FAQ Category: Cervical Spine

When conservative care does not relieve the pain and other symptoms caused by degenerative neck disease known as cervical spondylosis, then spinal fusion is considered. Nearly 60 years ago, in the 1950s, the first anterior cervical diskectomy and fusion (ACDF) was done. This has now become the standard of care for symptomatic cervical spondylosis.

The surgeon removes the diseased or damaged disc and any bone spurs that might be causing problems. This part of the procedure is called decompression. Then the spine is surgically stabilized. This is the fusion part of the surgery. A metal plate is attached to the front (anterior) side of the spine. Bone graft material is used to help speed up the stabilization process.

Any surgery comes with its own set of risks and benefits. Adjacent segment disease (ASD) is one of the known problems that can develop after spinal fusion. ASD refers to breakdown of the vertebrae next to the fusion. According to current studies, the increased stress and strain from a fusion (no movement at the fused level) results in adjacent segment disease in approximately three per cent of patients each year after the procedure.

Based on collected data from studies over the years, there is an expectation that about 25 per cent (one in four) patients will have some adjacent segment disease within the first 10 years after their fusion procedure. These figures come from studies with follow-up X-rays, which is how adjacent segment disease is observed.

Not all patients with visible adjacent segment disease (ASD) seen on X-rays has any symptoms from this degenerative process. In fact, many patients with ASD still report decreased neck pain and improved neck motion as a result. The hope is that the number of patients who experience adjacent segment disease will decline in the future as surgical techniques continue to improve and advance.

Degenerative disc disease and other age- or trauma-related changes to the neck are referred to as cervical spondylosis. This is a common problem in adults that becomes more prevalent the older we get. In fact, MRIs and X-rays taken in normal groups of adults over the years show a 14 per cent rate of abnormalities before the age of 40.

The number of people affected by neck degeneration increases to 28 per cent after age 40 up to 89 per cent after age 60. The people in these studies did not have any symptoms indicating there was a problem. But for those who do develop severe pain and other symptoms (e.g., arm pain, numbness and tingling down the arm), treatment is recommended.

Conservative (nonoperative) care such as what you tried is first. But if that doesn’t work, then diskectomy (removal of the disk) may be suggested. The surgeon rarely just removes the disc as the only step in the treatment. Usually, the surgeon removes the diseased or damaged disc and any bone spurs that might be causing problems. This part of the procedure is called decompression.

Then the spine is surgically stabilized. This involves fusion of the two vertebrae on either side of the disc that was removed. A metal plate is attached to the front (anterior) side of the spine. A metal cage filled with bone graft material may be placed in the space where the disc once was. The bone graft is used to help speed up the stabilization process.

The entire procedure is referred to as an anterior cervical diskectomy and fusion or ACDF. More recently, ACDF has been replaced with a different surgical approach. The development of a total disc replacement (TDR) has been introduced. Disc replacement does not require bone grafts and preserves neck motion. Not all surgeons perform this procedure and studies are being done to compare the results between fusion and disc replacement.

In time with continued long-term follow-up, the results of fusion (ACDF) versus nonfusion (total disc replacement) surgery will be fully known. The hope is that the number of patients who experience problems after either procedure will decline as surgical techniques continue to improve and advance.

Diffuse Idiopathic Skeletal Hyperostosis (DISH) is a condition in the spine caused by ligaments that turn into bone. Spinal ligaments along the front and back of the spine that help stabilize the spine are affected.

As a result of this condition the spine becomes stiff, rigid, and more fragile in the older adult. The older adult may just think these changes are part of the aging process. They may have no other symptoms so don’t even know there is a problem until something like this happens and the diagnosis is made.

DISH generally occurs in people after age 50. It occurs more often in men than women. While the cause is unknown, there seems to be a connection with having diabetes, high blood pressure, coronary artery disease, and being overweight. Some researchers feel that the extra bone is made because of extra blood supply near the spine. Growth factors that affect the formation of calcium likely play a role.

A fall (even from ground level) or car accident can cause spinal fractures in the vertebrae already affected by this condition. Studies show there are many surgical and medical complications associated with cervical fractures in patients with DISH. These patients are at high risk for further problems during surgical management.

With a fractured skull and cervical spine fractures, there is concern for serious neurologic damage. An unstable cervical fracture can cause paralysis from spinal cord injury. Several studies reporting on conservative (nonoperative) care for serious injuries in patients like these have shown poor results. This is the main reason surgical fusion is the recommended choice of treatment for some patients.

You have probably been informed by the surgeon or medical staff that the type of problems your father may face during surgery include pneumonia, pulmonary edema (fluid in the lungs), respiratory failure, urinary tract infections, seizures, blood clots, and even death. Patients at greatest risk for complications are those who have a spinal cord injury from the cervical fracture before surgery is done.

Patients are who have this condition known as DISH and who then sustain cervical spine fractures are considered very fragile. Even with surgery serious disability is possible. Experts who have studied this problem say these patients are at high risk for poor results but the outcomes are still better than without surgery. Only the surgeon can really define the prognosis for your father. Once the surgery is complete, you’ll likely have a better idea what to expect and the time frame involved.

The vast amount of information on the Internet can be very overwhelming. Even with a reputable and trustworthy site like PubMed, it is easy to get lost in the volume of studies and available analysis. Sometimes it seems without a degree in statistics, just understanding the value of each study published can be a challenge.

That’s why many folks looking for reliable research information turn to studies that are either systematic reviews or meta-analyses. Each of these types of studies provides conclusions based on a more careful review of the literature.

In the case of outcomes for fusion versus disc replacement, there is one study from medical personnel at three different reputable institutions that might give you some helpful information. They specifically evaluated the results of cervical spine (neck) fusion against disc replacement in terms of a condition known as adjacent segment disease (ASD). This is one of the major potential complications to consider after either one of these surgeries.

Adjacent segment disease (ASD) refers to the degeneration of tissue (disc, joints, vertebra) at the spinal level above or below where the fusion or disc replacement took place. It occurs because of increased load transmitted to the surrounding areas when the primary (first) site of disease is disrupted surgically and treated.

The authors of this review of surgical treatment for painful cervical disc disease describe their work as “structured” and “rigorous.” And it was truly both! They did a very thorough review of published studies comparing the results of cervical spine (neck) fusion with total disc replacement and that’s what you are looking for.

Their search was for information on radiographic (X-ray) results and clinical pathology after these two treatment approaches. The specific focus was on adjacent segment disease (ASD). Like you, they found hundreds of possible studies (276 to be exact using some criteria for inclusion and exclusion that they describe in their summary article).

They were able to drill down those 276 studies to 14 that were of high enough quality that actually compared radiographic and/or clinical results after these two different procedures. In most of the studies, the information was either not recorded or incomplete.

Their conclusions? First and foremost, studies comparing fusion versus disc replacement for cervical spine degenerative disc disease come up short. There was a moderate amount of evidence that no difference exists in short-term or medium-length follow-up results between fusion and disc replacement. In other words, the development of adjacent segment disease is about the same after either type of treatment. But no specific recommendation could be made to guide the selection of treatment without further studies with stronger evidence.

Likewise, they were unable to offer any firm conclusions about the value or benefit of one disc replacement system over another. There just isn’t enough evidence or enough strong evidence to make such a statement.

You are entering an area of medical research that has more unknowns than knowns. Although either treatment is considered safe and effective, each one has its own advantages and disadvantages. Don’t give up the search! But take the information you find and talk to your surgeon about his or her opinions, experiences, and recommendations for you. Current evidence in the literature is always helpful but each patient is different and cannot be treated in a cookie cutter approach. Your surgeon will evaluate your specific situation, condition, and circumstances and guide you.

Not all patients with neck and/or arm pain from degenerative disc disease are good candidates for disc replacement. So the first step is always to have a surgeon evaluate your situation and advise you regarding the best treatment. Since you have it in mind to pursue a disc replacement, we are assuming you have the go-ahead from your surgeon.

That being said, sometimes the choice of a specific implant (total disc replacement or TDR) is really up to the surgeon. Experience with a particular TDR, technical skill, and overall expertise may be more important than the specific type of device used.

Placing the implant with the right angle and position is very important in restoring normal kinematics (spinal motion). Even a small amount of asymmetry or being off center can result in uneven wear and tear on the spinal joints or increased load on the segment above or below the implant.

Studies show that adjacent segment disease (ASD) is a problem after spinal surgery of this type. ASD refers to degeneration or breakdown of disc and/or vertebra above or below a spinal segment that has been fused. ASD can also occur after a disc has been replaced with an implant. And although very limited at this time, there isn’t strong evidence that one implant is better than another for preventing ASD.

In fact, there was a recent systematic review published with information you might find helpful. The researchers evaluated all the studies published so far comparing adjacent segment disease (ASD) after fusion and disc replacement. A subset of their study was to look at the difference in outcomes between two implant devices (Bryan and ProDisc-C).

Their conclusions? First and foremost, studies comparing fusion versus disc replacement for cervical spine degenerative disc disease come up short. Many of these studies are conducted by companies that make the disc replacement devices. So there is a clear need for independent research. Independent means the research isn’t carried out by (or paid for) by companies manufacturing these implants.

There is a moderate amount of evidence that no difference exists in short-term or medium-length follow-up results between fusion and disc replacement. In other words, the development of adjacent segment disease is about the same after either type of treatment. But no specific recommendation can be made to guide the selection of treatment without further studies with stronger evidence.

Likewise, they were unable to offer any firm conclusions about the value or benefit of one disc replacement system over another. There just isn’t enough evidence or enough strong evidence to make such a statement. They do point out that it is difficult to perform a blind study, which would be more objective.

In a blind study, the outcomes would be measured without patients or physicians knowing who had which treatment. Since X-rays are one of the main ways to assess results, it is always clear what type of treatment was provided each patient.

It is good to gather as much information as you can before making a final decision about surgery of this type. We hope what we have provided will help you formulate questions for your surgeon. Ultimately, your decision will be made in consultation with the surgeon and your resaerch will provide you with the answers you need.

There are many variables to consider when making a decision between these two surgical procedures. As you point out, there are advantages and disadvantages to both. The goal is to weigh the risks against the benefits in light of your own situation and make the best choice you can for yourself.

It is agreed that if you have a disc replacement, it’s better than a fusion (in terms of motion). Movement of the spine is maintained with the implant (called a disc arthroplasty. But your question: does a disc arthroplasty provide the same kind of spinal movement (called kinematics) as the normal, natural spine is a good one? And one that a recent study was done to find out.

The authors conducted a systematic review (collecting all the published materials on this topic) and a meta-analysis (combined all the data together). They compared the results of a disc arthroplasty with anterior cervical disc removal and fusion (called an anterior discectomy and fusion or ACDF). The cervical spine refers to the neck.

The main measure of results or outcomes was change in movement at the spinal level next to (adjacent) the implant. Kinematic (movement) measurements were made by looking at overall (global) neck range of motion. Special flexion-extension X-rays were used to measure changes in cervical spine motion.

They looked at the motion at the spinal segments above and below the arthroplasty and the fusion site. There was interest in knowing if either of these adjacent areas would end up with increased stress, force, and motion.

They also looked at movement of the vertebra (spinal bone) forward over the vertebra below it. This motion is called anterior translation. And they studied changes in the center of rotation of the discs and vertebra above and below the sites of fusion or arthroplasty.

There really wasn’t any significant difference in motion at the adjacent levels between the two groups (arthroplasty versus fusion). The studies followed patients for up to two years after the surgery. Longer-term results might show a difference but this wasn’t evident in the short-term.

Likewise, there were no measurable differences in center-of-rotation or anterior translation motion between the two groups in the first two years. Observing center-of-rotation motion gives us an idea of the quality (not just quantity) of motion. And that’s important because early joint degeneration leading to arthritic changes can occur when the center-of-rotation is off. Uneven load on the spinal joints and increased pressure through the disc can occur when there is a shift in the vertebral center-of-rotation.

As this study showed, there was no major difference in kinematics at the adjacent levels after disc replacement compared with spinal fusion. There were some significant changes in alignment after disc replacement but they thought this was because decreased pain allowed for increased neck function.

There is still plenty of room for more research in this area. Most of the studies included only followed patients for two-years. So we don’t have long-term results to say what might happen 10 or even 20 years down the road. And implant design keeps changing as new technology arises and results of studies done so far are used to keep improving surgical techniques. But for the moment, there is probably enough information available to help you sort out what is the best choice for you.

When the spine is unstable from degenerative disc disease and conservative (nonoperative) care does not help reduce pain, improve function, and stabilize the spine, then surgery is sometimes the next step. Fusion is one option. Disc replacement is another. Each one of these choices has advantages and disadvantages to consider.

For example, when successful, fusion eliminates motion at the diseased level. That’s the positive aspect of this procedure. But at the same time, when one segment doesn’t move, the segment above and below the fused area takes on more stress and load. Over time the result can be a condition known as adjacent segmental disease or ASD.

With ASD, there is an increase in motion above and below the fused level. The center of rotation for those vertebra can be altered causing uneven wear on the spinal joints. Simply stated, fusion changes the normal, anatomic motion in the spine. That’s good when trying to stabilize a sloppy joint that is unstable and potentially damaging. That may not be so helpful if the result is a faster degenerative process in the spine around the fusion.

Total disc replacement (TDR) helps preserve spinal motion and therefore the risk of developing adjacent segmental disease (ASD). But it’s not entirely clear yet whether or not a disc replacement restores normal spinal motion. Are the joint <i kinematics (motion) exactly the same after disc replacement compared with normal motion? Or even compared with fusion?

Studies have already shown that compensatory motion occurs at adjacent spinal levels after spinal fusion. This increase in motion is accompanied by other effects such as increased pressure on the discs, a shift in the center of rotation, and increased vibrational stress on the spine.

As we mentioned, total disc replacement helps avoid these effects. But as a recent review of multiple studies showed, there is no major difference in kinematics at the adjacent levels after disc replacement compared with spinal fusion. The studies followed patients for up to two years after the surgery. Longer-term results might show a difference but this wasn’t evident in the short-term.

We hope this bit of information helps you sort out what you heard and your current understanding of these two different procedures. Don’t hesitate to ask your surgeon (or the physician’s assistant if there is one) to answer any further questions you may have before having whatever procedure is your final choice. You want to be comfortable that you were fully informed when making this treatment decision.

Even from your brief description, it sounds like your Grandpa’s situation was very complex. Medical and surgical treatment can be challenging for anyone with DISH complicated by multiple-level cervical spine fractures but even more so for an older adult.

Diffuse Idiopathic Skeletal Hyperostosis (DISH) is a condition in the spine caused by ligaments that turn into bone. Spinal ligaments along the front and back of the spine that help stabilize the spine are affected.

As a result of this condition the spine becomes stiff, rigid, and more fragile in the older adult. A fall (even from ground level) can cause spinal fractures affected by this condition. We can provide some perspective from a recent study. Surgeons from three separate medical centers reviewed their charts for patients who had a diagnosis of DISH, then fell, fractured their cervical spine (neck), and were treated surgically to fuse the spine.

Patient characteristics and results of treatment were key areas of interest. The goal was to understand this problem better and eventually develop guidelines for treatment. As it turned out, there were many surgical and medical complications associated with cervical fractures in patients with DISH. As these surgeons suspected from their experience, this group of patients were at high risk for further problems during surgical management.

All the patients in the study had a spinal fusion because the fractured spine was unstable. Ages ranged from 53 up to 98 years old. Concern for serious neurologic damage (including paralysis from spinal cord injury) was the main reason for fusion as the recommended choice of treatment. Several studies reporting on conservative (nonoperative) care for serious injuries in patients like these have shown poor results.

About half of the 33 patients in this study were fused from the front of the spine, called an anterior fusion. Another one-third had a posterior fusion (from the back). And the rest had both anterior and posterior fusions done. In all cases, more than one level was fused (some patients had as many as eight spinal levels fused).

The type of problems encountered during treatment included pneumonia, pulmonary edema (fluid in the lungs), respiratory failure, urinary tract infections, seizures, blood clots, and even death. The nine patients who died had a spinal cord injury from the cervical fracture before surgery was done. The medical complications and the deaths of all 33 patients were linked with the post-injury/pre-operative neurologic damage.

This study points out very clearly how fragile patients are who have DISH and then sustain cervical spine fractures. Despite surgery, serious disability and often death are the outcomes. Should surgery even be done for these individuals? That is a tough question to answer. Other experts who have studied this problem say these patients are at high risk for poor results but the outcomes are still better than without surgery.

Patients and their family members are always made aware of the high risk for serious complications and told that a second surgery may be needed. Death is always a possibility with any surgery but especially in this situation. None of this information changes your situation. But knowing that everything was done to treat your Grandpa should be a comfort. Without surgery he was likely at grave risk for spinal cord injury that could result in complete paralysis.

More study is definitely needed to improve the prognosis for patients with DISH who fall or somehow end up with an unstable spinal fracture. Future studies may also help surgeons develop a treatment protocol for managing these kinds of complex cases.

Anterior cervical discectomy and fusion (ACDF) is the procedure used most often to fuse the cervical spine (neck). ACDF is used for neck problems such as cervical radiculopathy, disc herniations, fractures, and spinal instability.

In this procedure, the surgeon enters the neck from the front (the anterior region) and removes a spinal disc. This portion of the operation is called a discectomy. The vertebrae above and below the disc are then held in place with bone graft and sometimes metal hardware.

The surgeon inserts the bone graft material into the space between the two vertebrae where the disc was removed. This space is called the interbody space. The goal of the procedure is to stimulate the vertebrae to grow together into one solid bone (known as fusion). Fusion creates a rigid and immovable column of bone in the problem section of the spine. This type of procedure is used to try and reduce neck pain and other symptoms.

There are several ways this procedure can be done. There is the autograft stand-alone procedure, the autograft with anterior (front of the spine) plate, and interbody cage supported by an anterior plate. Each of these approaches has its own benefits and disadvantages, which your surgeon can discuss with you.

Metal cages used in between the vertebral bones are usually filled with bone chips that will eventually grow together to support the fusion. Cages support the load and maintain spine height. These can be used as a stand-alone procedure (just the cage) but studies show results are much better when cages are accompanied by anterior metal plates (along the front of the fusion site).

One of the newest and latest developments in this procedure is the use of an artificial (substitute) bone graft. Substitute bone eliminates the long-term pain and discomfort that often occurs with bone graft taken from the patient’s hip.

The goal for the future is to develop a cage or other fusion device that doesn’t require the additional plating. This would decrease or even eliminate problems with plating such as difficulty swallowing and degeneration that often occurs at the spinal level next to the fused area.

Your surgeon is the best one to advise you on first, whether a fusion is the best treatment approach for you and two, if so, which surgical technique is best for you. Each patient should be evaluated individually with consideration given in the selection of treatment based on patient characteristics. Age, activity level, patient goals and expectations, bone health, and underlying cause of the problem are all important factors that must be weighed-in when making treatment decisions involving cervical spine fusion.

Many people start to develop disc degeneration in the cervical spine (neck) as a result of the degenerative and inflammatory processes associated with aging. These kind of changes are often the source of neck and/or arm pain.

Treatment usually starts with conservative (nonoperative) care to address motion, weakness, alignment, posture, and of course, the pain. Besides antiinflammatory medications, physical therapy is often a main feature of treatment at this stage.

The “do nothing” plan is referred to as “benign neglect” and may just result in spontaneous bony fusion. Studies show that removing the disc without doing anything else (or letting the disc degenerate to nothing) leads to the body taking care of itself by fusing the bones together. This occurs in up to 80 per cent of cases treated with benign neglect.

If conservative therapy fails or if painful symptoms get worse, then surgery may be advised. The surgeon may just go in and do some “clean up” work — shaving off osteophytes (bone spurs) or removing the disc (discectomy). Spinal fusion is another option. In this procedure, the surgeon joins two or more neck vertebrae into one solid section of bone. The medical term for fusion is arthrodesis.

There are many ways to perform a fusion of the cervical spine. The surgeon usually removes the degenerated, diseased disc from between two vertebrae. Bone chips (graft) are inserted into the space left by the removed disc. Sometimes a special metal cage is inserted in between the two vertebrae instead. The cage is then filled with bone chips. Hardware such as a metal plate held by screws may be placed along the front (anterior) portion of the spine to help stabilize and hold everything in place until fusion takes place.

But if you are a good candidate, disc replacement may be possible. With a disc replacement, motion is preserved. The artificial disc is inserted in the space between two vertebrae. The goal is to replace the diseased or damaged disc while keeping your normal neck motion. The hope is that your spine will be protected from similar problems above and below the affected spinal level.

We think it’s great there are so many options to choose from. Each case is individual and the patient and surgeon must work together to find the right “best” choice for each person. There are many choices and many reasons to choose one treatment option over another. Hopefully knowing what some of the options are will help you ask the questions for yourself that will guide you through this process.

Oculomotor control (the use of the eyes and head together) is a complex system that relies on the coordination of neck and eye muscles, cervical spine movement, neck stability, and even something called neck repositioning acuity.

Any injury to the neck (even mild sprains, strains, and contusions) can cause pain, stiffness, loss of motion, and dizziness. There are exercises to improve oculomotor control. These are usually prescribed and supervised by a physical therapist as it is very easy to overdo and end up with worse symptoms than before.

Here are a few examples of exercises a therapist might suggest for your problem:

Neck pain is a common problem among all age groups and often for different reasons. Women seem to be affected more than men. High-level athletes, weekend warriors, stay-at-home moms can all experience neck stiffness, pain, dizziness, and loss of muscle control. There doesn’t have to be a major injury to bring about symptoms of this type. Even minor injuries, sprains, strains, and soft tissue contusions can result in chronic pain and dysfunction.

So your question about what can be done is a good one. The neck is a sensitive area so starting simple and going slowly in progressing the program is always advised. As you have discovered, it’s easy to flare your symptoms when trying to exercise. It might be best to seek the advice and guidance of a physical therapist. They are specifically trained to evaluate symptoms, anatomy and movement patterns and then prescribe patient-specific (even sport-specific) exercises.

The therapist will “titrate” the exercises to achieve the desired results without side effects. This means the intensity, number of repetitions, and frequency of each exercise is carefully set and then progressed slowly over time. You may even be advised at first to do some exercises through partial (rather than full) neck motion.

Other areas must be assessed and addressed, too. For example, shoulder and trunk muscles might be involved requiring attention. Weakness in the muscles of these structures can contribute to neck pain. In some cases, people with neck pain hold the head at an angle without even realizing it. They may have lost the natural function referred to as head/neck repositioning acuity. There are exercises to improve these deficits as well.

Anyone with neck pain (whether a top athlete, weekend warrior, or nonathlete) can benefit from specific exercises to address the problems they are facing. Pain, stiffness, loss of motor control, poor muscle contraction, and even dizziness can be addressed with exercises to improve repositioning acuity and postural stability. But don’t try to do this on your own to get started. A carefully prescribed and supervised program of exercise can get you on the right track and stay there to meet your intended goals and desires.

Up to 40 per cent of individuals who hurt their necks in a car accident end up with chronic pain and loss of neck motion. It’s likely that trigger points (TrPs) are a large part of the picture both in cause and effect. We’ll explain what that means.

First, trigger points (TrPs) are hyperirritable spots in the muscle caused by muscle immobilization (e.g., in a cast or splint or in response to pain after an accident) or overuse (repetitive motion). When active, these points create painful muscles and limited range-of-motion. Trigger points develop along with whiplash-associated disorder as a result of something called central sensitization.

Central sensitization is a hyperexcitability of the central nervous system. In other words, when present, TrPs “revv” up the engine of the nervous system and it doesn’t slow down when the foot is taken off the accelerator. But there may be more to it than that as some research has shown a bidirectional mechanism. Input from TrPs to the nervous system increase pain sensitivity and vice versa. Increased sensitivity of the nervous system to stimuli may actually create the TrPs.

A recent study from the University of Granada in Spain showed that people with higher levels of neck pain were more likely to have trigger points and more of them. The number of days from the accident was a factor. The more time the nervous system is stimulated by the trigger points, the less it takes to set them off. At the same time, decreased neck motion was linked with TrPs. But which came first (the altered neck motion and then the TrPs or the TrPs and then the decreased neck motion) remains unclear. Higher pressure pain sensitivity over the cervical spine (neck) is linked with more trigger points.

These findings support the idea that active TrPs generate pain in people with neck pain from a whiplash injury. The natural conclusion is that treating TrPs may be one way to reduce pain for individuals with whiplash-associated disorder.

You may be experiencing a pain-spasm cycle of chronic whiplash known as whiplash-associated disorders (WAD). And as a result, you may have developed trigger points (TrPs) that are keeping the pain at such high levels.

Trigger points (TrPs) are hyperirritable spots in the muscle caused by muscle immobilization (e.g., in a cast or splint or as a result of pain from an accident) or overuse (repetitive motion). When active, these points create painful muscles and limited range-of-motion. Trigger points develop along with whiplash-associated disorder as a result of something called central sensitization.

Central sensitization is a hyperexcitability of the central nervous system. In other words, when present, TrPs “revv” up the engine of the nervous system and it doesn’t slow down when the foot is taken off the accelerator. But there may be more to it than that as some research has shown a bidirectional mechanism. Input from TrPs to the nervous system increase pain sensitivity and vice versa. Increased sensitivity of the nervous system to stimuli may actually create the TrPs.

In situations like these, the affected individual’s pressure pain threshold, a measure of how much pressure it takes to create a painful response is lowered. Small amounts of pressure result in high levels of pain. This is referred to as pressure pain hypersensitivity, which may be what you are experiencing.

Treating TrPs may be one way to reduce your pain. You may want to see a physical therapist and/or an acupuncturist to get started. Follow-up with massage may help dissipate some of the waste products that build up in muscles that are constantly contracting in pain. The therapist will also provide you with some stretching and strengthening exercises to help in the recovery process. It may take four to six weeks but stick with it and you should see some good results.

If the vertebral bones are destroyed, a disc replacement probably won’t help you but an orthopedic surgeon who can examine you directly is really the one to evaluate and advise you.

The disc is a gel-like cushion that sits between the vertebrae. Disc replacements are usually used for patients who have degenerative disc disease rather than bone disease. Without the structural support of the bones, a disc replacement isn’t recommended. Cancer affecting the bones (either primary or metastases) is usually a contraindication to disc replacement when there is disc disease.

Sometimes even with spinal instability, conservative (nonoperative) care is helpful — and all that’s needed. It is possible that your situation may require a fusion procedure. This would be possible if the adjacent bones are strong enough to support bone grafting materials. Treatment may be influenced by your age, activity level, amount of instability present in the spine, and cancer prognosis.

Other factors the surgeon will take into consideration include presence of osteopenia (decreased bone density), osteoporosis (brittle bones), spinal deformity, and results of any imaging studies done (e.g., X-rays, CT scans, MRIs).

We are sorry for your loss and applaud your brother’s contribution to this fast-changing area of medicine. Much has happened in the last few years related to disc replacements for the neck called cervical disc arthroplasty. The first FDA-approved studies on the subject have been published for three different devices: the Prestige System, the ProDisc-C system, and the Bryan disc. Since the first cervical disc replacement didn’t come out until 2007, the results so far are fairly limited. Later implant systems weren’t available until 2009, so research data is fairly limited as well.

What do we know so far? Short- and mid-term results are very favorable. Patients are able to get pain relief and return of motion and function. Results are measured using a specific Neck Disability Index (NDI) and assessment of neurologic function after surgery. A report of any adverse events, implant failures, or need for a second surgery is also reviewed.

One of the key areas of interest in these studies is the rate of adjacent-level degeneration. There is a belief and hope that disc replacement will reduce the risk of deterioration at the spinal level above and below the new disc. Disc replacements allow for continued neck motion so that force and load transmitted through the neck are not transferred to the adjacent segment.

It is believed that this scenario is more likely after a fusion procedure (compared with a disk replacement). But proving that normal neck joint motion prevents or reduces adjacent segment degeneration remains a goal for the industry.

In the future, we can expect to see continued changes and improvements in the technology behind cervical disc replacement. Answers are still needed to the question of whether cervical disc arthroplasty have similar problems to other joint replacements (e.g., wear and debris creating an inflammatory response).

Indications and precautions for the use of cervical disc replacements are also under investigation. Currently, anyone who is a candidate for a discectomy and fusion is also likely to do well with disc replacement. Patients with bone deformities, severe spinal joint arthritic changes, or osteoporosis (brittle bones) may be excluded from having a disc replacement. A history of prior neck surgery, bone or disc infection, and cancer metastases may also prevent a patient from having a disc replacement at this time.

There is a curious observation about patients who have a cervical spine fusion procedure when those patients are part of a Food and Drug Administration (FDA) study. They have a higher reoperation rate compared with people who have a cervical fusion outside of an FDA study.

Cervical fusion patients in two groups studied (private investigation versus FDA study) received the standard anterior cervical discectomy and fusion (ACDF) procedure you mentioned. One group was part of the FDA investigational studies comparing results of ACDF (the control group) with disc replacement. The second group was patients who had the same ACDF procedure as part of their regular clinical treatment (not as a control group or experimental group).

It is suspected that just being part of an investigational study comparing disc replacement to cervical fusion is enough to produce the difference in results. In other words, being a patient in an FDA study is a risk factor for a second surgery.

Why is that? There are several theories to help explain these differences. First, surgeons working within an FDA study may be quicker to intervene when the results aren’t satisfactory. A second surgery is scheduled sooner than it would be out in a private orthopedic practice.

Second, in the FDA study, the surgeons were only allowed to make corrections at one level, whereas fusion surgeries in real clinical practice could have two or more spinal levels fused. The result is a more stable spine for the group outside the FDA and higher reoperation rates for the FDA participants.

The FDA patients who needed a multi-level fusion but only got a single-level fusion went into the procedure (and came out of the surgery) with greater instability compared with those individuals who only needed a single-level fusion and got it.

The higher reoperation rate in the FDA fusion group doesn’t reflect or match the reoperation rate after fusion in usual clinical practices. Just being in the control group could be the trigger for poor results. We don’t know for sure yet.

Where do we go from here? There is a need to establish some basic guidelines (“criteria”) for when someone should have a reoperation following spinal fusion. Right now, there are multiple factors that influence the decision to reoperate after the first fusion procedure. For example, the surgeon may respond more to the patient’s complaints of pain and disability than to the results seen on X-rays.

Finding a way to describe a “failed” first fusion procedure that could be used in all studies would be very helpful. If each surgeon identifies what he or she views as a “failure” but it’s not routinely the same from study to study, then the results measured in terms of reoperation rates isn’t possible. Studies are needed to establish “thresholds” for reoperation (i.e., at what point would reoperation always be recommended no matter what study the person is in?).

Although this study does not have all the answers yet, it does raise some interesting observations and suggestions about the use of anterior cervical discectomy and fusion inside and out of the FDA. Further evaluation of these differences are needed.

There was a study done recently that may help answer your question. The study was done because of an observation that was made about patients who have a cervical spine fusion procedure when those patients are part of a Food and Drug Administration (FDA) study. They have a higher reoperation rate compared with people who have a cervical fusion outside of an FDA study.

To be more specific, the cervical fusion patients in this study received the standard anterior cervical discectomy and fusion (ACDF) procedure. Two groups of fusion patients were compared. One group was part of the FDA investigational studies comparing results of ACDF (the control group) with disc replacement. The second group were patients who had the same ACDF procedure as part of their regular clinical treatment (not as a control group or experimental group).

It is suspected that just being part of an investigational study comparing disc replacement to cervical fusion was enough to produce the difference in results. In other words, being a patient in an FDA study is a risk factor for a second surgery.

But there may be a simpler explanation than that. It’s possible that the way a fusion was defined as “failed” is the real problem. Not every surgeon, researcher, or investigator who conducted the various studies used the same criteria to describe what was (or wasn’t) a failed result.

Finding a way to describe a “failed” first fusion procedure that could be used in all studies would be very helpful. If each surgeon identifies what he or she views as a “failure” but it’s not routinely the same from study to study, then the results measured in terms of reoperation rates isn’t possible. Studies are needed to establish “thresholds” for reoperation (i.e., at what point would reoperation always be recommended no matter what study the person is in)?

Pressure on the spinal cord or spinal nerves in the cervical (neck) region can cause painful disabling symptoms. This condition is called cervical radiculopathy. Usually, it’s a herniated disc pressing on the nerve tissue that’s causing all of the problems.

When it comes to the treatment of herniated discs, for the most part, patients have several choices. First, conservative care can be tried. This may involve rest, activity modification, medications (pain relievers and antiinflammatories), and physical therapy.

If you don’t get at least 50 per cent improvement in pain within six to eight weeks, then it may be time to consider an epidural steroid injection (ESI). As the name implies, epidural steroid injection (ESI) is the injection of a numbing agent (like Novocain) and an antiinflammatory (steroid). A long, thin needle is used to inject the medication into the space between the spinal cord and the lining around the spinal cord. The effect of the injection is to block pain messages. It also decreases swelling that is putting pressure on the nerve tissue.

A recent study showed that 80 per cent of patients who were considered good candidates for surgery actually got significantly better with ESI. And since ESI is much less invasive than surgery, patients with cervical radiculopathy should consider one to three injections first. Only 20 per cent of the group failed to get pain relief and ended up having follow-up surgery.

In some cases, ESI was helpful but either the pain came back or some patients had pain relief but not total elimination of painful symptoms. In those cases, conservative care was prescribed including rest, change in activities, medications, and physical therapy. Only a small portion of the total patient group actually ended up having surgery.

The take home message? Unless there is paralysis or a worsening of pain and/or other neurologic symptoms, patients with cervical radiculopathy should consider ESI therapy before surgery. If you have already gone through all of these steps and it is really the consensus that you need surgery, then the choice between discectomy (disc removal) with fusion and disc replacement is the next consideration.

There are many advantages and disadvantages to each choice. The main difference between fusion and disc replacement is the preservation of neck movement. Only the disc replacement will maintain motion for you. Disc replacement for the neck is a fairly new procedure so if you go this direction, you will want a surgeon who is well-trained and has a good success rate.

With either surgery, there are the usual postoperative risks of infection, poor wound healing, blood clots, and no change in symptoms. Surgical fusion doesn’t always work and patients develop a false joint called pseudoarthrosis. Without the disc to protect the area, any movement at the spinal segment can lead to painful degenerative arthritis. In the case of the implant to replace the disc, there can be a shifting of the device or subsidence (implant sinks down into the bone).

Your surgeon is really the best one to advise you as to what might be best for you. Your individual risk factors and predictive factors for failure/success can be explored and discussed. But if you haven’t tried conservative care or epidural spinal injections, then this might still be the best place to start.

Two of the most popular treatment methods for chronic neck pain are spinal manipulation and exercise.
Research has shown us that exercise therapy works well for neck pain. Spinal manipulation is also helpful for neck pain. Would combining the two make a difference? And if so, how much more benefit is there of adding spinal manipulation to an exercise program?

To find out, a group of chiropractors, physicians, and physical therapists treated adults who had chronic neck pain with either supervised exercise therapy (ET), home exercise and advice (HEA), or exercise therapy and spinal manipulation therapy (ET + SMT).

The supervised exercise therapy groups received high-dose strengthening exercises. High-dose means many repetitions with increased resistance (load). The exercises for this group were geared toward the neck and upper body. The home exercise group performed low-dose exercises that were gentle and emphasized motion rather than strength. The home exercise and advice group also received patient education about neck anatomy, posture, and ways to reduce strain on the neck.

Results were compared after a 12-week treatment period. Follow-up was one full year. Neck pain, neck motion, and neck strength were the main measures of outcomes. Everyone in all three groups showed improvements but the exercise groups had the most gains in all areas measured.

Patient satisfaction was highest in the supervised exercise therapy group. And overall results were better for the exercise groups with or without spinal manipulation. This last finding suggests that adding spinal manipulation to supervised exercise therapy for chronic neck pain has little value.

The authors summarized their findings by saying that intense, supervised exercise may be the best way to treat chronic neck pain. Spinal manipulation does not appear to add enough benefit to be helpful in this approach. Since there was a significant response among the patients receiving home therapy and advice (HEA), perhaps it makes the most sense to being with HEA and then try supervised high-dose exercise therapy if the HEA isn’t successful. Spinal manipulation may not be needed at all.

As always, any treatment program should be provided based on each individual’s needs. Exercise therapy with or without supervision requires discipline and a long-term commitment on the part of the patient. But for those who are seeking pain relief and improved function, the results are consistent with exercise.