RCSI Royal College of Surgeons in Ireland Coliste Roga na Minle in irinn

Cervical Radiculopathy
a review of best evidence to guide Primary Care
practice

Enter subtitle
Louise hereSMISCP,
Keating (24pt, Arial Regular)
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. Radiating pain in the arm with motor,
reflex and/or sensory changes (such
as paraesthesiae or numbness),
Frequent signs and symptoms
provoked by neck posture(s)
include varying degrees of
and /or movement(s)
sensory, motor and reflex changes
as well as dysesthesias and
paresthesias related to nerve Thoomes et al (2012)
root(s) without evidence of spinal
cord dysfunction (myelopathy)

NASS Work Group Consensus Statement

(2011)
Peripheral NeuP Pain

IASP definition
Pain caused by a lesion or disease
of the peripheral somatosensory
nervous system NeuP
Jensen et al 2011 Pain
Cx
In developed countries, most Rad
frequent causes
Diabetic Polyneuropathy and
Radiculopathies with neuropathic
pain components
Haanpaa et al 2009
 Most
common

Reasons for non-dermatomal pain patterns Schmid et al 2013

Inclusion Criteria Variability
Aetiology
25%

75%
25% 75%
Soft Disc Spondylosis
Single level Uncovertebral joint
Inflammation: degeneration
Interleukins & Multiple levels common
Prostaglandin
Majority spontaneously
resolve (weeks months)
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 Kuijper et al 2009

Recurrence 12.5% in 1-2yrs 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 Articular Remote
duration Pain Area sensory loss (kPa) pillar site -Tib
(kPa) (kPa) -C5/6 (kPa) Ant (kPa)
Chien et al Mean Median N 203 199 440
2008 19.7 mos. (95% CI 179-228) (95% CI 173- (95% CI
(n=38) +/- 14.2 226) 378-503)

Moloney Mean Median N 161 381

et al 2013 4.9 yrs (172) (IQR 135)
(n=17) +/- 6.2 Ulnar N 223
(148)
Radial N 217
(155)
Tampin et 3-18 403 vs. 572 vs. 492
al 2013 mos. 434 (asymp)
(n=23) (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 Wainner et al 2003

Diagnostic criteria:
Cluster of four items (3/4)
1. Positive ULNT1
2. Positive Spurlings A test
3. Limited cervical rotation
to affected side
(<60degs)
4. Positive distraction test

LR Point estimates:
3 tests = 6.1 (95% CI 2.0-
18.6)
4 tests = 30.3 (95% CI 1.7-
538.2)
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
3 Passive manual therapy
4 Nerve gliding exercises
5 Stretching
6 Taping
7 Thermal agents
8 Traction
9 Prescription HEP
Motor Control
Muscle Strength & Endurance
ROM
Joint Mobilisation
(not manipulation)
Neck and Axioscapular muscles
Neck & Shoulder
Heat > Cold
Manual not mechanical / home
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 Gross et al 2010
No conclusions due to low quality trials Leininger et al 2011
MT and Ex benefits chronic CR 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 6 mo 12 mo

Fritz et al 2014
n=86
Neck Pain

Langevin et al 2015
n=36

Baseline

Kuijper et al 2009
n=205
4 wks 6 mo 12 mo

Fritz et al 2014
n=86
 Neck Disability Index

Langevin et al 2015
n=36
Baseline 3 wks 6 wks 26 wks
Cervical 41 33.8 25.9 8
Collar (17.6) (18.7) (19.1)
Physio 45.1 34.6 27.8 10
(17.4) (16.1) (17.7)
Baseline
Control 39.8 34.3 29.9 8
(18.4) (18.8) (20)
Kuijper et al 2009
n=205
4 wks 6 mo 12 mo

Fritz et al 2014
n=86
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 Radicular
2014 Pathway
Predictors of Surgical Outcome

SHORT-TERM (1-2 yrs)

Lower levels pre-op pain and disability
Male
Not MRI findings
Non-smoker
Good hand strength & neck AROM
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 (non-
tolerable 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
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Full list available on request

Lkeating@rcsi.ie