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Cervical Spine Anatomy

A Patient’s Guide to Cervical Spine Anatomy

Introduction

Knowing the main parts of your neck and how these parts work is important as you learn to care for your neck problem.

Two common anatomic terms are useful as they relate to the neck. The term anterior refers to the front of the neck. The term posterior refers to the back of the neck. The part of the spine that moves through the neck is called the cervical spine. The front of the neck is therefore called the anterior cervical area. The back of the neck is called the posterior cervical area.

In addition to reading this article, be sure to watch our Cervical Spine Anatomy Animated Tutorial Video.

This guide gives a general overview of the anatomy of the neck. It should help you understand

what parts make up the neck
how these parts work

Important Structures

The important parts of the cervical spine include

bones and joints
nerves
connective tissues
muscles
spinal segments

This section highlights important structures in each category.

Bones and Joints

The human spine is made up of 24 spinal bones, called vertebrae. Vertebrae are stacked on top of one another to form the spinal column. The spinal column is the body’s main upright support.

The first seven vertebrae make up the cervical spine. Doctors often refer to these vertebrae as C1 to C7. The cervical spine starts where the top vertebra (C1) connects to the bottom of the skull. The cervical spine curves slightly inward and ends where C7 joins the top of the thoracic spine (the chest area).

The base of the skull sits on top of C1, also called the atlas. Two thickened bony arches form a large hole through the center of the atlas. The opening is large because the spinal cord is wider where it first exits the brain and skull. Compared to other vertebrae, the atlas also has much wider bony projections pointing out to each side.

The atlas sits on top of the C2 vertebra. The C2 is called the axis. The axis has a large bony knob on top, called the dens. The dens points up and fits through a hole in the atlas. The joints of the axis give the neck most of its ability to turn to the left and right.

Each vertebra is made of the same parts. The main section of each cervical vertebra, from C2 to C7, is formed by a round block of bone, called the vertebral body. A bony ring attaches to the back of the vertebral body. This ring has two parts. Two pedicle bones connect directly to the back of the vertebral body. Two lamina bones join the pedicles to complete the ring. The lamina bones form the outer rim of the bony ring. When the vertebrae are stacked on top of each other, the bony rings form a hollow tube that surrounds the spinal cord. The laminae provide a protective roof over the spinal cord.

A bony knob projects out at the point where the two lamina bones join together at the back of the spine. These projections, called spinous processes, can be felt as you rub your fingers up and down the back of your spine. The largest bump near the top of your spine is the spinous process of C2. At the base of the neck where the cervical and thoracic spines join together, you’ll feel another large spinous process. That’s C7.

Each vertebra in the spine has two bony knobs that point out to the side, one on the left and one on the right. These bony projections are called transverse processes. The atlas has the widest transverse processes of all the cervical vertebrae. Unlike the rest of the spine, the neck vertebrae have a hole that passes down through each transverse process. This hole, called the transverse foramen, provides a passageway for arteries that run up each side of the neck to supply the back of the brain with blood.

Between each pair of vertebrae are two joints called facet joints. These joints connect the vertebrae together in a chain but slide against one another to allow the neck to move in many directions. Except for the very top and bottom of the spinal column, each vertebra has two facet joints on each side. The ones on top connect to the vertebra above; the ones below join with the vertebra below.

The surfaces of the facet joints are covered by articular cartilage. Articular cartilage is a smooth, rubbery material that covers the ends of most joints. It allows the ends of bones to move against each other smoothly, without friction.

On the left and right side of each vertebra is a small tunnel called a neural foramen. (Foramina is the plural term.) The two nerves that leave the spine at each vertebra go through the foramina, one on the left and one on the right. The intervertebral disc (described later) sits directly in front of the opening. A bulged or herniated disc can narrow the opening and put pressure on the nerve. A facet joint sits in back of the foramen. Bone spurs that form on the facet joint can project into the tunnel, narrowing the hole and pinching the nerve.

Nerves

The hollow tube formed by the bony ring on the back of the spinal column surrounds the spinal cord as it passes through the spine. The spinal cord is a similar to a long wire made up of millions of nerve fibers. Just as the skull protects the brain, the bones of the spinal column protect the spinal cord.

The spinal cord travels down from the brain through the spinal column. Two large nerves branch off the spinal cord from each vertebra, one on the left and one on the right. The nerves pass through the neural foramina. These spinal nerves group together to form the main nerves that go to the limbs and organs. The nerves that come out of the cervical spine go to the arms and hands.

Connective Tissues

Ligaments are strong connective tissues that attach bones to other bones. (Connective tissues are networks of fiber that hold the cells of the body together.) Several long ligaments connect on the front and back sections of the vertebrae. The anterior longitudinal ligament runs lengthwise down the front of the vertebral bodies. Two other ligaments run full length within the spinal canal. The posterior longitudinal ligament attaches on the back of the vertebral bodies. The ligamentum flavum is a long elastic band that connects to the front surface of the lamina bones.

A special type of structure in the spine called an intervertebral disc is also made of connective tissue. The fibers of the disc are formed by special cells, called collagen cells. The fibers may be lined up like strands of nylon rope or crisscrossed like a net.

An intervertebral disc is made of two parts. The center, called the nucleus, is spongy. It provides most of the shock absorption in the spine. The nucleus is held in place by the annulus, a series of strong ligament rings surrounding it.

Muscles

The anterior cervical area is covered with muscles that run from the rib cage and collar bone to the cervical vertebrae, jaw, and skull. The posterior cervical muscles cover the bones along the back of the spine and make up the bulk of the tissues on the back of the neck.

Spinal Segment

A good way to understand the anatomy of the cervical spine is by looking at a spinal segment. Each spinal segment includes two vertebrae separated by an intervertebral disc, the nerves that leave the spinal cord at each vertebra, and the small facet joints that link each level of the spinal column.

The intervertebral disc separates the two vertebral bodies of the spinal segment. The disc normally works like a shock absorber. It protects the spine against the daily pull of gravity. It also protects the spine during heavy activities that put strong force on the spine, such as jumping, running, and lifting.

The spinal segment is connected by a facet joint, described earlier. When the facet joints of the cervical spine move together, they bend and turn the neck.

Summary

Many important parts make up the anatomy of the neck. Understanding the regions and structures of the neck can help you be more involved in your health care and better able to care for your neck problem.

Scheuermann’s Disease

A Patient’s Guide to Scheuermann’s Disease

Introduction

The section of spine from below the neck to the bottom of the rib cage is called the thoracic spine. From the side, the thoracic spine appears slightly rounded. Its shape is like the letter “C” with the opening facing the front of the body. This normal curve is called kyphosis. With excessive kyphosis, the thoracic spine takes on a hunchbacked appearance.

Scheuermann’s disease (also called Scheuermann’s kyphosis) is a condition that starts in childhood. It affects less than one percent of the population and occurs mostly in children between the ages of 10 and 12. It affects boys and girls with a slightly higher number of boys affected. Those who do not get proper treatment for the condition during childhood often experience back pain from the spinal deformity as adults. Sometimes Scheuermann’s disease doesn’t develop until adulthood.

This guide will help you understand

how the problem develops
how doctors diagnose the condition
what treatment options are available

Anatomy

What parts of the spine are involved?

A healthy human spine has three gradual curves. From the side, the neck and low back curve gently inward. This is called lordosis. The thoracic kyphosis (outward curve) gives the mid back its slightly rounded appearance. These normal curves help the spine absorb forces from gravity and daily activities, such as lifting.

The angle of normal kyphosis in the thoracic spine varies. During the growth years of adolescence, a normal curve measures between 25 and 40 degrees. If the curve angles more than 40 degrees, doctors consider the kyphosis a deformity. In general, kyphosis tends to be more exaggerated in girls. The angle increases slightly throughout life both in women and men. Scheuermann’s disease causes the thoracic kyphosis to angle too far (more than 45 degrees).

The 12 thoracic vertebrae are known as T1 to T12. The main section of each thoracic vertebra is a round block of bone, called a vertebral body. A ring of bone attaches to the back of the vertebral body. This ring surrounds and protects the spinal cord.

In Scheuermann’s disease, the front of the vertebral body becomes wedge-shaped, possibly from abnormal growth. This produces a triangular-shaped vertebral body, with the narrow, wedged part closest to the front of the body. The wedge puts a bigger bend in the kyphosis of the thoracic spine.

The vertebral bodies are separated by a cushion, called an intervertebral disc. Between each disc and vertebral body is a vertebral end plate. Sometimes one or more discs in patients with Scheuermann’s disease squeeze through the vertebral end plate, which is often weaker in patients with Scheuermann’s disease. This forms pockets of disc material inside the vertebral body, a condition called Schmorl’s nodes.

A long ligament called the anterior longitudinal ligament connects on the front of the vertebral bodies. This ligament typically thickens in patients with Scheuermann’s disease. This adds to the forward pull on the spine, producing more wedging and kyphosis.

The disease usually produces kyphosis in the middle section of the thorax (the chest), between the shoulder blades. The condition sometimes causes kyphosis in the lower part of the thoracic spine, near the bottom of the rib cage.

Causes

Why do I have this problem?

Famed for discovering this disease, Scheuermann himself thought a lack of blood to the cartilage around the vertebral body caused the wedging. Though scientists have since disproved this theory, the root cause of the disease is still unknown.

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Mounting evidence suggests wedging develops as a problem vertebral body grows. During normal growth, the cartilage around the vertebral body turns evenly and completely to bone. If the change from cartilage to bone doesn’t happen evenly, one side of the vertebral body grows at a faster rate. By the time the entire vertebral body turns to bone, one side is taller than the other. This is the wedge shape that leads to abnormal kyphosis.

Other theories of how Scheuermann’s kyphosis starts include

genetics
childhood osteoporosis
mechanical reasons

Genetics

Researchers have suggested that this disease can be passed down in families. Studies have shown multiple families who have passed the disease through inheritance of certain types of genes. The genetic link is uncommon but remains under investigation.

Childhood Osteoporosis

One medical study found that some patients with Scheuermann’s disease had mild osteoporosis (decreased bone mass) even though they were very young. Other studies did not show problems with osteoporosis. More research is needed to confirm the role of osteoporosis in Scheuermann’s disease.

Related Document: A Patient’s Guide to Osteoporosis

Mechanical Reasons

These include strains from bending, heavy lifting, and using poor posture. This theory makes sense because the back braces used in treating kyphosis work. If a back brace can straighten a bent spine, then perhaps mechanical forces could cause more kyphosis than naturally occurs in the spine. (Back braces are discussed in more detail later.) Some experts think that tight hamstring muscles (along the back of the thigh) pull on the pelvis contributing to spinal deformity.

Scientists are not convinced that mechanical reasons cause the disease; rather, these factors likely aggravate the condition. And in some cases, it is difficult to tell which came first: the mechanical changes causing the deformity or the deformity resulting in the anatomical and thus mechanical changes.

Other Reasons

Other theories put forth that might help explain the cause(s) of Scheuermann’s disease include biochemical changes in the collagen that make up the end-plates altering bone growth, above-average disc height, and increased levels of growth hormone.

Symptoms

What does the condition feel like?

Hunched posture or a round back in children usually alerts parents or teachers to the need for a doctor visit. Children don’t typically complain of back pain or other symptoms.

This is not the case in adolescents who are nearing puberty and have kyphosis in the lowest part of the thorax, near the bottom of the rib cage. In these patients, back pain is the overriding problem. This happens most often to young, active males. Doctors suspect this unique form of the disease occurs because the condition is overlooked during childhood, delaying treatment.

Adults who’ve lived with the hunched posture for many years may note worsening pain. They may be disturbed by the physical changes and deformity that develop.The pain and/or the physical changes typically causes them to seek medical help.

Besides having a forward curved spine, most people affected by Scheuermann’s report back pain, stiffness, and loss of flexibility. The neck and low back try to compensate by increasing the natural lordotic curves in these two areas. Since the person cannot straighten the thoracic spine, the cervical and lumbar spines increase their curves to compensate for the round back. All of these changes in posture are usually accompanied by tight shoulder, hip, and leg muscles.

Degenerative spondylosis is also reported as part of the natural history in middle-aged adults with Scheuermann’s kyphosis. Degenerative changes in the spine (usually from aging) can cause bone spurs to form around the spinal joints. The joint spaces start to narrow. This condition is called spondylosis, which can also contribute to pain and stiffness.

Patients of all ages who experience pain generally report feeling discomfort along the sides of the spine, slightly below the main part of the abnormal curve.

Exaggerated kyphosis can lead to an increased lordosis (inward curve) in the low back. This puts extra strain on the tissues of the low back. Over many years, this added wear and tear may produce low back pain. This mainly occurs in adults who have extra lumbar lordosis from years of untreated Scheuermann’s disease.

In rare cases, the spinal cord is affected. A severe kyphosis stretches the spinal cord over the top of the curve. This can injure the spinal cord. Also, patients with Scheuermann’s disease have a greater chance of having a herniated thoracic disc. This is where the disc material from inside the disc begins to squeeze out and press on the spinal cord. Spinal cord symptoms for both situations include sensations of pins and needles and numbness. The leg muscles may feel weak. Symptoms from an injured spinal cord can also include changes in bowel and bladder function.

When the kyphosis angle exceeds 100 degrees (rare), the sharply bent spine puts pressure on the heart, lungs, and intestines. When this occurs, patients may tire quickly, suffer shortness of breath, feel chest pain, and lose their appetite.

Diagnosis

How do doctors diagnose the problem?

Doctors start with a complete history and physical examination. However, X-rays are the main way to diagnose Scheuermann’s kyphosis. Taken from the side, an X-ray may show vertebral wedging, Schmorl’s nodes, and changes in the vertebral end plates. Doctors use X-ray images to measure the angle of kyphosis. Doctors diagnose Scheuermann’s disease when three vertebrae in a row wedge five degrees or more and when the kyphosis angle is greater than 45 degrees.

Scheuermann’s disease or kyphosis is diagnosed as either being typical (Type I) or atypical (Type II). These two forms of the disease affect different parts of the spine. The typical form (most common type) has the thoracic kyphotic pattern described in this section. The lower (lumbar) spine compensates by becoming hyperlordotic. Lordosis is the spinal curve exactly opposite of kyphosis. Hyperlordotic means the curve increases beyond what is considered “normal.”

The atypical form of Scheuermann’s (Type II) affects the low back known as the lumbar spine. The upper lumbar spine (where the thoracic spine transitions to become the lumbar spine) is involved. Type II is seen most often in young boys before puberty who are active in sports activities. They experience pain that goes away with rest and change in position or activity level.

A side-view X-ray can also show if the spine is flexible or rigid. Patients are asked to bend back and hold the position while an X-ray is taken. The spine straightens easily when it is flexible. In patients with Scheuermann’s disease, however, the curve stays rigid and does not improve by trying to straighten up.

From the front, X-rays show if the spine curves from side to side. This sideways curve is called scoliosis and occurs in about one-third of patients with Scheuermann’s kyphosis.

X-rays can show signs of wear and tear in adults who have extra lumbar lordosis from years of untreated Scheuermann’s disease.

Computed tomography (a CT scan) may be ordered. This is a detailed X-ray that lets doctors see slices of the body’s tissue.

Myelography is a special kind of X-ray test. For this test, dye is injected into the space around the spinal canal. The dye shows up on an X-ray. This test is especially helpful if the doctor is concerned whether the spinal cord is being affected.

Magnetic resonance imaging (MRI) uses magnetic waves rather than X-rays to show the soft tissues of the body. This machine creates pictures that look like slices of the area the doctor is interested in. The test does not require special dye or a needle.

Treatment

What treatment options are available?

Nonsurgical Treatment

A child or youth with mild kyphosis may simply need to be observed. Unless the curve or pain becomes worse, no other treatment may be needed. Some children who don’t require treatment eventually improve and have no long-term problems. Others may always have a mild thoracic kyphosis but are able to function normally without pain or other problems.

If the doctor is concerned that the curve will worsen, he or she may suggest bracing and exercise. A brace is most effective when used before the skeleton matures at about age 14. Doctors commonly chose a Milwaukee brace, which is designed to hold the shoulders back and gradually straighten the thoracic curve. The brace won’t reverse the curve in a fully developed spine. Nor is it helpful for rigid curves that angle more than 75 degrees.

The Milwaukee brace is made of molded plastic that conforms to the waist. On the back, two upright, padded bars line up along the sides of the spine. Pressure from the upright bars straightens the spine. Patients usually remove the brace to shower, but they keep it on at night.

Younger patients (under 15) generally wear the brace all the time. The doctor adjusts the brace regularly as the curve improves. When the thoracic curve has improved enough, the brace is worn part-time (eight to 12 hours per day) until the skeleton is done growing, typically around age 14 or 15.

A physical therapist may show the patient recommended exercises. When used in combination with a brace, exercises appear to maximize the effect of the brace by strengthening muscles that help align the spine. Certain exercises, such as general conditioning and stretching, are also worthwhile for helping patients control pain. Core training for spinal stabilzation is an important part of the pain management program. However, exercises alone don’t reduce kyphosis in Scheuermann’s disease.

Doctors may prescribe anti-inflammatory medication for pain. Younger patients generally use this medicine on a short-term basis, in combination with other treatments. Adults who have ongoing pain sometimes require long-term use of anti-inflammatory medication. Sometimes adults obtain partial correction of the kyphosis and pain relief with bracing even though they have reached full bone growth. Bracing for pain relief in adults is also considered when surgery is not an option.

Surgery

Surgeons rarely recommend fusion surgery for Scheuermann’s disease. Certain situations may require it, however. For example, surgery may be needed if pain becomes severe and doesn’t go away with nonoperative treatment or if pressure on the spinal cord or spinal nerves is causing problems. Some people request surgery if the deformity is severe enough that their appearance causes them considerable psychologic and/or emotional distress.

Patients whose skeletons are done growing may require surgery. Patients with a rigid kyphosis that angles more than 75 degrees may also need surgery. The entire length of the kyphosis is fused.

Two procedures commonly used to treat thoracic kyphosis are

posterior fusion
combined fusion

Posterior Fusion

In a fusion operation, two or more bones are joined into one solid bone. Surgeons perform posterior fusion for Scheuermann’s disease on the rare patient who prefers not to use a brace and whose spine is still growing, is mildly flexible, and has a kyphosis of less than 65 degrees.

This surgery is done through the back (posterior) of the spine. After making an incision in the back, the surgeon applies pressure to straighten the kyphosis. Small strips of bone graft are then laid over the back of the spinal column. These strips encourage the bones to grow together. Metal rods are attached along the spine to prevent the vertebrae from moving. The rods hold the spine in better alignment and protect the bone graft so it can heal better and faster.

The posterior-only approach has the advantage of less blood loss than an anterior approach and does not interfere with major anterior blood supply to the spinal cord. Surgical time is shorter with the posterior-only method. Improved instrumentation and surgical technique has improved results for posterior-only fusions. Many more surgeons are using this approach with fewer problems even with more rigid curves.

Combined Fusion

Combined fusion is actually two fusion surgeries, one from the back (posterior) and one from the front (anterior) of the spine. In the past, two separate operations were needed, but now some surgeons do both fusions in the same operation. This surgery is commonly used if the spine is finished growing and the kyphosis angle is more than 75 degrees.

The surgeon starts with anterior fusion. With the patient on his or her side, the surgeon cuts away a piece of rib to make a small opening on the side of the thorax. The rib opening is spread apart so the surgeon can reach the spine better. The surgeon operates on the front of the spine through the chest cavity.

A section of the anterior longitudinal ligament is cut. This makes it easier to straighten the hunched spine. The intervertebral discs in the problem area are taken out, and the spaces between the wedged vertebrae are filled with bone graft. One method is to take a graft of bone from the pelvis and tamp it into the place of each removed disc. This requires another incision over one side of the pelvis. A second method is to grind up the piece of rib that was removed and place it in the disc spaces. As the grafts heal, the vertebrae become fused into solid bone.

The second part of surgery is an involved form of posterior fusion using special rods and hooks. This part of the operation can be done right after the anterior fusion or scheduled for one week later.

First, the surgeon makes an incision over the back of the spine. The skin and muscles are spread apart.

Then strips of bone graft are laid across each vertebra to be fused. Long rods are inserted along the sides of the spine. The rods have hooks attached on both ends. Wire is wrapped between the top and bottom hooks. Tightening the wires causes the spine to straighten. The rods help hold the spine steady as the bone grafts heal. The rods are usually left in permanently.

Rehabilitation

What should I expect as I recover?

Nonsurgical Rehabilitation

Children and adolescents treated nonsurgically sometimes work with a physical therapist. Certain exercises are beneficial when used in combination with a brace. Upper back exercises, such as gentle back bends (extension) can improve posture and prevent the spine from slouching forward. Hamstring stretches and pelvis exercises improve posture by preventing extra lordosis in the low back. Aerobic exercise improves heart and lung health and combats pain.

Pain is also addressed by the physical therapist. The therapist may apply heat, cold, ultrasound, and massage treatments. Adults who’ve had kyphosis for many years (and the resulting low back pain from too much lordosis) benefit from postural exercises to reduce the lumbar curve, followed by stabilization exercises to help them keep better posture. Patients benefit most when these exercises are done regularly and for a lifetime.

After Surgery

Rehabilitation after surgery is more complex. Although some patients leave the hospital shortly after surgery, some surgeries require patients to stay in the hospital for a few days. Soon after surgery, a physical therapist may visit patients who stay in the hospital. The treatment sessions help patients learn to move and do routine activities without putting extra strain on the back.

During recovery from surgery, patients should follow their surgeon’s instructions about wearing a back brace or support belt. They should be cautious about overdoing activities in the first few weeks after surgery.

Many surgical patients also need physical therapy outside of the hospital. Patients normally wait up to three months before beginning a rehabilitation program after fusion surgery for Scheuermann’s disease. They typically need to attend therapy sessions for eight to 12 weeks. Full recovery may take up to eight months.

Upon completing physical therapy, patients are in charge of doing their exercises as part of an ongoing home program. Final results are overall favorable following surgery. The majority of patients report being satisfied with their cosmetic appearance. Some patients even experience complete relief from their pain. There may be some low back pain or discomfort with strenuous activity. Complications are rare but can include infection, loss of correction, spinal cord injury or other neurologic problems. In a small number of cases, a second surgical procedure may be required.

Kyphoplasty

A Patient’s Guide to Kyphoplasty

Introduction

Patients with osteoporosis are prone to compression fractures in the spine bones, or vertebrae. The bone cracks under pressure, causing it to collapse in height. More than 700,000 such fractures occur every year in the United States.

The fracture angles the spine forward and produces a hunchbacked appearance, called kyphosis. Patients with this condition are subject to debilitating pain, disturbed sleep, decreased lung and intestinal function, and difficulty completing routine activities.

Kyphoplasty restores the size and strength of the fractured vertebra. This realigns the spine and reduces pain. Nearly 95 percent of patients get immediate relief of pain with this procedure.

This guide will help you understand

why the procedure becomes necessary
what surgeons hope to achieve with kyphoplasty
what to expect during recovery

Anatomy

What parts of the spine are involved?

The main section of each spine vertebra is a large, round structure called a vertebral body. Compression fractures cause the front portion of this round bone to collapse in height. Because the back section of the bone stays intact, the damaged vertebral body becomes wedge-shaped.

It is this wedge shape that angles the spine forward into kyphosis. The vertebral body is the main structure treated in the kyphoplasty procedure.

Rationale

What do surgeons hope to achieve with this procedure?

In the past, surgeons used standard open surgical procedures to fix compression fractures from osteoporosis. Open procedures require larger incisions to give the surgeon more room to operate. The results of open surgery for this condition have generally been poor, mainly because operating on bones that are weak and soft from osteoporosis is difficult. In addition, some aging adults with fractures may not be physically able to tolerate such a surgery.

Kyphoplasty gives surgeons a way to fix the broken bone without the problems associated with open surgery. Unlike open surgery, which involves an incision and the use of larger instruments, kyphoplasty is a minimally invasive procedure. It requires a small opening in the skin and small instruments. This lessens the chance of bleeding, infection, and injury to muscles and soft tissues.

The goal of kyphoplasty is to return the fractured vertebra as close as possible to its normal height. This is done by inflating a balloon inside the fractured bone to restore the vertebral body to its normal size. Special cement is then injected into the bone, fixing it in place. The cement strengthens the broken vertebra and stiffens it in its original height and position. This reduces pain and spine deformity (kyphosis), enabling patients to get back to normal activities.

Preparations

How will I prepare for the procedure?

The decision to proceed with kyphoplasty must be made jointly by you and your surgeon. You should understand as much about the procedure as possible. If you have concerns or questions, talk to your surgeon.

Kyphoplasty is normally done on an outpatient basis, meaning patients go home the same day as the surgery. You shouldn’t eat or drink anything after midnight the night before.

Surgical Procedure

What happens during the procedure?

The patient lies on his or her stomach. To begin, the surgeon cleans the skin on the back with an antiseptic. Then the skin over the problem area is numbed using an anesthetic. Patients may also receive general anesthesia to put them to sleep during the procedure.

Two small openings are made in the skin on each side of the spinal column. Long needles are inserted through the openings. The needles are passed completely through the back of the spinal column into the fractured vertebral body. These needles serve as guides while the surgeon drills two holes into the vertebral body. The surgeon uses a fluoroscope to make sure the needles and drill holes are placed in the right spot. A fluoroscope is a special X-ray television that allows the surgeon to see your spine on a screen.

The device works like a video, though the images are in the form of an X-ray. Metal objects show up clearly on X-rays. The needle is easy for the surgeon to see on the fluoroscope screen. This helps the surgeon know the needle goes into the correct spot.

A hollow tube with a deflated balloon on the end is then slid through each drill hole. The balloons are inflated with air. This restores the height of the vertebral body and corrects the kyphosis deformity.

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Next, the surgeon removes the balloon and injects bone cement into the hollow space formed by the balloon. A chemical reaction in the cement causes it to harden in about 15 minutes.

This fixes the bone in its corrected height and position. Bandages are then applied over the small incisions.

Complications

What might go wrong?

Serious complications from kyphoplasty are rare, involving less than five percent of cases. As with other procedures, however, complications can occur. Some of the most common complications of kyphoplasty include

problems with anesthesia
thrombophlebitis
infection
cement leakage
ongoing pain

This is not intended to be a complete list of the possible complications.

Problems with Anesthesia

Problems can arise when the anesthesia given during surgery causes a reaction with other drugs the patient is taking. In rare cases, a patient may have problems with the anesthesia itself. In addition, anesthesia can affect lung function because the lungs don’t expand as well while a person is under anesthesia. Be sure to discuss the risks and your concerns with your anesthesiologist.

Thrombophlebitis (Blood Clots)

View animation of pulmonary embolism

Thrombophlebitis, sometimes called deep venous thrombosis (DVT), can occur after any operation. It occurs when the blood in the large veins of the leg forms blood clots. This may cause the leg to swell and become warm to the touch and painful. If the blood clots in the veins break apart, they can travel to the lung, where they lodge in the capillaries and cut off the blood supply to a portion of the lung. This is called a pulmonary embolism. (Pulmonary means lung, and embolism refers to a fragment of something traveling through the vascular system.) Most surgeons take preventing DVT very seriously. There are many ways to reduce the risk of DVT, but probably the most effective is getting you moving as soon as possible. Two other commonly used preventative measures include

pressure stockings to keep the blood in the legs moving
medications that thin the blood and prevent blood clots from forming

Infection

Infection following spine procedures is rare but can be a very serious complication. Some infections may show up early, within the first few days after the procedure. Infections on the skin’s surface usually go away with antibiotics. Deeper infections that spread into the bones and soft tissues of the spine are harder to treat. They may require surgery to treat the infected portion of the spine.

Cement Leakage

The cement used in kyphoplasty is squeezed into the fractured vertebra in liquid form. Because it is injected at low pressure, cement leakage during kyphoplasty is rare. If some of the cement happens to leak out of the vertebra, it usually doesn’t cause any problems. Only rarely does a cement leak cause pressure on the spinal cord or nearby nerves. In these cases, surgery may be required to remove the pressure.

Ongoing Pain

Many patients get nearly complete relief of symptoms from kyphoplasty. As with any procedure, however, you should expect some pain afterward. If the pain continues or becomes unbearable, talk to your surgeon about treatments that can help control your pain.

After Surgery

What happens after surgery?

Patients are monitored in the recovery room for two to three hours after the procedure before going home. You are instructed to move your back only carefully and comfortably. Some patients who are feeling extra pain or other problems after kyphoplasty may need to stay in the hospital overnight.

Patients rarely need to wear a brace after kyphoplasty, since bone cement immediately improves the strength and stiffness in the fractured vertebra.

Rehabilitation

What should I expect as I recover?

The cement used to fix the broken vertebra hardens quickly, within about 15 minutes. As a result, people often find it easier to do daily activities within one week. Pain also decreases rapidly, and most people require less pain medication within two weeks. Despite these improvements, most orthopedists consider that it takes about three months for the bone to heal after kyphoplasty.

Patients are encouraged to walk and do moderate activity as they recover. However, they should avoid strenuous exertion until their surgeon approves resuming normal levels of activity.

When the fracture was from osteoporosis, the doctor will suggest ways to prevent future problems. Patients may be prescribed medications and supplements (calcium and vitamin D) to maximize bone health. Lifestyle changes, such as quitting smoking and taking up exercising, may also be discussed.

Related Document: A Patient’s Guide to Osteoporosis

Patients who continue to have problems with posture and pain or who have lost muscle tone and strength may need the help of a physical therapist. These patients typically need to attend therapy sessions for four to six weeks.

The goal of therapy is to safely advance strength and function.
The therapist may use treatments such as heat or ice, electrical stimulation, and massage to help calm pain. Gentle exercise is used to improve strength of the spine and limbs. Patients begin learning how to move safely using healthy postures to reduce strain on the healing back. Exercises for the heart and lungs improve stamina and help with pain control.

As the therapy sessions come to an end, the therapist helps patients get back to the activities they enjoy. Ideally, patients are able to resume normal activities. They may need guidance on which activities are safe or how to change the way they go about their activities.

When treatment is well under way, regular visits to the therapist’s office will end. The therapist will continue to be a resource. But patients are in charge of doing their exercises as part of an ongoing home program.

Thoracic Disc Herniation

A Patient’s Guide to Thoracic Disc Herniation

Introduction

A rise in the use of magnetic resonance imaging (MRI) has led to the discovery that many people, perhaps as many as 15 percent of Americans, have a thoracic disc herniation. Seeing a herniated thoracic disc on MRI is often incidental, meaning it shows up when the person has MRI testing for another problem.

Few people with a thoracic disc herniation feel any symptoms or have any problems as a result of this condition. In rare cases when symptoms do arise, the main concern is whether the herniated disc is affecting the spinal cord.

Although people often refer to a thoracic disc herniation as a slipped disc, the disc doesn’t actually slip out of place. Rather, the term herniation means that the material in the center of the disc has squeezed out of the normal space. In the thoracic spine, this condition mostly affects people between 40 and 60 years old.

This guide will help you understand

how the problem develops
how doctors diagnose the condition
what treatment options are available

Anatomy

What parts of the spine are involved?

The human spine is formed by 24 spinal bones, called vertebrae. Vertebrae are stacked on top of one another to create the spinal column. The main section of each vertebra is a round block of bone, called the vertebral body.

The thoracic spine is made up of the middle 12 vertebrae.

Doctors often refer to these vertebrae as T1 to T12. The thoracic spine starts at the base of the neck. The lowest vertebra of the thoracic spine, T12, connects below the bottom of the rib cage to the first vertebra of the lumbar spine, called L1.

The upper half of the thoracic spine is much less mobile than the lower section, making disc herniations in the upper thoracic spine rare. About 75 percent of thoracic disc herniations occur from T8 to T12, with the majority affecting T11 and T12.

The intervertebral disc is a specialized connective tissue structure that separates the vertebral bodies. The disc is made of two parts. The center, called the nucleus, is spongy. It provides most of the disc’s ability to absorb shock. The nucleus is held in place by the annulus, a series of ligament rings surrounding it. Ligaments are strong connective tissues that attach bones to other bones.

Healthy discs work like shock absorbers to cushion the spine. They protect the spine against the daily pull of gravity and during activities that put strong force on the spine, such as jumping, running, and lifting.

The spinal canal is a hollow tube inside the spinal column. It surrounds the spinal cord as it passes through the spine. The spinal cord is similar to a long wire made up of millions of nerve fibers. Just as the skull protects the brain, the bones of the spinal column protect the spinal cord. The spinal canal is narrow in the thoracic spine. Any condition that takes up extra space inside this canal can injure the spinal cord.

Blood vessels that run up and down the spine nourish the spinal cord. However, only one vessel, the anterior spinal artery, goes to the front of the spinal cord in the area between T4 and T9. Doctors call this section of the spine the critical zone. If this single vessel is damaged, as can happen with pressure from a herniated thoracic disc, the spinal cord has no other way to get blood. Left untreated, this section of the spinal cord dies, which can lead to severe problems of weakness or paralysis below the waist.

Causes

Why do I have this problem?

View animation of degeneration

Thoracic disc herniations are mainly caused by wear and tear in the disc. This wear and tear is known as degeneration. As a disc’s annulus ages, it tends to crack and tear. These injuries are repaired with scar tissue. Over time the annulus weakens, and the nucleus may squeeze (herniate) through the damaged annulus. Spine degeneration is common in T11 and T12. T12 is where the thoracic and lumbar spine meet. This link is subject to forces from daily activity, such as bending and twisting, which lead to degeneration. Not surprisingly, most thoracic disc herniations occur in this area.

Less commonly, a thoracic disc may herniate suddenly (an acute injury). A thoracic disc may herniate during a car accident or a fall. A thoracic disc may also herniate as a result of a sudden and forceful twist of the mid-back.

Diseases of the thoracic spine may lead to thoracic disc herniation. Patients with Scheuermann’s disease, for example, are more likely to suffer thoracic disc herniations. It appears these patients often have more than one herniated disc, though the evidence is not conclusive.

The spinal cord may be injured when a thoracic disc herniates. The spinal canal of the thoracic spine is narrow, so the spinal cord is immediately in danger from anything that takes up space inside the canal. Most disc herniations in the thoracic spine squeeze straight back, rather than deflecting off to either side. As a result, the disc material is often pushed directly toward the spinal cord. A herniated disc can cut off the blood supply to the spinal cord. Discs that herniate into the critical zone of the thoracic spine (T4 to T9) can shut off blood from the one and only blood vessel going to the front of the spinal cord in this section of the spine. This can cause the nerve tissues in the spinal cord to die, leading to severe problems of weakness or paralysis in the legs.

Symptoms

What does the condition feel like?

Symptoms of thoracic disc herniation vary widely. Symptoms depend on where and how big the disc herniation is, where it is pressing, and whether the spinal cord has been damaged.

Pain is usually the first symptom. The pain may be centered over the injured disc but may spread to one or both sides of the mid-back. Also, patients commonly feel a band of pain that goes around the front of the chest. Patients may eventually report sensations of pins, needles, and numbness. Others say their leg or arm muscles feel weak. Disc material that presses against the spinal cord can also cause changes in bowel and bladder function.

Disc herniations can affect areas away from the spine. Herniations in the upper part of the thoracic spine can radiate pain and other sensations into one or both arms. If the herniation occurs in the middle of the thoracic spine, pain can radiate to the abdominal or chest area, mimicking heart problems. A lower thoracic disc herniation can cause pain in the groin or lower limbs and can mimic kidney pain.

Diagnosis

How do doctors diagnose the problem?

Diagnosis begins with a complete history and physical examination. Your doctor will ask questions about your symptoms and how your problem is affecting your daily activities. These include questions about where you feel pain, if you have numbness or weakness in your arms or legs, and if you are having any problems with bowel or bladder function. Your doctor will also want to know what positions or activities make your symptoms worse or better.

Then the doctor examines you to see which back movements cause pain or other symptoms. Your skin sensation, muscle strength, and reflexes are also tested.

X-rays show the bones. They normally don’t show the discs, unless one or more of the discs have calcified. This is significant in the diagnosis of thoracic disc herniation. A calcified disc that appears on X-ray to poke into the spinal canal is a fairly reliable sign that the disc has herniated. It isn’t clear why a problem thoracic disc sometimes hardens from calcification, though past injury of the disc is one possibility.

The best way to diagnose a herniated thoracic disc is with magnetic resonance imaging (MRI). The MRI machine uses magnetic waves rather than X-rays to show the soft tissues of the body. It gives a clear picture of the discs and whether one has herniated. This machine creates pictures that look like slices of the area your doctor is interested in. The test does not require dye or a needle. This test has shown doctors that many people without symptoms have thoracic disc herniations. This has led some doctors to suggest that thoracic disc herniations not causing symptoms are normal.

Before MRI, doctors relied mainly on myelography to diagnose thoracic disc herniations. By itself, myelography only helps diagnose this condition in about half the cases. Myelography is a kind of X-ray test. A special dye is injected into the space around the spinal canal. The dye shows up on an X-ray. It helps a doctor see if the disc is pushing into the spinal canal.

Computed tomography (CT scan) may be ordered. This is a detailed X-ray that lets doctors see the body’s tissue in images that also look like slices. The images provide more information about calcified discs. Doctors may combine the CT scan with myelography. When the CT scan is performed, the myelography dye highlights the spinal cord and nerves. The dye can improve the accuracy of a standard CT scan for diagnosing a herniated thoracic disc.

Doctors rely mostly on MRI for diagnosing thoracic disc herniations. However, they may use myelography and CT scans when preparing to do surgery to fix a herniated thoracic disc.

Treatment

What treatment options are available?

Nonsurgical Treatment

Doctors closely monitor patients with symptoms from a thoracic disc herniation, even when the size of the herniation is small. If the disc starts to put pressure on the spinal cord or on the blood vessels going to the spinal cord, severe neurological symptoms can develop rapidly. In these cases, surgery is needed right away. However, unless your condition is affecting the spinal cord or is rapidly getting worse, most doctors will begin with nonsurgical treatment.

At first, your doctor may recommend immobilizing your back. Keeping the back still for a short time can calm inflammation and pain. This might include one to two days of bed rest, since lying on your back can take pressure off sore discs and nerves. However, most doctors advise against strict bed rest and prefer their patients do ordinary activities, using pain to gauge how much activity is too much. Another option for immobilizing the back is a back support brace worn for up to one week.

Doctors prescribe certain types of medication for patients with thoracic disc herniation. Patients may be prescribed anti-inflammatory medications such as aspirin or ibuprofen. Muscle relaxants may be prescribed if the back muscles are in spasm. Pain that spreads into the arms or legs is sometimes relieved with oral steroids taken in tapering dosages.

Your doctor will probably have a physical therapist direct your rehabilitation program. Therapy treatments focus on relieving pain, improving back movement, and fostering healthy posture. A therapist can design a rehabilitation program for your condition that helps you prevent future problems.

Most people with a herniated thoracic disc get better without surgery. Doctors usually have their patients try nonoperative treatment for at least six weeks before considering surgery.

Surgery

Surgeons may recommend surgery if patients aren’t getting better with nonsurgical treatment, or if the problem is becoming more severe.

When there are signs that the herniated disc is affecting the spinal cord, surgery may be required, sometimes right away. The signs surgeons watch for when reaching this decision include weakening in the arm or leg muscles, pain that won’t ease up, and problems with the bowels or bladder.

Surgical treatment for this condition includes

costotransversectomy and discectomy
transthoracic decompression
video assisted thoracoscopy surgery (VATS)
fusion

Costotransversectomy

Surgeons use costotransversectomy to open a window through the bones that cover the injured disc. Operating from the back of the spine, the surgeon takes out a small section on the end of two or more ribs where they connect to the spine. (Costo means rib.) Then the bony knob on the side of the vertebra (the transverse process) is removed. (Ectomy means to remove.) This opens space for the surgeon to work. The injured portion of the disc that is pressing against the spinal cord is removed (discectomy) with small instruments. Surgeons take extreme care not to harm the spinal cord.

Transthoracic Decompression

Transthoracic describes the approach used by the surgeon. Trans means across or through. The thoracic region is the chest. So in transthoracic decompression, the surgeon operates through the chest cavity to reach the injured disc. This approach gives the surgeon a clear view of the disc.

With the patient on his or her side, the surgeon cuts a small opening through the ribs on the side of the thorax (the chest). Instruments are placed through the opening, and the herniated part of the disc is taken out. This takes pressure off the spinal cord (decompression).

Video Assisted Thoracoscopy Surgery (VATS)

Recent developments in thoracic surgery include video assisted thoracoscopy surgery (VATS). This procedure is done with a thoracoscope, a tiny television camera that can be inserted into the side of the thorax through a small incision. The camera allows the surgeon to see the area where he or she is working on a TV screen. Small incisions give passage for other instruments used during the surgery. The surgeon watches the TV screen while cutting and

removing damaged portions of the disc.

Categorized as minimally invasive surgery, VATS is thought to be less taxing on patients. Advocates also believe that this type of surgery is easier to perform, prevents scarring around the nerves and joints, and helps patients recover more quickly.

Fusion

After removing part or all of the disc, the spine may be loose and unstable. Fusion surgery may be needed immediately afterward. The medical term for fusion is arthrodesis. This procedure locks the vertebrae in place and stops movement between the vertebrae. This steadies the bones and can ease pain. Fusion surgery is not usually needed if only a small amount of bone and disc material was removed during surgery to fix a herniated thoracic disc.

In this procedure, the surgeon lays small grafts of bone over or between the loose spinal bones. Surgeons may use a combination of screws, cables, and rods to prevent the vertebrae from moving and allow the graft to heal.

Rehabilitation

What should I expect as I recover?

Nonsurgical Rehabilitation

Even if you don’t need surgery, your doctor may recommend that you work with a physical therapist. Patients are normally seen a few times each week for four to six weeks.

The first goals of treatment are to control symptoms, find positions that ease pain, and teach you how to keep your spine safe during routine activities.

As patients recover, they gradually advance in a series of strengthening exercises. Aerobic exercises, such as walking or swimming, can ease pain and improve endurance.

After Surgery

Rehabilitation after surgery is more complex. Some patients leave the hospital shortly after surgery. However, some surgeries require patients to stay in the hospital for a few days. Patients who stay in the hospital may be visited by a physical therapist soon after surgery. The treatment sessions help patients learn to move and do routine activities without putting extra strain on the back.

Many surgical patients need physical therapy outside of the hospital. They see a therapist for one to three months, depending on the type of surgery. At first, therapists may use treatments such as heat or ice, electrical stimulation, massage, and ultrasound to calm pain and muscle spasm. Then they teach patients how to move safely with the least strain on the healing back.

As patients recover, they gradually begin doing flexibility exercises for the hips and shoulders. Mobility exercises are also started for the back. Strengthening exercises address the back muscles. Patients may work with the therapist in a pool. Patients progress with exercises to improve endurance, muscle strength, and body alignment.

As the rehabilitation program evolves, patients do more challenging exercises. The goal is to safely advance strength and function.

Ideally, patients are able to go back to their previous activities. However, some patients may need to modify their activities to avoid future problems.

Spinal Compression Fractures

A Patient’s Guide to Spinal Compression Fractures

Introduction

Compression fractures are the most common type of fracture affecting the spine. A compression fracture of a spine bone (vertebra) causes the bone to collapse in height.

Compression fractures are commonly the result of osteoporosis. About 700,000 cases of compression fractures due to osteoporosis occur each year in the United States. Spine bones that are weakened from osteoporosis may become unable to support normal stress and pressure. As a result, something as simple as coughing, twisting, or lifting can cause a vertebra to fracture.

An injury to the spine, such as from a hard fall on the buttocks or blow to the head, can cause a spinal compression fracture. Compression fractures may also occur if cancer from other parts of the body spreads to the spine. Cancer weakens the spine bones and makes them prone to fractures.

This guide will help you understand

how compression fractures happen
how doctors diagnose the problem
what treatment options are available

Anatomy

What parts of the spine are involved?

The human spine is made of 24 spinal bones, called vertebrae. Vertebrae are stacked on top of one another to create the spinal column. The spinal column gives the body its form. It is the body’s main upright support.

The main section of each vertebra is a large, round structure called a vertebral body.

Compression fractures cause this section of bone to collapse. When the fracture is due to osteoporosis, it usually occurs in the lower part of the thoracic spine, near the bottom of the rib cage.

A bony ring attaches to the back of each vertebral body. When the vertebrae are stacked on one another, the bony rings form a hollow tube. This tube, or canal, surrounds the spinal cord. The spinal cord is like a long wire made of millions of nerve fibers. Just as the skull protects the brain, the bones of the spinal column protect the spinal cord.

Severe compression fractures from forceful impact on the spine, as can happen in a car accident, can cause fragments of the vertebral body to push into the spinal canal and press against the spinal cord. This can cause damage to the spinal cord that can result in partial or complete paralysis below the waist. It is rare for a typical compression fracture from osteoporosis to cause damage to the spinal cord.

Causes

Why do I have this problem?

Strong, healthy bones are able to withstand the forces and strains of normal activity. Compression fractures in the spine happen when either the forces are too great or the bones of the spine aren’t strong enough. The vertebral body cracks under pressure. Fractures from forceful impact on the spine tend to crack the back (posterior) part of the vertebral body. Fractures from osteoporosis usually occur in the front (anterior) part of the vertebral body.

Osteoporosis is a disease that weakens bone. Sometimes the bones in the spine weaken to the point that even mild forces can lead to a compression fracture. A simple action like reaching down to pull on a pair of socks can cause a weakened vertebra to fracture. The front of the vertebra (the part closest to the front of the body) crumbles, causing the round vertebral body to become wedge-shaped. This angles the spine forward, producing a hunch-backed appearance, called kyphosis.

Related Document: A Patient’s Guide to Osteoporosis

Diseases or conditions that affect the parathyroid gland can also weaken bones. Four pea-sized parathyroid glands are located just behind the thyroid gland in the throat. They produce a substance called parathyroid hormone (PTH), which normally regulates the amount of calcium in the blood stream. An overactive parathyroid gland releases too much PTH, causing the body to leach calcium from bones, even when there is more than enough calcium circulating in the blood stream. This disorder is called hyperparathyroidism It occurs when a tumor, called an adenoma, forms in one of the parathyroid glands. Cancers that affect the kidney, skin, or parathyroid gland may also cause the parathyroid gland to malfunction. If the problem isn’t fixed, bones continue to lose calcium and eventually weaken. Weakening in the spine bones makes the vertebrae more prone to crack in front, as is typical with osteoporosis.

Cancers that form in other parts of the body have a tendency to spread, or metastasize, to the spine. When this happens, the cancer weakens the spine bones, making them susceptible to compression fractures. Doctors may suspect unrecognized cancer if a patient has a compression fracture without any particular cause or reason.

Spine trauma can produce mild or severe compression fractures. Compression fractures from trauma usually involve high forces that impact the spine when it is bent forward. This is typically what happens when a person falls onto the buttocks or strikes his head on the windshield in a car accident. Again, these traumatic fractures usually affect the back part of the vertebral body.

Symptoms

What does the condition feel like?

Compression fractures caused by thin, weakened bones may cause little or no pain at first. Sometimes pain is centered over the area where the fracture has occurred. The collapsed vertebra gives the spine a hunched appearance, and the loss of vertebral height shortens the muscles on each side of the spine. This forces the back muscles to work harder, causing muscle fatigue and pain. When pain does occur, it usually goes away after a few weeks. However, back pain sometimes escalates to the point that patients seek medical help.

Traumatic compression fractures can produce intense pain in the back that spreads into the legs. If the fracture severely damages the vertebral body, bone fragments may lodge in the spinal canal, pressing on the spinal cord. This can paralyze muscles and impair sensation in the areas supplied by the damaged nerve tissue. Such a fracture may also cause the spine to become unstable. When this happens, the spine eventually tilts forward into increased kyphosis, and the potential grows for future complications with the spinal cord.

Diagnosis

How do doctors diagnose the problem?

Diagnosis begins with a complete history and physical examination. The doctor asks questions about your symptoms and how your problem is affecting your daily activities. These include questions about where you feel pain and if you have numbness or weakness in your limbs. Your doctor will also want to know what positions or activities make your symptoms worse or better.

Then the doctor examines you to see which back movements cause pain or other symptoms. Your skin sensation, muscle strength, and reflexes are also tested. The doctor uses gentle pressure to feel the tissues over the sore area, since compression fractures often cause soreness and tenderness in the muscles over fractured vertebra.

If the doctor believes there is a compression fracture, X-rays are ordered. X-rays can show fractures of the vertebrae.

When an X-ray confirms a compression fracture, computed tomography (a CT scan) may be ordered. This is a detailed X-ray that lets the doctor see slices of the body’s tissue. The image can show whether the compression fracture has caused the area to become unstable from the injury.

If symptoms suggest problems with the spinal cord, the doctor may combine the CT scan with myelography. To do this, a special dye is injected into the space around the spinal canal (the subarachnoid space). When the CT scan is performed, the dye highlights the spinal cord and spinal nerves. The dye can improve the accuracy of a standard CT scan for diagnosing the health of the spinal cord and spinal nerves.

Magnetic resonance imaging (MRI) can show the doctor problems affecting the nerves or causing pain. The MRI machine uses magnetic waves rather than X-rays to show the soft tissues of the body. It shows problems in other soft tissues such as the discs and spinal cord. This machine creates pictures that look like slices of the area your doctor is interested in. The test does not require special dye or a needle.

Your doctor may order a bone scan to get additional information. This involves injecting chemical tracers into your blood stream. The tracers then show up on special X-rays of your spine. The tracers build up in areas of extra stress to bone tissue. This test can show if there are any old compression fractures, which would alert the doctor to problems with osteoporosis. If you have osteoporosis, the doctor will suggest ways to prevent future problems.

Treatment

What treatment options are available?

Nonsurgical Treatment

The majority of patients with compression fractures are treated without surgery. Most compression fractures heal within eight weeks with simple remedies of medicine, rest, and a special back brace.

Most patients are given medication to control pain. Although medications can help ease pain, they are not designed to heal the fracture. With pain under control, patients find it easier to get up and move about, avoiding the problems that come from remaining immobile in bed.

Patients are usually prescribed a short period of rest. This gives the fracture a chance to heal and aids in pain control. In some cases, the doctor may have a patient stay in bed for up to one week.

Most patients are fit with a special back brace, called an orthosis. This type of brace is molded to the patient’s body. It limits spine movement in general, though the brace is usually fashioned to keep patients from bending forward. This protects the fractured vertebral body so it can heal. Patients who wear a special brace may be advised to move about but to limit strenuous activities, such as lifting and bending

Surgery

Open surgical treatment for spinal compression fractures due to osteoporosis is infrequently needed. (Open procedures require larger incisions to give the surgeon more room to operate.) In rare cases of severe trauma, however, open surgery is sometimes required. Open surgery is done if the spinal segment has loosened and bone fragments have damaged the spinal cord and spinal nerves.

Surgeons have begun using two new procedures to treat compression fractures caused by osteoporosis. Both are considered minimally invasive. Minimally invasive means the incisions used are very small, and there is little disturbance of the muscles and bones where the procedure is done. These two procedures help the fracture heal without the problems associated with more involved surgeries. These new procedures are

vertebroplasty
kyphoplasty

Vertebroplasty

This procedure is most helpful for reducing pain. It also strengthens the fractured bone, enabling patients to rehabilitate faster.

To perform vertebroplasty, the surgeon uses a fluoroscope to guide a needle into the fractured vertebral body. A fluoroscope is a special X-ray television that allows the surgeon to see your spine and the needle as it moves. Once the surgeon is sure the needle is in the right place, bone cement, called polymethylmethacrylate (PMMA), is injected through the needle into the fractured vertebra. A reaction in the cement causes it to harden within 15 minutes. This fixes the bone so that it does not collapse any further as it heals. More than 80 percent of patients get immediate pain relief with this procedure.

Related Document: A Patient’s Guide to Vertebroplasty

Kyphoplasty

Kyphoplasty is another way for surgeons to treat vertebral compression fractures. Like vertebroplasty, this procedure halts severe pain and strengthens the fractured bone. However, it also gives the advantage of improving some or all of the lost height in the vertebral body, helping prevent kyphosis.

Two long needles are inserted through the sides of the spinal column into the fractured vertebral body. These needles guide the surgeon while drilling two holes into the vertebral body. The surgeon uses a fluoroscope (mentioned above) to make sure the needles and drill holes are placed in the right spot.

View animation of inflating the balloons

The surgeon then slides a hollow tube with a deflated balloon on the end through each drill hole. Inflating the balloons restores the height of the vertebral body and corrects the kyphosis deformity. Before the procedure is complete, the surgeon injects bone cement into the hollow space formed by the balloon. This fixes the bone in its corrected size and position.

Related Document: A Patient’s Guide to Kyphoplasty

Rehabilitation

What should I expect as I recover?

Rehabilitation after traumatic vertebral fractures can be a slow process. In these cases, patients sometimes need to attend therapy sessions for two to three months and should expect full recovery to take up to one year.

Most spinal compression fractures caused by osteoporosis get better within eight weeks. As mentioned, most patients who suffer compression fractures from osteoporosis don’t require surgery. Instead they are treated conservatively.

Patients who were fit with a special brace are usually able to begin increasing their activity level after about one week. However, patients are encouraged to avoid strenuous activity until their doctor approves resuming normal levels of activity.

People who have back pain generally find their pain improves as the fracture heals. However, the fracture changes the way the spine works, so it is not unusual for patients to have some lingering soreness in the muscles and joints near the fractured vertebra. If pain continues, let your doctor know.

After six to eight weeks, doctors may have their patients begin a period of physical therapy. This is especially true when patients lose muscle tone, are deconditioned from having to limit their activities, or have ongoing pain.

At first, treatments help control pain and inflammation. Ice and electrical stimulation treatments are commonly used to help with these goals. Your therapist may also use massage and other hands-on treatments to ease muscle spasm and pain.

Treatments are also used to improve posture. A combination of flexibility, strength, and postural exercise may be all that is needed to help your posture. Sometimes patients may need additional support with either a rigid brace or a fabric corset.

Your therapist also works with you on how to move and do activities. This form of treatment, called body mechanics, is used to help you develop new movement habits. This training helps you keep your back in safe positions and avoid extra strain near the fracture as you go about your work and daily activities. Training includes positions you use when sitting, lying, standing, and walking. You’ll also work on safe body mechanics with lifting, carrying, pushing, and pulling.

The therapist periodically tests your posture, balance, and strength to see how well you are improving. The therapist’s goal for you is to become proficient and safe with your exercises and improve your posture, strength, and flexibility. The therapist gives you tips on how to avoid future problems.

When patients are well under way, regular visits to the therapist’s office end. The therapist continues to be a resource, but patients are in charge of doing their exercises as part of an ongoing home program.

Lumbar Degenerative Disc Disease

A Patient’s Guide to Lumbar Degenerative Disc Disease

Introduction

The intervertebral discs in the lower spine are commonly blamed for low back pain. Yet low back pain has many possible causes, and doctors aren’t always certain why symptoms occur.

During an office visit for low back pain, your doctor may describe how changes in the discs can lead to back pain. When talking about these changes, your doctor may use the terms degeneration or degenerative disc disease. Although the parts of the spine do change with time and in some sense degenerate, this does not mean the spine is deteriorating and that you are headed for future pain and problems. These terms are simply a starting point for describing what occurs in the spine over time, and how the changes may explain the symptoms people feel.

This guide will help you understand

how degenerative disc disease develops
how doctors diagnose the condition
what treatment options are available

Anatomy

What parts of the spine are involved?

The human spine is made up of 24 spinal bones, called vertebrae. Vertebrae are stacked on top of one another to form the spinal column. The spinal column gives the body its form. It is the body’s main upright support. The section of the spine in the lower back is known as the lumbar spine.

An intervertebral disc sits between each pair of vertebrae. The intervertebral disc is made of connective tissue. Connective tissue is the material that holds the living cells of the body together. Most connective tissue is made of fibers of a material called collagen. These fibers help the disc withstand tension and pressure.

The disc normally works like a shock absorber. It protects the spine against the daily pull of gravity. It also protects the spine during strenuous activities

that put strong force on the spine, such as jumping, running, and lifting.

An intervertebral disc is made of two parts. The center, called the nucleus, is spongy providing most of the disc’s ability to absorb shock. It is held in place by the annulus, a series of strong ligament rings surrounding it. Ligaments are connective tissues that attach bones to other bones.

Between the vertebrae of each spinal segment are two facet joints. The facet joints are located on the back of the spinal column. There are two facet joints between each pair of vertebrae, one on each side of the spine. A facet joint is made of small, bony knobs that line up along the back of the spine. Where these knobs meet, they form a joint that connects the two vertebrae. The alignment of the facet joints of the lumbar spine allows freedom of movement as you bend forward and back.

Causes

Why do I have this problem?

Our intervertebral discs change with age, much like our hair turns gray. Conditions such as a major back injury or fracture can affect how the spine works, making the changes happen even faster. Daily wear and tear and certain types of vibration can also speed up degeneration in the spine. In addition, strong evidence suggests that smoking speeds up degeneration of the spine. Scientists have also found links among family members, showing that genetics play a role in how fast these changes occur.

Disc degeneration follows a predictable pattern. First, the nucleus in the center of the disc begins to lose its ability to absorb water. The disc becomes dehydrated. Then the nucleus becomes thick and fibrous, so that it looks much the same as the annulus. As a result, the nucleus isn’t able to absorb shock as well. Routine stress and strain begin to take a toll on the structures of the spine. Tears form around the annulus. The disc weakens. It starts to collapse, and the bones of the spine compress.

View animation of degeneration

Related Document: A Patient’s Guide to Low Back Pain

This degeneration does not always mean the disc becomes a source of pain. In fact, X-rays and MRI scans show that people with severe disc degeneration don’t always feel pain.

Pain caused by degenerative disc disease is mainly mechanical pain, meaning it comes from the parts of the spine that move during activity: the discs, ligaments, and facet joints. Movement within the weakened structures of the spine causes them to become irritated and painful.

Symptoms

What does the condition feel like?

Pain in the center of the low back is often the first symptom patients feel. It usually starts to affect patients in their twenties and thirties. Pain tends to worsen after heavy physical activity or staying in one posture for a long time. The back may also begin to feel stiff. Resting the back eases pain. At first, symptoms only last a few days.

This type of back pain often comes and goes over the years. Doctors call this recurring back pain. Each time it strikes, the pain may seem worse than the time before. Eventually the pain may spread into the buttocks or thighs, and it may take longer for the pain to subside.

Diagnosis

How do doctors diagnose the problem?

Diagnosis begins with a complete history and physical exam. Your doctor will ask questions about your symptoms and how your problem is affecting your daily activities. Your doctor will also want to know what positions or activities make your symptoms worse or better.

Then the doctor does a physical examination by checking your posture and the amount of movement in your low back. Your doctor checks to see which back movements cause pain or other symptoms. Your skin sensation, muscle strength, and reflexes are also tested.

Doctors rely on the history and physical exam to determine which treatments will help the most. X-rays are rarely ordered on the first doctor visit for this problem. This is because over 30 percent of low back X-rays show abnormalities from degeneration, even in people who aren’t having symptoms.

However, if symptoms are severe and aren’t going away, the doctor may order an X-ray. The test can show if one or more discs has started to collapse. It can also show if there are bone spurs in the vertebrae and facet joints. Bone spurs are small points of bone that form with degeneration.

When more information is needed, your doctor may order a magnetic resonance imaging (MRI) scan. The MRI machine uses magnetic waves rather than X-rays to show the soft tissues of the body. It is helpful for showing if the tissues in the disc are able to absorb water and whether there are cracks inside the disc. It can also show if there are problems in other soft tissues, such as the spinal nerves.

Discography can help with the diagnosis. This is a specialized X-ray test in which dye is injected into one or more discs. The dye is seen on X-ray and can give some information about the health of the disc or discs. This test may be done when the surgeon is considering surgery, since it can help determine which disc is causing the symptoms.

Treatment

What treatment options are available?

Nonsurgical Treatment

Whenever possible, doctors prefer treatment other than surgery. The first goal of nonsurgical treatment is to ease pain and other symptoms so the patient can resume normal activities as soon as possible.

Doctors rarely prescribe bed rest for patients with degenerative disc problems. Instead, patients are encouraged to do their normal activities using pain as a gauge for how much is too much. If symptoms are severe, a maximum of two days of bed rest may be prescribed.

Back braces are sometimes prescribed. Keeping the moving parts of the low back still can help calm mechanical pain. When a doctor issues a brace, he or she normally asks that the patient only wear it for two to four days. This lessens the chance that the trunk muscles will shrink (atrophy) from relying on the belt.

Patients may also be prescribed medication to help them gain control of their symptoms so they can resume normal activity swiftly.

If symptoms continue to limit a person’s ability to function normally, the doctor may suggest an epidural steroid injection (ESI). Steroids are powerful anti-inflammatories, meaning they help reduce pain and swelling. In an ESI, medication is injected into the space around the lumbar nerve roots. This area is called the epidural space. Some doctors inject only a steroid. Most doctors, however, combine a steroid with a long-lasting numbing medication. Generally, an ESI is given only when other treatments aren’t working. But ESIs are not always successful in relieving pain. If they do work, they often only provide temporary relief.

In addition, patients often work with a physical therapist. After evaluating a patient’s condition, the therapist can assign positions and exercises to ease symptoms. The therapist can design an exercise program to improve flexibility of tight muscles, to strengthen the back and abdominal muscles, and to help a patient move safely and with less pain.

Surgery

People with degenerative disc problems tend to gradually improve over time. Most do not need surgery. In fact, only one to three percent of patients with degenerative disc problems typically require surgery.

Doctors prefer to try nonsurgical treatment for a minimum of three months before considering surgery. If, after this period, nonsurgical treatment hasn’t improved symptoms, the doctor may recommend surgery. The main types of surgery for degenerative disc problems include

lumbar laminectomy
discectomy
fusion

Lumbar Laminectomy

The lamina forms a roof-like structure over the back of the spinal column. When the nerves in the spinal canal are squeezed by a degenerated disc or by bone spurs pushing into the canal, a laminectomy removes most, or all of the lamina to release pressure on the spinal nerves.

Related Document: A Patient’s Guide to Lumbar Laminectomy

Discectomy

Surgery to take out part or all of a problem disc in the low back is called discectomy. Discectomy is done when the degenerated disc has ruptured (herniated) into the spinal canal, putting pressure on the spinal nerves. Surgeons commonly perform this operation through an incision in the low back. Before the disc material can be removed, the surgeon must first remove part of the lamina. Generally, only a small piece of the lamina is chipped away to expose the problem disc. This is called laminotomy. It usually creates enough room for the surgeon to remove the disc. If more room is needed, the surgeon may need to take out a larger section of the lamina by doing a laminectomy (described above).

Many surgeons now do minimally invasive surgeries that require only small incisions in the low back. These procedures are used to remove damaged portions of the problem disc. Advocates believe that this type of surgery is easier to perform. They also believe it prevents scarring around the nerves and joints and helps patients recover more quickly. Minimally invasive surgeries include percutaneous lumbar discectomy, laser discectomy, and microdiscectomy.

Related Document: A Patient’s Guide to Lumbar Discectomy

Fusion

Fusion surgery joins two or more bones into one solid bone. This prevents the bones and joints from moving. The procedure is sometimes done with a discectomy. Mechanical pain is eased because the fusion holds the moving parts steady, so they can’t cause irritation and inflammation.

The main types of fusion for degenerative disc problems include

anterior lumbar interbody fusion
posterior lumbar fusion
combined fusion

Anterior Lumbar Interbody Fusion

Anterior lumbar interbody fusion surgery is done through the abdomen, allowing the surgeon to work on the anterior (front) of the lumbar spine. Removing the disc (discectomy) leaves a space between the pair of vertebrae. This interbody space is filled with a bone graft. One method is to take a graft from the pelvic bone and tamp it into place. Another method involves inserting two hollow titanium screws packed with bone, called fusion cages, into the place where the disc was taken out. The bone graft inside the cages fuses with the adjacent vertebrae, forming one solid bone.

Posterior Lumbar Fusion

A posterior lumbar fusion is done though an incision in the back. In this procedure, the surgeon lays small grafts of bone over the problem vertebrae. Most surgeons will also apply metal plates and screws to hold the vertebrae in place while they heal. This protects the graft so it can heal better and faster.

Combined Fusion

A combined fusion involves fusing the anterior (front) and posterior (back) surfaces of the problem vertebrae. By locking the vertebrae from the front and back, some surgeons believe the graft stays solid and is prevented from collapsing. Results do show improved fusion of the graft, though patients seem to fare equally well with other methods of fusion.

Rehabilitation

What should I expect as I recover?

Nonsurgical Rehabilitation

Your doctor may recommend that you work with a physical therapist a few times each week for four to six weeks. In some cases, patients may need a few additional weeks of care.

The first goal of treatment is to control symptoms. Your therapist will work with you to find positions and movements that ease pain. The therapist may use heat, cold, ultrasound, and electrical stimulation to calm pain and muscle spasm.

The therapist may perform hands-on treatments such as massage and specialized forms of soft-tissue mobilization. These can help a patient begin moving with less pain and greater ease. Spinal manipulation provides short-term relief of degenerative disc symptoms. Commonly thought of as an adjustment, spinal manipulation helps reset the sensitivity of the spinal nerves and muscles, easing pain and improving mobility. It involves a high-impulse stretch of the spinal joints and is characterized by the sound of popping as the stretch is done. It doesn’t provide effective long-term help when used routinely for chronic conditions.

Traction is also a common treatment for degenerative disc problems. Traction gently stretches the low back joints and muscles. Patients are also shown stretches to help them move easier and with less pain.

As you recover, you will gradually advance in a series of strengthening exercises for the abdominal and low back muscles. Working these core muscles helps patients move more easily and lessens the chances of future pain and problems.

A primary purpose of therapy is to help you learn how to take care of your symptoms and prevent future problems. You’ll be given a home program of exercises to continue improving flexibility, posture, endurance, and low back and abdominal strength. The therapist will also discuss strategies you can use if your symptoms flare up.

After Surgery

Rehabilitation after surgery is more complex. Some patients leave the hospital shortly after surgery. However, some surgeries require patients to stay in the hospital for a few days. Patients who stay in the hospital may visit with a physical therapist in the hospital room soon after surgery. The treatment sessions help patients learn to move and do routine activities without putting extra strain on their backs.

Many surgical patients need physical therapy outside of the hospital. Patients who’ve had lumbar fusion surgery normally need to wait up to three months before beginning a rehabilitation program. They typically need to attend therapy sessions for eight to 12 weeks and should expect full recovery to take up to six months.

Cervical Laminectomy

A Patient’s Guide to Cervical Laminectomy

Introduction

A laminectomy is a surgical procedure to relieve pressure on the spinal cord due to spinal stenosis. In spinal stenosis, bone spurs press against the spinal cord, leading to a condition called myelopathy. Myelopathy can produce problems with the bowels and bladder, disruptions in the way you walk, and impairments with fine motor skills in the hands. In a laminectomy, a small section of bone covering the back of the spinal cord is removed. Lamina refers to the roof of bone over the back of the spinal cord, and ectomy means the medical procedure for removing a section of the bony roof to take pressure off the spinal cord.

This guide will help you understand

why the procedure becomes necessary
what surgeons hope to achieve
what to expect during your recovery

Anatomy

What parts of the neck are involved?

Surgeons perform this procedure through the back of the neck. This is known as the posterior neck region. It includes the parts that make up the bony ring around the spinal cord (the pedicles and laminae.)

Rationale

What do surgeons hope to achieve?

View animation of disc collapse

A laminectomy can alleviate the symptoms of spinal stenosis, a condition that causes the spinal cord to become compressed inside the spinal canal. Wear and tear on the spine from aging and from repeated stresses and strains can cause a spinal disc to begin to collapse. This is the first stage of spinal stenosis. As the space between the vertebrae narrows, the posterior longitudinal ligament that attaches behind the vertebral body may buckle and push against the spinal cord. The degenerative process can also cause bone spurs to develop. When these spurs point into the spinal canal, they squeeze the spinal cord. In a laminectomy, the surgeon removes a section of the lamina bone, the buckled parts of the posterior longitudinal ligament, and the bone spurs, taking pressure off the spinal cord.

Preparation

How will I prepare for surgery?

The decision to proceed with surgery must be made jointly by you and your surgeon. You should understand as much about the procedure as possible. If you have concerns or questions, you should talk to your surgeon.

Once you decide on surgery, your surgeon may suggest a complete physical examination by your regular doctor. This exam helps ensure that you are in the best possible condition to undergo the operation.

On the day of your surgery, you will probably be admitted to the hospital early in the morning. You shouldn’t eat or drink anything after midnight the night before.

Surgical Procedure

What happens during the operation?

Patients are given a general anesthesia to put them to sleep during most spine surgeries. As you sleep, your breathing may be assisted with a ventilator. A ventilator is a device that controls and monitors the flow of air to the lungs.

This surgery is usually done with the patient lying face down on the operating table. The surgeon makes an incision down the middle of the back of the neck. The skin and soft tissues are separated to expose the bones along the back of the spine. Some surgeons use a surgical microscope during the procedure to magnify the area they’ll be working on.

Surgeons have found that complete removal of the laminae loosens the facet joints that connect the back of the spine. This can cause the spine to tilt forward. To avoid this, a hinge can be formed by only cutting partially through the lamina on one side. A second cut is made all the way through the other lamina. This edge is then lifted away from the spinal cord, and the other edge acts like a hinge. The hinged side forms a bone union, which holds the opposite side open and keeps pressure off the spinal cord.

Small cutting instruments may be used to carefully remove soft tissues near the spinal cord. Then the surgeon takes out any small disc fragments and scrapes off nearby bone spurs. In this way, additional tension and pressure are taken off the spinal cord.

The muscles and soft tissues are put back in place, and the skin is stitched together. Patients are usually placed in a neck brace after surgery to keep the neck positioned comfortably.

Complications

What might go wrong?

As with all major surgical procedures, complications can occur. Some of the most common complications following laminectomy include

problems with anesthesia
thrombophlebitis
infection
nerve damage
segmental instability
ongoing pain

This is not intended to be a complete list of the possible complications, but these are the most common.

Problems with Anesthesia

Thrombophlebitis (Blood Clots)

View animation of pulmonary embolism

pressure stockings to keep the blood in the legs moving
medications that thin the blood and prevent blood clots from forming

Infection

Infection following spine surgery is rare but can be a very serious complication. Some infections may show up early, even before you leave the hospital. Infections on the skin’s surface usually go away with antibiotics. Deeper infections that spread into the bones and soft tissues of the spine are harder to treat and may require additional surgery to treat the infected portion of the spine.

Nerve Damage

Any surgery that is done near the spinal canal can potentially cause injury to the spinal cord or spinal nerves. Injury can occur from bumping or cutting the nerve tissue with a surgical instrument, from swelling around the nerve, or from the formation of scar tissue. An injury to these structures can cause muscle weakness and a loss of sensation to the areas supplied by the nerve.

Segmental Instability

Laminectomy surgery can cause the spinal segment to loosen, making it unstable. The facet joints that connect the back of the spine normally give enough stability, even when the lamina is taken off. This is why surgeons prefer to leave the facet joints in place whenever possible. But these joints may have to be removed if they are enlarged with arthritis. During total laminectomy, the facet joints are removed. This procedure creates extra space around the nerves but often leads to segmental instability. Fusion surgery is generally needed to fix the loose segment.

Ongoing Pain

Many patients get nearly complete relief of symptoms from the laminectomy procedure. As with any surgery, however, you should expect some pain afterward. If the pain continues or becomes unbearable, talk to your doctor about treatments that can help control your pain.

After Surgery

What happens after surgery?

Patients are usually able to get out of bed within an hour or two after surgery. Your surgeon may have you wear a soft neck collar. If not, you will be instructed to move your neck only carefully and comfortably.

Most patients leave the hospital the day after surgery and are safe to drive within a week or two. People generally get back to light work by four weeks and can do heavier work and sports within two to three months.

Outpatient physical therapy is usually prescribed when patients have extra pain or show significant muscle weakness and deconditioning.

Rehabilitation

What should I expect as I recover?

Rehabilitation after laminectomy surgery is generally only needed for a short period of time. If you require outpatient physical therapy, you will probably need to attend therapy sessions for two to four weeks. You should expect full recovery to take up to three months.

Many surgeons prescribe outpatient physical therapy within four weeks after surgery. At first, treatments are used to help control pain and inflammation. Ice and electrical stimulation treatments are commonly used to help with these goals. Your therapist may also use massage and other hands-on treatments to ease muscle spasm and pain.

Active treatments are added slowly. These include exercises for improving heart and lung function. Walking, stationary cycling, and arm cycling are ideal cardiovascular exercises. Therapists also teach specific exercises to help tone and control the muscles that stabilize the neck and upper back.

Your therapist works with you on how to move and do activities. This form of treatment, called body mechanics, is used to help you develop new movement habits. This training helps you keep your neck in safe positions as you go about your work and daily activities. At first, this may be as simple as helping you learn how to move safely and easily in and out of bed, how to get dressed and undressed, and how to do some of your routine activities. Then you’ll learn how to keep your neck safe while you lift and carry items and as you begin to do other heavier activities.

As your condition improves, your therapist will begin tailoring your program to help prepare you to go back to work. Some patients are not able to go back to a previous job that requires heavy and strenuous tasks. Your therapist may suggest changes in job tasks that enable you to go back to your previous job. Your therapist can also provide ideas for alternate forms of work. You’ll learn to do your tasks in ways that keep your neck safe and free of extra strain.

Before your therapy sessions end, your therapist will teach you a number of ways to avoid future problems.

Cervical Spinal Stenosis

A Patient’s Guide to Cervical Spinal Stenosis

Introduction

The spinal cord is a column of nerve tissue protected by a bony tube in the spinal column. Conditions that narrow the space in this tube put the spinal cord at risk of getting squeezed. This narrowing in the spinal column of the neck is called cervical spinal stenosis, or cervical stenosis. Pressure against the spinal cord as a result of spinal stenosis causes myelopathy, a condition that demands medical attention. Myelopathy can cause problems with the bowels and bladder, change the way you walk, and affect your ability to use your fingers and hands.

This guide will help you understand

what parts make up the spine and neck
what causes cervical spinal stenosis
how the condition is diagnosed
what treatment options are available

Anatomy

What parts make up the spine and neck?

The spine is made of a column of bones. Each bone, or vertebra, is formed by a round block of bone, called a vertebral body. A bony ring attaches to the back of the vertebral body, forming a canal.

This bony ring is formed by two sets of bones. One set, the pedicle bones, attaches to the back of each vertebral body.

On the other end, each pedicle bone connects with a lamina bone. The lamina bones form a protective roof over the back of the spinal cord. When the vertebra bones are stacked on top of each other, the bony rings forms a long bony tube that surrounds and protects the spinal cord as it passes through the spine.

An intervertebral disc fits between each vertebral body and provides a space between the spine bones. The disc works like a shock absorber. It protects the spine against the daily pull of gravity. It also protects the spine during activities that put strong force on the spine, such as jumping, running, and lifting.

An intervertebral disc is made up of two parts. The center, called the nucleus, is spongy. It provides most of the ability to absorb shock. The nucleus is held in place by the annulus, a series of strong ligament rings surrounding it. Ligaments are strong connective tissues that attach bones to other bones.

Causes

Why do I have this problem?

The bony spinal canal normally has more than enough room for the spinal cord. Typically, the canal is 17 to 18 millimeters around, slightly less than the size of a penny. Spinal stenosis occurs when the canal narrows to 13 millimeters or less. When the size drops to 10 millimeters, severe symptoms of myelopathy occur. Myelopathy is a term for any condition that affects the spinal cord. The symptoms of myelopathy result from pressure against the spinal cord and reduced blood supply in the spinal cord as a result of the pressure.

Spinal stenosis may develop for any number of reasons. Some of the more common causes of spinal stenosis include

congenital stenosis
degeneration
spinal instability
disc herniation
constriction of the blood supply to the spinal cord

Congenital Stenosis

Some people are born with a spinal canal that is narrower than normal. This is called congenital stenosis. They may not feel problems early in life, but having a narrow canal to begin with places them at risk for stenosis. Even a minor neck injury can set them up to have pressure against the spinal cord. People born with a narrow spinal canal often have problems later in life, because the canal tends to become narrower due to the affects of aging. These degenerative changes often involve the formation of bone spurs (small bony projections) that point into the spinal canal and put pressure on the spinal cord.

Degeneration

Degeneration is the most common cause of spinal stenosis. Wear and tear on the spine from aging and from repeated stress and strain can cause many problems in the cervical spine. The intervertebral disc can begin to collapse, shrinking the space between vertebrae. Bone spurs may form that protrude into the spinal canal and reduce the space available to the spinal cord. The ligaments that hold the vertebrae together may become thicker and can also push into the spinal canal. All of these conditions narrow the spinal canal.

Spinal instability

Spinal instability can cause spinal stenosis. Spinal instability means there is extra movement among the bones of the spine. Instability in the cervical spine can happen if the supporting ligaments have been stretched or torn from a severe injury to the head or neck. People with diseases that loosen their connective tissues may also have spinal instability. For example, rheumatoid arthritis can cause the ligaments in the upper bones of the neck to loosen, allowing the topmost neck bones to shift and close off the spinal canal. Whatever the cause, extra movement in the bones of the spine can lead to spinal stenosis and myelopathy.

Disc herniation

Spinal stenosis can occur when a disc in the neck herniates. Normally, the shock-absorbing disc is able to handle the downward pressure of gravity and the strain from daily activities. However, if the pressure on the disc is too strong, such as from a blow to the head or neck, the nucleus inside the disc may rupture through the outer annulus and squeeze out of the disc. This is called a disc herniation. If an intervertebral disc herniates straight backward, it can press against the spinal cord and cause symptoms of spinal stenosis.

Constriction of the blood supply to the spinal cord

The changes that happen with degeneration and disc herniation can choke off the blood supply that goes to the spinal cord. The sections of the spinal cord that don’t get blood have less oxygen and don’t function normally, leading to symptoms of myelopathy.

Symptoms

What does cervical stenosis feel like?

Cervical stenosis usually develops slowly over a long period of time. This is partly because degeneration in later life is the main cause of spinal stenosis. Symptoms rarely appear all at once when degeneration is causing the problems. A severe injury or a herniated disc may cause symptoms to come on immediately.

The first sign to appear in some patients is a change in the way they walk. They don’t realize this problem is coming from their neck. But pressure on the spinal cord in the neck can affect the nerves and muscles in the legs, leading to changes in the way they walk. Eventually their walking pattern gets jerky and they lose muscle power in the legs. This is called spasticity.

Most patients also have problems in their hands. The main complaint is that their hands start to feel numb. Others feel clumsy when doing fine motor activities like writing or typing. The ability to grip and let go of items becomes difficult because the muscles along the inside edge of the palm and fingers weaken.

Shoulder weakness also develops in many patients. This happens most often when the spinal cord is compressed in the upper part of the neck. Most affected are the shoulder blade muscles and the deltoid muscle, which covers the top and outside of the shoulder. These muscles weaken and begin to show signs of wasting (atrophy) from not getting nerve input.

The area where the spinal cord is compressed in patients with stenosis is very close to the nerves that go to the arm and hand. The problem that compresses the spinal cord in the neck may also affect the nerves where they leave the spinal column. Nerve pressure can cause pain to radiate from the neck to the shoulder, upper back, or even down one or both arms. It can also cause numbness on the skin of the arm or hand and weakness in the muscles supplied by the nerve.

Pressure against the spinal cord also creates problems with the bowels and bladder. Mild spinal cord pressure makes you feel like you have to urinate more often. But it also makes it difficult to get urine to flow (urinary hesitancy). Moderate disturbances cause people to have a weak flow of urine, making them dribble urine. They also have to strain during bowel movements. In severe cases, people aren’t able to voluntarily control their bladder or bowels. This is called incontinence.

Diagnosis

How will my doctor identify the condition?

Diagnosis begins with a complete history and physical exam. Your doctor will ask questions about your symptoms and how your problem is affecting your daily activities. This will include questions about pain, feelings of numbness or weakness, changes in bowel or bladder function, and whether you’ve noticed any changes in the way you walk.

Then the doctor does a physical examination to see which neck movements cause pain or other symptoms. Your skin sensation, muscle strength, and reflexes are tested. Your doctor will also watch you walk to see if there are any subtle changes in your walking pattern.

X-rays are used to look for the cause of pressure against the spinal cord. The images can show if degeneration has caused the space between the vertebrae to collapse and may show if a bone spur is pressing against the spinal cord.

If more information is needed, your doctor may order a magnetic resonance imaging (MRI) scan. The MRI machine uses magnetic waves rather than X-rays to show the soft tissues of the body. This test gives a clear picture of the spinal cord and can show where it is being squeezed. This machine creates pictures that look like slices of the area your doctor is interested in. The test does not require any special dye or a needle.

A computed tomography (CT) scan may also be ordered. The CT scan is a detailed X-ray that lets doctors see slices of bone tissue. The image can show if bone spurs are protruding into the spinal column and taking up space around the spinal cord.

Your doctor may recommend electrical tests of the nerves that go to your arm and hand. An electromyography (EMG) test is used to check if the motor pathway in a nerve is working correctly. Doctors may also order a somatosensory evoked potential (SSEP) test to locate more precisely where the spinal cord is getting squeezed. The SSEP is used to measure whether a nerve is able to get and send sensory information such as pain, temperature, and touch. The function of a nerve may be recorded with an electrode placed over the skin or with a needle that is inserted into the nerve or sensory center of the brain.

Treatment

What can be done for the problem?

Nonsurgical Treatment

Spinal myelopathy is a serious condition. If your condition is causing significant problems or is rapidly getting worse, your doctor may not begin with nonsurgical treatments and instead recommend surgery immediately. If the symptoms are mild, nonsurgical treatment may be tried initially to see if the symptoms improve.

At first, doctors may suggest immobilizing the neck. Keeping the neck still for a short time can calm inflammation and pain. Patients are instructed to restrict their daily activities by avoiding heavy and repeated motions of the neck, arms, and upper body. Doctors may also prescribe a soft neck collar. The collar is a padded ring that wraps around the neck and is held in place by a Velcro strap. Patients wear the collar during waking hours for up to three months. Then they slowly begin to taper the amount of time they wear it each day.

If the condition is very mild, some doctors have their patients work with a physical therapist. At first, treatments are used to ease pain and inflammation. Electrical stimulation treatments can help calm muscle spasm and pain. Traction is a way to gently stretch the joints and muscles of the neck. It can be done using a machine with a special head halter, or the therapist can apply the traction pull by hand.

Some patients are given an epidural steroid injection (ESI). The injection is given in a part of the spinal canal called the epidural space. This is the area between the dura (the material that covers the spinal cord) and the spinal column. It is thought that injecting steroid medication into this space fights inflammation around the nerves and discs. This can reduce the swelling and give the spinal cord more room.

Surgery

When there are signs that pressure is building on the spinal cord, surgery may be required, sometimes right away. Surgeries used to treat spinal stenosis include

laminectomy
anterior cervical discectomy and fusion
corpectomy and strut graft

Laminectomy

The lamina is the covering layer of the bony ring of the spinal canal. It forms a roof-like structure over the back of the spinal cord. When bone spurs or disc contents have pushed into the spinal canal, a laminectomy is done to take off the lamina bone in order to release pressure on the spinal cord.

Some surgeons completely remove the entire lamina bone, called a total laminectomy. Others prefer to keep the lamina in place by forming a hinge on one edge of the bone. This hinge is formed by cutting partially through the lamina on one side.

A second cut is made all the way through the lamina on the other side. This edge is then lifted away from the spinal cord, and the other edge acts like a hinge. The hinged side eventually forms a bone union, which holds the opposite side open and keeps pressure off the spinal cord.

Related Document: A Patient’s Guide to Laminectomy

Anterior Cervical Discectomy and Fusion

A fusion surgery joins two or more bones into one solid bone. Fusion of the neck bones is most often done through the front of the neck. The surgeon takes out the intervertebral disc (discectomy) between two vertebrae. A layer of bone is shaved off the flat surfaces of the two vertebrae to be fused. This causes the surfaces to bleed and stimulates the bone to heal. (This is similar to the way two sides of a fractured bone begin to heal.) A section of bone is grafted from the top part of the pelvis bone and inserted into the space where the disc was taken out. This separates the two vertebra bones, taking pressure off the spinal cord. As the bone graft heals in place, the vertebral bones fuse together into one solid bone.

Corpectomy and Strut Graft

A corpectomy relieves pressure over a large part of the spinal cord. In this procedure, the surgeon takes off the front part of the spinal column and removes several vertebral bodies. The spaces are then filled with bone graft material. Metal plates and screws are generally used to hold the spine in place while it heals. A corpectomy is used in cases of severe spinal stenosis.

Rehabilitation

What should I expect after treatment?

Nonsurgical Rehabilitation

Patients with mild symptoms of cervical myelopathy may try nonsurgical treatment for three to six months. After wearing a neck brace for up to three months, patients will slowly resume routine activities. They usually visit their doctor every four to six weeks to check their progress.

After Surgery

Some patients leave the hospital shortly after surgery, but some surgeries require patients to stay in the hospital for a few days. A physical therapist may see the patient for treatment in the hospital room after surgery. Therapy sessions are designed to help patients learn to move and begin doing routine activities without putting extra strain on the neck.

During recovery from surgery, a patient may be placed in a halo vest or rigid neck brace. These braces are used to restrict the motion in the neck to allow the fusion to heal. Patients generally need to be extremely cautious about overdoing activities in the first few weeks to months after surgery.

Most patients spend time rehabilitating at home. Bone fusion may take several months. When the surgeon is absolutely certain the bones have fused together, patients are able to discontinue using the neck brace or halo vest.

After being in a rigid neck brace for four to six months, patients are often weak and deconditioned. They sometimes need the help of a physical therapist to work on neck movement, strength, and general conditioning.

As therapy sessions come to an end, the therapist may help patients with decisions about getting back to work.

Ideally, patients are able to go back to their previous activities. However, some patients may need to modify their activities to avoid future problems.

Cervical Radiculopathy

A Patient’s Guide to Cervical Radiculopathy

Introduction

Neck pain has many causes. Mechanical neck pain comes from injury or inflammation in the soft tissues of the neck. This is much different and less concerning than symptoms that come from pressure on the nerve roots as they exit the spinal column. People sometimes refer to this problem as a pinched nerve. Health care providers call it cervical radiculopathy.

This guide will help you understand

how the problem develops
how doctors diagnose the condition
what treatment options are available

Anatomy

What part of the neck is involved?

The spine is made of a column of bones. Each bone, or vertebra, is formed by a round block of bone, called a vertebral body. A bony ring attaches to the back of the vertebral body. When the vertebra bones are stacked on top of each other, the bony rings forms a long bony tube that surrounds and protects the spinal cord as it passes through the spine.

Traveling from the brain down through the spinal column, the spinal cord sends out nerve branches through openings on both sides of each vertebra. These openings are called the neural foramina. (The term used to describe a single opening is foramen.)

The intervertebral disc sits directly in front of the opening. A bulged or herniated disc can narrow the opening and put pressure on the nerve. A facet joint sits in back of the foramen. Bone spurs that form on the facet joint can project into the tunnel, narrowing the hole and pinching the nerve.

An intervertebral disc fits between the vertebral bodies and provides a space between the spine bones. The disc normally works like a shock absorber. An intervertebral disc is made of two parts. The center, called the nucleus, is spongy. It provides most of the shock absorption. The nucleus is held in place by the annulus, a series of strong ligament rings surrounding it. Ligaments are strong connective tissues that attach bones to other bones.

Causes

Why do I have this problem?

Cervical radiculopathy is caused by any condition that puts pressure on the nerves where they leave the spinal column. This is much different than mechanical neck pain. Mechanical neck pain is caused by injury or inflammation in the soft tissues of the neck, such as the discs, facet joints, ligaments, or muscles.

The main causes of cervical radiculopathy include degeneration, disc herniation, and spinal instability.

Degeneration

View animation of degenerative changes

As the spine ages, several changes occur in the bones and soft tissues. The disc loses its water content and begins to collapse, causing the space between the vertebrae to narrow. The added pressure may irritate and inflame the facet joints, causing them to become enlarged. When this happens, the enlarged joints can press against the nerves going to the arm as they try to squeeze through the neural foramina. Degeneration can also cause bone spurs to develop. Bone spurs may put pressure on nerves and produce symptoms of cervical radiculopathy.

Herniated Disc

Heavy, repetitive bending, twisting, and lifting can place extra pressure on the shock-absorbing nucleus of the disc. A blow to the head and neck can also cause extra pressure on the nucleus. If great enough, this increased pressure can injure the annulus (the tough, outer ring of the disc). If the annulus ruptures, or tears, the material in the nucleus can squeeze out of the disc. This is called a herniation.

Although daily activities may cause the nucleus to press against the annulus, the body is normally able to withstand these pressures. However, as the annulus ages, it tends to crack and tear. It is repaired with scar tissue. Over time, the annulus becomes weakened, and the disc can more easily herniate through the damaged annulus. If the herniated disc material presses against a nerve root it can cause pain, numbness, and weakness in the area the nerve supplies.

Spinal Instability

Spinal instability means there is extra movement among the bones of the spine. Instability in the cervical spine (the neck) can develop if the supporting ligaments have been stretched or torn from a severe injury to the head or neck. People with diseases that loosen their connective tissue may also have spinal instability. Spinal instability also includes conditions in which a vertebral body slips over the one just below it. When the vertebral body slips too far forward, the condition is called spondylolisthesis. Whatever the cause, extra movement in the bones of the spine can irritate or put pressure on the nerves of the neck, causing symptoms of cervical radiculopathy.

Symptoms

What does the condition feel like?

The symptoms from cervical radiculopathy are from pressure on an irritated nerve. These symptoms are not the same as those that come from mechanical neck pain. Mechanical neck pain usually starts in the neck and may spread to include the upper back or shoulder. It rarely extends below the shoulder. Headaches are also a common complaint of both radiculopathy and mechanical neck pain.

The pain from cervical radiculopathy usually spreads further down the arm than mechanical neck pain. And unlike mechanical pain, radiculopathy also usually involves other changes in how the nerves work such as numbness, tingling, and weakness in the muscles of the shoulder, arm, or hand. With cervical radiculopathy, the reflexes in the muscles of the upper arm are usually affected. This is why doctors check reflexes when people have symptoms of cervical radiculopathy.

Diagnosis

How do doctors diagnose the problem?

Doctors gather the information about your symptoms as a way to determine which nerve is having problems. Diagnosis begins with a complete history of the problem. Your doctor will ask questions about your symptoms and how your problem is affecting your daily activities. Your answers can help your doctor determine which nerve is causing problems.

Next, the doctor examines you to see which neck movements cause pain or other symptoms. Your skin sensation, muscle strength, and reflexes are tested in order to tell where the nerve problem is coming from.

X-rays of the cervical spine can show the cause of pressure on the nerve. The images show whether degeneration has caused the space between the vertebrae to collapse. They may also show if a bone spur is pressing against a nerve.

If more information is needed, your doctor may order magnetic resonance imaging (MRI). The MRI machine uses magnetic waves rather than X-rays to show the soft tissues of the body. This test gives a clear picture of the discs, nerves, and other soft tissues in the neck. The machine creates pictures that look like slices of the area your doctor is interested in. The test does not require any special dye or needles and is painless.

Sometimes it isn’t clear where the nerve pressure is coming from. Symptoms of numbness or weakness can also happen when the nerve is being pinched or injured at other points along its path. (An example of this is pressure on the median nerve in the wrist, known as carpal tunnel syndrome.) Electrical studies of the nerves going from the neck to the arm may be requested by your doctor to see whether the nerve problem is in the neck or further down the arm. However, most doctors take X-rays and try other forms of treatment before ordering electrical tests. These tests are usually only needed when the diagnosis is not clear.

If your doctor orders electrical studies, several tests are available to see how well the nerves are functioning, including the electromyography (EMG) test. This test measures how long it takes a muscle to work once a nerve signals it to move. The time it takes will be slower if nerve pressure from radiculopathy has affected the strength of the muscle.

Another electrical test that may be used instead of EMG is cervical root stimulation (CRS). This test involves putting a small needle through the back of the neck into the nerve where it leaves the spinal column. Readings of muscle action are then taken of the muscles on the front and back of the upper arm and along the inside of the lower arm. Doctors use the readings to determine which nerve is having problems.

Treatment

What treatment options are available?

Nonsurgical Treatment

Unless the nerve problem is getting worse rapidly, most doctors will begin with nonsurgical treatments.

At first, your doctor may prescribe immobilization of the neck. Keeping the neck still for a short time can calm inflammation and pain. This might include one to two days of bed rest and the use of a soft neck collar. This collar is a padded ring that wraps around the neck and is held in place by a Velcro strap. Normally, a patient need only wear a collar for one to two weeks. Wearing it longer tends to weaken the neck muscles.

Doctors prescribe certain types of medication for patients with cervical radiculopathy. Severe symptoms may be treated with narcotic drugs, such as codeine or morphine. But these drugs should only be used for the first few days or weeks after problems with radiculopathy start because they are addictive when used too much or improperly. Muscle relaxants may be prescribed to calm neck muscles that are in spasm. You may be prescribed anti-inflammatory medications such as aspirin or ibuprofen.

Some doctors have their patients work with a physical therapist. At first, treatments are used to ease pain and inflammation. Electrical stimulation treatments can help calm muscle spasm and pain. Traction is a way to gently stretch the joints and muscles of the neck. It can be done using a machine with a special head halter, or the therapist can apply the traction pull by hand.

Some patients are given an epidural steroid injection (ESI).The spinal cord travels in a tube within the bones of the spinal canal. The cord is covered by a material called dura. The space between the dura and the spinal column is the epidural space. It is thought that injecting steroid medication into this space fights inflammation around the nerves, the discs, and the facet joints. In some cases, the steroid injection is given around one specific nerve. This is called a selective nerve block. The response to this treatment helps confirm which nerve root is causing the symptoms.

Doctors usually have their patients try nonoperative treatments for at least three months before considering surgery. But when patients simply aren’t getting better, or if the problem is becoming more severe, surgery may be suggested.

Surgery

Most people with cervical radiculopathy get better without surgery. In rare cases, people don’t get relief with nonsurgical treatments. They may require surgery. There are several types of surgery for cervical radiculopathy. These include

foraminotomy
discectomy
fusion

Foraminotomy

A foraminotomy is done to open the neural foramen and relieve pressure on the spinal nerve root. A foraminotomy may be done because of bone spurs or inflammation.

Discectomy

In a discectomy, the surgeon removes the disc where it is pressing against a nerve. Surgeons usually perform this surgery from the front (anterior) of the neck. This procedure is called an anterior cervical discectomy. In most patients, discectomy is done together with a procedure called cervical fusion, which is described next.

Fusion

A fusion surgery joins two or more bones into one solid bone. The purpose for treating cervical radiculopathy with fusion is to increase the space between the vertebrae, taking pressure off the nerve. The surgery is most often done through the front of the neck. After taking out the disc (discectomy), the disc space is filled in with a small block of bone graft. The bone is allowed to heal, fusing the two vertebrae into one solid bone. The space between the vertebrae is propped and held open by the bone graft, which enlarges the neural foramina, taking pressure off the nerve roots.

Rehabilitation

Nonsurgical Rehabilitation

What should I expect from treatment?

Even if you don’t need surgery, your doctor may recommend that you work with a physical therapist. Patients are normally seen a few times each week for one to two months. In severe cases, patients may need a few additional weeks of care.

Your therapist creates a program to help you regain neck and arm function. Treatments for cervical radiculopathy often include neck traction, described earlier. Though neck traction is often done in the clinic, your therapist may give you a traction device to use at home.

It is very important to improve the strength and coordination in the neck and shoulder blade muscles. Your therapist can also evaluate your workstation or the way you use your body when you do your activities and suggest changes to avoid further problems.

After Surgery

Rehabilitation after surgery for cervical radiculopathy can be a slow process. You will probably need to attend physical therapy sessions for six to eight weeks, and you should expect full recovery to take up to four months.

During physical therapy after surgery, your therapist may use treatments such as heat or ice, electrical stimulation, massage, and ultrasound to help calm pain and muscle spasm. Then you begin learning how to move safely with the least strain on the healing neck.

As the rehabilitation program evolves, you will do more challenging exercises. The goal is to safely advance your strength and function. As your therapy sessions come to an end, your therapist will help you with decisions about getting you back to work. Your therapist can do a work assessment to make sure you’ll be able to do your job safely. Your therapist may suggest changes that could help you work safely, with less chance of reinjuring your neck.

When your treatment is well under way, regular visits to the therapist’s office will end. The therapist will continue to be a resource for you. But you will be in charge of doing your exercises as part of an ongoing home program.

Neck Pain

A Patient’s Guide to Neck Pain

Introduction

Neck pain is a common reason people visit their doctor. Neck pain typically doesn’t start from a single injury. Instead, the problem usually develops over time from the stress and strain of daily activities. Eventually, the parts of the spine begin to degenerate. The degeneration can become a source of neck pain.

Knowing how your neck normally works and why you feel pain are important in helping you care for your neck problem. Patients are often less anxious and more satisfied with their care when they have the information they need to make the best decisions about their condition.

This document will give you a general overview of neck pain. It should help you understand

what parts make up the spine and neck
what causes neck pain
what tests your doctor may run
how to decrease your pain and increase your mobility

Anatomy

What parts make up the cervical spine, and how do they work?

The human spine is made up of 24 spinal bones, called vertebrae. Vertebrae are stacked on top of one another to form the spinal column. The spinal column is the body’s main upright support.

The cervical spine is formed by the first seven vertebrae. Doctors often refer to these vertebrae as C1 to C7. The cervical spine starts where the top vertebra (C1) connects to the bottom edge of the skull. The cervical spine curves slightly inward and ends where C7 joins the top of the thoracic spine. This is where the chest begins.

Each vertebra is formed by a round block of bone, called a vertebral body. A bony ring attaches to the back of the vertebral body. When the vertebrae are stacked on top of each other, the rings form a hollow tube. This bony tube surrounds the spinal cord as it passes through the spine. Just as the skull protects the brain, the bones of the spinal column protect the spinal cord.

As the spinal cord travels from the brain down through the spine, it sends out nerve branches between each vertebrae called nerve roots. These nerve roots join together to form the nerves that travel throughout the body and form the body’s electrical system. The nerve roots that come out of the cervical spine form the nerves that go to the arms and hands. The thoracic spine nerves go to the abdomen and chest. The nerves coming out of the lumbar (lower) spine go to the organs of the pelvis, the legs, and the feet.

One way to understand the anatomy of the cervical spine to look at a spinal segment. Each spinal segment includes two vertebrae separated by an intervertebral disc, the nerves that leave the spinal cord at that level, and the small facet joints (described later) that link each level of the spinal column.

An intervertebral disc is made of connective tissue. Connective tissue is the material that holds the living cells of the body together. Most connective tissue is made of fibers of a material called collagen. In some cases, the collagen fibers join together to form a structure like a rope. In other cases, the fibers are arranged like a piece of cloth, or knitted materials such as you find in a sweater. The disc is a specialized connective tissue structure that separates the two vertebral bodies of the spinal segment. The disc normally works like a shock absorber. It protects the spine against the daily pull of gravity. It also protects the spine during activities that put strong force on the spine, such as jumping, running, and lifting.

There are two facet joints between each pair of vertebrae, one on each side of the spine. A facet joint is made up of small, bony knobs that line up along the back of the spine. Where these knobs meet, they form a joint that connects the two vertebrae. The alignment of the facet joints of the cervical spine allows freedom of movement as you bend and turn your neck.

The surfaces of the facet joints are covered by articular cartilage. Articular cartilage is a smooth, rubbery material that covers the ends of most joints. It allows the bone ends to move against each other smoothly, without pain.

Two spinal nerves exit the sides of each spinal segment, one on the left and one on the right. As the nerves leave the spinal cord, they pass through a small bony tunnel on each side of the vertebra, called a neural foramen. (The term used to describe more than one opening is neural foramina.)

Causes

Why do I have neck pain?

There are many causes of neck pain. Doctors are not always able to pinpoint the source of a patient’s pain. Your doctor will make every effort to ensure that your symptoms are not from a serious medical cause, such as cancer or a spinal infection. Below is a brief overview of some of the most common causes of neck pain.

Spondylosis

Most neck problems happen after years of wear and tear on the parts of the cervical spine. At first, these small injuries are not painful. But over time they can add up. Eventually they begin to cause neck pain.

Doctors sometimes call these degenerative changes in the spine spondylosis. Spondylosis can affect the bones and soft tissues of the spine. However, it is important to know that most problems with spondylosis are a normal part of aging.

Degenerative Disc Disease

The normal aging process involves changes within the intervertebral discs. Repeated stresses and strains weaken the connective tissues that make up a disc. Over time, the nucleus in the center of the disc dries out. When this happens, it loses some of its ability to absorb shock. The annulus also weakens and develops small cracks and tears.

Often these changes are not painful. But larger tears that reach to the outer edge of the annulus can cause neck pain. The body tries to heal the cracks with scar tissue. But scar tissue is not as strong as the tissue it replaces. At some point the disc may finally lose its ability to absorb shock for the spine. Then forces from gravity and daily activities can take even more of a toll on the disc and other structures of the spine.

View animation of degeneration

As the disc continues to degenerate, the space between the vertebrae becomes smaller. This compresses the facet joints along the back of the spinal column. As these joints are forced together, extra pressure builds on the articular cartilage on the surface of the facet joints. This extra pressure can damage the facet joints. Over time, this may lead to arthritis in the facet joints.

These degenerative changes in the disc, facet joints, and ligaments cause the spinal segment to become loose and unstable. The extra movement causes even more wear and tear on the spine. As a result, more and larger tears occur in the annulus.

The nucleus may push through the weakened and torn annulus and into the spinal canal. This is called a herniated or ruptured disc. The disc material that squeezes out can press against the spinal nerves. The disc also emits enzymes and chemicals that produce inflammation. The combination of pressure on the nerves and inflammation caused by the chemicals released from the disc cause pain.

As the degeneration continues, bone spurs develop around the facet joints and around the disc. No one knows exactly why these bone spurs develop. Most doctors think that bone spurs are the body’s attempt to stop the extra motion between the spinal segment. These bone spurs can cause problems by pressing on the nerves of the spine where they pass through the neural foramina. This pressure around the irritated nerve roots can cause pain, numbness, and weakness in the neck, arms, and hands.

Muscle Strain

People with minor neck pain or stiffness are often told they have a muscle strain. However, unless there was a severe injury to the neck, the muscles probably haven’t been pulled or injured. Instead, the problem may be coming from irritation or injury in other spine tissues, such as the disc or ligaments. When this happens, the neck muscles may go into spasm to help support and protect the sore area.

Mechanical Neck Pain

Mechanical neck pain is caused by wear and tear on the parts of the neck. It is similar in nature to a machine that begins to wear out. Mechanical pain usually starts from degenerative changes in the disc. As the disc starts to collapse, the space between the vertebrae narrows, and the facet joints may become inflamed. The pain is usually chronic. (Chronic pain builds over time and is long-lasting.) The pain is typically felt in the neck, but it may spread from the neck into the upper back or to the outside of the shoulder. Mechanical neck pain usually doesn’t cause weakness or numbness in the arm or hand, because the problem is not from pressure on the spinal nerves.

Radiculopathy (Pinched Nerve)

Pressure or irritation in the nerves of the cervical spine can affect the nerves’ electrical signals. The pressure or irritation can be felt as numbness on the skin, weakness in the muscles, or pain along the path of the nerve. Most people think of these symptoms as indications of a pinched nerve. Health care providers call this condition cervical radiculopathy.

Several conditions can cause radiculopathy. The most common are degeneration, disc herniation, and spinal instability.

Degeneration: As the spine ages, several changes occur in the bones and soft tissues. The disc loses its water content and begins to collapse, causing the space between the vertebrae to narrow. The added pressure may irritate and inflame the facet joints, causing them to become enlarged. When this happens, the enlarged joints can press against the nerves going to the arm as they squeeze through the neural foramina. Degeneration can also cause bone spurs to develop. Bone spurs may put pressure on nerves and produce symptoms of cervical radiculopathy.

Herniated Disc: Heavy, repetitive bending, twisting, and lifting can place extra pressure on the shock-absorbing nucleus of the disc. If great enough, this increased pressure can injure the annulus (the tough, outer ring of the disc). If the annulus ruptures or tears, the material in the nucleus can squeeze out of the disc. This is called a herniation. Although daily activities may cause the nucleus to press against the annulus, the body is normally able to withstand these pressures. However, as the annulus ages, it tends to crack and tear. It is repaired with scar tissue. Over time, the annulus becomes weakened, and the disc can more easily herniate through the damaged annulus.

If the herniated disc material presses against a nerve root it can cause pain, numbness, and weakness in the area the nerve supplies. This condition is called cervical radiculopathy (mentioned earlier). And any time the herniated nucleus contacts tissues outside the damaged annulus, it releases chemicals that cause inflammation and pain. If the nucleus herniates completely through the annulus, it may squeeze against the spinal cord. This causes a condition that is even more serious because it affects all the nerves of the spinal cord. This condition is called cervical myelopathy.

Spinal Instability: Spinal instability means there is extra movement among the bones of the spine. Instability in the cervical spine can develop if the supporting ligaments have been stretched or torn from a severe injury to the head or neck. People with diseases that loosen their connective tissue may also have spinal instability. Spinal instability also includes conditions in which a vertebral body slips over the one just below it. When the vertebral body slips too far forward, the condition is called spondylolisthesis. Whatever the cause, extra movement in the bones of the spine can irritate or put pressure on the nerves of the neck, causing symptoms.

Spinal Stenosis (Cervical Myelopathy)

Stenosis means closed in. Spinal stenosis refers to a condition in which the spinal cord is closed in, or compressed, inside the tube of the spinal canal. Spinal stenosis may be caused by degenerative changes, such as bone spurs pushing against the spinal cord within the spinal canal.

However, stenosis can also develop when a person of any age has a disc herniation that pushes against the spinal canal. When the spinal cord is squeezed in the neck, doctors call the condition cervical myelopathy.

This is an alarming condition that demands medical attention. Cervical myelopathy can cause problems with the bowels and bladder, change the way you walk, and affect your ability to use your fingers and hand.

Symptoms

What are some of the symptoms of neck problems?

Symptoms from neck problems vary. They depend on your condition and which neck structures are affected. Some of the more common symptoms of neck problems are

neck pain
headaches
pain spreading into the upper back or down the arm
neck stiffness and reduced range of motion
muscle weakness in the shoulder, arm, or hand
sensory changes (numbness, prickling, or tingling) in the forearm, hand, or fingers

Diagnosis

How will my doctor find out what is causing my problem?

The diagnosis of neck problems begins with a thorough history of your condition. You might be asked to fill out a questionnaire describing your neck problems. Then your doctor will ask you questions to find out when you first started having problems, what makes your symptoms worse or better, and how the symptoms affect your daily activity. Your answers will help guide the physical examination.

Your doctor will then physically examine the muscles and joints of your neck. It is important that your doctor see how your neck is aligned, how it moves, and exactly where it hurts.

Your doctor may do some simple tests to check the function of the nerves. These tests measure your arm and hand strength, check your reflexes, and help determine whether you have numbness in your arms, hands, or fingers.

The information from your medical history and physical examination will help your doctor decide which tests to run. The tests give different types of information.

Radiological Imaging

Radiological imaging tests help your doctor see the anatomy of your spine. There are several kinds of imaging tests.

X-rays

X-rays show problems with bones, such as infection, bone tumors, or fractures. X-rays of the spine also can give your doctor information about how much degeneration has occurred in the spine, by showing the amount of space in the neural foramina and between the discs. X-rays are usually the first test ordered before any of the more specialized tests. Special X-rays called flexion and extension X-rays may help to determine if there is instability between vertebrae. These X-rays are taken from the side as you lean as far forward and then as far backward as you can. Comparing the two X-rays allows the doctor to see how much motion occurs between each spinal segment.

MRI

The magnetic resonance imaging (MRI) scan uses magnetic waves to create pictures of the cervical spine in slices. The MRI scan shows the cervical spine bones, as well as the soft tissue structures such as the discs, joints, and nerves.

MRI scans are painless and don’t require needles or dye. The MRI scan has become the most common test to look at the cervical spine after X-rays have been taken.

CT scan

The computed tomography (CT) scan is a special type of X-ray that lets doctors see slices of bone tissue. The machine uses a computer and X-rays to create these slices. It is used primarily when problems are suspected in the bones.

Myelogram

The myelogram is a special kind of X-ray test where a special dye is injected into the spinal sac. The dye shows up on an X-ray. It helps a doctor see if there is a herniated disc, pressure on the spinal cord or spinal nerves, or a spinal tumor. Before the CT scan and the MRI scan were developed, the myelogram was the only test that doctors had to look for a herniated disc. The myelogram is still used today but not nearly as often. The myelogram is usually combined with CT scan to give more detail.

Bone Scan

A bone scan is a special test where radioactive tracers are injected into your blood stream. The tracers then show up on special X-rays of your neck. The tracers build up in areas where bone is undergoing a rapid repair process, such as a healing fracture or the area surrounding an infection or tumor. Usually the bone scan is used to locate the problem, and other tests such as the CT scan or MRI scan are then used to look at the area in detail.

Other Tests

Your doctor may also ask you to have other tests done.

Electromyogram

An electromyogram (EMG) is a special test used to determine if there are problems with any of the nerves going to the upper limbs. EMGs are usually done to determine whether the nerve roots have been pinched by a herniated disc. During the test, small needles are placed into certain muscles that are supplied by each nerve root. If there has been a change in the function of the nerve, the muscle will send off different types of electrical signals. The EMG test reads these signals and can help determine which nerve root is involved.

Laboratory Tests

Not all causes of neck pain are from degenerative conditions. Doctors use blood tests to identify other conditions, such as arthritis or infection. Other tests may be needed to rule out problems that do not involve the spine.

Treatment

What can be done to relieve my symptoms?

Nonsurgical Treatment

Whenever possible, doctors prefer to use treatments other than surgery. The first goal of these nonsurgical treatments is to ease your pain and other symptoms.

Your health care providers will work with you to improve your neck movement and strength. They will also encourage healthy body alignment and posture. These steps are designed to slow the degeneration process and enable you to get back to your normal activities.

Medications

Many different types of medications are typically prescribed to help gain control of the symptoms of neck pain. There is no medication that will cure neck pain. Your doctor may prescribe medications to ease pain, fight inflammation, and to help you get a better night’s sleep.

Soft Neck Collar

If your pain is severe, your doctor may recommend a soft neck collar to keep your neck still for short periods of time. Resting the muscles and joints can help calm pain, inflammation, and muscle spasm.

Ice and Heat Applications

You might also be advised to place a cold pack on your neck for 10 to 15 minutes at a time, or you may be shown how to do a contrast treatment. Contrast treatments involve switching between a cold pack and a hot pack.

Physical Therapy

Some doctors ask their patients to work with a physical therapist. Therapy treatments focus on relieving pain, improving neck movement, and fostering healthy posture. A therapist can design a rehabilitation program to address your particular condition and to help you prevent future problems.

Injections

Spinal injections are used for both treatment and diagnostic purposes. There are several different types of spinal injections that your doctor may suggest. These injections usually use a mixture of an anesthetic and some type of cortisone preparation. The anesthetic is a medication that numbs the area where it is injected. If the injection takes away your pain immediately, this gives your doctor important information suggesting that the injected area is indeed the source of your pain. The cortisone decreases inflammation and can reduce the pain from an inflamed nerve or joint for a prolonged period of time.

Some injections are more difficult to perform and require the use of a fluoroscope. A fluoroscope is a special type of X-ray that allows the doctor to see an X-ray picture continuously on a TV screen. The fluoroscope is used to guide the needle into the correct place before the injection is given.

Epidural Steroid Injection: Neck pain or pain that spreads down the arm may require treatment with an epidural steroid injection (ESI). In an ESI, the medication mixture is injected into the epidural space around the nerve roots. Generally, an ESI is given only when other nonoperative treatments aren’t working. ESIs are not always successful in relieving pain. If they do work, they may only provide temporary relief.
Selective Nerve Root Injection: Another type of injection to place steroid medication around a specific inflamed nerve root is called a selective nerve root injection. The fluoroscope is used to guide a needle directly to the painful spinal nerve. The nerve root is then bathed with the medication. Some doctors believe this procedure gets more medication to the painful spot. In difficult cases, the selective nerve root injection can also help surgeons decide which nerve root is causing the problem before surgery is planned.

Facet Joint Injection: When the problem is thought to be in the facet joints, an injection into one or more facet joints can help determine which joints are causing the problem and ease the pain as well. The fluoroscope is used to guide a needle directly into the facet joint. The facet joint is then filled with medication mixture. If the injection immediately eases the pain, it helps confirm that the facet joint is a source of pain. The steroid medication will reduce the inflammation in the joint over a period of days and may reduce or eliminate your neck pain.

Trigger Point Injections: Injections of anesthetic medications mixed with a cortisone medication are sometimes given in the muscles, ligaments, or other soft tissues near the spine. These injections are called trigger point injections. These injections can help relieve neck pain and ease muscle spasm and tender points in the neck muscles.

Surgery

Only rarely is cervical spine surgery scheduled immediately. Your doctor may suggest immediate surgery if there are signs of pressure developing on the spinal cord or if your muscles are becoming weaker very rapidly.

For other conditions, doctors prefer to try nonsurgical treatments for a minimum of three months before considering surgical options. Most people with neck pain tend to get better, not worse. Even people who have degenerative spine changes tend to gradually improve with time.

Surgery may be suggested when severe pain is not improving.

There are many different operations for neck pain. The goal of nearly all spine operations is to remove pressure from the nerves of the spine, to stop excessive motion between two or more vertebrae, or both.

The type of surgery that is best depends on the patient’s conditions and symptoms.

Foraminotomy

A foraminotomy is done to open up the neural foramen and relieve pressure on a spinal nerve root. A foraminotomy may be done because of bone spurs or inflammation.

Laminectomy

The lamina is the covering layer of the bony ring of the spinal canal. It forms a roof-like structure over the back of the spinal cord. When the nerves in the spinal canal are being squeezed by a herniated disc or from bone spurs pushing into the canal, a laminectomy removes part or all of the lamina to release pressure on the spinal cord.

Related Document: A Patient’s Guide to Laminectomy

Discectomy

In a discectomy, the surgeon removes a problem disc. Surgeons usually do this surgery from the front of the neck. This procedure is called anterior cervical discectomy. In most patients, discectomy is done together with a procedure called cervical fusion (described next).

Cervical Fusion

A fusion surgery joins two or more bones into one solid bone. The purpose for doing spinal fusion is to increase the space between the vertebrae and to keep the sore joint from moving. This is usually done by placing a small block of bone graft in the space where a disc was removed. Opening up more space enlarges the neural foramen, takes pressure off the nerve roots, and eases tension on the facet joints. Cervical fusion is used to treat neck problems such as cervical radiculopathy, disc herniations, fractures, and spinal instability. There are two main types of fusion for neck problems.

Anterior Discectomy and Fusion: Anterior discectomy and fusion is done through the front of the neck. After taking out the disc (discectomy), the disc space is filled with a small graft of bone. The bone is allowed to heal, fusing the two vertebrae into one solid bone.
Related Document: A Patient’s Guide to Anterior Cervical Discectomy and Fusion

Posterior Fusion: In posterior fusion, the surgeon lays small grafts of bone over the back of the spine. When these bones heal together, they fuse the two vertebrae into one solid bone. Posterior fusions in the cervical spine are primarily used to treat fractures of the neck.
Related Document: A Patient’s Guide to Posterior Cervical Fusion

The bone graft needs time to heal in order for the fusion to succeed. This requires the neck to be held still. After cervical fusion surgery, patients usually have to wear a special neck brace for several months. These neck braces are often bulky and restrictive. Recently, surgeons have begun using metal plates and screws (often referred to as instrumentation) to lock the bones in place. The instrumentation is fastened to the vertebrae, where it holds the bones still while the graft heals.

Corpectomy and Strut Graft

Rehabilitation

What should I expect after treatment?

Nonsurgical Rehabilitation

Nonsurgical treatments can maximize the health of your neck and prolong the time before some type of surgery is needed. Physical therapy treatment is often prescribed for two to four weeks for patients with neck pain. Treatments are designed to help ease pain and to improve mobility, strength, posture, and function. Therapy treatments will teach you how to control your symptoms and protect your neck in the years ahead. You may be given exercises to do on a regular basis.

After Surgery

Rehabilitation after surgery is much more complex. Some patients leave the hospital shortly after surgery, but some surgeries require patients to stay in the hospital for a few days. Patients who stay in the hospital may visit with a physical therapist in the hospital room soon after surgery. The treatment sessions help patients learn to move and do routine activities without putting extra strain on the neck.

Many surgical patients need physical therapy outside of the hospital as well. They often see a therapist for one to three months, depending on the type of surgery. Therapy treatments are designed to calm pain and muscle spasm, teach patients to move safely, and help patients develop strength and mobility.

As the therapy sessions come to an end, the therapist may help the patient get back to work. The therapist can do a work assessment to ensure the patient can do his or her job safely. Some patients may need to modify their work or other activities to avoid future problems.