FAQ Category: Cervical Spine

To answer your first question, it is true that only 100 cases of cervical spondylolysis have ever been reported in the entire world since it was first diagnosed by X-rays back in 1946.

To answer your second question, what is cervical spondylolysis? Cervical refers to the neck or upper portion of the spine. Spondylolysis tells us there is a defect or deformity of some kind. In the lumbar spine (low back), spondylolysis means there is a fracture in the pedicle, a supporting column of bone. In the cervical spine, spondylolysis describes a cleft or place where the bone doesn’t meet in the middle.

Cervical spondylolysis occurs where the upper or superior facet (spinal) joint meets the lower or inferior facet joint. This defect occurs most often at the C6 segment and is usually present on both sides (bilateral). The disruption in the bone bilaterally results in a forward migration or movement of the affected vertebra over the intact vertebral bone below.

Any time a vertebral body shifts forward, it pulls on the spinal cord and spinal nerve roots causing neck and/or arm pain and neurologic symptoms such as numbness and tingling or even paralysis. When the bone is disconnected in this way, instability of the spine is a major concern. Because of the risk of permanent paralysis, treatment to stabilize the spine is important.

A fracture of the odontoid process (dens) is the most common type of fracture in the upper cervical spine. Just as you described, the odontoid process is a knob of bone attached to the second cervical vertebra. It pokes up through the hole formed by the first cervical vertebra. Together, these two cervical vertebrae (C1 and C2) form a stable based for the head to sit upon. They allow the head to flex, extend, tilt, turn, and shift without falling off. Of course, a series of ligaments and muscles help hold everything together and in place.

You can see why a fracture at this site can create instability of the head on the spine. A type II odontoid fracture extends through the base of the dens. Without treatment, pressure on the spinal cord can cause serious neurologic damage (e.g., paralysis and even death). It’s clear that some type of treatment is required.

What’s the best way to secure this broken bone? There are two basic choices: a rigid neck brace that holds the spine still until the fracture heals or surgical fixation. Surgical fixation means that screws are used to hold everything together while the bone knits itself back together.

The bracing option is really more for the younger crowd (50 years old and younger). Studies have shown that the complication rate is so high for older adults treated this way, it’s just not worth it. So that leaves surgical fixation as the best practice for older adults (over age 70). As you have discovered, patients in the between ages (50 to 70) may have to consider the pros and cons of both when deciding.

Here are some things to think about. The fusion rate in older adults using external bracing with the halo vest is much lower than in younger folks. Poor fusion can mean an unstable spine. Patients 65 and older seem to have a much higher death rate when placed in this type of brace compared with younger patients. Cardiac complications, pneumonia, and respiratory arrest are a few of the potential hazards of bracing in older adults. That’s why surgical stabilization is often the recommended course of action.

Surgery can be done from the front of the spine (the anterior approach) or from the back of the spine (the posterior approach). The anterior approach is often preferred by surgeons because it helps preserve neck motion. It also decreases the amount of trauma to the surrounding soft-tissues and doesn’t require bone grafting to provide the stability needed. This approach reduces the time it takes to perform the operation and that’s important for the older age group. There is also less risk of damage to the nerves and blood vessels compared with the posterior approach.

There are two major downsides to an anterior spinal procedure. And that’s the fact that the patient can end up with difficulty swallowing called dysphagia. Dysphagia can lead to aspiration. Aspiration refers to inhaling food into the lungs. The result of aspiration can be pneumonia, a potentially life-threatening complication in this age group. All of that sounds rather dire when in fact, the surgery can, and often does, go well.

But you aren’t left alone in making this decision. Your surgeon will be able to advise you based on the specifics of your mother’s condition. Having some idea of the potential pitfalls will give you some idea what questions to ask. You want to feel confident that the best decision has been made based on all factors including age, severity of the fracture, your mother’s general health, the presence of other health concerns, and so forth.

Cervical myelopathy refers to any condition that causes degeneration, damage, or pathologic changes of the spinal cord in the cervical (neck) area. This condition can present with many different signs and symptoms. Difficulty walking has been mentioned. Limb spasticity (increased muscle tone) creates balance and walking problems. Other symptoms include neck and arm pain, electric shock sensation down the arms (called Lhermitte’s sign), clumsiness of the hand(s), and difficulty with finger motion to name just a few.

Treatment for this problem can begin with nonoperative measures to improve posture and strengthen the neck muscles to help hold up the head. Stretching and relaxation techniques to help reduce muscle tightness or spasm may be needed. Sometimes a supportive collar is used at first for a short time to get symptoms under control. Surgery to decompress (take pressure off) the spine is advised when conservative care fails to change the clinical picture or when symptoms are no longer transient (come and go).

As to your question when is the best time to do surgery, the Japanese have come up with a new test for cervical myelopathy that can give doctors an idea of how severe the problem is and help predict when surgery might be helpful. The triangle step test (TST) is a motor performance test that reflects the condition of the pathways inside the spinal cord that control movement. It is called the triangle step test because of the way it’s performed. No walking or upright balance is required. The patient sits in a chair and uses one foot to tap the three corners of a triangle (one corner after another). The number of steps or taps completed in 10 seconds is recorded. The test is repeated using the other foot.

Testing has shown that the TST can be used to predict when surgery might be helpful. They found that patients who could complete 20 or more steps in 10 seconds would benefit from surgery. Any less than that was predictive that surgery would not be beneficial. The TST is also a sensitive measure of change from before to after surgery and can be used to assess outcomes of treatment.

There’s no easy answer for problems like this, no crystal ball to predict the future without surgery, or even the results of surgery should she have it done. Because of a concern for permanent paralysis when surgery is delayed, it is best to hear what the surgeons have to say and act accordingly.

Spinal stenosis is a narrowing of the opening called the spinal canal where the spinal cord travels from the brain down to the lumbar spine. Although stenosis is most common in the low back region, it can occur anywhere along the spine from the neck down to the lumbar spine.

It’s possible your father has some stenosis in the cervical spine (neck). This could put pressure on the spinal cord in that area causing difficulty walking, electric shock sensations down the arms (called Lhermitte’s sign), and clumsiness of the hands and fingers. Other symptoms such as head and neck pain, and changes in bowel and bladder function can also develop.

Any time the spinal cord is affected by disease, damage, or compression causing symptoms of this type, the condition is referred to as myelopathy. When the area affected is the cervical spine, then it’s referred to as cervical myelopathy.

Cervical myelopathy can develop as a result of a disc protrusion pressing on the spinal cord. Changes in the alignment of the vertebral bodies such as occur with spondylolisthesis can also contribute to this problem. In spondylolisthesis, there is a fracture and separation of one of the supporting columns of the vertebra. The affected vertebral body shifts forward over the bone below it. As this shift occurs, the spinal canal narrows between the two vertebrae and traction (pull) is placed on the spinal cord and spinal nerve roots.

Age-related factors are another category of factors leading to the development of myelopathy. For example, thickening and/or ossification (hardening) of the spinal ligaments within the spinal canal takes up space normally needed for the passage of the spinal cord. Degenerative changes of the vertebral bodies with bone spur formation and narrowing of the joint spaces compress the vertebral bodies. The result is a narrowing of the spinal canal (stenosis). Spinal stenosis is a big reason why older adults develop cervical myelopathy.

Your father will need to see his physician for an examination to determine what might be causing these new symptoms. Don’t let him put this off as nothing to worry about. Early diagnosis and treatment is best to avoid more serious problems later.

It sounds like you are investigating the effects of a procedure called anterior cervical (neck) decompression and fusion or ACDF. The surgeon does, indeed, use special tools to remove any soft tissue or bone that is putting pressure on the spinal nerve roots as they leave the spinal canal and travel out to the arms (or legs). That’s the decompression part of the procedure. The next part of the surgery uses bone graft (and sometimes metal plates and/or screws) to fuse two or more vertebrae together. Fusion is necessary to stop the pain and help stabilize the affected segments.

Pressure on the nerve tissue occurs when there’s foraminal stenosis. The foramen is the opening in the bone through which the spinal nerve roots pass as they travel from the spinal cord down to the arms (or legs in the lower extremities). Stenosis means narrowing. So foraminal stenosis refers to a narrowing of the openings for the spinal nerve roots. Pressure on the nerves at this point is what causes neck pain, headaches, numbness and other symptoms suffered by patients affected by this condition.

Studies show that spinal fusion does increase the load and stress placed on the adjacent segments. Adjacent segments refer to the vertebra just above and just below the fused site. But there’s been some question about whether those changes would have occurred anyway because of the natural process of aging.

A recent study comparing patients who had an ACDF with normal, healthy adults with no sign of neck problems was done to sort out how much adjacent degeneration occurs in both groups. They expected to find more cases of disc degeneration in the surgical group and that’s exactly what was seen. But the surprising finding was that people in both groups (surgical and healthy normals) had signs of disc degeneration without symptoms.

So, you may not know if or when you are developing adjacent disease without an MRI to show what’s going on in the spine. Any increase in painful neck, shoulder, or arm symptoms may be your first sign that problems are developing. Headaches; stiff neck and shoulders; and numbness, tingling, or weakness of the arms are other symptoms of possible pressure on spinal nerve roots from disc protrusion at another level.

See your surgeon right away if you notice any of those changes. Conservative care may be all you’ll need to resolve those symptoms. Activity modification, physical therapy, and medications can help. Additional surgery may be needed but you are a long way from that at this point and don’t need to worry about that just now.

There are some long-term studies comparing the results of patients with degenerative disc disease and herniation who are treated conservatively versus surgically. Ten years down the road, the results are often the same. When compared over time, patients in both groups report similar results in terms of pain, other symptoms, and function.

The difference may be in terms of pain management at the time of the event (disc herniation) and the potential for transient (temporary) versus permanent neurologic damage. Left untreated, some disc herniations can put enough pressure on the spinal cord or spinal nerve roots to cause permanent damage. That can result in muscle weakness, loss of motor control, and even paralysis.

But it’s not clear yet how to predict who will have a natural healing without permanent problems and who won’t. Some people just can’t tolerate the pain until the disc has been resorbed by the body — that can take months to years. And during that painful period of time, muscle guarding and splinting in response to the pain can set up postural changes that get set and affect health in other ways.

There isn’t a perfect formula that doctors can use to determine who should have surgery and who doesn’t need surgery for disc herniation. All factors are taken into consideration including patient preferences, results of imaging studies such as MRIs, and patient clinical presentation (signs and symptoms).

Together, the surgeon and the patient make a treatment decision based on all the variables and factors present. Many times, surgery is delayed or avoided altogether by conservative care using activity modification, physical therapy, and medications. But when all else fails to relieve pain and restore function, then surgery might be the best course of action.

A brief anatomy lesson might help you understand what an odontoid fracture is and where it’s located. First of all, the area affected is the second cervical (neck) vertebra. At the very top of the cervical spine is the atlas bone labeled C1. Directly underneath the atlas (C1) is the axis bone, also known as C2. C2 or the second vertebral bone is our destination.

The axis (C2) has a knob of bone that is attached to the main body of the vertebra. It sticks straight up and is called the dens or odontoid process. The dens pokes up through the opening of the atlas (C1) above the axis (C2). A series of complex ligaments holds the skull on top of the atlas. You can nod, shake, tilt, and turn your head — all done as the skull moves around the pivot point of the upper cervical spine.

A fracture of the odontoid process (dens) can create instability of the head on the spine. A type II odontoid fracture extends through the base of the dens. It is the most common type of fracture in this area. Without treatment, difficulty breathing, paralysis, and even death can occur.

This type of fracture occurs most often associated with a car accident or a traumatic fall from a height (e.g., off a ladder, from the roof top). In older adults, a simple fall at ground level can be enough to cause this type of fracture. It’s a serious break because of the close proximity of the spinal cord right there inside the axis and the atlas. If the broken bone gets displaced, the jagged edge can cut right through the spinal cord.

Even when the broken bone remains in place, bleeding into the area from the injury and swelling from the inflammatory and healing process can put pressure on the spinal cord. If unattended, the resulting neurologic damage can be permanent. Surgery is often done to stabilize the area until bone union and healing are complete.

Cervical compression myelopathy is a condition that puts pressure on the vertebrae (bones) in the neck, also called the cervical spine. The symptoms of cervical compression myelopathy can include:

Stiffness in the neck
Pain in the arm
Numb hands
Weakness in arms and legs
Stiff legs
Difficulty walking
Loss of control of bladder or bowels

If the problem causing the compression continues, the symptoms can get worse and could become irreversible.

The condition cervical compression myelopathy can be caused by a number of problems, including arthritis in the neck or injuries. Treatment for the compression depends on the severity and the urgency.

If the problem is limited to pain, the treatment may include medications for pain and/or physiotherapy. If there are other symptoms, another option is traction. Finally, surgery may be called for if the symptoms are becoming or have become severe and other treatments don’t work.

A broken neck, or fracture of the cervical spine, is usually very serious but the seriousness depends on which bone(s) are broken and how they broke. The dangerous part of injuring your neck is the damage that is done to the nerves that run down the spinal column.

If an injury avoids damaging the nerves, this can be “fixed,” but if the nerves are damaged or severed, this may not be fixable and could, in fact, lead to death.

Spinal stenosis, a narrowing of the spinal canal where the spinal cord is located can cause spinal cord compression. Headache, neck pain, numbness and tingling down the arms can develop as a result. This condition is called cervical myelopathy. Cervical refers to the neck region. Myelopathy tells us there’s a problem at the spinal cord.

A pinched nerve causing neck and/or arm pain is one thing. But when the spinal cord in the neck area gets pinched or compressed, that’s more serious. Permanent paralysis can develop if the problem isn’t corrected. One of the most popular surgical procedures to decompress the spinal cord is called an open-door laminoplasty.

The lamina is a ring of bone around the spinal cord to protect it. And it works very well in doing so until outside forces create a stenosis or narrowing of the spinal canal. And then suddenly, that protection becomes a problem. Aging and the degenerative changes associated with getting older are the most common reasons for spinal stenosis. For example, disc degeneration brings vertebral bones and spinal joints closer together. Closer proximity of the bone and joint surfaces without a healthy disc to hold them apart can cause bone spurs and other bony changes to develop.

The posterior longitudinal ligament (PLL) along the back of the spine thickens and takes up additional space inside the canal. Disc degeneration and arthritic changes cause the vertebral bones to shift or collapse slightly. Even a minor shift in the vertebral bone alignment can put pressure on the spinal cord.

A laminoplasty involves cutting through the lamina on one side and swinging the bone away from the spinal cord. It’s much like swinging a door open, which is why it’s called an open-door laminoplasty. The surgeon places a laminoplasty plate on the opposite side to help hold the door open. It’s a popular procedure because patients get pain relief without causing harm or injury to any of the soft tissues or spinal structures. And neck motion isn’t limited or compromised as occurs with a neck fusion.

A laminectomy actually removes some or all of the lamina (usually on one side of the spine). If a large portion of the lamina is removed, then it may be necessary to fuse the spinal segments together. This limits motion but provides the stability needed without the laminal support.

With different surgical opinions, some patients opt for getting a third opinion before making a decision. When making a decision, you will want to ask your surgeon to describe the recommended procedure and explain why one approach might be better than another for you.

One of the most popular surgical procedures to decompress (take pressure off) the spinal cord is an open-door laminoplasty. It sounds like that’s what you had done. A laminoplasty involves cutting through the lamina on one side and swinging the bone away from the spinal cord. It’s much like swinging a door open, which is why it’s called an open-door laminoplasty.

The surgeon places special laminoplasty plates on the opposite side to help hold the door open. It’s a popular procedure because patients get pain relief without causing harm or injury to any of the soft tissues or spinal structures. Studies show that recovery from neurologic symptoms following an open-door procedure is as high as 72 per cent.

But in up to 10 per cent of the time, the symptoms may be only partially relieved or they may get worse. This can happen when the underlying problem (arthritis, degenerative changes) gets worse, causing more stenosis (narrowing of the spinal canal). This cause of symptom recurrence is referred to as disease progression. And in some cases symptoms come back or get worse because there just wasn’t enough decompression to relieve the spinal cord compression.

In either case, a revision surgery may be needed. The type of revision procedures done varies. The surgeon may remove the lamina from around the spinal cord. This procedure is called a laminectomy. Sometimes enough bone is removed during the laminectomy that a spinal fusion is required. Motion in the neck is limited by fusing spinal segments together, but the added stability provides symptom relief.

You’ll want to discuss the potential cause of your worsening symptoms with your surgeon. He or she will be able to advise you as to the best course of action. Don’t wait to get a follow-up appointment. It may be possible to correct the problem quickly and easily early on before other problems develop.

Bioabsorbable plates are fairly new to the spinal fusion scene. For a long time now, surgeons have used an approach called the anterior cervical discectomy and fusion (ACDF). Anterior refers to the location of the incision and the way surgeon enters the spine (front of the neck). Anterior fusion is performed through the front of the spine to avoid the spinal cord and spinal nerves. Cervical refers to the neck and discectomy is the removal of the disc from between two vertebrae. Most surgeons use bone graft material to fill in the space left by removal of the disc and a metal plate to hold the spine in place while the bone graft material fills in.

Fusion rates have improved greatly with this surgical technique. But even as successful as this approach has been, there can still be problems. Sometimes the screws back out and/or the plate shifts its position. Because the plate is along the front of the spine, swallowing can be impaired. Stiffness is the desired outcome of fusion in order to provide stability. But too much stiffness is a potential problem when using a metal plate system. And X-rays can’t penetrate the metal plate, so it’s difficult to assess the fusion site.

That’s why plates that eventually break down and become absorbed into the fusion have been developed. But even with all of the technical advances with this procedure, there can still be problems. Studies show that while the fusion rate is good, the rate of subsidence is still high for the bone graft used in the procedure. Subsidence means the extra bone used to fill in sinks down into the vertebra, leaving it less stable than a solid fusion.

Major complications (e.g., infection, bleeding) are about the same as with the standard metal instrumentation. Some patients still reported neck and arm pain. Loss of function or failure to resume normal everyday activities accounted for a 41 per cent rating of poor-to-good (rather than excellent). Slightly more than half (59 per cent) of the patients had excellent results.

The result of research suggests that bioabsorbable plates stabilize the spine better than having no plate but there are enough problems that further study and improvements in this technique are required before it can be recommended instead of metal instrumentation for ACDF procedures. Long-term study is also needed to see how patients (and the graft site) fare years down the road. Unlike permanent plates, with the dissolving kind, there won’t be any plate-related complications years later as there have been with metal instrumentation.

Sometimes when there’s bone or disc degeneration in the cervical spine (neck), fusion is needed to stabilize the area. Over the years, one procedure in particular has gained popularity because of its effectiveness: the anterior cervical discectomy and fusion (ACDF).

ACDF involves removal of the disc from between two vertebrae, a procedure called discectomy. Most surgeons use bone graft material to fill in the space left by the discectomy and then and a metal plate to hold the spine in place while the bone graft material fills in. The use of a metal plate and screws to hold it in place is called instrumentation.

Stiffness is the desired outcome of fusion in order to provide stability. Fusion rates have improved greatly with this surgical technique. Too much stiffness is a potential problem when using a metal plate system but there is general agreement that fusion without instrumentation is less effective than with instrumentation.

Some of the decision depends on the number of levels that need to be fused, the condition of the bone, and surgeon preference. Surgeon preference is often the result of training and experience. Surgeons recommend treatment based on patient history, clinical findings (pain intensity, neurologic symptoms), and level of function (independence in daily activities, level of disability, ability to perform work tasks).

Before making a decision of this nature, you might want to consult with a second surgeon for his or her opinion as well. It is a permanent procedure so you’ll want to feel comfortable that the type of surgery is what you want and need.

The condition you were treated for is called myelopathy. Myelopathy refers to a narrowing of the spinal canal, the opening formed by the vertebral bodies when stacked on top of one another. The spinal cord travels through the open spinal canal. Anything that narrows this opening (e.g., disc protrusion, bone spurs, hardening of the spinal ligaments) can put pressure on the spinal cord and cause serious neurologic problems.

Myelopathy from disc herniation is the main reason why disc replacements are done. In the early days of this procedure, the type of patients who qualified for the operation was limited to that clinical picture. With new and improved technology, better surgical instruments, and various sizes and styles of implants now available, the patients who can have this procedure has expanded. They are now able to use disc arthroplasty (replacement) in the lumbar spine (low back) and the cervical spine (neck).

The conditions must still be just right for the best results. There can’t be too much degeneration of the vertebral bones or facet (spinal) joints. Osteophytes (bone spurs) can be removed if they are small enough or few in number. But patients with major arthritic changes of this type may not be good candidates for disc replacement.

Surgeons are better informed of the potential pitfalls of disc replacement. They are more tuned in than ever about the importance of proper patient positioning during the surgery, how to prepare the disc space for the implant, and how to insert the implant to get the best placement and function. The surgery is still saved for patients who don’t have too much narrowing of the spinal canal and who have good spinal stability. Without those two criteria, spinal fusion is the procedure of choice.

Painful symptoms from a herniated disc can limit function and really reduce quality of life. If the condition gets worse, patients can end up with irreversible neurologic damage. That’s why surgery is recommended if conservative care doesn’t result in any change in the clinical picture.

Pressure on the spinal cord from a disc protrusion or herniation in the neck is called cervical myelopathy. Anything in the spinal canal can cause a narrowing of this opening designed to let the spinal cord travel from the brain down to the base of the spine. Besides disc material, bone spurs, hardening of the spinal ligaments, and arthritic changes of the facet (spinal) joints can change spinal alignment resulting in pressure on the spinal cord.

Because disc replacement is a fairly new procedure, there remain questions about whether disc replacement versus spinal fusion is the best treatment approach to the problem of cervical myelopathy. Disc replacement preserves motion but might cause ongoing microtrauma to the spinal cord if the implant puts any pressure on the spinal cord. Fusion eliminates any ongoing microtrauma but limits motion and may increase stress and load on the vertebral segments above or below the fused level.

There are no direct studies comparing the two methods. There has been one review published in 2008 in which surgeons looked at the results of two large studies — each one evaluated one of the two procedures separately. By comparing the final outcomes of each approach, the authors of that study could give us some idea how these two approaches stack up against one another.

The results were measured using patient reports of neck and arm pain, function, gait (walking ability), and self-reported general physical and mental health. They found that either treatment worked well and the myelopathy did not get worse after disc replacement. Treatment was restricted to one spinal segment and patients were only followed for two years.

Since that time, cervical disc arthroplasty (replacement) has continued to be used in younger patients who don’t have a lot of degenerative changes seen in older adults. When pressure is placed on the spinal cord because of disc protrusion, then disc replacement is the treatment of choice. Cervical disc arthroplasty is not recommended when the patient has bone spurs, significant wear and tear on the facet (spinal) joints, or other age-related changes.

Other contraindications to cervical disc arthroplasty include fracture, unstable segments due to rheumatoid arthritis, or previous surgery to remove the lamina, a supporting column of bone that’s part of the vertebra. Contraindication means reasons why something should not be done, in this case, the disc replacement. Anything that might compromise the stability of the spine is considered a contraindication. Infection, extreme obesity, osteoporosis (brittle bones), or other arthritic conditions that limit spinal motion are also contraindications to cervical disc arthroplasty.

Your surgeon is the best one to advise you in this matter. Once all the information is gathered from the tests that will be done, the pros and cons of each procedure can be evaluated. Surgeons are aware of the pitfalls of each approach as well as what patient factors to take into consideration. Age, previous spine surgeries, age-related or other degenerative changes in the spine, and location of the herniation are just some of the things the surgeon will be taking into account when planning the best treatment for you.

Your desire to protect your husband, the patient is very admirable. Given the stress of the accident and preparation for the upcoming surgery, a low key approach is often needed for the involved individual. But questions like this are appropriate and the information important to family members trying to plan ahead.

Cervical spine injuries from trauma are not uncommon but their management isn’t standard. In other words, one treatment doesn’t work for everyone with this type of injury. The severity of the injury dictates the treatment.

An unstable cervical fracture suggests that the bones have separated at the fracture site. We call this a displaced fracture. There may or may not be torn or ruptured ligaments, which adds to the instability. It’s difficult to tell how much soft tissue damage there is until the surgeon gets inside the surgical site and takes a closer look.

The goal of treatment is to put the bones back together as close to normal as possible and keep them there during the healing process. The hope is to avoid further displacement and minimize any neurologic damage (to the spinal cord and spinal nerve roots). Fractures can occur in any of four major anatomical locations of each cervical vertebra. Sometimes there’s more than one fracture.

All of these variables determine the severity of the injury and the need for surgery to stabilize (hold the spine together) the neck until healing can take place. Don’t hesitate to contact the surgeon at a time when you can speak with him or her privately to find out the extent of the injury and anticipated surgery.

The Cervical Spine Injury Severity Score (CSISS) is one of several different ways to classify the severity of cervical spine injuries in order to predict who might need surgery to stabilize the spine. The CSISS is favored by some surgeons because it’s easy to use by the surgeon and proven to be reliable and valid (accurate in predicting who needs surgery). The CSISS is for patients with neck injuries involving the lower cervical spine (C3 to C7).

Other classification models for the lower cervical spine focus on how the injury occurred (called the mechanism of injury). But the CSISS uses X-rays and CT scans to take a look at four anatomical features of the cervical spine and scores them based on injury present (e.g., fracture, dislocation).

The scoring system of the CSISS takes into account the location of the injury, severity (nondisplaced vs. displaced fracture), and neurologic damage. Four columns of the cervical spine are evaluated separately: the two facet (spinal) joints, the vertebral body, and the posterior area of the spinous process. You can feel the spinous processes of your spine by rubbing your fingers up and down the back of your neck. As you probably know, the largest bump near the top of your spine is the spinous process of C2. At the base of the neck where the cervical and thoracic spines join together, you’ll feel another large spinous process. That’s C7.

These bony knobs are the place where the two lamina bones join together at the back of the spine. There is a bony ring that attaches to the back of the vertebral body. The ring forms an opening for the spinal cord to travel from the brain down to the end of the spine. This ring has two parts. Two pedicle bones form a short column of bone that connects directly to the back of the vertebral body. Two lamina bones join the pedicles to complete the outer rim of the ring.

The surgeon uses a CT scan of the injury and scores the four columns based on where the fracture(s) occurred and how many fractures there are. Each of the four areas (right and left facet joints, vertebral body, posterior ring with spinous process) is scored from zero to five. Each column is scored independently and then the scores are added up for all four columns. Zero indicates no fracture or dislocation is present. A score of one is given for a mild (one to three millimeter) nondisplaced fracture. A score of two means there is a one to three millimeter displaced fracture. Three is for a three to five millimeter displacement. And anything more than five millimeters is scored as a five.

The total score reflects not only the amount of displacement (the higher the score, the more severe the injury), but also gives the surgeon an idea of how stable/unstable the fracture site is. A CSISS score of seven or more is a sure sign that surgery is needed to stabilize the spine. A score of three suggests there is one fracture that is moderately displaced. It’s also possible to obtain a score of three with three nondisplaced fractures or even one nondisplaced fracture and one moderately displaced columns.

With this information, if you are still unclear about the injury, you may want to go back and take a second look at the X-rays or CT scans. It’s not uncommon for patients and/or family members to need additional information — especially when a child of any age is involved.

Spinal fusion surgery has become a standard procedure for degenerative spine conditions that leave the cervical (neck) or lumbar (low back) area painful and unstable. There are many different ways to fuse the spine — not only in types of materials available, but also approaches (from the front, side, back, or combination of directions) and techniques (with bone grafts, bone substitute, titanium cages, metal plates, screws).

The first place to start in making this decision is with your surgeon. What does he or she recommend? Often there are patient-related factors that guide or direct the decision-making process. Sometimes the surgeon has a preference because of personal experience.

Grafts from a bone bank are preferred by some because the patient doesn’t have to deal with the potential complications of donor site pain and poor wound healing. But the bone from cadavers is no longer able to generate new bone growth. It just provides a foundation or support for the body to fill in with its own bone.

Donating bone to yourself (autogenic grafts) may speed up the fusion process. There’s no problem with rejection of the graft material and because it’s bone that can create or stimulate other bone cells to form, the fusion may take faster. The downside is as mentioned, the possibility of a painful donor site. In fact, some patients find the donor site to be more painful than the surgical site.

The problems with bone grafts of both kinds have prompted scientists to formulate a bone graft substitute. Bone morphogenetic protein or BMP has been developed, tested, and approved by the Food and Drug Administration (FDA) for use in lumbar spine fusions. BMPs have not been formally tested in the cervical spine. But some surgeons have tried them with good results.

BMPs seem to have the ability to induce new bone growth at a very fast rate. The success with this method has convinced many surgeons to switch from bone grafts to BMPs for spinal fusions. In 2002 less than one per cent of all fusions were done with BMPs. By 2006 that number had risen to 25 per cent. On the heels of this success came the use of BMPs for the cervical spine.

There are a couple caveats (cautions) about the use of BMPs in cervical spine fusions. First, since they have not been tested for safety, their use in this part of the spine is considered off-label. The surgeon who originally tested BMPs for the lumbar spine has repeatedly pronounced that these BMPs are not intended (and should not be used) for the neck — at least not until properly and fully tested.

There have been reports and even one formal study that showed an increased rate of complications when using BMPs for anterior cervical fusion. Anterior means the incision and procedure are performed from the front of the neck/spine, rather than from the back.

A 50 per cent increase in complications led to some serious concerns about the use of BMPs for anterior cervical fusions. Too much bone growth resulted in swelling of the airway, compression of the airway, difficulty swallowing, hoarseness, and poor wound healing. These complications were not minor, but serious enough to potentially be life-threatening.

Talk with your surgeon about these three choices. Ask for his or her personal opinion and recommendations for you specifically given your own unique situation. Hopefully the information here will help you put together some questions that might help you make the right choice for you.

Off-label use means the drug, implant, procedure, or device is not being used for what it was originally intended or tested for. The practice is not illegal — doctors who discover a drug that works well for one application may see many other potential uses. But without proper testing for safety, the Food and Drug Administration cannot approve that drug for a secondary or off-label use.

The high cost of research and development for products like this is prohibitive for most companies to launch another off-shoot series of studies for a product they already know works well for the first application. So the pharmceutical companies cannot advertise their products for off-label uses (that WOULD be illegal). They depend on physicians doing some practical hands-on research to help support other uses for their medications.

In the case of bone substitute, products like INFUSE, a bone morphogenetic protein (BMP) has gained quite a foothold in the world of spinal fusions. Surgeons found that this product hurries the body up in forming new bone cells at the surgical site. The fusion quickly stabilizes the spine with its ability to induce rapid bone growth.

At first it was just designed and tested for lumbar (low back) spinal fusions. But it worked so well, surgeons started trying it in other parts of the spine (thoracic or midback and cervical or neck). Placing the bone substitute anywhere but in the lumbar spine is considered off-label use.

There have been some problems in patients who received BMPs for cervical spine fusion done from an anterior approach. Unexpected swelling of the throat with difficulty swallowing and speaking was one of thos complications. Compression of the airway and cutting off the air was another even more serious (life-threatening) problem. Off-label use of medications can be perfectly safe but without adequate testing, there’s an increased risk that something might go wrong.

No doubt your surgeon explained all of this to you. That’s what the paper you signed was for — to make sure you know what the risks and potential complications of an off-label use of bone substitute could be. If you are still in doubt, don’t hesitate to call the surgeon’s office and ask for a copy of the paper you signed. Review it again and make sure you know what it is you are agreeing to.

Your surgeon will be willing to answer any further questions you have. Don’t hesitate to ask for more information until you feel comfortable that you know what is going to happen and be able to explain it to someone else.