Neck Pain and Cervical Disc Disease: Basics of Diagnosis and Treatment. Aaron J. Bianco, MD March 11, 2016

Transcription

1 Neck Pain and Cervical Disc Disease: Basics of Diagnosis and Treatment Aaron J. Bianco, MD March 11, 2016

2 Disclosures Stryker consultant for surgeon training No conflicts of interest directly related to this presentation

3 Cervical Disc Disease Arthritic changes in the neck develop with aging Loss of disc height, bony spurs, and disc herniations occur This can cause: Neck pain Arm pain from nerve root irritation (Radiculopathy) Loss of balance and numbness in hands from compression of spinal cord (Myelopathy)

4 Anatomy Tanaka, Fujimoto, An et al, Spine, 2000

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9 Neck Pain Common in US population Often associated with minor trauma, car accidents, etc. Can have associated headaches Usually self-limited but may be treated with medications, exercises, and physical therapy Most cases are nonsurgical

10 Cervical Radiculopathy Pain radiating to arm(s) in a radicular distribution Loss of reflexes, sensation, or motor deficit can occur Often confused with shoulder pathology, carpal tunnel syndrome, etc.

11 Disc herniation Tear in outer layer (annulus) allows inner soft layer (nucleus) to push out

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13 Cervical Myelopathy Compression of spinal cord (not nerve roots) by bone spurs and discs Leads to weakness, loss of balance, and trouble walking. Can be irreversible Generally gets progressively worse over time, with brief periods of plateau

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17 Important Questions You Should Ask Your Patients Location of neck pain Radiating into trapezius, rhomboid, periscapular area Arm pain Limited motion Occipital headache Relieving positions?

18 Source of pain Muscle strain/ligaments Disc Discograms do not always predict Facet Mixed results with Facet blocks Loss of sagittal balance Muscle/ Ligament strain Direct compression of nerves

19 Diagnostic Imaging X-ray Disc height Spur formation Facet Hypertrophy

20 Diagnostic Imaging - MRI Assess disc herniation Canal stenosis Foraminal stenosis

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22 Natural History: Radiculopathy Lees and Turner At long term follow- up (2-19 years) of 51 patients with radiculopathy 45% had only a single episode of pain without recurrence 30% had mild symptoms 25% had persistent or worsening symptoms

23 Non operative Treatment Neck pain or radiculopathy (arm pain) with less than 4-6 weeks of symptoms No major weakness (motor deficit) No cord compression

24 Types of Nonoperative Treatment NSAIDs, soft collar Physical Therapy isometric stabilizing excercises, traction Epidural & nerve root injections 40-71% success Risks of nerve injury or stroke (rare) Manipulation Can be useful in muscle strains for short-term use

25 Indications for Surgical treatment Myelopathy Infection Tumor Progressive neurologic deficit Pain persists despite non operative treatment course (6-12 weeks)

26 Operative treatment Anterior Discectomy and Fusion Removes disc and replaces with bone graft Most common approach Posterior Laminectomy (sometimes combined with Fusion) Laminoplasty Disc Replacement Motion-sparing Long-term results not as well known

27 Anterior Discectomy and Fusion

28 Anterior Cervical Fusion Iliac crest (your own bone) or allograft (from Bone Bank) Plate and screws often used to allow early motion and avoid bracing Some surgeons use collar 6-12 weeks No clear evidence of increased fusion rates with postoperative immobilization

29 Placement of bone graft and plate for stability

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33 Posterior Decompression Laminotomy Foraminotomy Disc excision

34 Cervical Laminectomy

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37 Laminoplasty Provides Decompression Less risk of junctional stenosis and instability Only for patients with normal (lordotic) alignment

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40 Disc Replacement

41 Conclusions Conservative treatment is first option for cervical radiculopathy and axial neck pain Earlier surgical treatment usually recommended for myelopathy (spinal cord compression) Outcomes are generally excellent when diagnosis and treatment started early

42 Thank you!