©2016 MFMER | 3572499-1 ©2016 MFMER | 3572499-1

PAIN MEDICINE FOR THE NON-PAIN SPECIALIST 2017

FEBRUARY 16-18, 2017

JW MARRIOTT DESERT SPRINGS RESORT & SPA PALM DESERT, CALIFORNIA

Learn the latest treatment strategies and multidisciplinary management options for patients with acute and chronic pain.

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A Clinical Approach to Neck Pain

Richard H. Rho, M.D. Pain Medicine For The Non-Pain Specialist

February 18, 2017

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Disclosure Statement • Nothing to disclose

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Learning Objectives After completion of this activity the participants will be able to: • Identify the features of common sources of neck

pain. • Identify the characteristics of “red flag” sources

of neck pain. • Identify a general clinical framework in the

assessment and conservative treatment of neck pain.

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Neck Pain is a common problem

• About 2/3 of the population have neck pain during their life, with the highest prevalence during middle age1,2

• Lack of consensus in the medical community for evidence based care pathways

1. Aker PD, et al. Conservative management of mechanical neck pain: systematic overview and meta-analysis. BMJ 1996; 313:1291-6.

2. Philadelphia panel. Evidence-based clinical practice guidelines on selected rehabilitation interventions for neck pain. Phys Ther 2001; 81-:1701-17.

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A Variety of Pathways Exist: Spine Pain

Geriatrics

PMR

Ortho Surgery

Neurosurgery

Neurology Oncology

Rheumatology

Emergency Med

Primary Care

Pain Medicine

Prev Med

Endocrinology

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Neck Pain comes in different flavors

Axial Limb Myofascial

Facet Radiculopathy Discogenic Myelopathy

Bone

RED FLAGS: CANCER, INFECTION, CERVICAL MYELOPATHY, FRACTURE, AUTOIMMUNE DZ, RADICULOPATHY

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Axial Neck Pain • Myofascial • Facet • Bone pain • Discogenic

Diagnosis Treatment Preserved Functioning

+ Reduced Pain

An accurate diagnosis can be difficult

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Axial Neck Pain • Myofascial • Facet • Bone pain • Discogenic

Which of these causes of low back pain have evidence based treatments available?

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Upper Limb Pain • Radiculopathy • Cervical myelopathy

Diagnosis Treatment Preserved Functioning

+ Reduced Pain

An accurate diagnosis can be difficult

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Upper Limb Pain • Radiculopathy • Cervical Myelopathy

Which of these causes of low back pain have evidence based treatments available?

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Neck pain is complicated

Figure 2 taken from Dwyer AB, et al. Cervical zygapophyseal joint pain patterns. I: a study in normal volunteers. Spine 1990; 15:453-457. Figure 3 taken from Mizutamari, M, et al. Corresponding scapular pain with the nerve root involved in cervical radiculopathy. J Orthopaedic Surg 2010; 18(3):356-60.

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Spine Pain Red Flags – do not miss… • Cancer

• Persistent/worsening pain > 1 month • Unexplained weight loss • Previous history of non-skin cancer

(positive likelihood ratio 14.7) • Age > 50 years • No relief with bedrest

• Infection • History of IV drug use, urinary tract

infection or skin infection

• Cervical Myelopathy • Spasticity in arms/legs • urinary urgency

• Fracture • Corticosteroid use • Age > 50 years • Trauma; pain intensity

• Ankylosing Spondylitis/Rheumatoid Arthritis/Polymyalgia Rheumatica

• Age < 40 years • Chronic onset, duration > 3 months • Morning stiffness > 30 minutes • Improvement with exercise but not

rest • Awakening during second half of

night only • Alternating buttock pain

• Herniated Disc or Radiculopathy • Positive straight leg test and crossed

straight leg test • Motor/sensory deficit, DTR changes

1. Chou R, Huffman, LH. Guideline for the evaluation and management of low back pain. Evidence review. American Pain Society. 2009

2. Cohen SP. Epidemiology, Diagnosis and Treatment of Neck Pain. Mayo Clin Proc. 2015.90(2):284-299.

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Cervical Myofascial Pain

• Pearls • May have spasms or

“knots” in tissue • Physical Examination

• Pain distribution is along muscle/trigger point patterns*

• Neuro WNL

• Testing • Cervical xray if pain > 6

wks or if red flags (+) • Treatment

• Core treatment plan* • PT: stretches, strengthening • Trigger point injections

*Travell J, et al. Myofascial pain and dysfunction: the trigger point manual (2 vol. set, 2nd Ed.). Lippincott Williams & Williams. 1999. ISBN 0-683-08363-5.

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Cervical Facet Joint Pain

• Pearls • More likely with increased

age

• Physical Examination • Cervical extension and

rotation • Reduced range of motion • Neuro WNL

• Testing • Cervical xray if pain > 6

wks or if red flags (+)

• Treatment • Core treatment plan* • PT: stretches,

strengthening • Radiofrequency ablation

1. Figure 2 taken from Dwyer AB, et al. Cervical zygapophyseal joint pain patterns. I: a study in normal volunteers. Spine 1990; 15:453-457. 2. Engel A, et al. The effectiveness and risks of fluoroscopically-guided cervical medial branch htermal radiofrequency neurotomy: a systematic review with comprehensive analysis of the published data. Pain medicine 2016; 17:658-669.

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Cervical Discogenic Pain

• Pearls • More likely with younger

patients • Physical Examination

• Patients may tilt head or support arm during office visit

• Pain reproduced with axial loading, neck flexion/extension

• Neuro WNL unless radiculopathy present

• Testing • Cervical xray/MRI if pain >

6 wks or if red flags (+) • Treatment

• Core treatment plan* • PT: mobilization • Epidural steroid injections,

provocative discography • Spine surgery

Hirsch JA, et al. Efficacy of epidural injections in managing chronic spinal pain: a best evidence synthesis. Pain physician 2015; 18:E939-E1004.

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Cervical Bone Pain

• Pearls • More likely with

osteoporosis, malignancy, steroid exposure, elderly, significant trauma

• Physical Examination • Focal pain over spine • Any movement of spine is

severely painful • Spasms may be significant • Neuro WNL

• Testing • Neck xray if pain > 6 wks or

if red flags (+) • Treatment

• Core treatment plan* • PT: DLS, core

strengthening, bracing • Percutaneous Vertebral

Augmentation (i.e. vertebroplasty, kyphoplasty)

De la Garza-Ramos, Rafael, Mario Benvenutti-Regato, and Enrique Caro-Osorio. “Vertebroplasty and Kyphoplasty for Cervical Spine Metastases: A Systematic Review and Meta-Analysis.” International Journal of Spine Surgery 10 (2016): 7. PMC. Web. 19 Sept. 2016.

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Cervical Radiculopathy

• Pearls • Neuropathic descriptors:

burning, tingling, electric shock

• Physical Examination • Neuro may reveal changed

motor/sensory/DTR to C5-T1 spinal segments

• Testing • Cervical MRI if pain > 6 wks or

if red flags (+) • EMG if clinical suspicion,

weakness

• Treatment • Core treatment plan* • PT: mobilization, strength

maintenance in affected region • Epidural steroid injection • Spine surgery

Manchikanti L, et al. Cervical radicular pain: the role of interlaminar and transforaminal epidural injections. Curr Pain Headache Rep (2014) 18:389.

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Cervical Myelopathy

• Pearls • May report weakness in

arms and legs, difficulty with coordination, loss of control of bowel/bladder function

• Most commonly occurs age 50-70 years old

• Physical Examination • Neuro: upper motor

neuron syndrome with

hyperreflexia/spasticity, spastic gait pattern; +/- Lhermitte’s Sign

• Testing • Urgent MRI

• Treatment • Urgent consultation from

Spine Surgeon

Rhee JM, et al. Nonoperative management of cervical myelopathy: a systematic review. Spine 2013; 38:22S S55-S67.

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Axial Limb Myofascial

Facet Radiculopathy Discogenic Myelopathy

Bone

RED FLAGS: CANCER, INFECTION, CERVICAL MYELOPATHY, FRACTURE, AUTOIMMUNE DZ, RADICULOPATHY

Summary: Neck Pain

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References 1. Aker PD, et al. Conservative management of mechanical neck pain: systematic overview and

meta-analysis. BMJ 1996; 313:1291-6.

2. Philadelphia panel. Evidence-based clinical practice guidelines on selected rehabilitation interventions for neck pain. Phys Ther 2001; 81-:1701-17.

3. Dwyer AB, et al. Cervical zygapophyseal joint pain patterns. I: a study in normal volunteers. Spine 1990; 15:453-457.

4. Mizutamari, M, et al. Corresponding scapular pain with the nerve root involved in cervical radiculopathy. J Orthopaedic Surg 2010; 18(3):356-60.

5. Travell J, et al. Myofascial pain and dysfunction: the trigger point manual (2 vol. set, 2nd Ed.). Lippincott Williams & Williams. 1999. ISBN 0-683-08363-5.

6. Binder AI. Cervical spondylosis and neck pain. BMJ 2007; 334:527-31.

7. Chou R, et al. Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society. Ann Intern Med. 2007: 147:478-491.

8. Deyo R, Diehl A. Cancer as a cause of back pain: frequency, clinical presentation, and diagnostic strategies. J Gen Intern Med. 1988;3(3):230-238.

9. Cohen SP. Epidemiology, Diagnosis and Treatment of Neck Pain. Mayo Clin Proc. 2015.90(2):284-299.

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Questions & Discussion