RCSI Royal College of Surgeons in Ireland Coláiste Ríoga na Máinleá in Éirinn
Cervical Radiculopathy –
a review of best evidence to guide Primary Care
practice
Enter
subtitle
hereSMISCP,
(24pt,
Arial Regular)
Louise
Keating
MPhtySt (Manip),
Enter date:
25.06.13
Lecturer
in Physiotherapy
Irish Pain Society Annual Scientific Meeting,
Sept 2015
lkeating@rcsi.ie
RCSI
Outline
– Epidemiology
– Natural history
– Global Clinical Practice
– Best Evidence
– Assessment in Primary care
– Conservative management
– Outcome predictors
– Surgical management
– Indications for referral
– Outcome predictors
– Research gap
Definition
•
•
Pain in a radicular pattern in one
or both upper extremities related
to compression and/or irritation
of one or more cervical nerve
roots.
Frequent signs and symptoms
include varying degrees of
sensory, motor and reflex changes
as well as dysesthesias and
paresthesias related to nerve
root(s) without evidence of spinal
cord dysfunction (myelopathy)
NASS Work Group Consensus Statement
(2011)
•
Radiating pain in the arm with motor,
reflex and/or sensory changes (such
as paraesthesiae or numbness),
provoked by neck posture(s)
and /or movement(s)
Thoomes et al (2012)
Peripheral NeuP Pain
• IASP definition
Pain caused by a lesion or disease
of the peripheral somatosensory
nervous system
Jensen et al 2011
• In developed countries, most
frequent causes 
• Diabetic Polyneuropathy and
• Radiculopathies with neuropathic
pain components
Haanpaa et al 2009
NeuP
Pain
Cx
Rad
Most
common
Reasons for non-dermatomal pain patterns
Schmid et al 2013
Inclusion Criteria Variability
Aetiology
75%
25%
25%
Soft Disc
• Single level
• Inflammation:
– Interleukins &
Prostaglandin
• Majority spontaneously
resolve (weeks – months)
75%
Spondylosis
• Uncovertebral joint
degeneration
• Multiple levels common
Natural History
• 88% CR patients show improvement within 4/52
Alentado et al 2014
• 90% have no or mild symptoms after 4-5yrs
– 20% did not improve  surgery
Radhakrishan et al 1994
• Deg CR - Arm pain VAS 7  5 in 6/52
• Recurrence – 12.5% in 1-2yrs
Kuijper et al 2009
Honet & Puri 1976
Limited studies supporting any optimal duration of conservative treatment
prior to surgery  evidence-based conclusions cannot be made
Alentado et al 2014
Traditional failure of 6/52 conservative management
 escalation
Background
• WHO Bone & Joint Decade
Taskforce on Neck Pain
– Research Gap exists in CR
Hurwitz et al 2008
– Higher levels of pain, disability & healthcare costs
Haldeman et al 2008
• Axial neck pain
• Chronic non-neuropathic pain
Recommendations for Assessment Chronic
NeuP in Primary Care - NeuPSIG
• Consensus on Diagnostic processes
– Categorisation of Pain mechanism  Neuropathic /
Nociceptive pain
– Sensory tests: Touch, pinprick, thermal & vibration
– Identify Underlying cause
• Pivotal role for GPs
– Early identification & Management
– Triage for appropriate Rx strand
• Mixed Pain
– Lack of response to Nociceptive analgesics  Neuropathic
pain may be primary
Haanpaa et al 2009
Screening Tools
•
•
•
•
LANSS
S-LANSS
painDETECT*
DN4
QST for Cervical Radiculopathy - PPT
Symptom Maximal Derm area Nerve trunks
duration Pain Area sensory loss (kPa)
(kPa)
(kPa)
Articular
pillar
-C5/6 (kPa)
Remote
site -Tib
Ant (kPa)
Chien et al
2008
(n=38)
Mean
19.7 mos.
+/- 14.2
Median N – 203
199
440
(95% CI 179-228)
(95% CI 173226)
(95% CI
378-503)
Moloney
et al 2013
(n=17)
Mean
4.9 yrs
+/- 6.2
Median N – 161
381
(172)
(IQR 135)
Ulnar N – 223
(148)
Radial N – 217
(155)
Tampin et
al 2013
(n=23)
3-18
mos.
403 vs.
434
(asymp)
572 vs. 492
(asymp)
QST in the German Research Network on Neuropathic Pain (DFNS):
Somatosensory abnormalities in 1236 patients with different neuropathic pain
syndromes. (n=15 radiculopathy)
Maier et al, Pain; 150 (2010) 439-450
QST for Cervical Radiculopathy - PPT
• Profile of altered mechanosensitivity previously found in
WAD has also been identified in patients with chronic CR
• More gain vs. loss noted
Chien et al 2008
• More loss vs. gain noted
Tampin et al 2013
• CR research to date has not used PPT as outcome
Clinical Prediction Rule
• Diagnostic criteria:
Cluster of four items (3/4)
1. Positive ULNT1
2. Positive Spurling’s A test
3. Limited cervical rotation
to affected side
(<60degs)
4. Positive distraction test
• LR Point estimates:
– 3 tests = 6.1 (95% CI 2.018.6)
– 4 tests = 30.3 (95% CI 1.7538.2)
Wainner et al 2003
Global Clinical Practice
NeuPSIG Pharma Recommendations
Finnerup et al 2015
NICE Guidelines NeuP pain
Pharma Mgmt adults in non-specialist settings
2013
• First Line - choice of Amitriptyline, Duloxetine,
Gabapentin or Pregabalin
• If the initial treatment is not effective or is not tolerated,
offer one of the remaining 3 drugs, and repeat.
• Consider tramadol only if acute rescue therapy is
needed
• Consider capsaicin cream for people with localised
neuropathic pain who wish to avoid, or who cannot
tolerate, oral treatments.
• NICE Pathway for NeuP pain (2015)
MSK Physiotherapy Practice
Nee et al 2013
Rank Treatment Options
Type
1
Explanation & Advice
2
Exercise
Motor Control
Muscle Strength & Endurance
ROM
3
Passive manual therapy
Joint Mobilisation
(not manipulation)
4
Nerve gliding exercises
5
Stretching
Neck and Axioscapular muscles
6
Taping
Neck & Shoulder
7
Thermal agents
Heat > Cold
8
Traction
Manual not mechanical / home
9
Prescription HEP
Conservative Management
(non-invasive and non-pharma)
• Cohort studies
– Initially promising results
Saal et al 1996, Murphy et al 2006
• Clinical Trials
– Persson et al 1997, Young et al 2009, Joghataei et al 2004, Kuijper et al 2009,
Langevin et al 2014, Fritz et al 2014
• Systematic Reviews
– Manual therapy
• Cochrane – no conclusions
• No conclusions due to low quality trials
• MT and Ex benefits chronic CR
Gross et al 2010
Leininger et al 2011
Boyles et al 2011
– Conservative Rx
• Collar or Physiotherapy show promising short-term results
Thoomes et al 2013
0-12 weeks
•
Systematic Review
– Cochrane RV Exercise: low quality evidence for small benefit for pain
reduction immediate post treatment with cervical stretch / strengthening
/ stabilization in acute CR
Gross et al 2015
•
Clinical Trials emerging (Dose: 4-6/52)
– Manual Therapy + Exercise
+ Postural Advice + Pharma (analgesics, NSAIDs, steroids or anti-depressants)
(n=36)
Langevin et al 2014
– Exercise
+ Advice + Pharma (Paracetamol, NSAIDs or Opioids) (n=205)
Kuijper et al 2009
•
Rationale for early intervention
– Nerve unloading: irritation vs. compression
Manual therapy (non-provocative)
– Lateral Glide causes immediate change to ULNT 1 & NPRS
•
Coppieters et al 2003
Langevin et al (2014) Results –
both groups received varied manual therapy & exercise  no true control
to measure natural hx.
Arm Pain
Langevin et al 2015
n=36
Baseline
Kuijper et al 2009
n=205
4 wks
Fritz et al 2014
n=86
6 mo
12 mo
Neck Pain
Langevin et al 2015
n=36
Baseline
Kuijper et al 2009
n=205
4 wks
Fritz et al 2014
n=86
6 mo
12 mo
Neck Disability Index
Langevin et al 2015
n=36
Cervical
Collar
Physio
Control
Baseline
41
(17.6)
45.1
(17.4)
39.8
(18.4)
3 wks
33.8
(18.7)
34.6
(16.1)
34.3
(18.8)
6 wks
25.9
(19.1)
27.8
(17.7)
29.9
(20)
26 wks
8
10
8
Baseline
Kuijper et al 2009
n=205
4 wks
Fritz et al 2014
n=86
6 mo
12 mo
Predictors of good response to
Physiotherapy
• 4 variable model - at 4/52
– age greater than 54 years,
– non-dominant arm,
– cervical flexion not aggravating symptoms,
– Multimodal Physiotherapy: MT, cervical traction and DNF
strengthening at half of clinical visit
• + LR ratio 8.3 (95% CI = 1.9-63.9)
Cleland et al 2007
Surgery vs. Conservative Rx
Systematic Review - Cochrane
– Surgery leads to faster improvement in pain and disability
at 3/12 vs. conservative management for chronic CR
– Similar outcomes at 1 yr
Nikolaidis et al 2010
RCT
– Physio vs. Surgery + Physio – no additional benefit from
surgery
Peolsson et al 2013
Protocol
– CASINO Trial currently recruiting CR (disc) – Surgery vs. GP
care (n=400)
van Geest et al 2014
Surgical Review Criteria for CR Best evidence synthesis
• Sensory symptoms (radicular pain and/or
paraesthesia) in dermatome corresponding to involved
cervical level
AND
• Motor deficit OR reflex changes OR positive EMG
AND
• MRI OR Myelogram with CT – concordant
AND
• At least 6/52 of conservative Rx
– Exception = clear motor deficit after acute injury
Leveque et al 2015
Surgical Review Criteria for CR –
Best evidence synthesis
• Sensory symptoms (radicular pain and/or
paraesthesia) in dermatome corresponding to involved
cervical level
AND
• Positive response (80% improvement or 5 VAS pts) to
Selective Nerve Root Block (SNRB)
Leveque et al 2015
NHS National
Pathway of
Care for Low
Back &
Radicular Pain
2014
Radicular
Pathway
Predictors of Surgical Outcome
SHORT-TERM (1-2 yrs)
• Lower levels pre-op pain and disability
• Male
• Non-smoker
• Good hand strength & neck AROM
Not MRI findings
Peolsson & Peolsson 2008
LONG-TERM (10-13 yrs)
• Higher levels pre-op pain
• Male
• Non-smoker
• Low level depression
Hermansen et al 2013
Biopsychosocial assessment is suggested pre-surgery
Research Gaps
• Primary Care practice patterns in Ireland
– Pharmacology
– Surgical referral
– Pain Specialist referral
• 0-12 weeks
– RCTs needed: MMT + Pharma vs. Pharma
• Sub-group responders
– Somatosensory & biopsychosocial profile
• Surgery
• Recurrence
– Lack of guidance for secondary prevention
Key Messages
Best evidence Approach
• Assessment:
• History taking for arm pain vs. neck pain,
• Categorise pain mechanisms (screening tools) and aetiology
(MRI)
• Sensory testing
• Diagnosis – CPR to rule in (MRI to confirm) and ULNT1 to
rule out
• Self-report outcome measures – VAS (neck & arm), NDI
Key Messages
Best evidence Approach
• Conservative Rx:
• Reassurance
• Pharmacology – high level of evidence
• 0-12 weeks – RCT evidence has not yet established efficacy
of MMT vs. time. Exercise (/ collar) has efficacy in
spondylotic CR.
• > 12 weeks - Multimodal PT more evidence
• Surgical Referral: Major motor radiculopathy, suspected
myelopathy, failure of 6/52 Cons Rx, patient profile (nontolerable pain)
RCT of Multimodal Physiotherapy for Acute or
Sub-Acute Cervical Radiculopathy
www.rcsi.ie/PACeRtrial
Prof. Ciaran Bolger, Consultant Neurosurgeon, Beaumont Hosp
Dr. Dara Meldrum, RCSI
Dr. Catherine Doody, UCD,
Caroline Treanor, Clinical Specialist Physiotherapist,
Julie Sugrue, Senior Physiotherapist, Beaumont Hosp
@UqLouise
References
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Full list available on request
Lkeating@rcsi.ie