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Suggest Treatment For Right Sided Arm Pain And Weakness
Question: Chief complaints/History of present Illness
This is a 50-year-old male who presented with complaints of severe right sided arm pain brachialgia with weakness. Currently it is around 3 years but for the last 1 year the patient deteriorated. He did MRI at Al Garhoud Hospital and previously did physical therapy. He was treated by Tramal, Neurontin, Lyrica and Arcoxia.
MRI done showed DDD bulge disc at the level C6-C7 with C7 exiting nerve root compression right and severe C7 radiculopathy right. On follow up visit, the patient did nerve conducting study which is normal and X-ray of the C-spine which shows osteoarthritis C-spine with ossification of all posterior composite osteophyte and symptomatic disc disease C6-C7.
Currently the patient prefers selective nerve root block by dorsal root ganglion pulse radiofrequency C7 on the right side. He has to perform middle electromyography because previously he did only nerve conducting study as a neurophysiological investigation.
Past medical/surgical history
• Nothing significant.
Clinical examination
• His cervical spine does not show any mal alignment.
• There is persistent localized right arm pain with weakness in the upper limbs.
• Neurological examination shows severe C7 radiculopathy right. Reflexes are absent in the right upper limb there is weakness.
• Adson sign is positive and there is no any misalignment for the C-spine.
• The axial rotation and forward bending is pain provocative.
MRI Cervical spine (30/07/2015)
• Posterior and left posterolateral C5-C6 disc bulge/protrusion.
• C6-C7 shows posterior and right posterolateral disc bulge/protrusion.
• Diffuse annular bulge at C3-C4.
EMG and Nerve conduction studies report (08/29/2015)
• Motor, sensory and late responses are normal in both arms.
• Needle EMG in right triceps muscle showed fibrillation potentials and positive sharp waves along with reduced recruitment.
• Needle EMG in right extensor digitorum communis muscle showed large polyphasic motor units along with reduced recruitment.
• The rest of needle EMG is normal.
• Impression: This study is consistent with active and chronic right C7 radiculopathy.
Diagnosis
• Herniated nucleus pulposus C6-C7 right.
• C7 radiculopathy right with weakness.
Hospital plan
o Procedure: Dorsal root ganglion - Pulsed radiofrequency (DRG-PRF)
o Indication: Herniated nucleus pulposus C6-C7 right with C7 radiculopathy right with weakness.
Concern:
the requested procedure is not recommended as per international guidelines and have little evidence for the improvement of symptoms. Would like you to confirm if the requested procedure is adviced or not and is FDA approved or not.
This is a 50-year-old male who presented with complaints of severe right sided arm pain brachialgia with weakness. Currently it is around 3 years but for the last 1 year the patient deteriorated. He did MRI at Al Garhoud Hospital and previously did physical therapy. He was treated by Tramal, Neurontin, Lyrica and Arcoxia.
MRI done showed DDD bulge disc at the level C6-C7 with C7 exiting nerve root compression right and severe C7 radiculopathy right. On follow up visit, the patient did nerve conducting study which is normal and X-ray of the C-spine which shows osteoarthritis C-spine with ossification of all posterior composite osteophyte and symptomatic disc disease C6-C7.
Currently the patient prefers selective nerve root block by dorsal root ganglion pulse radiofrequency C7 on the right side. He has to perform middle electromyography because previously he did only nerve conducting study as a neurophysiological investigation.
Past medical/surgical history
• Nothing significant.
Clinical examination
• His cervical spine does not show any mal alignment.
• There is persistent localized right arm pain with weakness in the upper limbs.
• Neurological examination shows severe C7 radiculopathy right. Reflexes are absent in the right upper limb there is weakness.
• Adson sign is positive and there is no any misalignment for the C-spine.
• The axial rotation and forward bending is pain provocative.
MRI Cervical spine (30/07/2015)
• Posterior and left posterolateral C5-C6 disc bulge/protrusion.
• C6-C7 shows posterior and right posterolateral disc bulge/protrusion.
• Diffuse annular bulge at C3-C4.
EMG and Nerve conduction studies report (08/29/2015)
• Motor, sensory and late responses are normal in both arms.
• Needle EMG in right triceps muscle showed fibrillation potentials and positive sharp waves along with reduced recruitment.
• Needle EMG in right extensor digitorum communis muscle showed large polyphasic motor units along with reduced recruitment.
• The rest of needle EMG is normal.
• Impression: This study is consistent with active and chronic right C7 radiculopathy.
Diagnosis
• Herniated nucleus pulposus C6-C7 right.
• C7 radiculopathy right with weakness.
Hospital plan
o Procedure: Dorsal root ganglion - Pulsed radiofrequency (DRG-PRF)
o Indication: Herniated nucleus pulposus C6-C7 right with C7 radiculopathy right with weakness.
Concern:
the requested procedure is not recommended as per international guidelines and have little evidence for the improvement of symptoms. Would like you to confirm if the requested procedure is adviced or not and is FDA approved or not.
Brief Answer:
DRG-PRF is yet to be clinically approved.
Detailed Answer:
Hello, Sir.
I understand your concern.
I have gone through your uploaded images as well.
Yes certainly your inference with regards to DRG-PRF.
A double-blind sham-controlled randomized clinical trial found that pulsed radiofrequency treatment of the cervical dorsal root ganglion may provide pain relief for a limited number of carefully selected patients with chronic cervical radicular pain
In summary, there is currently insufficient evidence to support the use of PRF in the treatment of various chronic pain syndromes including cervical radiculopathy.
Well-designed studies (prospective, randomized, placebo-controlled trials with large sample size and long-term follow-up) are needed to ascertain the clinical value of this approach.
This is yet to be approved by FDA.
In the presence of significant disc bulge causing nerve compression and weakness, it is advisable to go one of these open surgical procedures.
Surgery is best indicated in patients with radiculopathy with clearly identified pathology — for example, single-level disc herniation that correlates with the findings on history and physical examination.
Procedures include laminectomy, discectomy, corpectomy, and fusion. With appropriate indications, surgery can result in resolution of symptoms and excellent outcomes in the majority of patients.
DRG-PRF is yet to be clinically approved.
Detailed Answer:
Hello, Sir.
I understand your concern.
I have gone through your uploaded images as well.
Yes certainly your inference with regards to DRG-PRF.
A double-blind sham-controlled randomized clinical trial found that pulsed radiofrequency treatment of the cervical dorsal root ganglion may provide pain relief for a limited number of carefully selected patients with chronic cervical radicular pain
In summary, there is currently insufficient evidence to support the use of PRF in the treatment of various chronic pain syndromes including cervical radiculopathy.
Well-designed studies (prospective, randomized, placebo-controlled trials with large sample size and long-term follow-up) are needed to ascertain the clinical value of this approach.
This is yet to be approved by FDA.
In the presence of significant disc bulge causing nerve compression and weakness, it is advisable to go one of these open surgical procedures.
Surgery is best indicated in patients with radiculopathy with clearly identified pathology — for example, single-level disc herniation that correlates with the findings on history and physical examination.
Procedures include laminectomy, discectomy, corpectomy, and fusion. With appropriate indications, surgery can result in resolution of symptoms and excellent outcomes in the majority of patients.
Note: For further queries, consult a joint and bone specialist, an Orthopaedic surgeon. Book a Call now.
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
Answered by
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