FAQ Category: Cervical Spine

In fact, a recent study from Japan has reported a link between wrist and finger rheumatoid arthritic changes and the neck leading to neck instability. Orthopedic surgeons from the Kobe University School of Medicine explored the natural history of rheumatoid arthritis (RA) affecting the cervical spine (neck).

They followed a group of patients (267 total) over a period of five years to see what happens over time. They hoped to see if it’s possible to predict who will develop cervical spine instability from RA.

By performing serial (repeated) X-rays, the authors were able to observe progression of disease over time. They compared erosive joint destruction of the fingers with changes in the cervical spine.

Analysis of the data showed that early signs of cervical instabilities and worsening of hand involvement were two predictive factors for progression of cervical spine instability. As the hands got worse, the neck got worse.

This study showed that by observing early changes (as seen on X-rays) in the neck and hands, it is possible to target patients most likely to develop cervical spine degeneration. Preventing the risks associated with this problem is a more attainable goal now with the new disease modifying antirheumatic drugs (DMARDs) and biologic agents currently available.

Cervical instabilities are considered by some experts the most serious problem associated with rheumatoid arthritis (RA). Understanding and preventing cervical instabilities in this patient population is extremely important. A sudden shift of the vertebra putting pressure on the spinal cord can cause difficulty breathing that could be life-threatening.

Have your primary care physician or rheumatologist take a look at you. An X-ray may be all that’s needed to answer the question of whether or not you are experiencing some early changes in the cervical spine. A change in medication and/or a couple of visits with your physical therapist may be all that’s needed to maintain alignment, mobility, and function.

Although rheumatoid arthritis (RA) seems to target the small joints of the hands and feet, in fact, it can affect any joint in the body, including the cervical spine (neck).

Head, neck, and/or arm pain with or without numbness and tingling of the arms and/or hands can signal arthritis of the neck. There could be an electric shock sensation (called Lhermitte sign) down the arms if there is pressure on the spinal cord.

Muscle weakness and atrophy are further neurological signs observed with this problem. Anyone with RA who develops new symptoms of this type should report this change to his or her physician. These are potentially early signs and symptoms of degenerative changes in the cervical spine that could lead to serious instability.

Cervical spine instability is defined as movement, translation, or “slippage” of one cervical vertebra over the vertebra below it. Two other words used to describe this problem are translation and subluxation.

To form a true subluxation (partial dislocation), the vertebra has to slide at least two millimeters (as measured on X-rays). This measurement refers to the reducible difference. In other words, when the bone is shifted and lined up as much as possible, there is still at least two millimeters of displacement. The shift can be in any direction (forward, backward, rotation, sideways). Most of the time, the displacement is anterior or forward.

An X-ray is needed to confirm the diagnosis. The physician will perform a clinical examination and perform some tests of neck motion, arm strength, and screen for neurologic involvement.

Early diagnosis and treatment is best for problems like this so don’t delay. Make an appointment at your earliest convenience. There may be nothing to it but even that information will provide a measure of comfort and reassurance.

Instability of the cervical spine (neck) severe enough to require surgical fixation occurs as a result of trauma, congenital malformations, or bony destruction from diseases such as cancer, arthritis, and infections.

As in your case, the upper cervical bones degenerate to the point of collapsing from underneath the skull. Without support of some kind, the risk of pressure on the spinal cord is too great to leave the problem untreated.

External “fixation” such as collars and halo vests are temporary until surgery can be done. Internal fixation is the next step. Fixation means the surgeon is literally using metal plates, screws of various types, and rods to hold the base of the skull attached to the back of the cervical vertebrae.

Modern rod-and-screw fixation techniques have replaced the earlier wire and bone graft methods of fixation. Bone grafts are still used to augment fixation devices such as preshaped rods and contoured plates.

Different types of locking screws are used and placed in different positions or parts of the spinal bones. These devices can be angled to meet each patient’s needs. Specific motions (side bending or rotating the head) can be prevented according to the patient’s pattern of instability.

Once the surgeon has a chance to evaluate your particular situation, then a plan of care can be developed. You will likely be shown X-rays, MRIs, and schematic drawings of the proposed procedure. Be sure and ask any questions you may have in order to fully understand what is being proposed and what you can do to get the best result.

Although this procedure requires a highly trained surgeon and a surgical team that works well together, it can be done with 100% accuracy and excellent results. What you are looking at is a modern posterior fixation for someone (your husband) with an unstable occipito-cervical spine. As you have described it, that’s where the skull meets the upper cervical spine (neck).

Preshaped rods and contoured plates have increased the technical difficulty of the surgery. But these devices can be angled specifically to meet each patients needs. And the improvements in design have reduced problems with the plates pulling out or screws backing out.

MRIs are studied to make sure the surgeon knows exactly where the major blood vessels and nerves are located (and to avoid cutting into them). Bone thickness of the skull as well as the vertebrae are taken into consideration in choosing the right type of fixation and finding the best place to secure it (i.e., screw it in).

Careful surgical technique requires a very detailed knowledge of skull and cervical vertebrae anatomy. The surgeon tries to avoid blood loss, prevent blood clots, and minimize damage to the soft tissues. Each surgical step is performed slowly and deliberately with checking and double-checking holes and screws before making the final placement.

With careful preoperative planning, surgeons can anticipate what is needed before attempting an occipito-cervical fusion with fixation devices and bone graft. As mentioned, 100 per cent accuracy in placement of the plates and screws can be achieved. Solid fusion is the final goal with patient safety a high priority throughout the procedure.

Two very good questions. Let’s start with the first one: why does degenerative disc disease cause pressure on the spinal nerve root resulting in neck and/or arm pain? The disc is like a gel- or fluid-filled cushion between two vertebrae (spinal bones). Disc act to cushion and disperse load, force, and friction. When it loses its shape and form, the bones collapse toward each other.

Disc disease of this type means the pressure and load on the vertebrae increases. It also means the facet (spinal) joints move closer together. Compression and added load there can cause bone spurs to form as the body responds to the added friction and shear forces.

A smaller space between the vertebrae also affects the spinal ligaments with resultant increase in stiffness of the spine. All of these factors together reduce the size of the foramen (hole through which the spinal nerve travels as it leaves the spinal cord and travels down the arm).

And over time, with thinning of the bones and compression, the front of the vertebral bodies get pushed down. Vertebral compression fractures can develop. These are two more anatomical factors that can contribute to narrowing of the foramen. The final result? Pinching or pressing on the spinal nerve root(s) and cervical radiculopathy.

If it happens in one place, why doesn’t this happen at every level of the spine? There isn’t a clear-cut answer to that question. We simply don’t know. Educated guesses have been made. For example, there may have been known or unknown trauma at that spinal level some time in the past. Over time, the disc has lost fluid and nutrients until it end up being paper thin and not much good for anything.

It’s possible that small deviations in posture and alignment have created uneven force and shearing forces at that level with the final result being changes in the disc. There is even some study to suggest disc degeneration at any level (even single levels) has some genetic links.

Finding out what risk factors might predict degenerative disc disease may eventually help us screen for those and prevent future disease. We are still quite a ways away from being there. But efforts are already being made to find treatment that works based on current evidence. Guidelines based on best evidence found so far have been published. Those practice guidelines will be reviewed and revised as new information is discovered.

There are potential complications with any surgery. Infection, bleeding, blood clots, and poor wound healing are the major problems to watch out for. With the particular surgery you are considering, some of the complications may depend on the technique used for the procedure.

Surgeons have found various ways over the years to give the spinal cord some added room while stabilizing the vertebrae (spinal bones). For one thing, they found they could cut through the lamina (pillar of bone that forms an arch around the spinal cord) and make a hinge to move the bone away from the spinal cord without removing the bone. It sounds like this is the procedure planned for you.

Once the hinge-door has been created, it has to be propped open so it doesn’t swing back and shut against the spinal cord again. There are various ways to accomplish this. When this procedure was first developed, the surgeon used stitches but they didn’t give the rigid support needed. So they moved on to using bone and ceramic struts or spacers placed between the open edge of the door and the other side of the bone.

With this method, there is a risk that the struts will pop out (causing the hinge-door to close) or drop back into the spinal canal. If the strut falls into the spinal canal, pressure on the spinal cord can redevelop. A newer approach is the use of metal plating to expand the space around the spinal cord, provide rigidi support to the bone, and hold the hinge-door open. With this technique, the surgeon doesn’t need to use supplemental bone grafting, the costs are less, and the patient can get up and move around right away.

Check with your surgeon to find out what types of problems you might face. Besides the surgical technique used, your age and general health are factors.

Plate-only open door laminoplasty (the procedure you just described) is a fairly new approach to expanding the space around the spinal cord and taking pressure off the nerve tissue. The surgeon cuts through the lamina (pillar of bone that forms an arch around the spinal cord) and makes a hinge to move the bone away from the spinal cord without removing the bone.

But to keep the door from swinging shut, it is necessary to hold the gate open so-to-speak. To accomplish this, the surgeon can use a prop or spacer made out of bone or ceramic. The spacer is called a strut and functions like a door stop. The plating system you described connects the open edge of the “door” to the other side of the bone. It also holds the door open, expands the space around the spinal cord, and gives rigid support to the spine where the bone has been cut open.

The plating system is fairly new so there aren’t a lot of studies done yet. But one published in 2004 and another that came out in 2010 give it high ratings for success. Using CT scans to evaluate bone healing and remodeling, 93 per cent of the levels operated on were healed and stable at the end of 12 months. The remaining seven per cent were considered “nonunions”. The area filled in with fibrous scar tissue rather than bone but the spine was still stable.

The surgeons reported very few complications or problems beyond a couple of screws backing out that were used to hold the plate in place. And even in those cases, no neurologic symptoms were reported. There were no cases where the plates broke, shifted, or failed in any way.

Two additional advantages of a plate-only approach are the cost savings (it’s much more expensive to add bone struts) and the shorter time under anesthesia required for a plate-only procedure. A shorter operative time also saves money but even more importantly, reduces the risk of complications for the patient.

Evidently, the plate-only procedure is less technical than some of the ones that use struts. The technique of using the spacers requires advanced surgical skills much like a master carpenter. The high success and low complication rates without the use of supplemental bone grafting suggests this technique to expand the spinal canal may become a standard procedure in the future. Patients have immediate spinal stabilization and can move after surgery right away. The cost savings is an added feature to consider.

The medical term for your condition is cervical radiculopathy from degenerative disease. That’s a mouthful to really describe a pinched nerve from age-related changes in the spine. Just as you described, cervical radiculopathy can develop as the discs thin out, lose fluid, and compress down. Just that change alone results in a series of other changes as well.

Disc disease leads to an increase in the pressure and load on the vertebrae. It also means the facet (spinal) joints move closer together. Compression and added load there can cause bone spurs to form as the body responds to the added friction and shear forces.

A short space between the vertebrae also affects the spinal ligaments with resultant increase in stiffness of the spine. All of these factors together reduce the size of the foramen (hole through which the spinal nerve travels as it leaves the spinal cord and travels down the arm). And over time, with thinning of the bones and compression, the front of the vertebral bodies get pushed down. Vertebral compression fractures can develop. These are two more anatomical factors that can contribute to narrowing of the foramen.

The final result? Pinching or pressing on the spinal nerve root(s) and cervical radiculopathy. Studies show that in the case of a simple nerve compression, the condition is self-limiting. This means it will probably get better on its own without treatment. The length of time it takes for this to happen varies from person-to-person.

The physician who examined you and made the diagnosis may have some suggestions for you based on the location of the spinal changes and severity of your symptoms. If the painful symptoms get to be too much for you, nonoperative care may offer you some relief. This could include nonsteroidal antiinflammatory medications, massage, physical therapy, and/or chiropractic care.

You may be able to find something that fits your budget and helps in the early (acute) stages of the problem. Hands-on therapy may help improve alignment and reduce pressure on the nerve. Antiinflammatories reduce swelling around the nerve and can also result in pain relief. Combined together, the medications and the manual therapy could help you get through to complete resolution of the problem.

For any diagnosis, conservative care refers to any form of nonoperative treatment. In the case of neck pain (and other symptoms) from degenerative disc disease of the cervical spine, nonoperative care often begins with medications.

The surgeon may have prescribed for you a pain reliever (e.g., Tylenol) or antiinflammatory drug (e.g., over-the-counter ibuprofen or any of its prescribed derivatives). Physical therapy is often helpful in addressing the symptoms, motion, posture and spinal alignment, strength, and function.

Other treatment options include chiropractic care, acupuncture, massage, and any of the alternative methods of healing (e.g., Reiki, BodyTalk, Rosen method, Feldenkrais, therapeutic touch, Rolfing).

Some patients begin with one modality and give it some time to see if it helps before adding another treatment approach. Others combine anything available seeking relief from symptoms as quickly as possible no matter what does the trick.

If, after several months, you do not experience any improvement, then your surgeon may suggest a steroid injection into the area. A second injection may also be advised if you didn’t get any relief the first time or if you obtained partial relief and want to try for complete freedom from symptoms.

Most surgeons allow at least six months of conservative care before considering surgery (fusion or disc replacement). Now that you have a diagnosis and baseline X-rays or other imaging studies, follow through with the nonoperative approach and keep your surgeon up-to-date on what is happening with you. Communication is the key to a collaborative decision-making process that will get you the best results possible.

There have been many reports that after a spinal fusion for disc degenerative disease, the disc at the next level (usually the one above the fused segment) is the next to degenerate. The loss of motion and adjacent segment disease were two reasons why scientists developed the artificial disc replacement (ADR).

At first, disc replacements were only available for the lumbar spine. But now, artificial disc replacements (ADRs) have been designed for the neck as well. Many studies have shown that disc replacements do indeed preserve joint motion, so the first problem has been solved. Naturally, surgeons (and patients) want to know if the artificial disc replacement also takes care of the problem of adjacent disc degeneration.

A recent study was done comparing results of fusion and disc replacement for the cervical spine that might offer you some helpful information. In this study, 93 patients with disc disease in the neck failed a minimum of six months of conservative (nonoperative) care and ended up with surgery. Conservative care included medications, physical therapy, chiropractic care, and steroid injections.

Half the group had the fusion procedure. The other half had an artificial disc replacement. The fusion technique used is called anterior cervical discectomy and fusion (ACDF). The name ACDF describes the approach (anterior is from the front), the location (cervical spine), and the actual procedure (discectomy removes the disc and fusion uses bone graft to fill in the hole where the disc once was).

The patients were randomly assigned to one or the other surgical treatment. Random assignment means a computer generated names for each group. The patients didn’t even know what type of surgery they had until after the fact.

In the group of patients who had a disc replacement, 43 patients had a one-level procedure and 16 had two-levels replaced at the same time. Three different types of FDA-approved disc replacements were used. In the fusion group, 28 patients had a fusion at one level and six patients had a two-level fusion. Data on bone density and the presence of lumbar disc degeneration was collected and compared for both groups.

Success of each procedure was determined by measuring before and after changes in pain (or other symptoms) and improvements in function (as measured by the Neck Disability Index).

X-rays were compared before surgery and at regular intervals after surgery for up to four years. Any sign of adjacent segmental disease was noted. Lack of improvement, new (or worsening) neurologic symptoms, and the need for more surgery affecting the operated area(s) were used as measures of failure.

The mid-term results (after a median of three years) showed no difference between disc replacement and fusion. Both groups experienced an equal number of cases of adjacent segment degeneration (ASD). Between 15 and 18 per cent of all patients were affected by ASD. The period of time free from this problem was about three years for both groups.

There did not appear to be any link between age, sex (male versus female), tobacco use, or number of levels of surgery with the final outcomes. One key finding in this study was the fact that patients who had lumbar disc degeneration were more likely to experience segmental disc degeneration in the cervical spine.

The patients will continue to be followed in order to see what happens over a longer period of time. The surgeons will also keep track of patients who experience implant failure for any reason and report on that in future publications. The finding that disc degeneration in the lumbar spine predicts adjacent segmental disease in the cervical spine following disc replacement will also be studied more closely.

It’s clear that artificial disc replacements are safe and effective in reducing pain and neurologic symptoms. This was the first study to examine patients receiving cervical spine disc replacement(s) for adjacent disc disease. It does not appear that this new technology preserves the disc segment above and below any better than fusion surgery does.

This is an important question because there may be altered muscle function depending on the etiology (cause) of each problem (neck versus shoulder). A recent study from the University of Iceland may offer some helpful insight.

They compared two groups of patients with neck pain. One group had been involved in a motor vehicle accident (MVA). The second group had neck pain but no history of MVA. There was actually a third (control) group who had no neck pain and no history of MVA. Most of the participants were women. Everyone was right-handed. And the groups were carefully matched by age, size, and activity level.

The main focus of the study was on movement of the scapula (shoulder blade) with arm elevation. We know that the muscles that control shoulder motion and in particular scapular motion can have a direct effect on the neck. Evaluating scapular motion and comparing between neck and shoulder injuries might give some clues about where the pain is coming from.

And comparing these results with results from other studies looking at shoulder pain has provided some interesting clues to what is happening. If scapular motion (and therefore muscle timing, rhythm, and control) is different depending on the etiology (cause) of neck pain, then treatment might vary accordingly.

They found that everyone with neck pain had a different scapular orientation during arm movement compared with normals. This suggests some type of movement impairment that needs to be addressed in treatment. Unless everything moves in proper alignment, uneven pull on the neck from altered dynamic stability of the scapula will cause continued neck pain.

Second, patients with neck pain from a whiplash had similar muscle patterns seen in patients with true shoulder problems (moreso than when compared with neck pain of unknown cause). There was an uneven pull between the muscles of the neck and shoulder contributing to clavicular elevation and scapular tilt.

The authors concluded that identifying patterns of muscle impairment with different types of problems may guide treatment of patients with neck and/or shoulder pain. Getting normal motor function and alignment may be the key to preventing ongoing or recurring neck pain whether the problem originates in the neck or the shoulder.

There is a problem called whiplash associated disorder (WAD). Patients with this problem experience neck pain, stiffness, and tenderness over the neck muscles. Sometimes there is a decrease in neck and/or shoulder motion.

Compensatory patterns of movement as you describe are not uncommon after a musculoskeletal injury. Pain can lead to a change in the way muscles contract and relax. They lose their natural rhythm and timing when they hold tightly to avoid painful movements.

This is a phenomenon called reflexive inhibition. Other muscles change the way they function to help compensate for the inhibited muscles. Sometimes there is a protective response as muscles contract to hold the arm in a position that reduces pressure on irritated or damaged nerves.

Any of these motor impairments can become “stuck” creating an ongoing feedback loop that doesn’t stop when the injury is healed. It’s not usually something you can change or control easily without some outside help.

Physical therapists are able to examine movement patterns, identify impairments, and help restore normal function once again. Some therapists who specialize in human movement impairments use biofeedback units that help them analyze specific motor patterns. You may want to seek some help with this problem before it becomes a chronic (long-term) situation with other negative side effects.

We are assuming that you have had adequate treatment following a conservative path before coming to the turning point to consider surgery

Most of the symptoms patients experience with neck instability (sensation of the head “clunking” with movement, headaches, neck pain, arm pain) go away with conservative care. Nonoperative treatment to address the contributing postural components, muscle weaknesses or imbalances, and other soft tissue issues should be given a fair trial.

But with degenerative conditions that don’t respond to nonoperative treatment, surgical intervention to stabilize the unstable segment(s) may be necessary. Evidently, that’s where you find yourself now.

In the past, the only real choice was neck fusion. And that worked “okay” (pain and other symptoms are relieved, the neck is stabilized) but there are problems with this approach. The biggest drawback is the fact that the patient loses neck motion at the fused level.

The subsequent problem is the increased load and force placed on the spinal segment above and below the fused level. The added stress speeds up wear and tear and can cause a condition called adjacent-segment degeneration. What’s the answer to this dilemma?

Well, the next development in this area has been an artificial disc replacement. The procedure is referred to as a cervical disc arthroplasty or CDA. In theory, the implant is designed to stabilize the neck AND maintain motion without transmitting load to the adjacent segments.

How well is that working? A recent report of all the findings to date didn’t come up with any firm conclusions. It’s not just because one method isn’t really working better than another. It has more to do with the way many research studies are designed and carried out. Without high quality research, the evidence gets downgraded.

Right now, the standard of care for cervical (neck) instability remains fusion. That’s not necessarily because it is the best treatment approach for every patient. We don’t have enough evidence to switch from fusion (with its known results) to disc replacement without better comparisons between the two.

If your surgeon feels you are a good candidate for either approach, then your decision is based on your goals, activity level, and expectations. Asking questions like this and searching for information will help you make the right choice for you.

Artificial disc replacement has been available for the lumbar spine for quite some time (with successful outcomes). As a result, this new technology has been developed for the cervical spine as well. And the procedure has been done enough that there are short- to mid-term results reported now.

As with any surgical procedure, there can be complications, problems, or adverse events. These can occur right in the operating room, shortly after in the recovery room, or postoperatively. Postop covers a wide range of time frames from hours, to days, to weeks, and beyond.

Patient complications can also be wide ranging from simple to complex infections, blood clots, fractures, and so on. There can be device failure — the implant may collapse into the bone or loosen and back out of the disc space. The implant (artifical disc device) itself can break. Sometimes the implant isn’t placed in the best or most optimal position creating biomechanical problems with movement.

Any of these problems can require additional surgery to correct. It may be necessary to remove the implant and try another or remove it and fuse the segment. In some cases, the surgeon just adds some additional fixation (metal plate, screws, pins) to hold the implant in place.

Your surgeon may have other thoughts in mind as to what can happen. You’ll probably still have opportunity to ask additional questions — either at your next visit or during the pre-operative work-up. Take advantage of that time to make sure you are clear on all aspects of your treatment and follow-up.

The term neuropraxia describes symptoms of bilateral (affecting both sides) burning, numbness, loss of sensation, and muscle weakness of the arms and hands. The symptoms are caused by pressure on the spinal cord in the cervical spine (neck). It is like having a concussion to the spinal cord (instead of to the brain). The symptoms can last minutes up to hours.

With burners or stingers, the spinal cord nerve root coming off the spinal cord (not the spinal cord itself) is pinched or compressed. The player experiences the same symptoms of burning, numbness, loss of sensation and/or weakness but in just one arm, not both arms.

Whether it’s burners, stingers, or neuropraxia, full recovery is expected — if the player doesn’t go back on the field and experience another high-energy contact injury to the head and/or neck. And if there isn’t an undetected fracture of the vertebra or damage to the disc. Only an examination and X-ray, MRI, or CT scan to rule out this type of trauma will answer that question.

It sounds like that’s where your son is in the process.

An expert panel of spine surgeons, neurologists, and orthopedic surgeons who specialize in trauma have suggested the following guidelines:

Since you are in professional sports, you know there’s an ongoing debate about head and neck injuries on the field. How soon should these players be allowed to return to play? Players who suffer an undiagnosed concussion, compression to the spinal cord or spinal nerve roots, or other neck injury are in danger of long-term consequences. Early diagnosis and treatment may prevent serious complications.

When the symptoms are mild, the athlete may “shake it off”. More serious symptoms such as loss of sensation and the use of the arms are harder to mask. One of these conditions affecting the neck is the one you experienced called neuropraxia or cervical cord neuropraxia.

The term neuropraxia describes symptoms of bilateral (affecting both sides) burning, numbness, loss of sensation, and muscle weakness of the arms and hands. The symptoms are caused by pressure on the spinal cord in the cervical spine (neck). It is like having a concussion to the spinal cord (instead of to the brain). The symptoms can last minutes up to hours.

In all cases, players should not be approved to return to their sport until and unless they have normal neurologic function and pain free (and full) motion. Imaging studies should confirm that there is plenty of room in the spinal canal for the spinal cord (i.e., no more stenosis). And the spine should be stable with no signs of subluxation, dislocation, or hypermobile (excess) motion.

With a past history of cervical cord neuropraxis, there is a risk of reinjury. The decision you must make is what degree of risk are you willing to accept in exchange for the financial gain by returning to play sports.

No one can guarantee your safety. But the surgeon who treated you or who is following your case can give you an idea of how stable is your spine.

Imaging studies can also offer information on the condition of your spinal cord and whether or not there is enough space around it to prevent compression under ordinary movement and activities. The spine should be stable with no signs of subluxation, dislocation, or hypermobile (excess) motion.

BOTOX stands for Botulinum toxin, which is a protein produced by a bacteria. It is used for various cosmetic and medical procedures because it is a powerful neurotoxin. In other words, it can paralyze a nerve. When the physician suspects arm pain and numbness are symptoms from thoracic outlet syndrome (TOS), Botox can be used on the scalene (neck) muscles as a test to see if that’s part of the problem.

The main cause of TOS is that the nerves and blood vessels going to the arm and hand get squeezed near the thoracic outlet. The thoracic outlet is this opening between the scalene (neck) muscles and the rib cage. The nerves and blood vessels then go under the collarbone (also known as the clavicle), through the armpit (the axilla), and down the arm to the hand.

Extra muscle or scar tissues in the scalene muscles can put extra pressure on the nerves and arteries. Heavy lifting and carrying can bulk up the scalenus muscles to the point where the nerve and arteries get squeezed. Muscle blocks can also be done to prevent muscles (like the scalenes) from contracting fully. The injection weakens the scalene muscle enough that it can no longer pull the first rib up against the nerves and blood vessels passing through the thoracic outlet. Such a test helps identify overused muscles that might be a problem.

Botox used for cosmetic purposes doesn’t make the lips look fuller (you are probably thinking of silicone injections for that). Botox is used more often to temporarily paralyze the muscles of the face to hide lines formed from raising the eyebrows or smiling.

When used to aid in the diagnosis of thoracic outlet syndrome by weakening scalene muscles, you should not experience any intentional swelling or fullness from the injection. Although small, there is always the risk of infection, swelling, or other unintended side effects from any invasive medical procedure.

Your concern is a legitimate one and one that you may want to bring up to your surgeon for discussion. She will be able to answer your questions and allay your fears. But let us give you some information that might help.

Surgeons have all manner of tools available to them now that have advanced their technical abilities during surgery. For example, preoperative X-rays and fluoroscopy (real-time 3-D X-rays during surgery) make it possible to line everything up accurately and with more precision than ever before.

Some disc replacement systems involve using a special machine that makes all the cuts. The surgeon lines everything up carefully but the machine makes even, equal amounts of bone cuts from each end. With this capability, bone resection isn’t a significant factor.

They even have computer programs that measure (in square millimeters) exactly how much bone has been removed. That gives the surgeon some feedback to gauge how much bone has been resected.

Studies show that there are some important factors that can predict who will have better motion after surgery. Men are more likely to have better motion than women. Patients of either sex who have the most motion before disc replacement have the best results after surgery.

Getting the disc implanted at the right angle and in the best position are technical factors only your surgeon can control. Patients must choose their surgeon carefully just as surgeons must select patients for this procedure with equal care.

Patients who have severe, advanced degenerative disease may be better off with a spinal fusion than a disc replacement. This is something surgeons and patients usually decide together. You may have already had this conversation with your surgeon, but if not, it’s always good to review what all your treatment are, which ones are best suited for you, and why.

Many studies have been done looking at neck motion before and after neck surgery. Disc degeneration is the usual reason why artificial disc replacement is considered. Before disc replacements became available, patients had one option: fusion.

With a cervical spine fusion, loss of motion is a certainty. In fact,that is the goal of fusion: to stabilize a segment that is diseased or damaged. Now, with artificial disc replacements, motion can be preserved. The damaged disc is removed and an artificial device is implanted in its place.

But not all units are the same. Some are made of stiffer materials. Each has its own working mechanical parts and biomechanical properties. These are factors that can affect results in terms of neck motion and stiffness.

Surgeons have also found that patients with severe disc collapse before surgery are more likely to have stiff, contracted (stuck) spinal ligaments and facet capsules. Facet capsules refers to the fibrous material around the spinal joints. When the capsule ages, dries out, and gets stiff, replacing the disc will help the vertebral segment move. But without a normal facet (spinal) joint, full motion still isn’t available.

There are a lot of other potential factors. Getting the right size of disc device and having it placed at the best angle and the correct depth are all important in neck motion postoperatively. An artificial disc that’s too big for you or too far forward can contribute to reduced motion and subsequent stiffness.

If you haven’t mentioned this to your surgeon, it might be a good idea to go in for a follow-up appointment. It’s possible there are issues with posture, muscle flexibility, motor control of the muscles, and proprioceptive (joint position awareness) that could be helped with intervention from a physical therapist.

You may be experiencing a potential side effect of spine surgery called heterotopic ossification — bone that forms outside the skeletal system. Usually, streaks of calcification or bone develop in the nearby muscles and soft tissues.

This problem is common after hip and knee replacements. And with the increased number of artificial disc replacements in the neck and low back, surgeons are finding the same phenomenon. In fact, a recent study comparing three different types of implants found an overall rate of heterotopic ossification in 40 per cent of the patients.

In the case of excess bone formation after joint replacements, there is some evidence that tissue trauma during surgery, removal of bone dust, and the use of nonsteroidal antiinflammatories before and after surgery might be contributing factors. But studies have not been done to see if any of these factors increase the risk of heterotopic ossification with disc replacements.

From what we do know so far, it looks like the type of implant makes a significant difference. Implants that fit well up against the endplate seem to avoid the problem of bony overgrowth. The endplate is a circle of cartilage between the disc and the vertebral body.

As far as possible patient factors, scientists propose genetic traits might be at work. Specific patient characteristics (age, gender, lifestyle, body size, level of implant, diagnosis, type of surgery, and so on) as contributing risk factors have not been investigated.