Surgical Considerations for the UE - Cervical Radiculopathy Flashcards
When is surgery indicated?
If conservative treatment fails over time over a reasonable time frame (2 to 3 months), dependent on:
- Response from PT
- Patient participation requirements
- Effectiveness of other treatment (Meds, injections, biologics)
- Worsening of neurological symptoms
What are 2 common surgical procedures to alleviate cervical radiculopathy?
- Cervical Laminectomy: this is where the corresponding cervical level’s lamina is removed, decreasing the compression of the nerve roots
- Cervical Discectomy and fusion
There’s an anterior and posterior approach
-Anterior is the most common
What takes place with an Anterior Discetomy and Fusion (ACDF) and what are the complications?
- There is an anterior incision that corresponds to the appropriate cervical vertebra level and between SCM muscles and the tracheoesophageal viscera. The appropriate disc is then excised out of the intervertebral space
- This vertebra is then plated, screwed or grafted using an anchoring angle of 30° upward and 10° outward
- If a bone graft is utilized, the graft can an autograft, allograft or synthetic (A typical autograft site is from the Iliac Crest)
With complications, the anatomy of the region should always be considered such as the vertebral artery, sympathetic chain, major BV and the corresponding nerve roots
When doing the Subjective on a Post-Op patient, what important information should we gather?
- We must do a Red/Yellow flag screening
- We must understand the full scope ot the surgeon
-Such as restrictions and the parameters of wearing the C-collar - We must ask if they will be working while rehabbing
- And must ask what level of activity they need to get back to
We can not get the info from the patient, then we must reach out to the surgeon so we can treat the patient safely
What are the Primary, Secondary and Tertiary structures affected by surgery?
Primary:
- Vertebra of the C-Spine
- Intervertebral discs
Secondary:
- Nerve roots (but are the primary tissue causing the patients pain and ADLs) and immediate surrounding tissues
Tertiary:
- Surrounding tissues disrupted by surgery to access the primary tissue
The amount of tissue disrupted during surgery can result in considerable pain, stiffness, weakness, hoarseness of voice, difficulty swallowing and kinesophobia. EDUCATION ON WHY THEY FEEL THESE Sx ARE IMPORTANT
What would take place in the Physical Examination, what do you expect to see?
- Integumentary Exam
-We would see redess, swelling and possible some ecchymosis around the incision. We must look for necrosis, excessive tenderness or endema, increased heat and drainage
-Before and after each treatment session - Neurological Exam
-May find sensation deficits based on severity of prior Sx
-Get the baseline for dermatomes and myotomes based on affected levels - Cervical AROM/PROM
-All directions will be limited due to pain and/or fear - Palpation
-Tenderness to palpate (TTP) of cervical paraspinals, suboccipital - Resisted Testing (if allowed)
-This would give an idea of their muscle activation ability
-If MMT is performed, it would be submaximal
What are the Prognostic Factors?
- Natural Hx
-The bodies ability to heal itself over time - Primary tissue healing time
-Bone, may take 6-8 weeks - Return to activity/sport timeline
-Highly variable based on patient’s activities and participations
-For improved outcomes, rehab may last 6 months
Clinical Rehab for Cervical Discectomy and Fusion
What is Phase 1? What is the timeline, primary pain mechanism and Goals?
Phase 1 - Protected Motion
- From weeks 0-4
- Patients will be in the acute stage and inflammatory phase of tissue healing
- Their primary pain mechanism will be nociceptive from the trauma of the surgical procedure and will include both somatic and deep somatic mechanisms. It is possible to have neuropathic pain due to nerve root irriatation
- The Goal is to protect the procedure, pain and swelling controland return to basic ADLs independently
Clinical Rehab for Cervical Discectomy and Fusion
What is Phase 2? What is the timeline, primary pain mechanism and goal?
Phase 2 - Progressive Loading/Strengthening Phase
- From weeks 4-8
- Patients will be in the subacute and proliferative phase of healing
- The primary pain mechanism will be the same as phase 1, but with decreased severity and sensitivity allowing for more activity in rehab
- The Goal is to regain full active ROM, increase strength and normalize cervical and UE movement patterns
Clinical Rehab for Cervical Discectomy and Fusion
What is Phase 3? What is the timeline, primary pain mechanims and goals?
Phase 3 - Functional and Sensorimotor Training
- From weeks 8-12 or more if necessary
- There should be no pain Sx in this phase, chronic stage of condition and phase of healing would be remodeling
- The goal is to return all other desired participation activities safely
What are the precautions of Phase 1?
- Soft or hard collar worn at all times
- Typically, no showering for 2-3 days post-op
- Avoid all sudden neck movements and limit cervical extension
- No lifting more than 2-5 lbs (or as directed by surgeon)
- No reaching above 90°
- Focus on proper posture
What Interventions take place in Phase 1?
What is the Criteria to progress to Phase 2?
- Manual Therapy
-Gental STM to suboccipitals, cervical paraspinals and SCM to reduce muscle guarding and improve ROM - Gentle AROM
-Flexion and Rotation, to reduce stiffness and avoid kinesoiphobia - Deep neck flexor training
- Education on pain management and post-operative restrictions
Criteria to progress to phase 2 is independence with ADLs and well-controlled pain symptoms
What are the Precautions of Phase 2?
- Continue to protect fusion and control pain
- Avoid lifting >10lbs (or as directed by surgeon)
- Increase A/PROM to full
- Normalize movement patterns
- Increase endurance
- Progressive strengthening
What interventions take place in Phase 2?
What is the Criteria to progress to Phase 3?
- Manual Therapy
-STM to cervical musculature
-Cervical/thoracic mobilizations above or below the fusion - Continue to progress A/PROM
- Isometric strengthening of neck musculature
-Flexion, extension, rotation and side-bending - Shoulder and periscapular strengthening
- Introduce functional activities
-Based on patients activity and/or participation limitations - Education on activity modifications to avoid prokoing or agg Sx
Critera to progress to Phase 3 is the ability to safely lift 10lbs, normal UE and scapular movement pattern and no pain symptoms
What are the precautions of Phase 3?
- Progress neck strengthening exercises
- Improve movement patterns and muscular endurance
- Create a long-term home exercise program
- Return to all functional activities
