FAQ Category: Cervical Spine

Botox refers to botulinum toxin, which is a protein that is toxic to the nerves. It can be used in very small doses to treat painful muscle spasms and as a cosmetic treatment in some parts of the world. Injecting overactive muscles decreases muscle activity by blocking the release of acetylcholine. Acetylcholine is a neurotransmitter. Without it, the muscle is unable to contract for up to six months.

There was a recent study done comparing BTX-A injection with a placebo (saline injection) in patients with myofascial pain syndrome (MPS). MPS is a condition of muscular pain and spasm linked with trigger points (TrPs). TrPs are areas of hyperirritability in a muscle. They can cause local pain that is referred to other nearby areas in the body.

The researchers wanted to see if BTX-A can give some relief from painful symptoms. One group received an injection in muscles with TrPs. The other group got an injection of the saline solution. Results were compared by measuring patients’ neck pain, body pain, function, and levels of disability.

They found that patients in both groups got equal relief from their neck pain. That suggests maybe the needling of the TrP was enough to make a difference. Other studies have shown a benefit of dry needling for TrPs, too. The BTX-A group did have better relief from bodily pain compared with the placebo group. Mental health was also improved in this treatment group.

As mentioned, BTX-A works by stopping the release of chemicals from the nerve endings where the nerve connects with the muscle. This site is called the neuromuscular junction. It’s possible that there is another mechanism by which BTX-A works to cause pain relief. It may be that the BTX-A acts directly on the spinal interneurons to block nociceptor function. Nociceptors send messages of pain to the brain. Pain can be reduced by blocking these messages.

Botox is not used routinely for neck and back pain. These studies are investigating how effective this approach may be for patients with conditions such as MPS.

Degenerative disc disease (DDD) can affect any part of the spine. The lumbar spine (low back) is the most common site of problems. But the cervical spine (neck) can also develop DDD.

Neck and arm pain are the most common symptoms with cervical spine disc disease. Daily function can be seriously compromised. Disability is the main reason patients seek fusion.

But studies show that disc disease is common at the level above or below the fusion. This is called adjacent degenerative disease. Since there’s no motion at the fused level, force and load transfer to the next level. Increased pressure within the discs leads to damage and break down of the disc material.

Up to 25 per cent of patients who have had a cervical fusion start to have neck and/or arm pain again within 10 years. Usually these symptoms are caused by degenerative changes of the adjacent segments. It is not uncommon for patients with one-level cervical fusion to require another fusion later on.

These complications are what have led scientists to develop artificial disc replacements (ADRs). Studies are ongoing comparing the results of fusion to ADRs. This treatment is a fairly new development so long-term studies aren’t completed yet. Hopefully, the problem of adjacent degeneration will be taken care of with ADRs.

Your brother may be having a cervical laminaplasty. Cervical refers to the cervical spine or neck. Laminaplasty means changes are made to the lamina. Instead of removing it (a procedure called a laminectomy), the bone is modified.

The lamina is a part of the bone that forms an arch around the spinal cord. As we get older, degenerative changes can cause a narrowing of the opening for the spinal cord. This narrowing is referred to as stenosis.

Removing the lamina can increase the opening for the spinal canal and take the pressure off the spinal cord. This is one type of spinal cord decompression.

But removing the bone can cause the bones to collapse. Laminaplasty avoids this complication. Instead of removing the lamina, the bone is cut on one side to form a hinge joint. The bone swings out and away from the spinal canal.

When the laminae are cut on both sides of the spine, and the spinous process (back bone) is split down the middle, then the laminae can swing out like French doors.

Laminectomy refers to surgically cutting the lamina and removing it. The lamina is a bridge of bone that helps form a protective arch around the spinal cord. There is a lamina on each side of the vertebra. In between the two laminae is the spinous process. The tip of the spinous process is what you feel as a bump down the back of your spine.

Removing the lamina takes the pressure off the sensitive nerve tissue. But without this bony support, the vertebra can collapse causing spinal deformity. And although the pressure is off the spinal cord, there’s no protective covering for it without the lamina.

The laminaplasty does not remove the lamina. Instead, a hinge joint is made by cutting completely through the lamina on one side. A second incision is made through half the lamina on the other side. This allows the back of the vertebral bone to swing away from the body of the vertebra. The pressure is off without removing the protective roof over the cord.

On the down side, laminaplasty is done from the back of the neck. This requires all of the muscles and soft tissues to be stripped away from the bone. Some patients report increased neck pain after surgery. The pain will gradually subside over the next few weeks to months.

With the anterior approach, there are risks for problems swallowing and speaking. A posterior approach avoids damage to the vocal cords and throat. One other advantage of the laminaplasty is the long-term results that have been reported. Many patients maintain the benefits of this operation up to 10 years or more.

Laminaplasty is a good option for some patients who want to avoid cervical fusion. There are some patients who are not eligible for a laminaplasty. Patients with severe neck pain may not want to risk even more pain afterwards.

Patients with increased kyphosis (a forward curve of the neck instead of a backward curve) are poor candidates for laminaplasty. Each procedure has its own pros and cons. Ask your surgeon to help you understand what these are for your particular situation. Once you know what all the factors are, there may be a clear choice for you.

The results of cervical fusion can depend on many factors. A single-level fusion has less risk of problems compared with multiple level fusions. The patient’s function, pain level, and motion before the operation also make a difference.

Most patients do get pain relief. This can be full or partial. Patients with higher levels of pain before the surgery who get pain relief seem to feel the results are much better. This is compared to patients with mild to moderate levels of pain who only get partial pain relief.

Level of activity and motion are also used to measure results. A poor result means there’s been no improvement or the patient is worse. X-rays showing neck motion (flexion and extension) may be helpful in showing progress. Fusion should limit motion at the level of the fusion. Any motion at the fusion site would signal less than optimal results.

Recovery can be slow at first. Most patients need at least eight weeks for the initial phase of healing. Your surgeon may have you wear a soft collar during this time period. Improving overall motion and strength comes later.

Surgeons rely on a variety of tools to help with spinal surgery. There is always a risk of puncturing blood vessels, spinal nerves, or the spinal cord. Problems of this type must be avoided at all costs.

Endoscopic surgery has been around for a while but its use has been fairly limited in the cervical spine. The close proximity of the blood and nerve supply to vital structures makes this a procedure with some increased risk.

First, the surgeon can use (but does not rely on) his or her knowledge of the local anatomy. Knowing where to make the incision to insert the scope is important. The surgeon must be careful not to damage the thyroid or vocal chords.

Second, a special X-ray called fluoroscopy helps guide the first channel into place. A C-arm apparatus encircles the area sending X-ray images to a computer screen for viewing.

Once the endoscopic channel is in place, then the surgeon can pass instruments down through the channel to the area of concern. A tiny TV camera on the end of the scope continues to broadcast pictures to the computer screen. The surgeon continues to navigate based on an understanding of the anatomy and both fluoroscopic and endoscopic images sent to the computer screen.

Laminoplasty is the removal of part of the lamina. The lamina is also known as the vertebral arch. This is the protective circle of bone along the back of the vertebra that goes around the spinal cord. Laminectomy means the entire lamina is removed.

Laminoplasty has become a popular and successful way to treat cervical myelopathy. Cervical myelopathy is any damage or disease of the spinal cord in the neck region. This is usually caused by a herniated disc or narrowing of the spinal canal.

The procedure is usually done by cutting the extensor muscles along the back of the neck and stripping them away from the vertebrae. Part of the lamina (bone around the spinal cord) is cut and removed. This takes the pressure off the nerve tissue.

The muscles are reattached but sometimes there is still a loss of cervical lordosis. This is an decreased curve in the neck. Some patients report muscle weakness in the arms and hands. This appears to be temporary and goes away over time.

Pain in the arms is also possible. The pain may slowly resolve but in a small number of patients, it can become permanent. Other complications that can occur are the usual problems linked with surgery of any kind. This may include infection, poor wound healing, or blood clots.

Laminotomy is a surgical procedure that removes part of the lamina of the vertebra. The lamina is the bone that curves around the spinal cord and forms an arch to protect the cord. Taking a piece of the lamina out removes pressure from around the spinal cord and/or the spinal nerve root at that level.

There are various ways to do a laminotomy. There is a lamina on each side of the vertebra connected in the middle by the spinous process. The spinous processes are what we feel as the bony knobs down the back of the spine. The neurosurgeon may remove the left or right half of one lamina.

It is more common that a portion of both sides of the lamina is removed. This leaves some of the laminae to preserve as much vertebral stability as possible. The surgeon can also perform a dome laminotomy. In this case, just the bottom half of the lamina is removed (rather than one side).

Most of the time, the extensor muscles of the neck are cut and stripped away from the vertebra before the bone can be removed. Although the surgeon reattaches the muscle, there may be a loss of cervical lordosis. Lordosis refers to the natural inward curve of the neck.

Scientists aren’t exactly sure why this happens. It appears to affect women more than men. The cervical muscles tend to be atrophied (wasted away) and weak before the operation.

Cutting and restoring them may be enough to alter other functions besides strength. This may include kinesthetic or proprioceptive perception. These functions allow the joints and muscles to work together to move the right amount for each motion and to sense movement through space.

Women seem to be affected more than men with loss of cervical lordosis after laminotomy. The reasons for this remain unknown. It’s also not clear what (if any) rehab is needed to restore full function, alignment, and posture.

The term Hangman’s fracture is the everyday name given to a fracture of the C2 vertebra. The cervical spine (neck) is made up of seven bones labeled one through seven. C1 is a ring that sits down over the top of C2. C2 is often referred to as the axis.

A Hangman’s fracture causes a break in the pedicle(s) of the axis. The pedicles is a connecting portion of the vertebrae between the main body and the tansverse process.

The transverse process is a projection from the side of the vertebra. This piece of bone has a place for the rib to attach. They also provide a place for ligaments and muscles to attach.

The injury that causes this type of fracture is usually forcible hyperextension of the head. The term originated from death by hanging. The noose placed below the condemned person’s chin forced the head back. When the subject was dropped, hyperextension with the full weight of the body caused enough force to fracture the axis.

In today’s world, this injury is still seen sometimes. But the cause is more likely from sports injuries or car accidents. In hangings from suicide, asphyxia (lack of air) is the usual cause of death. Accidental injuries of this type may require surgery to stabilize the spine.

Crowned dens syndrome is a syndrome that results from the build up of calcium around on the second vertebrae in your neck. The first vertebrae rotates on a small finger-like or tooth-like projection called the odontoid process.

When calcification occurs around this projection, it causes pressure and pain in your neck. Luckily, it can be treated and the pain usually resolves within a few days.

Surgery is the type of treatment that should only be done as a last resort if medical treatments don’t work. Surgery has many risks and when surgery is performed, the surgeon must decide that the risks of surgery are better than the risks of not performing the surgery.

In the case of crowned dens syndrome, where there is calcification on the second vertebrae, causing pain and pressure in the neck, medical treatment appears to be the best option.

Studies have shown that treatment with a corticosteroid and/or non-steroidal anti-inflammatories is very effective, with a low recurrence rate. For those patients who do have a recurrence, repeat treatment appears to be very successful as well.

You may have had the best type of operation available at the time of the accident. Fusion to hold the spine in place until it healed was (and still is) the standard of care in most places.

The ability to use screws to hold the fractured vertebra in place is a recent development. Advances in computer technology and imaging techniques have made this type of surgery possible. But it is expensive, requires a large facility, and isn’t available everywhere yet.

The advantage of screw fixation over fusion is the obvious restoration of neck motion. Surgery to repair a Hangman’s fracture of the C2 vertebra is a delicate operation and very difficult at best.

Real-time imaging is needed to allow the surgeon to see the spine after the patient is placed in the prone (face down) position. A special machine called Iso-C(3D) sends signals to a computer navigation system. The images are displayed on a TV screen during the operation.

Afterwards, CT scans and X-rays are used to verify the position of the spine. Once a segment is fused, it cannot be reversed.

The debate about cervical bracing (orthosis) is ongoing. Some surgeons advise their patients to wear some type of soft or rigid orthosis for the first two weeks.

Others do not think this is needed when metal plating is used along with bone graft material. There haven’t been enough studies done to fully answer the question.

It may be best if the decision is made on an individual basis. Patients who are only having a single-level fusion are less likely to have loosening at the fusion site. They may not need bracing at all.

But patients with reduced or poor bone quality, multi-level fusions, and allografts (donated bone) may need the extra support while fusion takes place.

A recent study from Baylor College of Medicine in Houston, Texas reported on this topic. They found measurable motion within the first two weeks after anterior cervical discectomy and fusion (ACDF). Adjustable titanium plates were used.

They thought the plates would reduce the motion enough to encourage the bone graft to form a bridge. The patients didn’t wear a brace of any kind afterwards. This may have resulted in loosening at the bone-to-screw interface.

If you have osteoporosis (decreased bone mass) and multi-level fixation, you may want to consider post-operative bracing for the first week or two. Your surgeon is the best one to make this decision.

The type of injury and quality of bone will determine the selection of implant used. Some implants have greater variability and are more likely to bend or provide too much rigidity at the fusion site.

Some patients have no symptoms at all with a failed fusion. Movement occurs at the fusion site but they aren’t aware of it. This is called a pseudoarthrosis, which means false joint.

But if a patient reports pain and/or other symptoms, then X-rays may be taken. If screws have come loose or start to back out, this will show up on the X-ray.

Special studies using fluoroscopy combined with motion tracking software can show motion at the fusion site. Fluoroscopy is a type of X-ray that allows the physician to watch the spinal segments as the head and neck bend forward and back.

Computer technology makes it possible to magnify and view the moving vertebrae on a screen. The software analyzes the movement and reports the presence or absence of motion. This method also allows the surgeon to see where the movement is coming from.

Many patients who have a fusion and later develop a pseudoarthrosis still report improvement. Further treatment may not be needed. When necessary, revision surgery can be performed.

Combining several modalities (treatment methods) is not uncommon in the treatment of cervical radiculopathy (CR). CR is another term for the type of neck and arm pain you are having.

In general, there’s been a shift in the focus of studies in health care. Researchers and scientists along with doctors and physical therapists are looking for solid support that the treatment prescribed for various patients is working. We call this evidence-based medicine.

Many musculoskeletal problems have a different underlying cause. This means studies must be done in each area to look for proof that the treatment used is working. In fact, we now try to find the best way to manage each type of injury, illness, or other conditions.

In the case of CR, it appears that a multimodal approach works best. Patients with CR who receive manual therapy and strengthening exercises along with neck traction seem to have the best early results.

This is important news because neck and arm pain can be very disabling. Finding a best practice treatment model that has short-term positive results may reduce or prevent disability in the long-run.

Right now, we still don’t know if some of the modalities used work better than others. Research is ongoing to find out what combination of treatment tools works best. How often the patient should be treated, by what methods, and in what order are still being tested out.

Neck and arm pain from cervical radiculopathy are fairly common problems in adults over the age of 50. Arthritic changes in the spine can result in pressure on the spinal nerves. Besides pain, patients report numbness, weakness, and loss of function.

When the problem doesn’t go away on its own, medical treatment may be needed. Anti-inflammatory drugs may help reduce swelling. This can help take pressure off the nerve.

Improving posture and positioning during daily activities, computer work, and while sleeping in bed are key features of a conservative approach to this problem. Modifying the way activities are done may be important.

Physical therapy intervention is another conservative way to approach this problem. The therapist uses a wide range of modalities for cervical radiculopathy. This may include manual therapy such as joint and soft tissue mobilization and joint manipulation. Cervical traction, strengthening exercises, and restoring nerve mobility may also be included.

When none of these efforts prove helpful in reducing painful symptoms, then surgery may be the next step. But studies show that more than 25 per cent of the patients who have surgery for this problem still have severe and debilitating pain 12-months later.

When looking at the long-term results, other studies support the use of conservative care over surgery. At least six months of conservative care are advised before considering surgery.

Sometimes it takes a combined effort of many treatments to get the desired results. Give yourself plenty of time to mix and match various approaches before moving on to a more invasive approach.

In a study of 64 patients, 22 had difficulty swallowing after anterior cervical surgery. The medical term for this is dysphagia. Dysphagia happened immediately after surgery in all of them. In the patients that got better, the dysphagia lasted from three to 365 days. 11 of the 22 patients had long-term difficulty with swallowing.

There is a trend among makers of cervical plates to make them thinner. This is in part due to the reported problems with difficulty swallowing after surgery. However, in a recent study with 64 participants, the thickness of the plate, or the degree that the plate protrudes after surgery did not seem to make a significant difference.

The anterior cervical decompression and fusion surgery is likely what your doctor means. The disc that is causing the problem is removed and bone is put in its place. Studies show this surgery is successful. However, in the long run, some people will have problems with wear and tear in the neck above and below the fusion. This is most likely because there is less range of motion in the neck where it has been fused. The other areas have to move more to compensate.

Disc replacement helps maintain range of motion at the site where the disc is removed. It is hoped that there will be less degeneration of the area above and below where the disc is replaced so that longterm satisfaction will be improved. Disc replacement surgery is being studied, we do not know if it is a better option long term yet.

You may have near normal neck motion following your surgery if it is at one level. However, the motion may be different at some of the segments. At the fusion site, range of motion is usually decreased. Motion at the segment above and below the fusion site will likely be increased from before surgery.