONS TRIAL OF TREATMENT
GROUP 1: GROUP 2: REFER IMMEDIATELY SPECIALIST REFERRAL GROUP 3: TRIAL OF GROUP 4: TREATMENT + INVESTIGATIONS TRIAL OF TREATMENT
KS Case 1 • Impression: – Whiplash injury with referred head pain – mild loss of ROM but normal neurology • therefore okay to proceed with conservative management • Treatment • Education, reassurance • Home exercises – self mobilisation with movement, self traction – Assisted by mobilisation CT junction right rotation decreased pain / stiffness, mobilisation C2/3 with right rotation increased to full ROM • 1 week follow up – only one headache which resolved with exercises, ROM improved, only mild stiffness • 2 week follow up - headaches and stiffness completely resolved – Full ROM painfree – discharged
KL Case 1 - Axial cervical pain and headache • 53 yr prison officer • Flexion/extension injury assault 2011 • Cervical pain and suboccipital headache • VAS 3 -10/10; ave 5/10 • Light duties, Poor sleep, ↓ Exercise, ↓Mood
GROUP 1: GROUP 2: REFER IMMEDIATELY SPECIALIST REFERRAL GROUP 3: TRIAL OF GROUP 4: TREATMENT + INVESTIGATIONS TRIAL OF TREATMENT
GROUP 1: GROUP 2: REFER IMMEDIATELY SPECIALIST REFERRAL GROUP 3: TRIAL OF GROUP 4: TREATMENT + INVESTIGATIONS TRIAL OF TREATMENT
Axial cervical pain and headache • 53 yr prison officer • Flexion/extension injury assault 2011 • Cervical pain and suboccipital headache • VAS 3 -10/10; ave 5/10 • Light duties, Poor sleep, ↓ Exercise, ↓Mood • Physical therapies, Panadol, Ibuprofen, Tramadol • Imaging normal • Not Improving – Now what?
GROUP 1: GROUP 2: REFER IMMEDIATELY SPECIALIST REFERRAL GROUP 3: TRIAL OF GROUP 4: TREATMENT + INVESTIGATIONS TRIAL OF TREATMENT
Axial cervical pain and headache • Diagnostic blocks positive for right C2/3 and C3/4 combined • RFN Nov 2014
Axial cervical pain and headache • Stop analgesics, return to full duties • Sustained 16 months; • Repeat RFN April 2016
DM Case 1 • 44m IT worker • 2 months hx – Sudden flexion and rotation force across neck when drying back of head with a towel – Left neck/shoulder pain radiating to dorsum of hand. PN three middle fingers. VAS 4-7. – No red flags • Exam: – Mild sensory disturbance Left C7 distribution
GROUP 1: GROUP 2: EXPIDITIOUS REFER IMMEDIATELY SPECIALIST REFERRAL GROUP 3: TRIAL OF GROUP 4: TREATMENT + INVESTIGATIONS TRIAL OF TREATMENT
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