Management of Cervical Arthritis. Stewart M. Kerr, MD Orthopaedic & Spinal Surgery Confluence Health Medical Center

Transcription

1 Management of Cervical Arthritis Stewart M. Kerr, MD Orthopaedic & Spinal Surgery Confluence Health Medical Center

2 Stewart M. Kerr, MD Board Certified Orthopaedic & Spinal Surgeon Combined Ortho / Neurosurgical Spine Surgery Trained --Rothman Institute (Philadelphia) Surgical Interests: Complex Cervical Surgery, Spinal Deformity & Cervical Disc Replacement Fracture Care, Total Hip & Total Knee Replacement

3 Disclosures Faculty for AO Spine Travel & compensation for Teaching Orthopaedic and Neurosurgical Residents / Attending Surgeons

4 Case #1: CSM 71 yo Female CC: Neck pain & numb hands, Reports falling down from weak legs Diffuse bilat arm weakness with gait disturbance

5 CSM

6 CSM Workup

7 Case #1 CSM

8 Cervical Myelopathy Upper Extremtity Dysfunction Dexterity Loss Weakness and numbness Gait impairment Hyperreflexia Arthritis compressing Spinal Cord (fall risk)

9 Discussion Outline: Review the Diagnosis & Medical Management of Cervical Arthritis (Spondylosis) including imaging Review Case-Based Surgical Treatment Options for Cervical Spondylosis affecting the Spinal Cord Review Case-Based Treatment Options for Cervical Spondylosis affecting the Nerve Roots Review Expectations / Outcomes of Surgical & Nonoperative Care

10 Goals: Six Case-Based learning vignettes to share examples of treatment principles and success To review some required clinical tools necessary to effectively manage these patients (and help with some of their questions) To provide prompt ongoing dialogue / assistance in caring for these patients

11 Case # 1 Principles decompress neural structure / ensure stability

12 The initial evaluation what our patients expect.. What are your symptoms? OPQRST? How do these symptoms limit you? BBB or gait dysfunction? NVFC/unexplained wt change? What do you hope we can accomplish during this visit?

13 Red Flags for Potentially Serious Conditions History of Trauma with significant E BBB dysfunction Constitutional Sx Progressive Neuro decline

14 H & P Document thorough history Sacral nerve function (if needed / appropriate) Constitutional ROS Management to date including Chiro, OTC meds, and non-traditional treatments Review gait and neuro function Review focal musculoskeletal testing

15 Physical Examination General observation of the patient; musculoskeletal testing A regional spine exam Focused Neurologic screening Testing for spinal cord / nerve root dysfunction

16 Observation and Regional Spine Examination Gait and coordination are observed Cervical and Lumbar ROM in all planes Vertebral point tenderness Palpable soft-tissue tenderness

17 Neurologic Screening Testing for muscle strength Dermatome Sensory Exam Reflexes Circumferential tape measure Special provocative testing Vascular exam

18 Physical Exam

19 Physical Exam

20 Other Tests Hoffman s Reflex Spurling s test Lhermitte s test

21 Initial Care Education and assurance Activity and lifestyle alterations Reasonably rule out Red Flags

22 Initial Assessment / Re-assurance: No need for special studies (CT or MRI) in the absence of signs/symptoms of dangerous conditions Many patients will recover spontaneously within 4-6 weeks

23 Cervical Traction Techniques

24 Spinal Pain Management NSAIDs (Mobic 15mg/d) Valium / Methocarbamol (if spasm present) Physical Therapy / Rehab Lifestyle modifications Tobacco cessation Wt loss Cardio Exercise, core strengthening, stretching Avoid exacerbating activities

25 Advanced Imaging Studies Symptoms have persisted for > 6 weeks When surgery is being considered for treatment of a specific detectable loss of neurologic function To further evaluate potentially serious spinal pathology (i.e. Tumor, Fx, infection)

26 Case # 1 CSM

27 CSM Neuro-inflammation Spinal Cord Microvascular insult Apoptosis 20-62% will deteriorate difficult to predict who worsens

28 Example Case #2: K.C. 53 yo male with 5 months of chronic neck pain, gait instability and progressive hand numbness. Past history of mid-cervical fracture 26 years prior from MVA (managed non-surgically) PE: Gross gait instability, BUE Weakness/Numbness and spasticity Hyper-reflexia

29 Imaging/Cases Pt #2 K.C.

30 Pt #2 K.C.

31 Cervical Spondylotic Myelopathy Both anterior and posterior effective posterior more common in older patients with increased disease-level burden / OPLL

32 CSM Younger Age and Higher baseline mjoa Scores achieve better outcomes following surgery (p<0.0001)

33 Case #3: C.R. 45 yo F (Mom and Accountant) CC: Neck and progressively worsening left arm pain / weakness Mild gait / balance disturbance Poor sleep from pain / arm burning

34 C.R. Workup

35 C.R. Workup

36 C.R. Post Op Well fused 1-2/10 pain Normal Neuro

37 C.R. Postop Plan: Cervical Collar for 8 weeks; then wean out Methocarbamol PRN for muscle spasm (trapezius) Unrestricted activity at 6-8 months post op

38 Case #4 F.D. 56 yo F with painful, weak R arm / dorsal hand

39 F.D.

40 F.D. (intra-op)

41 F.D. (1 year post op)

42 Cervical Radiculopathy ACDF with PT (n=31patients) vs PT alone 12 months 87% better with Surg-PT / 62% improved with PT 24 months 91% improved with Surg-PT / 69% with PT only (p<0.05 at both 12 and 24 months)

43 Cervical Radiculopathy

44 Case #5 N.O. 63 yo F with moderate neck pain, occasional arm tingling

45 Cervical Radiculopathy Data for 1352 patients, 98 sites from IDE trials Improved NDI, Neuro Function and survivorship with ACDA Success: 77% ACDA vs 70.8% ACDF at 24 months (p<0.007)

46 Cervical Radiculopathy Prospective ACDF vs ACDA comparison 105 vs 85 pts respectively 10.5% versus 8.8% adjacent segment 36 months No difference in NDI and in VAS

47 Cervical Radiculopathy Meta-analysis: adjacent segment degeneration 110 patients with 7% vs 5% degeneration in fusion vs. arthroplasty Degen Risk of 2.4%/yr ACDF and 1.1%/yr ACDA

48 Cervical Radiculopathy

49 Cervical Radiculopathy Tx with Lamino-foraminotomy

50 Cervical Radiculopathy Foraminotomy more cost effective more rapid return to work / duty

51 Case #6 C.P. 57 yo M with severe neck pain 3.5 years post op

52 Summary Many Cervical arthritis problems are self limiting. Often do not require surgery when series directed contemporary Tx is initiated Beware of Red Flags although rare, these are potentially serious & require prompt further evaluation Physical therapy, NSAIDs, Valium / SMRs

53 Summary: Cervical Myelopathy Spinal Cord Signs and Symptoms Cervical Radiculopathy Nerve Root Distribution Signs and Symptoms Axial Cervical Pain Pseudo if prior fusion?

54 Summary Bedrest is typically not very helpful (Limit to < 24 hours) Axial Neck Pain < Cervical Radicular Pain < Cervical Myelopathy on worrisome scale Ortho Spine Surgery Consult for non-emergent referral; E.D (or page me at ) for severe/rapid decline in function

55 Thank You