FAQ Category: Cervical Spine

Rheumatoid arthritis (RA) affects the joints but it also affects many other systems in the body. Half of all patients with RA become disabled. This happens in the first 10 years and adds to the risk of an earlier death.

The biggest risk factor is the presence of RA in the cervical spine (neck). Joint changes and collapse of the bones can cause a condition called cervical myelopathy.

Pressure on the spinal cord from cervical myelopathy can cause severe problems. Studies from autopies show sudden death occurs in as many as 10 percent of patients with RA affecting the cervical spine.

It’s possible but not probable. If the affected disc space is too narrow or not there at all on X-ray, a disc implant isn’t possible. The surgeon has to do too much pulling and lifting on the vertebrae to make space for a disc. The combination of lost disc space and arthritic changes make this surgery very complicated.

The risk of damage to nearby nerves, blood vessels, and soft tissues is too great. You may end up with a nice new disc but at the expense of great pain and perhaps nerve damage with loss of motion and function.

Artificial disc replacements (ADRs) are fairly new, especially for the cervical spine. With both severe arthritis and disc degeneration you’re likely still a better candidate for cervical fusion.

Most cervical disc implants are still in the clinical trial stage. The US Food and Drug Administration studies each new device as they come on the market. First, studies are done on a disc replacement at a single spinal level.

If the results are good, then they can try them on more than one level. The third step is to expand the group of patients who qualify. Just recently a group of doctors in Australia tried the Bryan cervical disc implant in 15 patients who had previous neck surgery. They either had a cervical spine fusion or a foraminotomy (bone removed to take pressure off the spinal cord or spinal nerves).

The early results were good. Researchers will continue to follow this group for long-term results. Another study with more patients will come next.

Cervical disc replacement after a previous surgery isn’t standard yet. It may become one of a patient’s many options in the near future.

Many of the new artificial disc replacements (ADRs) have an internal constraint mechanism to limit their motion. The manufacturer-suggested limit is two millimeters of motion. That’s a very slight amount. Just enough to allow the ADR to go with the flow of motion and not create a blockage or rigid stop.

Some ADRs have what look like teeth on the part that goes next to the bone. This helps anchor the implant in place. The bone grows in and around each spike to give it the strength it needs to keep from tilting or pushing one way or the other.

Even with these mechanisms there are times that the ADRs shift, tilt, or sink into the bone. Manufacturers are continuing to look for ways to improve the current devices.

Sometimes surgeons will try conservative care. This can include anti-inflammatory drugs, physical therapy, or a neck brace. This type of treatment doesn’t change the failed fusion but it can help the patient manage the painful symptoms.

A second option is revision surgery. Some surgeons advise doing a posterior fusion. They say that going back through the front of the neck requires cutting through scar tissue. This can cause further problems. Others suggest a posterior fusion makes the patient stiffer afterwards because of all the neck muscles cut.

A recent report from UCLA School of Medicine reported mixed results using the posterior approach. Although everyone in the study had a good fusion, about half still had pain. Some patients had severe pain and didn’t think the second operation was worth it.

Ask your surgeon for his or her opinion. There may be some things about your situation that lend guidance to a decision of this type. Smoking and overall health make a difference after fusion, too. Your doctor will know what might work best for you.

The operation you had is called an anterior cervical discectomy and fusion (ACDF). It’s widely used by many surgeons to treat cervical (neck) problems. Motion at the joint after ACDF is called pseudoarthrosis. Unfortunately it is all too common a result.

Research shows that pseudoarthrosis occurs in up to 20 percent of single-level fusions. The failure rate goes up to 50 percent with multiple-level fusions. There’s no clear reason why this happens. Studies do show that fusion at any level results in breakdown above and below the level of the fusion. With more than one level fused, there may be much more stress and load on the spine in and around the site of the fusion.

The surgeon’s level of experience may be a small factor. The number of complications does decrease the more operations a surgeon does. This is all part of the normal learning curve. No surgeon performs this operation without considerable training and practice first.

Others suggest diet, nutrition, tobacco use, and overall health may make a difference. It could be a combination of things that differ from patient to patient. More studies are needed to clear up this confusion.

Have you talked to your surgeon about this? There may be a local bone bank with donor bone available. National bone banks are also a possibility. Studies show good fusion results with donor bone without the complications of pain at the donor site.

Donor bone often comes from people having hip or knee replacements. It can also come from cadavers (bodies preserved after death). The bone that is removed to make room for the implant is ground up and preserved. All bone donors are carefully screened. All donated bone is treated to prevent the transmission of bacteria and viruses. The bone is packaged in sterile conditions so it’s safe to use.

Doctors and physical therapists wonder the same thing. Researchers are trying to figure it out. The Whiplash Research Unit in Australia may have come clues. They compared patients with mild, moderate, and severe pain from whiplash to subjects who had no injury
and no neck problems.

Motion, sensitivity to heat, and psychologic distress were all measured. The researchers found changes in how the nervous system feels the pain and how the muscles react. These changes were present in all whiplash patients. The patients with the most pain were the
most sensitive to the changes.

The scientists thought the differences in severity of symptoms might be related to psychologic distress. This study didn’t show that at all. More studies are needed to understand how the body processes pain after whiplash.

Good questions. It’s true that once a patient starts taking drugs to reduce anxiety or depression, symptoms of psychologic distress are less. This makes the symptoms harder to
measure. The fact that treatment for a mood disorder is needed is a key factor. Before treatment began, the patient reported some symptoms that led to the diagnosis.

There are tests that psychologists use to measure psychologic distress. Most of these tests are in the form of a survey. The patient answers many questions. The questions often ask about mood, concentration, sleep patterns, and sexual activity.

Researchers have spent many years finding tests that will measure psychologic distress. Studies have been done to make sure that these tests are valid and reliable.

Normal, no but common, yes. It seems the neck has lower heat pain thresholds after severe whiplash. This means you respond more quickly to changes in temperature. Even a drop of one or two degrees can cause pain to increase dramatically. Then pain triggers a muscle spasm.

Researchers think the sensitivity to cold may be caused by injured nerve tissue. Some patients also have increased sensitivity to heat. If the skin temperature around the neck goes up, pain increases. These changes aren’t found in patients with moderate whiplash injury. It’s more common with patients who have severe neck pain and disability.

We don’t know what to do about it yet, but more studies to understand what’s happening are planned.

Epidural steroid injection (ESI) is a way to inject anti-inflammatory drugs into the space surrounding the spinal cord. This helps with pain relief and swelling in the area from the local tissue damage.

Diabetes is a strong risk factor for blood infections that cause abscess formation in the epidural space. Poorly controlled diabetes can lead to a variety of blood vessel and
tissue changes. Without a good blood supply even small wounds heal slowly or not at all. Any small break in the skin or tissue underneath can lead to infection.

Once bacteria enter the open break, they multiply rapidly. The extra glucose in the body fluids and tissues feeds the bacteria. Patients with diabetes are at risk for any kind of infection (skin, urinary, blood).

Abscess formation doesn’t occur very often after ESI. When it does, pressure on the spinal cord in the neck region (or spinal nerves in the lumbar spine) can cause nerve damage. The patient may have extreme pain, numbness, and muscle weakness.

Epidural steroid injection puts a solution of numbing agent and steroid (anti-inflammatory) into the epidural space. This space surrounds the spinal cord. The result is to reduce pain and swelling and allow healing of the tissue.

Returning to work depends on several things. The doctor can best advise you based on how severe the disc protrusion is and the type of work you do. You may be able to return to work right away or within 48 to 72 hours.

Some doctors will do an MRI seven to 14 days after the injection to see the condition of the disc. Planning is easier when the tissue can be seen in this way.

You’ve run across a problem of words. Most likely all you need to do is call the doctor’s office and ask the billing staff to rebill it under a different code. Nonspecific neck pain means there’s no underlying disease such as cancer, arthritis, fibromyalgia, and
so on.

The cause is more likely to be linked to the way the muscles contract or the joints line up. Perhaps a past injury resulted in a tear in the ligaments. The neck may lack stability. The muscles try to compensate. They get overworked and tired and start hurting.

We call this a biomechanical problem. That’s just one example of how changes in the normal biomechanics can lead to pain and problems. Calling it “nonspecific” just says the cause is unknown, but not from a systemic illness.

You’ve asked a very good question. Much about health care is geared toward preventing problems from occurring. The first step in prevention is recognizing what puts us at risk for a problem. There aren’t any studies to show the effect of long versus short necks on
neck pain. But a recent study from Australia reports loss of neck motion may be a signal of future problems.

They found people with limited neck motion are more likely to have neck pain and/or stiffness. If detecting loss of motion early can restore mobility, then maybe neck problems can be avoided. Check your posture and range of motion. Check to see if you have limited motion in any direction.

If there is a loss of motion, consider seeing a physical therapist for an exercise program to improve your posture, restore your full motion, and build your strength. All three variables may be important in preventing future episodes of neck pain.

Removing the main body of the vertebral bone is called a corpectomy. Once this is
done, the spine is fused with a bone graft at that level. Sometimes a metal plate is also inserted. The plate gives the spine extra support until the graft fills in. This keeps the spine from further collapse.

The main problem after corpectomy is degeneration of the spine at the segment above or below. This is called the adjacent segment. Studies show adjacent degeneration occurs in up to 75 percent of all patients. Some researchers have tried to prove the
changes are just the result of a natural aging process.

The majority of studies report changes occur, but it hasn’t been proven to be caused by the fusion itself. Most scientists think the corpectomy and fusion causes a shift of the
load through the spine to the nearby vertebrae.

The authors of a recent study suggest the altered loads occur because of changes within the spinal ligaments. It’s possible that increased motion at the segment above and below the fused spine causes the ligaments to increase in size or hypertrophy. The ligaments put increased pressure on the spine, not the lack of motion at the fused site.

When the disc bulges backwards, it can put pressure on the spinal cord in the cervical and thoracic spines. In the low back or lumbar spine, the disc is more likely to press against a spinal nerve as the nerve leaves the spinal cord and travels down the back or
leg.

Cord compression is seen using magnetic resonance imaging (MRI). Mild cord compression means there is an indentation into the space where the spinal cord is housed.
The spinal cord itself isn’t touched yet.

In moderate encroachment the cord is being pressed by the disc, but there’s no obvious deformity of the spinal cord. A severe indentation leaves a lasting dent in the spinal cord and may even cause the cord to twist or buckle.

Several things can cause changes of this type. It isn’t always just a protruding or herniated disc. There are ligaments in the spine that can come in contact with the spinal cord. Hardening or buckling of the ligament can cause mild to severe pressure on the
spinal cord in the neck, too.

It’s long been reported that severe changes seen on MRI don’t always cause symptoms, whereas a mild change can cause severe symptoms. Doctors don’t know yet why this happens.
That’s how you can have a mild case of spinal cord compression with severe symptoms.

Wearing a seatbelt decreases the risk of death by 86 percent. Seatbelts don’t always prevent neck injuries. A large study from Finland reports 10 percent of deaths from a motor vehicle accident are caused by neck injuries. Improved safety features may help reduce these deaths.

The source of pain after whiplash injuries remains a mystery. Researchers are getting closer to solving the puzzle, but don’t have all the answers yet.

In one study at Yale University School of Medicine, scientists confirm that joint sliding and compression cause injury of the nearby soft tissues. The cartilage, synovium, and nearby ligament are in danger of inflammation.

The nerves and blood vessels to the area become sensitive. This causes pain with normal motion. Damage to the joints can also cause neck muscles to misfire and contract at the wrong time. Over time, this change in normal firing patterns causes pain and spasm.

The force of the impact does make a difference. In other words, the greater the force, the more likely damage will occur. A minor impact may have the same effect as a higher force if there is arthritis present or some other damage from prior injury or accident. It’s just a guess and hasn’t been proven yet.

Both. Whiplash has two separate phases very close to what you’ve described. In the first phase, the person’s head actually goes backward into extension. The head and neck then
return to the neutral, upright position before going forward and snapping back again. It happens so quickly the person isn’t really aware of all the distinct movements.

Strain to the joints and ligaments occurs at different points in this movement. The neck ligaments are strained the most during that first backward phase returning to neutral. Then the joints are pressed together and slide forward and back. Any of these motions can go beyond where the joint is normally capable of going.

The marriage of engineers who understand kinematics (joint motion) and technology is taking place more and more. For example, researchers at the Biomechanics Research Lab at Yale School of Medicine offer us a peek into whiplash injuries.

They used high-speed digital cameras along with motion-tracking software to study neck motion during rear-impact injuries. They were able to find what speed and force cause injury at different levels of the spine. In general a lower force can cause damage to the joint and neck ligaments in the upper neck (C4-5). A higher force is needed to injure the lower neck (C6-7).

They found joint compression was the most common injury with lower impact forces. When the joint is pressed together by force, the lining of the joint is at risk for injury. The body’s response to this is pain and inflammation, which may be what happened in your case.