Cervical Spondylosis A Case Study Leslie Rainey What

Cervical Spondylosis: A Case Study Leslie Rainey

What is Cervical Spondylosis 1, 2? “Spondylosis, ” meaning “vertebra” in Greek, is a general term for nonspecific, degenerative changes of the spine Degenerative changes occur due to aging in vertebral discs, facet and uncovertebral joints, and vertebral bodies bone formation or osteophytes due to increased stress Can result in cervical canal stenosis, narrowing of foramen, compression of nerve roots, and radicular symptoms Pathophysiology theory: desiccation of vertebral disc (90% water in early adulthood to 69% water by eighth decade of life) Height of disc decreases and annulus fibrosis is weakened

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Examination and Evaluation of Mrs. W Subjective 85 year old female Dull ache, occasional sharp pain Dx of “cervical spondylosis” from outside provider Aggs: turning head, reading Eases: rest PMHx: HTN (controlled w/ meds) Lives with husband Completely independent with all ADLs Has extended family support in the area Imaging showed extensive degenerative changes of C spine Chief complaint neck pain, loss of ROM, and frequent headaches, mild numbness and tingling Insidious onset, 2 years Pain 7/10 at worst, 2/10 at best

Examination and Evaluation of Mrs. W Objective Increased thoracic kyphosis, forward head and neck, rounded shoulders 4’ 11’’ Strength of UE: WFL ROM: Shoulder WFL Cervical Rotation: 39°/ 43° Cervical Lateral Flexion: 18°/ 20° Cervical Flexion: 30° Cervical Extension: 15° (-) Spurling (+) crepitus (+) Distraction Intact sensation Reflexes normal NDI: 33/50 (66%)

Goals Increase cervical rotation to 60° and lateral flexion to 45°bilaterally in 8 weeks to demonstrate improved function in ADLs Decrease NDI score from 33/50 to 23/50 to demonstrate improvement in symptoms of neck pain 8 weeks Decrease pain with neck positioning from 7/10 to 2/10 so patient can read for 30 minutes without a headache in 8 weeks

Seems pretty straightforward…

Intracranial Aneurysm 4, 5 Aneurysm: weak or bulging spot on the wall of an artery due to wear and tear Intracranial saccular aneurysms occur in 1 -2% of population 80 -85% of non-traumatic subarachnoid hemorrhages Primarily in proximal arterial bifurcations in the circle of Willis (85% are anterior) 20% of patients have more than one aneurysm More common in women (3: 1) Can be associated with some inherited disorders Image 5

Intracranial Aneurysm: Diagnosis 4 -6 Asymptomatic vs. Symptomatic (CN deficits) Identified on CT or MRI CTA or MRA Risk Factors: Smoking HTN Congenital abnormality Family history Age >40 Gender Drug use Image 5

Intracranial Aneurysm: Prognosis 4, 6 -8 SAH due to ruptured aneurysm has poor prognosis Treatment vs serial imaging Endovascular coiling vs. open surgical clipping Considerations: risk of hemorrhage, size and location, age and health of patient, family history, surgical risks, patient preference Predictors of rupture: smoking, size of aneurysm (>10 mm), age Health-promoting behaviors & perceived stress

Intervention: Surgical vs Endovascular 5

Back to Mrs. W…

Intervention: Conservative Management Plan of Care HEP Manual Therapy Chin Retractions & Scap Squeezes (10 x 10) Postural Education Upper Trap/LS/Pecs stretch (3 x 30 seconds) Therapeutic Exercise Shoulder Ext, IR/ER w/ Theraband (3 x 30) Images 9 -11

Evidence-Based Practice 12, 13 Strong evidence: Multimodal approaches (stretching/strengthening, mobilizations/manipulation) reduced pain, improved function, and resulted in favorable Global Perceived Effect in the long term Moderate evidence: Direct neck strengthening and stretching exercises for chronic mechanical neck disorders Reduce Headache: Cervical spine manipulation and mobilization Strengthening Postural of neck and upper quarter muscles education

Outcome Measures 14 Neck Disability Index (NDI) Patient Specific Functional Scale Disabilities Headache of the Arm, Shoulder, Hand (DASH) Disability Index Depression Anxiety Stress Scale (DASS)

Outcome Mrs. W only came for three visits… Reported lessening of sx after first couple treatments Having another MRA in a couple months to monitor aneurysm Did not have a chance to reassess ROM or progress with any of her goals

Bibliography 1. Lestini WF, Wiesel SW. The pathogenesis of cervical spondylosis. Clin Orthop Relat Res 1989; (239): 69 -93. 2. Robinson J, Kothari MJ. Clinical features and diagnosis of cervical radiculopathy. Up To Date 2018. Available at: https: //www-uptodate-com. libproxy. lib. unc. edu/contents/clinicalfeatures-and-diagnosis-of-cervicalradiculopathy? search=cervical%20 spondylosis&section. Rank=1&usage_type=default&anchor=H 7& source=machine. Learning&selected. Title=1~33&display_rank=1#H 7. Accessed November 27, 2018. 3. Cervical Spondylosis | Neck Pain | Tests and Treatment. Available at: https: //www. healthclues. net/cervical-spondylosis. Accessed November 27, 2018. 4. Brain Aneurysm Basics – Brain Aneurysm Foundation. Available at: https: //www. bafound. org/about-brain-aneurysms/brain-aneurysm-basics/. Accessed November 25, 2018. 5. Brown RD, Broderick JP. Unruptured intracranial aneurysms: epidemiology, natural history, management options, and familial screening. Lancet Neurol 2014; 13(4): 393 -404. doi: 10. 1016/S 1474 -4422(14)70015 -8. 6. Juvela S, Porras M, Poussa K. Natural history of unruptured intracranial aneurysms: probability of and risk factors for aneurysm rupture. J Neurosurg 2000; 93(3): 379 -387. doi: 10. 3171/jns. 2000. 93. 3. 0379.

Bibliography 7. Jeong HW, Seo JH, Kim ST, Jung CK, Suh S-I. Clinical practice guideline for the management of intracranial aneurysms. Neurointervention 2014; 9(2): 63 -71. doi: 10. 5469/neuroint. 2014. 9. 2. 63. 8. Lee M-S, Park CG, Hughes TL, Jun S-E, Whang K, Kim N. The predictive role of health-promoting behaviours and perceived stress in aneurysmal rupture. J Clin Nurs 2018; 27(5 -6): e 1068 -e 1077. doi: 10. 1111/jocn. 14149. 9. The Center for Total Back Care Top Neck and Shoulder Stretches: Trapezius Stretch - The Center for Total Back Care. Available at: http: //totalback. com/top-neck-shoulder-stretches-trapeziusstretch/. Accessed November 27, 2018. 10. Levator scapulae stretch. Available at: http: //www. physiowarzish. in/levator-scapulaestretch. html. Accessed November 27, 2018. 11. Doorway Pectoral Stretch (Flexibility) | Saint Luke’s Health System. Available at: https: //www. saintlukeskc. org/health-library/doorway-pectoral-stretch-flexibility. Accessed November 27, 2018. 12. Gross AR, Goldsmith C, Hoving JL, et al. Conservative management of mechanical neck disorders: a systematic review. J Rheumatol 2007; 34(5): 1083 -1102. 13. Childs JD, Fritz JM, Piva SR, Whitman JM. Proposal of a classification system for patients with neck pain. J Orthop Sports Phys Ther 2004; 34(11): 686 -96; discussion 697. doi: 10. 2519/jospt. 2004. 34. 11. 686. 14. Macdermid JC, Walton DM, Côté P, et al. Use of outcome measures in managing neck pain: an international multidisciplinary survey. Open Orthop J 2013; 7: 506 -520. doi: 10. 2174/1874325001307010506.