FAQ Category: Cervical Spine

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. But these same symptoms could also be caused by a bone spur, spinal infection, or tumor.

Painful symptoms associated with cervical radiculopathy can be managed with medication and physical therapy. But a loss of motor control of the arm and hand (progressing to paralysis) is a signal that it’s time for surgery. For patients with pain but no other neurologic symptoms, epidural steroid injection (ESI) may be helpful and may also eliminate the need for surgery.

As the name implies, epidural steroid injection (ESI) is the injection of a numbing agent (like Novocain) and 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.

As with any invasive procedure, there can be complications from the injection itself. And with any local delivery of medication, there can be adverse effects from the medication itself. In the case of epidural spinal injection for cervical radiculopathy, the most common side effect is nerve irritation (which is usually temporary). The use of fluoroscopy (3-D, real-time X-rays) allows the surgeon to place the needle very carefully without coming into contact with nerve tissue.

Only a very small number of patients ever develop serious neurologic damage leading to paralysis. Brain injury such as you mentioned can be caused by epidural hematoma or infection. Studies to date suggest the chances of this developing is less than two per cent. The improvements and advances in fluoroscopy and other imaging to guide surgeons has really improved safety considerably.

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.

You ask some interesting questions that will probably get a more accurate response from the orthopedic surgeon who is treating you. Having the full case history along with a clinical exam and imaging studies to look at (X-rays, CT scans, MRIs) gives your current physician important information needed to make a decision like this.

Certainly, spinal fusion at the most painful, unstable segment(s) is an option. Many patients obtain pain relief from this approach. But we do know that with a fusion, there is increased load, stress, and tension placed on the segments above and below the fused level(s). The long-term effect can be increased disc degeneration at the next spinal level. This condition is referred to as adjacent segment disease (ASD).

ASD can occur at whatever spinal level the fusion is done (neck or low back). At least one study comparing patients with degenerative disc disease who had cervical spine surgery (neck fusion or cervical disc replacement) showed similar results. Between 14 and 16 per cent of the patients developed adjacent-level disease no matter which type of surgery they had.

Two other factors were identified in that study as possibly contributing to an increased risk of adjacent-segment disease (ASD). The first was a condition known as osteopenia. Osteopenia is a decrease in bone mineral density and develops before osteoporosis (brittle bones). The second risk factor contributing to disc degeneration in the cervical spine after disc replacement or fusion was the presence of similar disc disease in the lumbar spine (low back area).

Before any surgery is done, experts recommend patients try conservative (nonoperative) care for at least six months. This could include the use of medications to control inflammation and pain, physical therapy, steroid injections, or other pain relieving techniques (e.g., massage, acupuncture).

Even with surgery at one or two levels, persistent pain may be aided with this type of adjunct treatment. Talk with your physician and see what would be recommended for you based on your age, activity level, severity of symptoms, and goals and expectations.

Ever since disc replacement became available for the cervical spine (neck), research has been ongoing to compare fusion surgery to disc replacement. One of the key questions has been whether or not disc replacement reduces the risk of adjacent-level disease. A recent study from the Spine Institute of Louisiana and Texas Spine and Joint Institute may provide you with some helpful information on this topic.

The assumption is that a fusion procedure stops motion thus increasing stress and load on the disc at the next spinal level (above or below the fusion). Disc replacement preserves motion so, in theory, should result in less adjacent-level deterioration.

Studies done so far show that patients obtain the desired pain relief with both procedures (fusion and disc replacement). The disc replacements are newer and appear to be safe and effective. Long-term studies of adjacent-level disease following disc replacement are not available just yet. Studies like this one offer short to mid-term results (two to four years follow-up).

The patient group in this study was made up of 170 adults with symptomatic cervical degenerative disc disease. They were randomly divided into the two treatment groups and followed at regular intervals over the next 32 to 54 months.

Imaging studies (MRIs, CT scans) were used to look for any evidence of degenerative changes at the nonoperated levels next to the surgical segment. They found no significant difference between the two groups in the number of patients who developed adjacent-level disc degeneration during that period of time.

About 14 to 16 per cent of the 170 patients developed problems at the next spinal level. Only a small number (four per cent) had severe enough disease to need further surgery. Most of the patients were treated conservatively without surgery.

They did examine a number of other factors as potential risk factors. These included patient age, sex (male or female), smoking habits, bone density, and previous history of back problems. Only two of these factors showed any statistical significance as factors that could predict adjacent segmental disease. Those two factors were osteopenia (decreased bone density) and current history of lumbar spine degenerative disc disease.

The authors point out that it will take time for the fairly new research on artificial disc replacement to catch up with the 10 years (or more) of outcome studies on fusion for the cervical spine. Two years is not enough to predict long-term effects on adjacent spinal segments.

The results of this mid-term study indicate there isn’t a significant difference in rates of adjacent-level disease between cervical fusion and cervical disc replacement. Other factors (besides the type of surgery performed) may have a greater impact (e.g., bone mineral density and presence of disc degeneration in the lumbar spine).

Before artificial disc replacements (also called cervical disc arthroplasty) were developed, patients with chronic neck pain and instability were treated with neck fusion. The fusion stopped motion at the diseased level and thus reduced pain. But the strain on the adjacent spinal levels contributed to further disc degeneration. This is considered a negative consequence of spinal fusion procedures.

Disc replacement preserves motion without putting increased stress on the spinal segments on either side of the disc replacement. Over the years, several companies have made different types of implants. The three major disc replacement devices currently on the market include: 1) BRYAN cervical disc, 2) ProDisc-C, and 3) Bristol Disc.

Most of the studies comparing results of cervical (neck) disc replacement to neck fusion have been done in the United States and Europe. Cervical artificial disc prostheses were first used in China around 2003. As a result, the first study comparing these two procedures among the Chinese population has been published.

Everyone in the study (120 adults) had a diagnosis of painful cervical disc disease. They were randomly placed in one of these two treatment groups. The group receiving a cervical disc implant were given the BRYAN cervical disc. The group having a fusion were treated with the Anterior Cervical Deompression and Fusion (ACDF) technique.

Results were compared over a two-year period of time. Pain, motion, and disability (measured by the Neck Disability Index) were compared between the two groups. Operation time, blood loss, and length of time in the hospital were also recorded and compared.

As expected, patients with the implant had more motion than the fusion group. Levels of pain and changes in neck disability from before to after surgery were not different between the two groups. Results were similar to outcomes reported in other studies making the same comparison between artificial disc replacement and neck fusion. The authors concluded that using the BRYAN disc replacement is an acceptable alternative to neck fusion for adults with painful and unstable cervical disc disease.

Although anterior cervical decompression and fusion (ACDF) is still the most common surgical procedure used in China for this condition, more and more surgeons are considering using disc replacements. More studies like this are needed to confirm the success of the artificial implants instead of the fusion procedure.

Since this was the first study in China and results so far are only short-term (two years), the authors themselves suggested further long-term follow-up over the next 10 years. Attention should be paid to whether the spinal motion and mechanics at the level where the disc was put in is preserved and maintained. Efforts should be made to monitor adjacent levels (above and below the artificial disc) for break down (and especially faster deterioration than expected).

Until this kind of study can be done and data confirm successful results, you may want to look for a surgeon who has completed many of these procedures successfully. Don’t be afraid to ask the prospective surgeon for information on success/failure rate, definition of failures, and how often re-operations are required. This type of information may help you decide where and when to have surgical intervention.

Before artificial disc replacements (also called cervical disc arthroplasty) were developed, patients with chronic neck pain and instability were treated with neck fusion. The fusion stopped motion at the diseased level and thus reduced pain. But the strain on the adjacent spinal levels contributed to further disc degeneration. This is considered a negative consequence of spinal fusion procedures.

Disc replacement preserves motion without putting increased stress on the spinal segments on either side of the disc replacement. Over the years, several companies have made different types of implants. The three major disc replacement devices currently on the market include: 1) BRYAN cervical disc, 2) ProDisc-C, and 3) Bristol Disc. Two of these products (BRYAN and Bristol Disc) are made by the same company (Medtronic).

Various studies have been done comparing the results of neck fusion versus disc replacement. The usual complications of surgery are always possible: infection, slow or poor wound healing, blood clot formation, and worse case scenario: death. The actual incidence of these events is very low.

Complications specific to disc replacement can include subsidence (implant sinks down into the bone), heterotropic ossification (bone formation in surrounding soft tissues), and postoperative dysphagia> (difficulty swallowing). There have been some reports of a decrease in cervical spine lordosis (natural neck curve). No one knows yet what the long-term (if any) consequences of this change might be.

Surgeons are actively seeking ways to reduce problems and complications while improving biomechanics of the spine. They recognize the need to properly implant the right sized implant. It takes a skilled surgeon to watch for and accommodate differences in individual anatomy when placing the implant.

Many changes have been made and suggested by surgeons who have expertise in this area. As a result, the design of the devices has also improved. We can expect to see continued improvements in surgical technique, implant design, and complications following surgery.

Fear of movement (also known as fear-avoidance behavior or FAB) is fairly common with chronic low back pain. Some people respond to pain with anxiety about their pain and fear about what it might do to them. They start to catastrophize the pain (build up negative thoughts in their minds about pain).

Before you know it, they are no longer moving freely out of fear that certain movements and actions “might” cause pain. They stop moving and start avoiding activities they previously enjoyed freely. Over time they become deconditioned and even disabled.

Studies show the same thing can happen with neck injuries. In a recent study, researchers from the George Institute for Global health in Sydney, Australia took a closer look at fear of movement as the possible mediating (indirect link or cause) between neck pain after whiplash injury and disability.

They wanted to know: when neck pain from a whiplash injury occurs and becomes chronic is it the pain that causes disability in a direct chain of events? Or is there some other indirect factor or variable that links pain with disability?

To find out, they took a group of patients (205) who had all been involved in a motor vehicle accident and had them each fill out four separate surveys. The questionnaires measured pain intensity, function, fear levels, and physical and mental health. These test measures were completed within four weeks of the accident and again three months after the accident and one final time six months after the accident.

It is not possible to assume that neck pain after whiplash influences (fear-avoidance) behavior and leads to disability just because this relationship has been shown for low back pain. A separate analysis is necessary, which is why this study was done.

After reviewing all the data and making comparisons, they found that fear of movement can explain about 20 to 40 per cent of pain-related disability. That means in 20 to 40 per cent of the patients, relieving pain did not reduce levels of disability.

And for the remaining 60 per cent of the patients, there was either another factor responsible (besides fear of movement) or perhaps several factors present at the same time. These other factors could be things like the presence (and severity) of other physical problems, mental health issues, or social, economic, or cultural differences.

Another conclusion from this study was the idea that there isn’t a direct cause and effect between fear-avoidance behavior and disability. It looks more like there is a relationship of some type between pain, fear of movement, and disability but the word association is a better descriptor than cause.

What are the clinical implications of these findings? Some, but not all, patients with whiplash associated disorders can be helped by therapy to reduce fear avoidance beliefs and behaviors. Knowing which patients might fall into this category will be the subject of future studies. Other studies are also needed to find out what other factors influence the pain-leading-to-disability phenomenon.

The authors also suggest there is a need to examine the different tools used to measure catastrophizing, fear-avoidance beliefs, and fear of movement. It is possible that one of the many questionnaires in use could be more accurate and reliable than others when given to neck pain patients (compared with back pain patients). For now, we can say there is a relationship between pain and disability in patients with whiplash associated disorders, and that in a subset of these patients, fear of movement is the key factor at play.

Trauma to the neck and/or arm can be severe enough to pull the brachial plexus right off. This injury is called a brachial plexus avulsion. These are serious injuries that are complex and difficult to treat. A little understanding of the anatomy may help for starters.

A nerve plexus is an area where nerves branch and rejoin. The brachial plexus is a group of nerves in the cervical spine (neck) from C5 to C8-T1. This includes the lower half of the cervical nerve roots and the nerve root from the first thoracic vertebra.

The brachial plexus begins with five roots that merge or join together to form three trunks. The three trunks are upper (C5-C6), middle (C7), and lower (C8-T1). Each trunk then splits in two, to form six divisions. These divisions then regroup to become three cords (posterior, lateral, and medial).

The nerves leave the spinal cord, go through the neck, under the clavicle (collar bone) and armpit, and then down the arm. The final branches result in three nerves to the skin and muscles of the arm and hand: the median, ulnar, and radial nerves.

Brachial plexus avulsion injuries don’t just cause pain and numbness in the shoulder, arm, and hand. This injury disrupts nerve messages to the shoulder, arm, and hand so the patient’s arm becomes paralyzed. Efforts to find ways to restore nerve function after such injuries are ongoing.

Often, major reconstruction surgery involving nerve transplants, nerve transfers, and muscle transplantation is required. Many times, the procedures are “staged” or done in a series one-at-a-time.
Recovery time can be very long and the rehab required is extensive.

It can take many years to fully recover from an avulsion injury of a nerve plexus. Studies show that results are often better for patients who are compliant (following the surgeon and therapist’s directions). It can take up to four years for some patients to regain as much sensory and/or motor recovery they are going to get. You didn’t mention how long ago the injury occurred so it may be your husband is still in that prolonged recovery time.

The most difficult recovery is usually finger flexion. Regaining some sensation is common but movement can be more difficult to restore. If the patient had even protective sensory recovery (ability to feel hot, cold, pressure), then the results are still considered a “functional” success.

Patients must expect an intense, focused period of rehab lasting years. Complete independent function of the arm and hand isn’t promised but improved function is possible. During this time, they must remain dedicated to their exercise program. As the results of some studies show, those who stick with it are often rewarded with the best results.

Even with complete compliance there are some people who have poor recovery — especially of the hand. There are several reasons why this may happen. First, the distance the nerve has to regenerate may be just too great to reach all the way down to the muscles of the hand.

Second, the muscles themselves might have been damaged during the injury. Extreme, prolonged swelling or bone fracture piercing the muscles could have this effect. And finally, irreparable damage to the blood vessels can account for poor results.

As your son has unfortunately experienced, trauma to the neck and/or arm can be severe enough to pull the brachial plexus right off. This injury is called a brachial plexus avulsion. A nerve plexus is an area where nerves branch and rejoin. The brachial plexus is a group of nerves in the cervical spine (neck) from C5 to C8-T1. This includes the lower half of the cervical nerve roots and the nerve root from the first thoracic vertebra.

The nerves leave the spinal cord, go through the neck, under the clavicle (collar bone) and armpit, and then down the arm. The final branches result in three nerves to the skin and muscles of the arm and hand: the median, ulnar, and radial nerves.

Brachial plexus avulsion injuries don’t just cause pain and numbness in the shoulder, arm, and hand. This injury disrupts nerve messages to the shoulder, arm, and hand so like in your son’s case, the person’s arm becomes paralyzed. Efforts to find ways to restore nerve function have resulted in the refinement of the contralateral C7 (CC7) nerve transfer you mentioned.

In this procedure, a portion of the C7 nerve from the uninvolved (uninjured) side of the neck is cut and used to reattach the avulsed or ruptured nerve on the other side. This can be done without causing any sensory or motor loss on the donor side.

The CC7 nerve transfer was first tried in the early 1990s with mixed results. Up to half the patients had some improvements in one study. But other surgeons reported much poorer results making them wonder if it was worth doing this procedure. The recovery time is long and the rehab required is extensive. But some surgeons have persisted in trying to improve the technique with the thought that for someone who is paralyzed, any amount of improvement is worth it.

And from the results reported in a recent article on this topic, it seems the patients would agree. Most of them do not regret the extensive surgery or the long recovery and rehab. And for those who are compliant (following the surgeon and therapist’s directions), results are reportedly good.

In that study there were 101 patients who had this procedure done, everyone was able to get some shoulder motion back. Depending on which nerves were transferred, rate of recovery for elbow flexion was high. The most difficult recovery was finger flexion. Regaining some sensation was common but movement was more difficult to restore. If the patient had even protective sensory recovery (ability to feel hot, cold, pressure), then the procedure was still considered a “functional” success.

The patients in the study who were treated with a CC7 transfer were still considered “disabled.” But they were far more functional than they would have been if the arm and hand remained totally paralyzed. After reconstructive surgery with the nerve transfer, they could use the injured hand to hold small or light objects, assist with dressing and self care, and even hold a light brief case, bag, or purse.

Right after surgery, patients should expect to be in a neck brace for the first three weeks. Physical therapy begins after that short period of immobilization. The therapist works with the patient to help them regain motor function and control.

Patients must be prepared for an intense, focused period of rehab lasting years. For example, shoulder motions on the healthy, normal side are encouraged up to 1,000 times a day for at least three years. It can take up to four years for some patients to regain as much sensory and/or motor recovery they are going to get. Complete independent function of the arm and hand isn’t promised but improved function is possible.

During this time, they must remain dedicated to their exercise program. As the results of this study showed, those who stuck with it were rewarded with the best results. Once there is some nerve recovery, additional surgery including muscle transfers may be needed.

There are many possible reasons for swallowing and breathing problems. Anything in the neck that can press on the trachea or respiratory airways can bring on these kinds of symptoms. Have you noticed any stiffness in the neck or difficulty moving the head and neck?

Any other symptoms such as choking, new episodes (or increased episodes) of snoring? Any numbness, tingling, or electric shock sensations down the arms? These would all be symptoms to report to your physician even if you are not having the symptoms at the time of your examination.

Perhaps keeping a log of what you notice, when you notice it, and any other observations you think are important will help. This type of record can bring to light a pattern or trend that can offer the physician some diagnostic clues.

You didn’t mention any imaging studies. Have you had an X-ray, CT scan, or MRI? Usually the first step is X-rays as they are the least expensive and often provide helpful information. Your age, sex (male or female), and general health may offer some additional clues.

A recent study from the Netherlands has identified more cases than expected of dysphagia (difficulty swallowing) and airway obstruction (difficulty breathing) from a condition called Diffuse Idiopathic Skeletal Hyperostosis (also known as DISH). Until now, it was believed that DISH was a rare cause of compression of the esophagus and trachea.

With DISH, the ligaments around the spine turn into bone causing pain, stiffness, and loss of motion. Compression on the soft tissues in the neck can produce the kind of symptoms you are describing. Muscle tension, anxiety, tumors, bone spurs, and spondylolisthesis (shift of the vertebrae out of their normal position) are other common causes of the symptoms you describe.

One other approach you may want to consider with this problem is to seek a second opinion. With a little more time and a record of what’s happening (your log), a more precise diagnosis may be possible even with symptoms that seem to come and go.

Dysphagia (difficulty swallowing), odynophagia (painful swallowing), and airway obstruction can be caused by this problem you have known as Diffuse Idiopathic Skeletal Hyperostosis or DISH. Until now, it was believed that DISH was a rare cause of compression of the esophagus and trachea. But thanks to the efforts of researchers in the Netherlands, we have found out that this condition is on the rise around the world.

The most common finding of Diffuse Idiopathic Skeletal Hyperostosis (DISH) is ligaments that turn into bone. It is also known as Forestier’s disease, after the name of the physician who first recognized it. DISH more commonly affects older males.

It is usually associated with stiffness and back pain, but often it causes no signs or symptoms. When the cervical spine (neck) is affected, other symptoms such as stiff neck with loss of motion, difficulty swallowing, painful swallowing, choking, and snoring may occur.

It is most often confirmed by x-ray when there are at least four vertebral segments in a row ossified (hardened into bone). Other imaging tests used in the differential diagnosis include barium swallow radiography, CT scan, laryngoscopy, and MRI.

It has been observed that adults who develop DISH are more likely to also have type 2 diabetes and be obese. Both of those conditions are abnormalities in metabolism. Since the formation of bone depends on growth factors such as insulin-like Growth Factor. With more and more people who are obese and developing diabetes, it’s possible the numbers of individuals affected by DISH will also increase in the coming years.

As difficult as it may be, weight loss becomes one aspect of treatment. Antiinflammatories to help reduce swelling combined with eating soft foods may help. A nutrition expert can help you find ways to manage with healthy choices to avoid further weight gain. Pain relievers such as Tylenol are recommended on an “as needed” basis.

Surgery to remove some of the bone build-up may be recommended. The surgeon may have to remove hardened ligaments, discs, and tendons. If the situation gets worse, the surgeon may opt to put a tube in the airway to allow you to breathe. There is always the chance of postoperative complications so prognosis varies depending on what treatment is used and whether or not surgery is involved.

Studies actually show fairly even outcomes between patients treated conservatively versus surgically. The more severe the symptoms, the more likely surgery will be required. Deaths have been reported associated with difficulty breathing but this is rare. Surgical resection (removal) of the bone does not prevent more bone spurs or bone growth so in that way the prognosis is “guarded.”

Some patients find that they do well with conservative care. But an episode of swallowing wrong, an upper respiratory infection, or even minor trauma to the neck can flare symptoms. Until the exact cause of this problem can be determined (and treatment to address that cause), it’s simply a matter of symptom management.

After all you have been through, this may sound a bit odd but studies show it may be possible to get too much medical help too soon after a whiplash injury. A recent review examining the results of early treatment for whiplash may be of interest to you. The researchers showed a surprising amount of evidence that iatrogenic disability is possible.

Iatrogenic disability refers to the development of problems caused by the treatment. Chronic pain is one of those problems. Studies consistently showed that too much treatment too soon actually increases the risk of chronic pain and disability. How do they explain this finding? And what kind of “treatment” are they talking about?

First, let’s look at the types of treatment studied. Fitness training, chiropractic care, and physical therapy during the early stages of recovery from whiplash were linked with slower recovery. The reason? Possibly too much attention creates illness behaviors. Calling the problem a “whiplash” injury instead of a “neck strain” may be a way health care providers cause or extend the sick-role. Not enough focus on self-care may encourage passive coping behaviors.

These findings prompt the next most logical question: how should whiplash injuries be handled early on? Efforts are made to help reduce patient’s pain and improve their function towards a goal of preventing chronic whiplash-associated disorders (WADs).

There is plenty of evidence that education, home exercise, and returning to normal activities as soon as possible is the most successful approach to this problem. Reducing patients’ fear and anxiety about their condition seems to be a big help (and more successful than other hands-on treatments).

Today’s view of whiplash is that it is a fairly benign problem that requires prevention management. Education, reassurance, and encouragement to get back to normal daily living is the number one effective approach to whiplash injuries. Once a patient has developed a chronic pain pattern, then the approach becomes a bit more complicated.

There is still a need to consider fear-avoidance movement patterns and behaviors. Patients become so afraid that a particular movement is going to increase the pain that they stop engaging in movements or activities that “might” aggravate their symptoms.

Here’s where a physical therapist could help you — not by using electrical or heal modalities but by guiding you through restricted neck motions and helping you regain your confidence. You may want to ask your therapist to evaluate you for “fear-avoidance behaviors” (FABs). You will probably surprise him or her with the question but at three months post-injury, the time for this question is right.

You may want to pursue other methods of breaking the pain-spasm cycle and get back to movement. For example, some patients add in massages and/or acupuncture along with slow moving exercise such as Tai Chi or QiGong or gentle yoga.

Anyone who has had an accident resulting in a whiplash injury knows the neck pain, stiffness, and loss of motion that can develop afterwards. Many people recover in a few days to a few weeks. But just as many develop chronic symptoms referred to as whiplash-associated disorder (WAD). Exercise may be a useful tool in getting past these symptoms and even preventing the transition from an acute problem to a chronic one.

A physical therapist may be able to help you. Therapists understand the impairments in movement and problems with neuromuscular control that can occur with neck injuries. Helping you regain motion, motor control, coordination, and muscle endurance are important goals.

A rehab approach may help prevent the development of a chronic whiplash-associated disorder. A second goal of rehab would be to reduce the number of repeat episodes of neck pain following your whiplash injury.

It can be a challenge to change the way muscles contract and relax when pain is the main feature preventing normal patterns of muscle activation. Coming out of a brace after four weeks has similar challenges. As you have discovered, movement patterns that are particularly affected by whiplash injury include the ability to move the head and neck quickly (speed) and smoothly.

Both the superficial (surface) and deeper muscles are often affected. If the problem is severe enough or goes on long enough, changes in muscle behavior and movement patterns begin to affect the nearby joints as well. Any rehab program that is successful must address all of these different components of the problem.

That is a very good question and one that is extremely important in the early days after a neck injury. Limiting motion and activities can actually contribute to an acute problem becoming a chronic one. There is plenty of evidence that whiplash (and other neck) injuries respond best to a very short period of rest with a return to normal movement and activities as soon as possible. So far you are right on track!

Experts advise patients keep up with this plan even if neck pain, stiffness, and loss of motion develop afterwards. This kind of approach may help prevent the impairments in movement and problems with neuromuscular control that so many people seem to develop after a neck injury.

It can be a challenge to change the way muscles contract and relax when pain is the main feature preventing normal patterns of muscle activation. Movement patterns that are particularly affected by whiplash injury include the ability to move the head and neck quickly (speed) and smoothly.

Both the superficial (surface) and deeper muscles are both affected. If the problem is severe enough or goes on long enough, changes in muscle behavior and movement patterns begin to affect the nearby joints as well. All of this points to the need to decrease pain and get the neck moving as normally as possible. This means resuming your usual activities as tolerated and being patient with the process.

Research has shown that fear, anxiety, and panic over the incident and subsequent injury only makes matters worse. Sometimes people start avoiding any movement they think might cause even the slightest pain. That phenomenon is called fear-avoidance behavior or FAB. You’ll want to avoid fear-avoidance!

Give yourself a few days to regroup and see how you are coming along. If you have any doubts or concerns about the stability of your neck, see a medical doctor (either your primary car physician or an orthopedic surgeon). If you need a little help through the process, see a rehab specialist such as a physical therapist. The therapist can guide you in establishing what to do, how to do it, and when to do it. This may help prevent repeat episodes of neck pain and foster healing so you don’t become a chronic whiplash sufferer.

Many efforts have been made to find treatment for whiplash that is safe, fast, and effective. Acupuncture has been shown helpful in restoring postural control by improving muscle sensitivity. Acupuncture improves circulation to the neck and is believed to facilitate faster healing. Restoring the natural flow of energy through the body via acupuncture may help patients avoid developing chronic pain.

Postural control is the ability to stay upright and move through space easily and efficiently. Head and neck alignment, vision, and balance are all components of postural control. You may not realize it but something as simple as walking across a room while carrying an object requires the complete coordination of multiple systems.

Anything (e.g., whiplash injury) that affects postural control may contribute to the development of chronic symptoms (dizziness, blurred vision, unsteadiness or loss of balance). We know that sensors called receptors in the head and neck communicate with the musculoskeletal system.

Together these mechanisms signal the nervous system, vestibular system, and the visual systems. The postural control that allows you to walk, see where you are going, carry objects with you, and maintain upright posture are all tied in together.

There are also reflexes between the eyes, neck, and vestibular (inner ear) system that can be altered because of damage to the cervical spine. Any change in the sensory input from the neck muscles, tendons, and joints to the postural control system can result in the common symptoms of chronic whiplash. And until the effects on the postural control system are addressed, an unending cycle occurs and the symptoms remain. Acupuncture has been shown effective in this regard.

Other treatment strategies aimed at restoring normal postural control after whiplash currently under investigation include acupressure, vestibular rehabilitation, coordination exercises, and spinal manipulation.

Results have been variable. Some of these treatment tools improve balance and dizziness but do not alter pain. Others seem better at reducing pain but without changing coordination. Various studies combining different programs together are still underway.

Physical therapists often treat patients with chronic symptoms of whiplash injury such as dizziness and vestibular dysfunction (unsteadiness). They use a variety of tools and techniques to help restore normal postural control so often affected by the type of injury you described. You may want to consider trying both physical therapy and acupuncture together. Some patients try one, then the other, and then combine them together to see what works best for them.

Studies show that up to 40 per cent of people involved in car accidents, with neck trauma in the form of whiplash develop persistent symptoms. Dizziness is one of three most common symptoms after whiplash trauma. Pain and postural unsteadiness are the other two common problems reported.

The presence of dizziness early on after whiplash injury may be an predicator of a worse prognosis than if you didn’t have any dizziness. Dizziness and unsteadiness are not just the end result of chronic whiplash but actually part of the reason why chronic whiplash develops in the first place.

Any change in the sensory input from the neck muscles, tendons, and joints to the postural control system can result in the common symptoms of chronic whiplash. And until the effects on the postural control system are addressed, an unending cycle occurs and the symptoms remain. Understanding how and why this happens may help you understand the need for early intervention.

Sensors called receptors in the head and neck communicate with the musculoskeletal system. Together these mechanisms signal the nervous system, vestibular system, and the visual systems. The postural control that allows you to walk, see where you are going, carry objects with you, and maintain upright posture are all tied in together.

Postural control is the ability to stay upright and move through space easily and efficiently. Head and neck alignment, vision, and balance are all components of postural control. You may not realize it but something as simple as walking across a room while carrying an object requires the complete coordination of multiple systems.

There are also reflexes between the eyes, neck, and vestibular (inner ear) system that can be altered because of damage to the cervical spine. And that brings us to the need to intervene early after neck injuries resulting in whiplash in order to prevent the transition from acute to chronic status. Physical therapy may be beneficial for you now to break the cycle.

If the therapist can alter the signals to and from the cervical spine (neck), it may be possible to do more than just manage symptoms but actually put an end to them. Restoring normal sensory function in the neck and resetting the postural control system may be possible. Research so far has focused on the role of exercise, acupuncture, and manual therapy to improve postural control.

The results have been encouraging. Pain is reduced, dizziness limited, the perception of neck disability is less, and visual gaze and eye-head coordination improved. It is thought that this treatment approach improves sensitivity of the deep muscle spindle and thus improves postural control. A muscle spindle is a small cluster of specialized muscle fibers within a muscle. Also called stretch receptors, they detect stretch (changes in the length) in the muscle.

Other treatment strategies aimed at restoring normal postural control after whiplash currently under investigation include acupuncture, acupressure, vestibular rehabilitation, coordination exercises, and spinal manipulation.

Sometimes computer simulated graphics are used to depict what happens during an accident causing injuries such as whiplash. But even those simulations are based on actual biomechanics studies conducted in research laboratories.

Biomechanics studies refer to research done on live humans (adults only). Volunteers willing to experience a low-speed rear impact are videotaped and X-rayed during the injury. This is how we know the sequence of events that occur within the cervical spine at the point of impact and the moments following. Correlating these cineradiography studies with postmortem examination of cadavers known to have a history of whiplash has confirmed some things.

First, compression and strain that exceeds the physiologic limits of the soft tissue structures around the facet joints has been identified. The greater the impact magnitude, the more damage is done. Low impact events seem to affect the C45 disc most often. But as the impact of the injury increases, damage extends to include C34, C56, and C67.

Tears in the anulus fibrosus (thick covering around the intervertebral discs) and tears in the joint capsules have been demonstrated. When the impact and force of injury is great enough, the anterior longitudinal ligament along the front of the cervical spine can be torn, too. Tiny meniscus cartilage in the facet joints called intraarticular meniscoids can become contused (compressed and bruised) and can even rupture.

The result of all the soft tissue damage is that the zygapophysial joints in the neck are left unprotected and can be injured as well. Animal studies added to what we know from biomechanics studies have shown that stretch of the joint capsule from the injury sets off nociceptors. Nociceptors transmit messages of pain. They are located at the joints and in the muscles and tendons near the joints. Once these transmitters get started, they don’t turn off and the result can be chronic pain.

There is one other area of study that has helped identify what really happens during a whiplash injury and that is postmortem studies. Postmortem refers to studies of humans after death. By examining all of the structures in the neck in people who had a history of whiplash, scientists have been able to see that tiny fractures and tears of the joint surface (called articular cartilage) and joint capsule are the main reasons for continued neck pain long after the car accident or other injury.

And the key finding here is the fact that these lesions don’t show up on X-rays or MRIs. They are only seen when the neck is studied directly in postmortem analysis. The agreement among all these studies called convergence has increased the validity of what were previously just theories about what happens inside the body during a sudden stop or collision and the physical causes of neck pain after whiplash.

Successful treatment for chronic neck pain associated with a history of whiplash has eluded physicians and patients for a long time. Part of the difficulty is the fact that the actual source of chronic neck pain after whiplash injuries has been a mystery.

It has been difficult to sort out because there are so many possibilities within the neck structures (hemorrhage, fracture, contusion, tears). But over the last 10 years studies have started to consistently point to one area: the cervical zygapophysial joints.

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

Studies of humans after death called postmortem studies have really helped identify the problem areas. Animal studies and biomechanics studies have also added similar information about the possible lesions of whiplash. The agreement among all these studies called convergence has increased the validity of what were previously just theories about the physical causes of neck pain after whiplash.

Experimental treatment blocking the nerves to the facet joints has also added confirmation that the source of chronic post-whiplash neck pain is coming from those particular joints. Nerve blocks have become both a diagnostic test and a treatment. In other words, if the nerve block eliminates the pain, the problem is coming from the facet joint.

Radiofrequency neurotomy is another treatment that has developed out of the knowledge that blocking nerve signals to the joint can eliminate the pain. This is a neurosurgical procedure. Radiofrequency waves directed at the tiny nerve branches to the joints create enough heat to destroy the nerve endings.

The pain relief is long-lasting and works better than any other surgical or conservative approach for 70 per cent of the patients studied. And if the pain comes back, the neurotomy procedure can be repeated successfully. Ongoing relief with return to work and daily activities is reported for 60 per cent of patients who have a repeat radiofrequency neurotomy.

Diagnostic nerve blocks help identify patients who might benefit from neurotomy before actually doing the procedure. This may be a good first step for you. But keep in mind that zygapophysial (facet) joint pain is not the only cause of chronic whiplash pain. But it does account for up to half of all chronic neck pain sufferers. A 70 per cent success rate for that many patients is considered a major breakthrough in this area.

That is actually a very good question and one that other people have given some thought. The actual word whiplash first appears in written form back in 1928. An orthopedic surgeon by the name of Crowe was the first to report on eight patients who suffered neck injuries from traffic collisions.

It’s very likely that before the modern invention of the automobile there were falls from horses and other injuries that led to neck pain and problems similar to what we refer to today as “whiplash.” Bicycles came on the scene in the late 1800s. And if you remember, the early bikes were high off the ground. Injuries from falls and collisions were likely even back then.

The focus on injuries and treatment today may be very different than it was back then. Without health insurance and medical care so readily available, it seems people got better faster. In fact, there’s some modern evidence that the availability and approach of health care professionals to this problem may actually make matters worse, not better.

Studies consistently show that too much treatment too soon after neck injuries actually increases the risk of chronic pain and disability. The reason? Possibly too much attention creates illness behaviors. Calling the problem a “whiplash” injury instead of a “neck strain” may be a way health care providers cause or extend the sick-role. Not enough focus on self-care may encourage passive coping behaviors.

There is plenty of evidence that education, home exercise, and returning to normal activities as soon as possible is the most successful approach to this problem. Reducing patients’ fear and anxiety about their condition seems to be a big help (and more successful than other hands-on treatments). And that is probably how things were handled back in the late 1800s to mid-1900s.

We can offer you the following information. This comes from a study performed by the Miller Scientific Consulting company in San Francisco, California. They investigated the results of treatment using the anterior cervical discectomy and fusion (ACDF) and disc replacement procedures you are considereing.

The fusion is accomplished with bone grafts or titanium cages. A decision must be made between bone grafts from the patient (autografts) or from a donor bank (allograft). There are price differences.

Each of these choices has positives and negatives associated with it. Weighing the benefits against the disadvantages doesn’t always give a clear picture of how the results from each of these approaches compares. That’s where this study comes in. This is the first study to compare the results of all four choices: 1) anterior cervical discectomy and fusion (ACDF) with allograft, 2) ACDF with autograft, 3) ACDF with cages, and 4) disc replacement called arthroplasty.

The authors of the article didn’t actually treat patients with these four methods and then compare the results. Instead, they reviewed all of the published studies on these topics and analyzed the data to get a general idea of how they compared.

Results were measured based on patient outcomes of neck and arm pain, neck disability, physical and mental function, and fusion rate (based on X-rays). Neck disability was measured using a special patient survey called neck disability index (NDI). There was one other measure used to compare the groups and that was adverse events (complications or problems) during or after surgery.

There wasn’t much difference in the final results among all of these surgical treatments. It seems that no matter how it’s done, removing the disc and any bone spurs that are pressing on the spinal nerve(s) gives immediate pain relief. But just removing these tissues would leave the spinal segment unstable. That’s why the affected spinal segment is supported with fusion or disc replacement.

So the question is still: which one of these approaches to fusion or disc replacement is best? With similar results in pain relief and function, other factors must be considered. For example, autografts require the harvesting of bone from the pelvic bone.

This procedure means a longer time in the operating room under anesthesia. Many studies have shown that the donor site can become a new source of pain or discomfort. There are no such side effects with allograft. The main concern with bone from a donor bank is rejection (rare). The major downside of fusion (no matter how it’s done) is the loss of neck motion.

Disc removal and replacement with an implant restores neck motion but is a much more expensive procedure. The surgery is much more complicated and takes much longer. The high cost of the disc implant must be factored in too. And since cervical disc replacements have only been around for the last five years, we don’t have long-term studies to see how well they hold up or if there are any problems down the road.

The authors concluded that with the improvements that have been made in preparation of allografts (from the bone bank) the advantages of allograft over autograft are clear. Eliminating the donor site pain that often interferes with daily activities is a big benefit of allograft fusion. The ACDF procedure with allograft costs half that of autografts. Allograft safety record is well-documented making this an excellent choice for anterior discectomy and fusion.

There’s no doubt you will need to talk with the physician’s business office to find out the potential charges for each procedure. Then take this information to your insurance company and see what they will cover. You may have to have prior authorization anyway — and it’s possible the insurance company covers one procedure but not another.