852: C spine radiculopathy, disc pathology, and myelopathy

CPG classifications for C spine disc pathology

• neck pain with mobility deficits

• Neck pain with radiating pain

C spine disc pathology

Cervical disc pathology primarily due to degenerative processes - degenerative disc disease

• annular tears

  • Due to repetitive movements or activities

• Nuclear disc material degradation

• Loss of disc height

Pathobiological mechanisms of C spine disc pathology

• the nucleus purposes and annulus fibrosis form small cysts and fissures that are the first indication of degradation

• Horizontal and vertical apertures form from extension of the fissures

• Vertical fissures extend to the cartilaginous end plate, which may result in portions being torn off

Pain associated with C spine disc pathology

• more likely from the inflammatory process due to adjacent structures, but more commonly initiated by nerve root compression

• The disc releases noneurogenic mediators that promote the inflammatory response

Disc protrusion

Nucleus pulposus bulges out into the annulus fibrosis, but no damage to the annulus

Disc prolapse

Nucleus pulposus bulges out into the annulus fibrosis, annular lamina damaged

Disc extrusion

Nucleus pulposus breaks past outer layer of the annulus and into the space outside

Disc sequestration

Nucleus pulposus breaks free of the annulus

C spine disc pathology risk factors

• uncommon in c spine

• DDD and HNP more likely due to repetitive movements and loading vs trauma alone

• Disc herniations can contribute to the development of cervical myelopathy and or cervical radiculopathy

Symptoms of C spine disc pathology

• dull, deep, diffuse, vague pain

• HNP may have radiating pain into the arm in dermatomal distribution

• DDD will be non dermatomal in presentation

The C6 nerve root will be impacted

If the C5 disc has a protrusion/herniation

Mechanisms of acute disc herniation

• usually insidious

• Due to slow, progressive degenerative changes

• Repeated movements or loads

Aggs for C spine disc pathology

Prolonged sitting, driving, sleeping prone or side lying, coughing or sneezing and lifting (due to increased disc pressure)

Eases for C spine disc pathology

Lying down, cervical collar, walking, moist heat/ice

24 hr pattern for DDD

Stiffness and pain in the morning, lasting >30 mins

Symptom increase during day and if sitting too long

24 hr pattern for HNP

Morning stiffness and pain as intense but usually get worse throughout the day with static activities or prolonged sitting

Objective examination for C spine disc pathology

• ROM: limited and painful in either flexion or extension, but may also have limited ispilateral rotation and lateral flexion

• Tenderness over adjacent cervical and scapular musculature

• Decreased segmental mobility with accessory motion testing at involved levels

Special Tests

• neuro screen may reveal dermatomal and myotomal pattern of impairments if nerve root compromised by disc bulge

• Pain with axial compression

Potential pertinent history for C spine disc pathology

• history of previous episodes of neck pain

• Work that requires prolonged sitting

• History of previous MVA

Potential predisposing factors for C spine disc pathology

Poor posture

Hypo mobility in adjacent areas

PT management for C spine disc pathology

• decrease pain and centralize symptoms if appropriate

  • Particularly in acute stage use positions that minimize load on disc such as hooklying and supported side lying

• Focus on improving mobility

• Focus on improving strength and activity tolerance

  • Anterior deep neck flexors, parascapular muscles

Medical management for C spine disc pathology

• pharm: NSAIDs or muscle relaxant during acute phase

• Surgery

  • Discectomy or microdiscectomy

  • Anterior or posterior cervical fusion

• MRI: only if neuro symptoms present

Discectomy procedure

• incision made along anterior aspect of the neck

• A thin muscle just under the incision is split

• Fluoroscopy provides x-ray guidance during surgery to confirm correct level

• Entire disc and cartilage end plates are removed

Dissection procedure

Of the posterior longitudinal ligament will occur to allow access to the spinal canal and remove any extruded disc material

• often all or portions of the uncinate processes are removed

Fusion procedure

Is performed using bone graft and cage implantation into the disc space

• a small plate is attached to the front of the spine with screws into each vertebral bone

Indications for anterior cervical Discectomy and fusion

• cervical disc herniation

• Spine instability

• Previous spine surgery

  • Adjacent segment degeneration

  • Spondylolisthesis

• Spinal stenosis

Rehab considerations for anterior cervical Discectomy and fusion

• may result in pain or tissue damage in adjacent segments due to increased load/mobility to non-fused segments

• Avoid scar mobilization until scar closure )6-8 weeks)

• Cervical collar will be based on patient history and surgeon preference

• PT initiated 4-6 weeks post op

• No driving while on narcotics or in collar

• Encourage movement

• May have movement restrictions

  • No lifting > 10 lbs and avoid lifting or reaching over head

Post-op management - acute/maximum protection phase

• edu on tissue healing timelines and post op restrictions for up to 3 months

• Look for and educate patient on signs of infection, check on efficacy of any pain medication

• Edu and practice bed mobility and transfers with restrictions

• Pts may or may not be given a cervical collar

• Encourage walking and gentle movement within precautions to tolerance

Post-op management: moderate/minimum protection phase

• Scar tissue mobilization performed once incision is healed to promote tissue mobility and decrease pain

• Gentle cervical AROM, low grade I/II joint mobs above and below surgical site where hypo mobility noted

• Lifting no more than 20 lbs, improved UE strength and ROM, cervical isos, scapulothoracic strengthening

• Work on balance and aerobic with walking program

• No joint manips or mobilizations at the level of a fusion

Post op complications specific to ACDF

• inadequate symptom relief

• Failure of bone graft healing

• Dysphagia

• Speech disturbance due to injury of the recurrent laryngeal nerve

• Dural tear or spinal fluid leak

• Nerve root damage

• Damage to spinal cord

• Damage to trachea/esophagus

• Hematoma causing airway compromise

PT diagnosis for cervical myelopathy

Likely an extension, rotation, or rotation with extension diagnosis

CPG classifications for cervical myelopathy

• neck pain with radiating pain

• Neck pain with mobility deficits

Pathobiological mechanisms of cervical myelopathy

• refers to compression on the cervical region of the spinal cord

• Can be caused by a variety of mechanisms including degenerative changes, disc bulges, congenital abnormalities, etc that result in narrowing of the spinal canal

• Narrowing or reduced diameter of the spinal canal leads to spinal cord compression and changes in neurological function

Symptoms of cervical myelopathy

• cervical, scapular, shoulder pain

• Weakness of UEs and or LEs

• Numbness or paresthesia in UEs and/or LEs

• Clumsiness with hand function/fine motor activity

• Gait clumsiness

• Bowel and/or bladder changes

Symptom behavior for cervical myelopathy

No specific aggs or eases or 24 hr pattern

Objective examination for cervical myelopathy

Neuro exam BL…

• hyperreflexia, sensory loss, and weakness

+ UMN signs

• babinski

• Clonus

• Hoffmann

• Inverted supination sign

Gait ataxia

Hand weakness

+ Cook’s cluster

Potential pertinent history for cervical myelopathy

• may or may not report history of neck pain

• Most common compliant is gait disturbance

Potential predisposing factors for cervical myelopathy

• age >50 → degenerative changes in the spine

• History of disc herniation → taking up space in the spinal canal

PT management for cervical myelopathy

• pts with suspicion of this should first be referred to neurology or neurosurgery

• Focus on improving strength and activity tolerance

  • Shoulder, neck, scapular stabilizers

• Focus on improving posture

  • Accessory motion, ROM, muscle length, and improving thoracic mobility

• Neuro dynamic mobility may be helpful if symptoms refer into the UE

Medical management for cervical myelopathy

• pharm: NSAID

• Surgery: ACDF typically reserved for significant extremity weakness and progressive neuro deficits

• Imaging: ACR recommends MRI with and without contrast

PT diagnosis for cervical radiculopathy

Likely an extension, rotation, or rotation with extension diagnosis

CPG classifications for cervical radiculopathy

Neck pain with radiating pain

Neck pain with mobility deficits

Pathobiological mechanisms for cervical radiculopathy

The result of an issue at the cervical root

• due to foraminal narrowing and/or an inflammatory component of the nerve root itself or surrounding structures

• These changes may result from

  • Disc herniation, DDD, stenosis, spondylolisthesis, DJD

• Most commonly due to degenerative changes

Symptoms of cervical radiculopathy

• pain, numbness, tingling in nerve root distribution pattern

• Weakness along corresponding myotome

• Pain in the cervical, scapular, intrascapular areas

• Often described as sharp, shooting, burning

• Arm pain and symptoms may be more severe than neck symptoms

Aggs for cervical radiculopathy

• may be aggravated by coughing, sneezing, bearing down

• If herniated disc at fault, movements away from side of discomfort will be more bothersome

• If foraminal stenosis, DDD, or DJD at fault, extension, ipsilteral rotation and ispilateral lateral flexion activities will likely be painful

Eases for cervical radiculopathy

• positions that open or decrease mechanical load on cervical spine nerve root

• Symptoms centralizing indicates decreased pressure on nerve root

• Placing arm on top of head on symptomatic side may also ease symptoms

24 hr pattern for cervical radiculopathy

Due to disc or arthritic change may be worse in the morning

Objective examination for cervical radiculopathy

Neuro exam will show LMN findings

• pattern of weakness and sensory loss in the affected nerve root pattern

• Should not have UMN signs

Posture: head may be laterally flexed away from or towards the painful side

ROM limitation dependent on cause of it

Joint accessory mobility may be painful and/or hypo mobile

Special tests: wainwright test cluster

• + upper limb median nerve neural provaction test, + cervical distraction test, + spurling’s test, ispilateral cervical rotation < 60 degrees, + shoulder abduction sign

Potential pertinent history for cervical radiculopathy

History of previous, intermittent neck pain

History of heavy or manual labor, excessive sitting

Potential predisposing factors for cervical radiculopathy

• age → degenerative changes in the spine

• Significant postural abnormalities or sustained loading postures

• History of disc herniation

PT management for cervical radiculopathy

• traction may be useful

• Decrease pain in acute stages

  • Manual, exercises with positions of relief, postural/work/activity modifications

• Focus on improving mobility

  • Thoracic mobility

• Focus on improving strength and activity tolerance

  • Shoulder, neck, scapular stabilizers

Traction

• manual or mechanical axial unloading force

• May allow for distraction force of the facet joint, increase in the intervertebral space, unloading the disc, stretching the joint capsule and ligaments

• Can be a sustained/static or intermittent force

• Used more commonly in earlier phases of management

Clinical prediction rule for cervical traction

1. Pt reported peripheralization of symptoms with C4-7 CPA assessment

2. Positive shoulder abduction test

3. Age > 55 years

4. Positive ULNPT A (median)

5. Positive cervical distraction test

Parameters for traction

• supine with legs supported with bolster/wedge

• Choose static vs intermittent

• If intermittent: 3:1 cycle with the force during the relax period being about 50% of the force in the on period

More parameters for cervical traction

Angle of pull

• if targeting C1-2, should be in neutral position >0 for C3 and lower

• If targeting C3 or below, need to be in slight flexion, usually 15 degrees

• If full cervical flexion ROM available, may position in flexion up to 24 degrees

Force

• initial force about 12 lbs

• Want a moderate-strong pull without an increase in symptoms

• Max force = 40 lbs

Manual cervical traction

• can be done as a trial to see how a patient responds before committing to mechanical

• Same positioning as mechanical

• Performed with hands or towel

• Be cognizant of the angle of pull

Medical management for cervical radiculopathy

• pharm: NSAIDs or may have steroid prescription

  • Cervical epidural corticosteroid injections

• Surgery: anterior cervical Discectomy and fusion, laminectomy, foraminotomy

• Imaging: EMG and nerve conduction studies more likely to be helpful