The pathomorphologic changes that accompany the resolution of cervical radiculopathy. A prospective study with repeat magnetic resonance imaging

Retrospective study assessing the efficacy of i.v. dexamethasone, SNRB, and nonsteroidal treatment for radiculopathy

Retrospective study. The purpose of this study was to investigate the clinical symptomatology of discopathies before and 7 days after treatment with one of the following: intravenous dexamethasone, selective nerve root block (SNRB), and systemic treatment with different nonsteroidal antiinflammatory drugs (NSAIDs). Radiculopathy is a clinical condition in which dysfunction of one or more nerves occurs due to mechanical compression and/or chemical irritation of the nerve roots. Most often located in the lumbar spine, radiculopathy remains one of the most common complaints in primary health. Some patients responded well to conservative treatment. However, those who show no improvement may benefit from more invasive treatment options, such as intravenous corticosteroids, spinal injections, and surgical procedures. We conducted a retrospective study of 81 male and female patients aged 18 years and above who had radicular pain and were referred to our facility over a 7-year period. Of the 100 patients assessed for eligibility, 19 patients were not included in the study due to malignancy or surgical intervention, 32 patients received intravenous dexamethasone, 24 patients received SNRB, and 25 received various NSAIDs as the control group. The visual analog scale, straight leg raise test and neurological deficits were assessed to evaluate the patients before and after receiving treatment. All patients underwent spinal computed tomography to confirm the diagnosis of disc herniation. Pearson chi-squared test, Kruskal-Wallis test, and Mann-Whitney test were used to evaluate the results. Visual analog scale scores and the ability to perform straight leg raise test significantly improved after treatment with dexamethasone, SNRB, and NSAIDs. However, clinical improvement was significantly better in both the dexamethasone and SNRB groups than in the control group. Motor deficits improved significantly after dexamethasone treatment alone. Dexamethasone and SNRB are useful and safe treatment options for treating patients with acute radicular pain. Randomized, double-blinded, control studies are warranted.

Acute Cervical Radiculopathy Outcomes: Soft Disc Herniations vs Osteophytes

OBJECTIVE

Prospectively evaluate the clinical outcomes of acute cervical radiculopathy with respect to soft disc herniations vs osteophytes.

METHODS

Sixty consecutive patients who had had cervical radiculopathy for ≤1 month were enrolled in the study. Inclusion criteria were radicular pain greater than axial pain and a pain score ≥4 out of 10 on a numerical rating scale. Patients had at least one positive clinical finding: motor, sensory, or reflex changes. Plain films and magnetic resonance imaging were ordered. Follow-up was at 6 weeks and 3, 6, and 12 months. Outcomes included pain scores (neck and upper limb), neck disability index, medication use, opioid use, and need for surgery. Two attending musculoskeletal radiologists reviewed imaging findings for osteophytes vs soft disc herniations at the symptomatic level.

RESULTS

More than 75% reduction in pain was seen in 77% of patients with soft disc herniations and 66% of patients with osteophytes (P > 0.05) at 12 months. A pain score ≤2 out of 10 within 6 to 12 months was seen in 86% of patients with soft disc herniations and 81% of patients with osteophytes (P > 0.05). Moderate or marked improvement at 12 months was seen in 85% of patients with soft discs and 77% of patients with osteophytes (P > 0.05). Baseline-to-12-month numerical rating scale pain scores of patients with soft discs vs osteophytes had overlapping confidence intervals at each follow-up. At 12 months, very few had undergone surgery (7% of patients with soft discs, 11% of patients with osteophytes; P > 0.05) or were on opioids (7% of patients with soft discs, 9% of patients with osteophytes; P > 0.05).

CONCLUSIONS

The majority of patients, but not all patients, with acute radiculopathies improved with time. This was seen with both soft disc herniations and osteophytes.

Prolonged pain reducing effect of sodium hyaluronate-carboxymethyl cellulose solution in the selective nerve root block (SNRB) of lumbar radiculopathy: a prospective, double-blind, randomized controlled clinical trial

BACKGROUND

The pattern of linear graph schematized by visual analogue scale (VAS) score displaying pain worsening between 2 days and 2 weeks after selective nerve root block (SNRB) is called rebound pain.

PURPOSE

The purpose of this study was to determine if sodium hyaluronate and carboxymethyl cellulose solution (HA-CMC sol) injection could reduce the occurrence of rebound pain at 3 days to 2 weeks after SNRB in patients with radiculopathy compared with injection with corticosteroids and local anesthetics alone.

STUDY DESIGN/SETTING

Double blinded randomized controlled clinical trial.

PATIENT SAMPLE

A total of 44 patients (23 of 24 patients in the Guardix group and 21 of 24 patients in the control group) who finished the follow-up session were subjects of this study.

OUTCOME MEASUREMENT

Patients were asked to write down their average VAS pain scores daily for 12 weeks. Functional outcomes were assessed by Oswestry Disability Index, Roland Morris Disability Questionnaire , and Short Form-36.

METHOD

A cocktail of corticosteroids, 1% lidocaine, 0.5% Bupivacaine, and 1 mL of normal saline was used for the control group whereas a cocktail of corticosteroids, 1% lidocaine, 0.5% Bupivacaine, and 1 mL of HA-CMC solution was used for the G group. Study participants were randomized into one of two treatment regimens. They were followed up for 3 months.

RESULTS

VAS score at 2 weeks after the procedure was 4.19±1.32 in the control group, which was significantly (p<.05) higher than that (2.43±1.24) in the G group. VAS score at 6 weeks after the procedure was 4.00±1.23 in the control group and 3.22±1.45 in the G group, showing no significant (p=.077) difference between the two groups. There were no significant differences in functional outcomes at 6 or 12 weeks after the procedure.

CONCLUSIONS

Compared with conventional cocktail used for SNRB, addition of HA-CMC sol showed effective control of rebound pain at 3 days to 2 weeks after the procedure.

The value of short-term pain relief in predicting the long-term outcome of 'indirect' cervical epidural steroid injections

BACKGROUND

The predictive value of short-term arm pain relief after 'indirect' cervical epidural steroid injection (ESI) for the 1-month treatment response has been previously demonstrated. It remained to be answered whether the long-term response could be estimated by the early post-interventional pain course as well.

METHODS

Prospective observational study, following a cohort of n = 45 patients for a period of 24 months after 'indirect' ESI for radiculopathy secondary to a single-level cervical disk herniation (CDH). Arm and neck pain on the visual analog scale (VAS), health-related quality of life with the Short Form-12 (SF-12), and functional outcome with the Neck Pain and Disability (NPAD) Scale were assessed. Any additional invasive treatment after a single injection (second injection or surgery) defined treatment outcome as 'non-response'.

RESULTS

At 24 months, n = 30 (66.7%) patients were responders and n = 15 (33.3%) were non-responders. Non-responders exited the follow-up at 1 month (n = 10), at 3 months (n = 4), and at 6 months (n = 1). No patients were injected again or operated on between the 6- and 24-month follow-up. Patients with favorable treatment response at 24 months had significantly lower VAS arm pain (p < 0.05) than non-responders at days 6, 8-11, and at the 3-month follow-up. The previously defined cut-off of > 50% short term pain reduction was not a reliable predictor of the 24-month responder status. SF-12 and NPAD scores were better among treatment responders in the long term.

CONCLUSIONS

Patients who require a second injection or surgery after 'indirect' cervical ESI for a symptomatic CDH do so within the first 6 months. Short-term pain relief cannot reliably predict the long-term outcome.

CASINO: surgical or nonsurgical treatment for cervical radiculopathy, a randomised controlled trial

Background

Cervical radicular syndrome (CRS) due to a herniated disc can be safely treated by surgical decompression of the spinal root. In the vast majority of cases this relieves pain in the arm and restores function. However, conservative treatment also has a high chance on relieving symptoms. The objective of the present study is to evaluate the (cost-) effectiveness of surgery versus prolonged conservative care during one year of follow-up, and to evaluate the timing of surgery. Predisposing factors in favour of one of the two treatments will be evaluated.

Methods/design

Patients with disabling radicular arm pain, suffering for at least 2 months, and an MRI-proven herniated cervical disc will be randomised to receive either surgery or prolonged conservative care with surgery if needed. The surgical intervention will be an anterior discectomy or a posterior foraminotomy that is carried out according to usual care. Surgery will take place within 2–4 weeks after randomisation. Conservative care starts immediately after randomisation. The primary outcome measure is the VAS for pain or tingling sensations in the arm one year after randomisation. In addition, timing of surgery will be studied by correlating the primary outcome to the duration of symptoms. Secondary outcome measures encompass quality of life, costs and perceived recovery. Predefined prognostic factors will be evaluated. The total follow-up period will cover two years. A sample size of 400 patients is needed. Statistical analysis will be performed using a linear mixed model which will be based on the ‘intention to treat’ principle. In addition, a new CRS questionnaire for patients will be developed, the Leiden Cervical Radicular Syndrome Functioning (LCRSF) scale.

Discussion

The outcome will contribute to better decision making for the treatment of cervical radicular syndrome.

Trial registration

NTR3504

Clinical outcomes of epidural neuroplasty for cervical disc herniation

Cervical disc herniation is a common disorder characterized by neck pain radiating to the arm and fingers as determined by the affected dermatome. This condition has a favorable prognosis, but pain can have a serious detrimental impact on daily activities. Epidural neuroplasty has been applied as a treatment option for cervical disc herniation; however, no study has addressed the clinical outcomes. This retrospective study evaluated the clinical outcomes of epidural neuroplasty on 128 patients for the treatment of cervical disc herniation. To measure pain-related disabilities over time, the changes of pain scores in neck and arm were evaluated using a numerical rating scale (NRS) and the neck disability index (NDI). Compared with preprocedural values, the pain NRS of neck and arm demonstrated significant improvement at day 1, and 1, 3, 6, and 12 months after the procedure (P < 0.001). Likewise, the NDI was significantly reduced at 3, 6, and 12 months after the procedure (P < 0.001). There were no serious complications. Cervical epidural neuroplasty shows good clinical outcomes in the treatment of cervical disc herniation and can be considered a treatment modality for cervical disc herniation refractory to conservative treatment.

The Efficacy and Persistence of Selective Nerve Root Block under Fluoroscopic Guidance for Cervical Radiculopathy

STUDY DESIGN

Retrospective study.

OBJECTIVES

To investigate the outcomes of fluoroscopically guided selective nerve root block as a nonsurgical treatment for cervical radiculopathy.

OVERVIEW OF LITERATURE

Only a few studies have addressed the efficacy and persistence of cervical nerve root block.

METHODS

This retrospective study was conducted on 28 consecutive patients with radicular pain due to cervical disc disease or cervical spondylosis. Myelopathy was excluded. Cervical nerve root blocks were administered every 2 weeks, up to 3 times. Outcomes were measured by comparing visual analogue scale (VAS) scores, patient satisfaction, and medication usage before the procedure and at 1 week and 3, 6, and 12 months after the procedure. In addition, complications associated with the procedure and need for other treatments were evaluated.

RESULTS

The average preoperative VAS score was 7.8 (range, 5 to 10), and this changed to 2.9 (range, 1 to 7) at 3 months and 4.6 (range, 2 to 7) at 12 months. Patient satisfaction was 71% at 3 months and 50% at 12 months. Five patients used medication at 3 months, whereas 13 used medication at 12 months. Average symptom free duration after the procedure was 7.8 months (range, 1 to 12 months). Two patients were treated surgically. Only two minor complications were noted; transient ptosis with Horner's syndrome and transient causalgia.

CONCLUSIONS

Although selective nerve root block for cervical radiculopathy is limited as a definitive treatment, it appears to be useful in terms of providing relief from radicular pain in about 50% of patients at 12 months.

The application of Mechanical Diagnosis and Therapy and changes on MRI findings in a patient with cervical radiculopathy

Cervical radiculopathy is an unusual presentation for patients with neck pain. Its diagnosis and management is uncertain. This case report presents an example of a patient with cervical radiculopathy who responded to Mechanical Diagnosis and Therapy, and whose MRI findings changed over time.

Imaging the intervertebral disk: age-related changes, herniations, and radicular pain

The articulations of the spinal motion segment, the intervertebral disk, and the zygapophyseal joints, inevitably undergo age-related changes. This article focuses on the intervertebral disk, specifically when fissures sufficiently weaken the posterior annulus so as to allow herniation of nuclear material into the outer annular structure as a contained protrusion or breach the annulus and pass into the epidural space as an extrusion. This article examines the imaging of the age-related changes of the disk and disk herniation: nomenclature, the reliability and relative merits of imaging modalities, the imaging natural history of disk herniations, and, most importantly, the clinical significance.

Cervical radiculopathy: a review

BACKGROUND

Cervical radiculopathy is defined as a syndrome of pain and/or sensorimotor deficits due to compression of a cervical nerve root. Understanding of this disease is vital for rapid diagnosis and treatment of patients with this condition, facilitating their recovery and return to regular activity.

PURPOSE

This review is designed to clarify (1) the pathophysiology that leads to nerve root compression; (2) the diagnosis of the disease guided by history, physical exam, imaging, and electrophysiology; and (3) operative and non-operative options for treatment and how these should be applied.

METHODS

The PubMed database was searched for relevant articles and these articles were reviewed by independent authors. The conclusions are presented in this manuscript.

RESULTS

Facet joint spondylosis and herniation of the intervertebral disc are the most common causes of nerve root compression. The clinical consequence of radiculopathy is arm pain or paresthesias in the dermatomal distribution of the affected nerve and may or may not be associated with neck pain and motor weakness. Patient history and clinical examination are important for diagnosis. Further imaging modalities, such as x-ray, computed tomography, magnetic resonance imaging, and electrophysiologic testing, are of importance. Most patients will significantly improve from non-surgical active and passive therapies. Indicated for surgery are patients with clinically significant motor deficits, debilitating pain that is resistant to conservative modalities and/or time, or instability in the setting of disabling radiculopathy. Surgical treatment options include anterior cervical decompression with fusion and posterior cervical laminoforaminotomy.

CONCLUSION

Understanding the pathophysiology, diagnosis, treatment indications, and treatment techniques is essential for rapid diagnosis and care of patients with cervical radiculopathy.

The fullendoscopic anterior cervical fusion: a new horizon for selective percutaneous endoscopic cervical decompression

As a bridge between open and percutaneous therapy, endoscopy of the cervical spine started to be used at the beginning of the 1990s, following good experiences on the lumbar spine. The principle of microsurgery is combined with the minimally invasive principles by bringing the optical level to the forefront of pathology. Access morbidity has been significantly reduced by the percutaneous access technique. However, this procedure cannot be applied in patients with cervical disc herniation accompanied by segmental instability.In further developing these endoscopic techniques, in view of the experiences with the classical "Cloward procedure", the aim was to do a bony fusion of the intervertebral space of the cervical spine by endoscopic access.

MATERIAL

A female patient with postraumatic instability of the cervical segments C4/5 underwent a fullendoscopic bony fusion. The technique will be described. The fusional process has been documented by CT and clinical assessment over 3 months.

RESULT

Having preoperative pain of VAS 8, it diminished to VAS 1 after surgery. The Ct-controls demonstrated a good placement of the bony dowel through the endoscopic sheath in the intervertebral space. After 3 months a bony fusion was documented by CT and in bending X-ray.

CONCLUSION

The result of this method displays that a fullendoscopic fusion of the cervical spine with a bone dowel is possible. The clinical result seems to be comparable to the classical Cloward procedure. To the best of my knowledge, this is the first report of a fullendoscopic osseous fusion on the cervical spine.

Plasma disc decompression for contained cervical disc herniation: a randomized, controlled trial

Prospective case series studies have shown that plasma disc decompression (PDD) using the COBLATION SpineWand device (ArthroCare Corporation, Austin, TX) is effective for decompressing the disc nucleus in symptomatic contained cervical disc herniations. This prospective, randomized controlled clinical trial was conducted to evaluate the clinical outcomes of percutaneous PDD as compared to conservative care (CC) through 1 year. Patients (n = 115) had neck/arm pain >50 on the visual analog scale (VAS) pain scale and had failed at least 30 days of failed CC. Patients were randomly assigned to receive either PDD (n = 62) or CC (n = 58). Clinical outcome was determined by VAS pain score, neck disability index (NDI) score, and SF-36 health survey, collected at 6 weeks, 3 months, 6 months, and 1 year. The PDD group had significantly lower VAS pain scores at all follow-up time points (PDD vs. CC: 6 weeks, -46.87 +/- 2.71 vs. -15.26 +/- 1.97; 3 months, -53.16 +/- 2.74 vs. -30.45 +/- 2.59; 6 months, -56.22 +/- 2.63 vs. -40.26 +/- 2.56; 1 year, -65.73 +/- 2.24 vs. -36.45 +/- 2.86; GEE, P < 0.0001). PDD patients also had significant NDI score improvement over baseline when compared to CC patients at the 6 weeks (PDD vs. CC: -9.15 +/- 1.06 vs. -4.61 +/- 0.53, P < 0.0001) and 1 year (PDD vs. CC: -16.70 +/- 0.29 vs. -12.40 +/- 1.26, P = 0.005) follow-ups. PDD patients showed statistically significant improvement over baseline in SF-36 physical component summary scores when compared to CC patients at 6 weeks and 1 year (PDD vs. CC: 8.86 + 8.04 vs. 4.24 +/- 3.79, P = 0.0004; 17.64 +/- 10.37 vs. 10.50 +/- 10.6, P = 0.0003, respectively). In patients who had neck/arm pain due to a contained cervical disc herniation, PDD was associated with significantly better clinical outcomes than a CC regimen. At 1 year, CC patients appeared to suffer a "relapse, showing signs of decline in most measurements, whereas PDD patients showed continued stable improvement.

Cervical collar or physiotherapy versus wait and see policy for recent onset cervical radiculopathy: randomised trial

OBJECTIVE

To evaluate the effectiveness of treatment with collar or physiotherapy compared with a wait and see policy in recent onset cervical radiculopathy.

DESIGN

Randomised controlled trial.

SETTING

Neurology outpatient clinics in three Dutch hospitals.

PARTICIPANTS

205 patients with symptoms and signs of cervical radiculopathy of less than one month's duration

INTERVENTIONS

Treatment with a semi-hard collar and taking rest for three to six weeks; 12 twice weekly sessions of physiotherapy and home exercises for six weeks; or continuation of daily activities as much as possible without specific treatment (control group).

MAIN OUTCOME MEASURES

Time course of changes in pain scores for arm and neck pain on a 100 mm visual analogue scale and in the neck disability index during the first six weeks.

RESULTS

In the wait and see group, arm pain diminished by 3 mm/week on the visual analogue scale (beta=-3.1 mm, 95% confidence interval -4.0 to -2.2 mm) and by 19 mm in total over six weeks. Patients who were treated with cervical collar or physiotherapy achieved additional pain reduction (collar: beta=-1.9 mm, -3.3 to -0.5 mm; physiotherapy: beta=-1.9, -3.3 to -0.8), resulting in an extra pain reduction compared with the control group of 12 mm after six weeks. In the wait and see group, neck pain did not decrease significantly in the first six weeks (beta=-0.9 mm, -2.0 to 0.3). Treatment with the collar resulted in a weekly reduction on the visual analogue scale of 2.8 mm (-4.2 to -1.3), amounting to 17 mm in six weeks, whereas physiotherapy gave a weekly reduction of 2.4 mm (-3.9 to -0.8) resulting in a decrease of 14 mm after six weeks. Compared with a wait and see policy, the neck disability index showed a significant change with the use of the collar and rest (beta=-0.9 mm, -1.6 to -0.1) and a non-significant effect with physiotherapy and home exercises.

CONCLUSION

A semi-hard cervical collar and rest for three to six weeks or physiotherapy accompanied by home exercises for six weeks reduced neck and arm pain substantially compared with a wait and see policy in the early phase of cervical radiculopathy. Trial registration Clinical trials NCT00129714.

Cervical epidural steroid injections in the management of cervical radiculitis: interlaminar versus transforaminal. A review

There has been recent concern regarding the safety of cervical epidural steroid injections. The decision to proceed with treatment requires balancing the risk and benefits. This article is an in depth review of the efficacy, complications, and technique of both interlaminar and transforaminal cervical epidural steroid injections in the management of cervical radiculitis.

Cervical foraminal selective nerve root block: a 'two-needle technique' with results

Several techniques have been described for selective nerve root blocks. We describe a novel 'two-needle technique', performed through the postero-lateral route with the patient in lateral position under C-arm guidance. The aim of the current study is to highlight the effectiveness and safety of cervical selective nerve root block for radiculopathy using this technique. We present results of a retrospective 2-year follow-up study of 33 injections carried out on 33 patients with radiculopathy due to cervical disc disease and or foraminal stenosis using this procedure. Patients with myelopathy, gross motor weakness and any other pathology were excluded. The outcome was measured comparing 'Visual Analogue Score' (VAS) and 'Neck Disability Index' (NDI) before the procedure with those at 6 weeks and 12 months after the procedure. Thirty patients were included in the final analysis. Average pre-operative VAS score was 7.4 (range 5-10), which improved to 2.2 (range 0-7) at 6 weeks and 2.0 (range 0-4) at 1 year and the mean NDI score prior to intervention was 66.9 (range 44-84), which improved to 31.7 (range 18-66) at 6 weeks and 31.1 (range 16-48) at 1 year. The improvements were statistically significant. Patients with involvement of C6 or C7 nerve roots responded slightly better at 6 weeks with regards to VAS improvement. Mean duration of radiation exposure during the procedure was 27.8 s (range 10-90 s). Only minor complications were noted-transient dizziness in two and transient nystagmus in one patient. Our 'two-needle technique' is a new, safe and effective non-surgical treatment for cervical radiculopathy.

Cervical Radiculopathy

Cervical radiculopathy is a condition encountered commonly in the evaluation of neck pain that may result in significant discomfort and functional deficits. Although the long-term prognosis of this condition is favorable, a standardized approach to therapy is important to minimize unnecessary tests and identify patients who require more urgent intervention. Patient education, pain control, and physical therapy are the first line of therapy. Patients who have protracted pain or significant functional deficits may require a more thorough evaluation, including imaging, electrodiagnostic testing, and, possibly, surgical referral. This article outlines the basic clinical, diagnostic, and therapy considerations in the evaluation of cervical radiculopathy.

Basic Science Research Related to Chiropractic Spinal Adjusting: The State of the Art and Recommendations Revisited

OBJECTIVE

The objectives of this white paper are to review and summarize the basic science literature relevant to spinal fixation (subluxation) and spinal adjusting procedures and to make specific recommendations for future research.

METHODS

PubMed, CINAHL, ICL, OSTMED, and MANTIS databases were searched by a multidisciplinary team for reports of basic science research (since 1995) related to spinal fixation (subluxation) and spinal adjusting (spinal manipulation). In addition, hand searches of the reference sections of studies judged to be important by the authors were also obtained. Each author used key words they determined to be most important to their field in designing their individual search strategy. Both animal and human studies were included in the literature searches, summaries, and recommendations for future research produced in this project.

DISCUSSION

The following topic areas were identified: anatomy, biomechanics, somatic nervous system, animal models, immune system, and human studies related to the autonomic nervous system. A relevant summary of each topic area and specific recommendations for future research in each area were the primary objectives of this project.

CONCLUSIONS

The summaries of the literature for the 6 topic sections (anatomy, biomechanics, somatic nervous system, animal models, immune system, and human studies related to the autonomic nervous system) indicated that a significant body of basic science research evaluating chiropractic spinal adjusting has been completed and published since the 1997 basic science white paper. Much more basic science research in these fields needs to be accomplished, and the recommendations at the end of each topic section should help researchers, funding agencies, and other decision makers develop specific research priorities.

Cervical stenosis in a professional rugby league football player: a case report

Background

This paper describes a case of C7 radiculopathy in a professional rugby league player after repeated cervical spine trauma. The report outlines the management of the patient following an acute cervical hyperflexion injury with chiropractic manipulation and soft tissue therapies. It also presents a change in approach to include distractive techniques on presentation of a neurological deficit following re-injury. The clinical outcomes, while good, were very dependent upon the athlete restricting himself from further trauma during games, which is a challenge for a professional athlete.

Case presentation

A 30-year old male front row Australian rugby league player presented complaining of neck pain after a hyperflexion and compressive injury during a game. Repeated trauma over a four month period resulted in radicular pain. Radiographs revealed decreased disc height at the C5-C6 and C6-C7 levels and mild calcification within the anterior longitudinal ligament at the C6-C7 level. MRI revealed a right postero-lateral disc protrusion at the C6-C7 level causing a C7 nerve root compression.

Conclusion

Recommendations from the available literature at the present time suggest that conservative management of cervical discogenic pain and disc protrusion, including chiropractic manipulation and ancillary therapies, can be successful in the absence of progressive neurological deficit. The current case highlights the initial successful management of a football athlete, and the later unsuccessful management. This case highlights the issues involvement in the management of a collision sport athlete with a serious neck injury.

Resolution of pronounced painless weakness arising from radiculopathy and disk extrusion

In this retrospective, consecutive case series, we report the nonsurgical and rehabilitation outcomes of consecutive patients who presented with pronounced painless weakness arising from disk extrusion. Seven consecutive patients who chose physiatric care were followed clinically, and strength return was monitored. Each presented with predominantly painless radiculopathy, functionally significant strength loss, and radiographic evidence of disk extrusion or sequestration. Each patient participated in a targeted strengthening program, and in some cases, transforaminal injection therapy was employed. Each patient demonstrated an eventual full functional recovery. In most cases, electrodiagnostic studies were performed and included a needle examination of the affected limb and compound muscle action potentials from the most clinically relevant and weakened limb muscle. The electrodiagnostic findings and, in particular, the quantitative compound muscle action potential data seemed to correlate with the timing of motor recovery. Patients with predominantly painless and significant weakness arising from disk extrusion can demonstrate successful rehabilitation outcomes. Despite a relative absence of pain, such patients can present with a more rapidly reversible neurapraxic type of weakness. The more quantitative compound muscle action potential data obtained through electrodiagnostic studies may offer the treating physician an additional means of characterizing the type of neuronal injury at play and the likelihood and timing of strength return.

Intermittent cervical traction and thoracic manipulation for management of mild cervical compressive myelopathy attributed to cervical herniated disc: a case series

STUDY DESIGN

Case series.

OBJECTIVE

To describe the management of 7 patients with grade 1 cervical compressive myelopathy attributed to herniated disc using intermittent cervical traction and manipulation of the thoracic spine.

BACKGROUND

Intermittent cervical traction has been indicated for the treatment of patients with herniated disc and has been suggested to be helpful for patients with cervical compressive myelopathy. Manipulation of the thoracic spine has been utilized to safely improve active range of motion and decrease pain in patients with neck pain.

METHODS AND MEASURES

Seven women with neck pain, 35 to 45 years of age, were identified as having signs and symptoms consistent with grade 1 cervical compressive myelopathy. Symptom duration ranged from less than 1 week to 52 weeks. All patients were treated with intermittent cervical traction and thoracic manipulation for a median of 9 sessions (range, 2-12 sessions) over a median of 56 days (range, 14-146 days). Numeric Pain Rating Scale and Functional Rating Index scores served as the primary outcome measures.

RESULTS

The median decrease in pain scores was 5 (range, 2-8) from a baseline of 6 (range, 4-8), and median improvement in Functional Rating Index scores was 26% (range, 10%-50%) from a baseline of 44% (range, 35%-71%). Dizziness was eliminated in 3 out of 4 patients and chronic headache symptoms were improved in 3 out of 3 patients. There were no adverse events or outcomes.

CONCLUSIONS

Intermittent cervical traction and manipulation of the thoracic spine seem useful for the reduction of pain scores and level of disability in patients with mild cervical compressive myelopathy attributed to herniated disc. A thorough neurological screening exam is recommended prior to mechanical treatment of the cervical spine.

Therapeutic selective nerve root block in the nonsurgical treatment of traumatically induced cervical spondylotic radicular pain

OBJECTIVE

To investigate the outcomes resulting from the use of fluoroscopically guided therapeutic selective nerve root block in the nonsurgical treatment of traumatically induced cervical spondylotic radicular pain.

DESIGN

Retrospective study with independent clinical review. A total of 15 patients who met specific physical examination or electrodiagnostic criteria and failed to improve clinically after at least 4 wks of physical therapy were included. Each patient demonstrated a positive response to a fluoroscopically guided cervical selective nerve root block. Therapeutic selective nerve root blocks were administered in conjunction with physical therapy. Outcome measures included visual analog scale pain scores, employment status, medication usage, and patient satisfaction.

RESULTS

Patients' symptom duration before diagnostic injection averaged 13.0 mos. An average of 3.7 therapeutic injections were administered. Follow-up data collection transpired at an average of 20.7 mos after discharge from treatment. An overall good or excellent outcome was observed in three patients (20.0%). Among those treated without surgery, a significant reduction (P = 0.0313) in pain score was observed at the time of follow-up. Six patients (40.0%) proceeded to surgery.

CONCLUSIONS

These initial and preliminary findings do not support the use of therapeutic selective nerve root block in the treatment of this challenging patient population with traumatically induced spondylotic radicular pain.

Imaging of the spine and nerve roots

Advances in imaging have greatly improved the ability to display spine anatomy and pathology. This article describes the imaging findings in degenerative, traumatic, infectious, and neoplastic disease. Anatomic information, however, must be tempered by an understanding of asymptomatic disease and interpreted in the context of the clinical syndrome.

Epidural steroids

Although possessing a long history of use, the therapeutic use of epidural steroid injections still needs substantiation. Refinements in our understanding of the pathophysiology of radicular pain and in the techniques used to deliver depo-steroids to the target tissue will lead to improved clinical outcomes and fewer technique and drug-related side effects. Administration of epidural steroids at lumbar spine sites is more common than at cervical spine levels, although the same pain management concepts are applicable. Comparative studies are necessary to clearly define the advantages and disadvantages of the use of fluoroscopy and the transforaminal technique.

Posterior disk displacement: morphologic assessment and measurement reliability--cervical spine

BACKGROUND

Magnetic resonance imaging (MRI) is often used to assess for disk displacement after manipulation, but limited information about the true incidence of iatrogenic herniations exists. Preliminary data must be obtained concerning the size of different types of displacement to further assess this relationship. The reliability of chiropractic radiologists in assessing disks, and a comparison of measuring devices should be evaluated.

OBJECTIVE

To identify average measurements for normal and displaced disks and to assess the reliability of measurements by chiropractic radiologists.

STUDY DESIGN

Intraobserver and interobserver reliability study assessing cervical disk displacement on MRI scans.

METHODS

Three evaluators assessed the disks on 106 MRI scans. Six categories were assessed and compared. Thirty-seven scans were reassessed for intraobserver comparisons. Interobserver and intraobserver variations and measurement-device correlations were determined.

RESULTS

Interexaminer measurement reliability for the 2 devices was 0.80 to 0.84. Intraexaminer reliability ranged from 0.58 to 0.94. Interexaminer and intraexaminer agreement for the presence of disk displacement was 86% (kappa = 0.69) and 78% to 85% (kappa = 0.50-0.67), respectively; for the presence of osteophytes, 92% (kappa = 0.54) and 86% to 95% (kappa = 0.60-0.80); and for the classification of disk displacements, 76% (kappa = 0.53) and 73% to 80% (kappa 0.44-0.61). Distinguishing between normal versus bulged disks demonstrated the greatest classification disagreement. Clear size differences between the types of disk displacement were noted. The ruler and digitizer correlation coefficient was 0.96.

CONCLUSIONS

Interexaminer and intraexaminer agreement were good to very good concerning measurements and fair to good concerning disk assessments. Different disk displacement types demonstrated obvious mean size differences. No significant mean difference in measurements between the ruler and the digitizer was noted.

Relationships between outcomes of conservative treatment and magnetic resonance imaging findings in patients with mild cervical myelopathy caused by soft disc herniations

STUDY DESIGN

A retrospective follow-up study of conservatively treated patients with mild cervical myelopathy caused by cervical soft disc herniation.

OBJECTIVE

To investigate the outcome of conservative treatment for patients with mild myelopathy caused by cervical soft disc herniation and to evaluate usefulness of magnetic resonance findings in the prediction of the outcomes.

SUMMARY OF BACKGROUND DATA

Recent studies on conservative treatment for cervical soft disc herniation have focused mainly on radiculopathy, and not on myelopathy.

METHODS

Twenty-seven patients with mild cervical myelopathy secondary to cervical soft disc herniation were treated conservatively for more than 6 months by cervical bracing and restriction of daily activities. Of the 27 patients, 17 patients (Group A) underwent conservative treatment only and it was associated with improvement in their neurologic deficits, while the other 10 patients (Group B) ultimately underwent decompression surgery because of neurologic deterioration. Comparisons between the two groups were made in regard to JOA scores, patient satisfaction, and magnetic resonance findings, including location of the disc herniation (focal or diffuse in the sagittal plane, median or paramedian in the axial plane).

RESULTS

The JOA scores were 13.6 +/- 1.6 in Group A and 14.1 +/- 1.6 in Group B before treatment, 14.9 +/- 1.0 and 12.9 +/- 2.1, respectively, at 3 months, and 16.2 +/- 0.8 and 16.0 +/- 1.2, respectively, at the final follow-up. The JOA scores at 3 months were significantly lower in Group B than in Group A. Satisfaction with the results of treatment at the final follow-up was reported by 77% of the patients in Group A and 90% in Group B. Focal-type herniation was present in 47% of the patients in Group A and 70% in Group B, while median-type herniation was diagnosed in 77% in Group A and 30% in Group B. Follow-up magnetic resonance imaging of the patients in Group A showed spontaneous regression of a herniated mass in 10 patients (59%). Diffuse-type herniations were more likely to regress spontaneously than focal-type herniations (78% vs. 37%).

CONCLUSIONS

Conservative treatment is an effective treatment option for mild cervical myelopathy caused by cervical soft disc herniation. A good outcome can be expected in patients with a median-type and/or diffuse-type herniation on magnetic resonance imaging.

Herniation of cervical intervertebral disc: immunohistochemical examination and measurement of nitric oxide production

STUDY DESIGN

Surgically obtained cervical herniated intervertebral discs were examined histologically and immunohistochemically. The production of nitric oxide (NO) in the local tissue was examined using the electron spin resonance (ESR) method.

OBJECTIVES

To investigate the local histologic and immunohistochemical changes in cervical disc herniation, including NO production, and to compare such changes with those in autopsy cases.

SUMMARY OF BACKGROUND DATA

Very little is known about the histopathologic processes of cervical disc herniation. In addition, no information is available on the level of in vivo NO production in cervical disc herniation.

METHODS

Thirty-six herniated cervical discs obtained from 31 patients were immunohistochemically examined for localization of blood vessels, matrix metalloproteinase (MMP)-3, and inducible NO synthetase (iNOS). We also compared the production of NO, measured by the ESR method, in eight specimens with that of five control discs obtained from fresh cadavers.

RESULTS

The presence of herniated discs correlated with the degeneration of cartilaginous endplate and torn anulus fibrosus. Formation of new blood vessels around the herniated discs was detected, using von Willebrand factor antibody, in seven uncontained hernias and 20 contained hernias. Immunohistochemical studies showed the presence of cells positive for MMP-3 (chondrocytes), iNOS (chondrocytes and granulation tissue) in cervical disc hernias. ESR analysis showed a significantly higher NO production in herniated cervical discs than in disc samples of fresh cadavers.

CONCLUSIONS

Herniated cervical intervertebral disc is characterized by the presence of an inflammatory process associated with neovascularization and increased expression of MMP-3. Production of NO was markedly high in both contained- and uncontained-type hernias.

Chronic cervical radiculopathy: lateral-approach periradicular corticosteroid injection

Thirty-two patients underwent periradicular corticosteroid injections with a lateral percutaneous approach under fluoroscopic guidance, to treat 34 foci of chronic cervical radiculopathy unresponsive to medical treatment alone. The mean evolutionary trends for radicular and neck pain relief were significant at 14 days (P <.001) and at 6 months (P <.001). The procedure did not produce any complications.

Thoracic disk herniation: a case report

OBJECTIVE

Thoracic disk herniations are relatively rare events that often mimic other, more serious disorders. This article discusses the case of a patient with thoracic disk herniation who required unusual treatment to aid resolution of her condition.

CLINICAL FEATURES

The patient, who had a complicated history of prior lumbar disk surgery, sustained a fall onto her buttocks and developed low back and bilateral leg pain. Initial suspicion was of reinjury of the L5 disk.

INTERVENTION AND OUTCOME

Light force spinal manipulation, physical therapies, and eventual cosmetic surgery were able to resolve the condition successfully.

CONCLUSIONS

A clinical situation often may require thinking "outside the box" in order for the patient's condition to be resolved. The failure of symptoms to correspond to the suspected condition should increase the suspicion that another problem may be present.

Diagnosis and nonoperative management of cervical radiculopathy

STUDY DESIGN

Qualitative, comprehensive literature review.

OBJECTIVE

To discuss and summarize the current peer-reviewed literature related to the management of patients with cervical radiculopathy.

BACKGROUND

Cervical radiculopathy is a lesion of the cervical spinal nerve root with a reported prevalence of 3.3 cases per 1000 people; peak annual incidence is 2.1 cases per 1000 and occurs in the fourth and fifth decades of life. Nerve root injury has the potential to produce significant functional limitations and disability.

METHODS AND MEASURES

A search of the MEDLINE, CINAHL, and Web of Science databases for the periods 1966, 1982, and 1996, respectively, to December 1999 was conducted using selected keywords and MeSH headings. The bibliography of all retrieved articles were searched and pertinent articles were obtained. The Cochrane Database of Systematic Reviews was also searched. Literature related to the diagnosis, prognosis, and treatment of cervical radiculopathy were thoroughly reviewed and summarized using a critical appraisal approach.

RESULTS

Although cervical radiculopathy remains largely a clinical diagnosis, the true diagnostic accuracy of the clinical examination for cervical radiculopathy is unknown. Imaging and electrophysiologic tests are capable of detecting clinically significant problems in many patients and each modality has inherent strengths and weaknesses; technical as well as practical factors affect the choice of procedure. The natural course of cervical radiculopathy appears to be generally favorable but no prognostic or risk factors have been firmly established and the efficacy of various nonoperative treatments for the condition is unknown.

CONCLUSION

A clear definition of terms and further research are required to establish definitive diagnostic criteria and effective treatment for the management of patients with cervical radiculopathy.

Therapeutic selective nerve root block in the nonsurgical treatment of atraumatic cervical spondylotic radicular pain: a retrospective analysis with independent clinical review

OBJECTIVE

To investigate the outcomes resulting from the use of fluoroscopically guided therapeutic selective nerve root block (SNRB) in the nonsurgical treatment of atraumatic cervical spondylotic radicular pain.

STUDY DESIGN

Retrospective study with independent clinical review.

PARTICIPANTS

Twenty subjects (10 men, 10 women) with mean age 56.6 years.

METHODS

Each patient met specific physical examination, radiographic, and electrodiagnostic criteria to confirm a level of cervical involvement. Those patients whose root level remained indeterminate were required to demonstrate a positive response to a fluoroscopically guided diagnostic SNRB prior to the initiation of treatment. Therapeutic injections were administered in conjunction with physical therapy. Data collection and analysis were performed by an independent clinical reviewer.

MAIN OUTCOME MEASURES

Pain score, work status, medication usage, and patient satisfaction.

RESULTS

Twenty patients with an average symptom duration of 5.8 months were included. An average of 2.2 therapeutic injections was administered. Follow-up data collection transpired at an average of 21.2 months following discharge from treatment. A significant reduction (p = .001) in pain score was observed at the time of follow-up. Medication usage was also significantly improved (p = .005) at the time of follow-up. An overall good or excellent result was observed in 60%. Thirty percent of patients required surgery. Younger patients were more likely (p = .0047) to report the highest patient satisfaction rating following treatment.

CONCLUSIONS

This study suggests that fluoroscopically guided therapeutic SNRB is a clinically effective intervention in the treatment of atraumatic cervical spondylotic radicular pain.

The degenerative cervical spine: pathogenesis and rehabilitation concepts

The degenerative process associated with spondylosis in the cervical spine has been reviewed. The two compressive syndromes commonly associated with spondylosis, radiculopathy and myelopathy, are briefly reviewed. Except for more severe, multilevel degenerative changes producing neurologic compromise, correlation between degenerative changes and patient symptoms or functional limitations is generally poor. A conceptual scheme for guiding rehabilitation of mechanical neck pain, based on irritability level and the effects of mechanical stress on symptoms, is proposed. Further research is required to test the reliability and validity of categorization schemes like the one proposed. Such schemes based on history and effects of mechanical stresses, rather than solely on degenerative radiographic findings, are necessary to classify patients in meaningful ways that help guide specific rehabilitation strategies and tactics. When meaningful classification schemes exist, treatments matched with specific categories of dysfunction can be tested for effectiveness.

Increased signal intensity of the spinal cord on magnetic resonance images in cervical compressive myelopathy. Does it predict the outcome of conservative treatment?

STUDY DESIGN

Correlation between a lesion of the spinal cord that elicits increased signal intensity (ISI) on magnetic resonance images (MRIs) and the outcome of conservative treatment for cervical compressive myelopathy was retrospectively investigated.

OBJECTIVE

To investigate whether ISI could predict the outcome of conservative treatment for cervical compressive myelopathy.

SUMMARY OF BACKGROUND DATA

It is unknown whether ISI is related to the outcome of conservative treatment for cervical compressive myelopathy.

METHODS

Fifty-two patients with mild cervical myelopathy underwent conservative treatment with a cervical brace. The compressive lesions were spondylosis in 29 patients, disc herniation in 12, and an ossification of the longitudinal ligament in 11. They also underwent MRI (1.5 T), and ISI was evaluated on T2-weighted sagittal and axial images. The ISI areas were classified as focal or multisegmental. Thirty-nine patients underwent follow-up MRI after a mean interval of 2 years, 4 months. The transverse area of the spinal cord was also measured on T2-weighted axial images. The outcome of conservative treatment was assessed using the Japanese Orthopedic Association Score (JOA score). Patients showing either an improvement in the JOA score or with a JOA score of 15 or more were considered to have a satisfactory outcome.

RESULTS

The average JOA score was 14.0 +/- 1.4 (range, 10-16) before conservative treatment and 14.4 +/- 1.9 (range, 10-17) at follow-up. The average gain in the JOA score was 0.4 points +/- 1.9 (range, -5 to +6). The outcome was satisfactory in 36 patients (69%). An area of ISI was observed in 34 patients (65%) before treatment (24 focal and 10 multisegmental). A satisfactory outcome was obtained in 78% of the patients without ISI, in 63% of those with focal ISI, and in 70% of those with multisegmental ISI. No statistically significant difference was seen among these three groups in the percentages of patients with satisfactory outcome, JOA scores before and after treatment or transverse spinal cord area. Of the 39 patients who were re-examined by MRI, 28 showed an area of ISI. The ISI regressed in five patients (18%). Satisfactory outcome was obtained in all 5 patients with regression of ISI, in 16 (70%) of the 23 patients without regression of ISI, and in 10 (91%) of the 11 patients without ISI apparent on the the first images (difference, not significant).

CONCLUSIONS

Increased signal intensity was not related to a poor outcome of conservative treatment or severity of myelopathy in the patients with mild cervical myelopathy.

Electromyography and magnetic resonance imaging in the evaluation of radiculopathy

Electromyography (EMG) and magnetic resonance imaging (MRI) are commonly used in the diagnosis of cervical and lumbosacral radiculopathy, but the agreement between the two studies is unknown. We retrospectively studied 47 patients with a clinical history compatible with either cervical or lumbosacral radiculopathy who were evaluated with both an EMG and a spine MRI within 2 months of each other. Among these patients, 55% had an EMG abnormality and 57% had an MRI abnormality that correlated with the clinically estimated level of radiculopathy. The two studies agreed in a majority (60%) of patients, with both normal in 11 and both abnormal in 17; however, only one study was abnormal in a significant minority (40%), suggesting that the two studies remain complementary diagnostic modalities. The agreement was higher in patients with abnormal findings on neurologic examination, underscoring the difficulty of confirming the diagnosis in mild radiculopathy.

A single case report of healing through specific martial art therapy: comparison of MRI to clinical resolution in severe cervical stenosis: a case report

OBJECTIVES

A 76-year-old patient with chronic and severe spinal cord compression secondary to cervical stenosis, a cervical osteophyte, and a herniated intervertebral cervical disk had lasting resolution of symptoms after completing a specific, martial art-based, physical therapy program. We wanted to determine if there were structural changes in the cervical spine that could account for the prompt resolution of symptoms.

DESIGN

A 76-year-old female completed 8 weeks of a specific, martial art-based, physical therapy. The pretherapy and posttherapy cervical magnetic resonance images (MRIs) were compared. A follow-up evaluation was done at 1 year.

RESULTS

The patient was symptom-free within 8 weeks of the start of therapy. She remained symptom-free at 1 year follow-up evaluation. There were no obvious structural differences in the pretherapy and posttherapy MRI studies.

CONCLUSIONS

Resolution of symptoms was directly related to the specific martial art therapy. However, there were no changes in the pretherapy and posttherapy MRI studies, suggesting a significant adaptation to the spinal compression had occurred. These data suggest a viable option to surgery in elderly patients with chronic and severe cervical spinal stenosis.