I went through a special pre-operative program at the hospital for people considering a neck fusion. They spent a lot of time talking about adjacent segment disease or ASD as they called it. I understand what this is — but how often does it really happen?

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.

I saw a surgeon this week for neck pain that has plagued me for years. Nothing I’ve done has helped (acupuncture, massage, physical therapy, chiropractic adjustments). It looks like the disc and bone around it is disintegrating. The surgeon is suggesting removing the damaged disc in a procedure she calls diskectomy. After thinking about it, I’m wondering how that will help. Without any disc there won’t it just be one vertebra bone rubbing against the one next to it?

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.

Our family was involved in a car accident over the weekend. Turns out my elderly father who was with us has a condition we didn’t know about called DISH. Now on top of that, he has a fractured skull and two fractures in the neck. He’s headed into surgery right now. Please help us understand this condition. What are his chances for a complete recovery?

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.

I am an assistant in a hospital library. So, although I’m not a fully trained librarian, I have learned how to do searches on the Internet and especially using PubMed to find things. This has been helpful since I am having some neck issues myself and looking at possible surgery to either fuse C56 or replace the disc there. However, when I did a search comparing these two treatments, I found almost 300 studies. I don’t have the ability to really figure this out. I’m hoping you can just tell me how to get down to the basic information I’m looking for.

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.

I’ve clearly made up my mind to have a disc replacement in my neck instead of a fusion. Now I’m surfing the web for any information I can find about the best kind of implant device to use. Do you have any information that might help me?

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.

Neck fusion or disc replacement? These are my two options right now for my degenerative disc disease. I’m slowly learning the pros and cons of each one. I’ll be doing a complete study before making the final decision. Just one question for you: does a disc replacement guarantee me normal neck motion once again?

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.

Why does neck fusion have the potential for making things worse instead of better? Should I skip this treatment idea and just go for a disc replacement? I thought I understood everything my surgeon told me about these two choices — right up until I got home and tried to explain it to my wife. Now I have more questions than answers.

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.

It is a holiday weekend and the first one without our beloved Grandpa. Our family is locked in the “what if” mode of grief. What if grandpa hadn’t had that last surgery that surely resulted in his death? Would he have died anyway? Can you help me sort through this myself? He was 77-years-“young” (as he liked to say). He had a condition called DISH but it wasn’t until he fell and fractured C567 that he needed surgery. Then it was all downhill: pneumonia, a blood clot, and he was gone in two weeks.

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.

I have significant degeneration in my neck at C56. The discs are almost gone. There are bone spurs everywhere. The surgeon I saw gave me some treatment options from doing nothing to a disc replacement. What do you recommend?

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.

I’m looking into the newest treatment for neck fusion. What’s available and what do you recommend?

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.

I’ve been told that my dizziness is probably coming from an old neck injury from high school but no one seems to know how to correct the problem. Can you suggest anything? Any exercises that might help?

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:

  • Using your eyes to trace the alphabet on the wall in front of you without moving your head.
  • Look at a target, move your eyes to the target without moving the head, now keep the eyes on the target and move the head to line up with the eyes once again.
  • Move your eyes to the right while moving the head to the left and vice versa.

    These activities may not be all that you need for your particular problem. There are many possible causes of dizziness related to neck injuries. The concept we mentioned: neck repositioning acuity is another important area to consider. This refers to the fact that there can be a decreased awareness of the position of the head and neck. In fact, sometimes people with neck injuries hold their head at a slight angle and don’t even realize it.

    There are specific exercises to help restore normal positional acuity and awareness. Likewise, areas may need some attention. For example, shoulder and trunk muscles might be impaired. Weakness in the muscles of these structures can contribute to neck pain. There are exercises to improve these deficits as well.

    One other area deserves mentioning and that’s the vestibular system (inner ear mechanism responsible for balance and preventing dizziness). A physical therapist can help you with any one (or all) of these problems. He or she will be able to evaluate what is going on, what’s missing, and what to do about it.

    You may be able to accomplish quite a bit on your own with a home program but it’s best to get an evaluation and see exactly what you need for your specific problem. With dizziness, there could be any number of different systems involved.

  • I’ve been watching the Olympics and thinking maybe I should get back into some kind of exercise program. But I’ve had neck pain off and on (especially when I do try to exercise). What can I do about this?

    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.

    I’m seeing a physical therapist for neck pain from a car accident two months ago. She says I have “trigger points” that have to be released before I’ll get my neck motion back. Is this a normal problem to have after a whiplash injury or am I unusual?

    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.

    I feel like a zombie. I can’t turn my head and neck more than a tiny bit or the pain shoots up from a three to a 10. If I even touch the tops of my shoulders, it is very painful. I did have a car wreck and a whiplash but that was a month ago. Why can’t I seem to get over this hump?

    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.

    I have two bones in my neck that have been destroyed by cancer. Thank God the cancer is gone now but my neck is terribly unstable. Could I be able to get a disc replacement? Would something like that work for me?

    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).

    My brother was involved in developing and testing disc replacements for the neck when he had a car accident and died. That was two years ago. I was just browsing the web and wondering whatever happened with those anyway?

    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.

    I have a chance to be in a study conducted by the Food and Drug Administration. But I could also go to my orthopedic surgeon and the get the same results. I’m thinking I’ll get better (more personalized) care with my own doc as opposed to being a number in a study. The procedure in question is an anterior cervical discectomy and fusion. They call it an ACDF. What’s your best advice in something like this?

    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.

    My surgeon and I are at an impasse. I had a neck fusion that wasn’t what I call ‘successful.’ The surgeon says from his perspective, the X-rays look great, I’m healing well, and I’m fine. I don’t feel fine. I have constant neck pain and numbness in my arm. How do you define a successful C56 neck fusion?

    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)?

    I see a chiropractor and a physical therapist alternately almost every week for my neck pain. My brother insists that all he ever needs is just a little “adjustment” and he’s good to go for another week. My experience has been that the exercises I’m doing help “hold” the adjustment. Is there any proof either way?

    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.

    I am doing the Internet version of crying, “Uncle!” and giving in. I’ve had neck pain for months now. In fact, it’s probably been years when I really think about it. So I Googled ‘neck pain’ and your site came up first. Without seeing me, what can you tell me about the best way to get out of this hole I’m in?

    It is always a good idea to see a physician and make sure there is nothing serious going on. Infection, tumor, and fracture are the three most important things to rule out. If it turns out you have mechanical pain (caused by soft tissue structures), then you have several options.

    Treatment choices for chronic biomechanical neck pain are broad and range from physical therapy to massage therapy, acupuncture, homeopathy, and much more. The physical therapist has many tools available to help including electrotherapy, traction, spinal manipulation, soft tissue mobilization, and exercise.

    And as it turns out, according to the latest research results, exercise provides the best results. Now there are different types of exercise and even this aspect has been studied. Low-dose exercise comprised of gentle range-of-motion exercises has been compared with high-dose (high load, high repetition) exercise. Both produce the desired results of reduced pain and improved function, but the high-dose exercise still comes out on top as being more effective.

    When patient results are compared between a home program of exercise and a supervised exercise program, patients prefer (and do better) with the supervised program. The personal guidance of one-on-one is still a powerful motivator that helps keep people on track.

    Once your doctor gives you the go-ahead, seek out the services of a local therapist. Give yourself plenty of time to recover slowly. You didn’t get this way overnight and you aren’t likely to recover without a little time and effort on your part. Most people say it is well worth it to dig in and get serious about the program.