FAQ Category: Cervical Spine

Even minor fender benders can produce enough force to cause a neck injury. Wearing seatbelts is the first important step in preventing injuries associated with car accidents. Rate of speed and direction of impact are important factors, too.

But beyond that, there are some risk factors that can predict chronic disability following a whiplash injury. For example, the intensity of the pain (high) early on after the accident points to a poor recovery process.

Studies show that anyone who suffers from chronic neck and/or head pain (headaches) before a whiplash injury is more likely to have chronic pain and disability after the accident. A previous history of anxiety or depression is also a poor prognostic indicator.

Fear of re-injury or increased pain with movement leads to a phenomenon called fear-avoidance behavior (FAB). Your brother-in-law may be demonstrating some of these behaviors. Behavioral counseling combined with physical therapy can help patients work through some of these fears and catastrophizing attitudes.

Head rests in cars are meant to prevent injuries such as whiplash. Whiplash occurs if you are in an accident and your head is forcefully thrown forward and then back again. The head rest should prevent the snapping back of your head past your body. If the head rest is too low, it won’t stop this action and whiplash can result.

The head rest should be moved up or down until it is directly at the center of the back of your head. However, that is not enough. You have to ensure that you’re sitting properly and not too forward in the seat. Studies have shown that women sit more forward in their seat, which means their head has farther to travel back if they are hit from behind. In this situation, the head rest can’t protect against whiplash. To prevent this, sit as far back in the car seat as is comfortable, reducing the amount of space between the back of your head and the head rest.

Whiplash, an injury to the neck following the head being forcefully thrown forward and then back again, can cause severe pain and even disability. It is, however, not always obvious immediately following an accident. The pain may start only after a few days and then can become gradually worse. These injuries can be stiffness and pain in the neck, towards the head, in the jaw, or even in the chest, upper arms, and shoulders.

Acute whiplash injuries usually involve a sudden flexion and then whip-like extension reaction. This sudden acceleration-deceleration energy transfers force to and through the cervical spine (neck). Pain, stiffness, and loss of motion are common in first days to weeks after the injury.

Most people recover within the first six weeks. Like any serious musculoskeletal injury, it takes about four to six weeks to complete the inflammatory-healing-recovery cycle. Pain and disability that persist beyond three months is a sign of an acute problem becoming a chronic situation.

Even before that, it would be a good idea to see a doctor for a medical diagnosis. X-rays may be needed to rule out serious complications such as fracture or ligamentous damage. Either of these injuries can lead to spinal instability.

The roadmap to recovery is much clearer once you know exactly what you are dealing with. If there is no fracture, a short course of chiropractic care or physical therapy might be helpful to prevent chronic disability. Now would be a good time (while you are still in the acute phase) to seek some additional help with this problem.

Rear-end or side-impact motor vehicle collisions are the number one cause of whiplash. When the head and neck are suddenly and forcefully whipped forward and back, mechanical forces place stress on the cervical spine. Traumatic disc rupture and soft tissue damage can occur. Injury to the muscles, ligaments, tendons, and joints of the cervical spine are common.

The first step is to have a proper medical examination. Serious injuries such as bone fracture or dislocation must be ruled out before treatment can begin. If you haven’t been seen by your doctor, make an appointment as soon as possible.

X-rays are usually ordered before any of the more specialized tests. Special x-rays called flexion/extension x-rays may help to determine if there is instability between vertebrae. These x-rays are taken from the side as you bend as far forward and then as far backward as you can. Comparing the two x-rays allows the doctor to see how much motion occurs between each spinal segment.

Whenever possible, doctors prefer to use treatments other than surgery. This can include immobilization, medication (pain relievers and antiinflammatory drugs), physical therapy, and/or chiropractic care. The first goal of these nonsurgical treatments is to ease your pain and other symptoms.

Keeping the neck still for a short time can calm inflammation and pain. This might include one to two days of bed rest and the use of a soft cervical (neck) collar. Soft collars should not be worn after 48 hours without a physician’s approval. Studies show that prolonged immobilization can delay healing and promote disability.

Physical therapy treatment is focused on easing pain and reducing inflammation. Ice and electrical stimulation treatments are commonly used to help with these goals. Electrical stimulation treatments can help calm muscle spasm and pain. Traction is a way to gently stretch the joints and muscles of the neck. Your therapist may also use massage and other hands-on treatments to ease muscle spasm and pain. The therapist will teach you specific exercises to help tone and control the muscles that stabilize the neck and upper back.

Chiropractic care also offers another way to obtain relief of pain from a whiplash injury. Chiropractors adjust misalignments of the facet joints and vertebrae to restore the nerve signals and improve spinal health.

You may want to take a look at the neck disability index (NDI). The NDI has been translated into several other languages. It is available in Dutch, French, Korean, Brazilian-Portugese, Swedish, Catalan, and Turkish.

It has been tested and found both valid and reliable when assessing pain-related disability. Many clinicians use this to formulate a treatment plan for neck pain patients. It helps identify specific problem areas such as physical function and cognitive function.

Personal care, lifting, work, driving, and recreation fall into the physical function category. Reading, concentrating, headache, and sleep problems come under the pain intensity affecting cognitive function.

There are several other instruments that can be used to measure pain, depression, and disability from neck and/or back problems. The Beck Depression Index (BDI) and Oswestry Disability Index (ODI) are two commonly used assessment tools.

The BDI is used measure symptoms of depression. It was first developed in English and then translated to Spanish. At the present time, there is only limited data available on the Spanish translation. The ODI is a questionnaire for rating the severity of back pain. It has been translated into at least nine other languages (other than English).

The physician begins with a detailed patient history (personal and family) followed by a careful physical exam. Neurologic exams include some special tests of nerve and nervous system function. The exam can include deep tendon reflex testing, muscle testing, and sensory testing (touch, temperature, vibration).

Other special tests performed include the Hoffmann test and Babinski. The Hoffmann sign is done by quickly snapping or flicking the patient’s middle fingernail. The test is positive for spinal cord compression when the tip of the index finger, ring finger, and/or thumb suddenly flex in response.

A positive Babinski sign is seen as downward flexion of the big toe and fanning outward of the toes when quick pressure is applied to the bottom of the foot from the heel to the toes.

Any time these tests are positive (and especially on both sides), further testing is warranted. The physician may order an MRI study of the spine. This shows areas of spinal cord compression and any deformity or malformation of the spinal cord.

There is also a test of function that correlates with the severity of cervical myelopathy. It’s called the modified Japanese Orthopaedic Association (mJOA) scale score. Points are given for ability to eat, walk, and bathroom without difficulty. A low score indicates motor or sensory dysfunction.

The human spine is made up of 24 spinal bones, called vertebrae. Vertebrae are stacked on top of one another to form the spinal column. The spinal column is the body’s main upright support.

From the side, the spine forms three curves. The cervical spine (neck) curves slightly inward. An inward curve of the spine is called lordosis. The middle back, or thoracic spine, curves outward. The outward curve of the thoracic spine is called kyphosis. The low back, also called the lumbar spine, curves slightly inward.

A kyphosis of the cervical spine usually means the spine in this area loses its natural inward curve. It becomes straight or slightly bent forward. The effect of this position is to put increased pressure along the front of the spine segment (vertebrae).

The anterior (front half) of the vertebrae (when viewed from the side) compresses down. If this position is held long enough under pressure, the bone can become wedge- or pie-shaped.

Fusing two segments together doesn’t usually change the curve of the cervical spine. The surgeon may perform reconstructive surgery to restore the natural cervical curve but this is unlikely.

Some studies show that kyphosis present before surgery doesn’t create any additional problems after surgical fusion. But the loss of space around the spinal nerves from thickening of the ligaments along the back of the spine can lead to new onset of kyphosis. In these patients, there is an increased rate of stenosis (narrowing of the opening for the nerve structures) at the segment above or below the fused site.

At the same time, fusion of the spine in a position of kyphosis can cause lordosis above the fusion site. This, in turn, can cause adjacent segment disease (ASD). The altered mechanics and increased compression and force through the joint contribute to degenerative changes at the next level.

Adjacent segment disease (ASD) may be a long-term consequence of spinal fusion. But it may just be what happens over time as a result of aging and degenerative changes. The argument centered on the cause(s) of ASD hasn’t been settled yet. There’s enough evidence to suggest it’s the result of many factors (multifactorial).

X-ray findings showing degeneration at the level next to a spinal fusion reportedly occur in 25 to 92 per cent of all cases. Analysis of data collected so far suggests at least a 25 per cent rate of ASD by the end of 10 years. That means one in four patients develops ASD after spinal fusion.

But that also means not everyone develops significant or symptomatic ASD. You may develop some degenerative changes that never cause you any problems. And reoperation rates for ASD are fairly low at this time. For those who do develop ASD, it doesn’t become evident until around seven to eight years after the first operation.

The authors of a recent study reviewed available literature and found that the evidence for radiofrequency neurotomy for the treatment of cervical facet joint pain was strong. Evidence for the use of medial branch blocks was moderate. Evidence for intraarticular joint injection was limited.

A recent study compared cervical medial branch blocks using an anesthetic, bupivacaine, with and without the use of a steriod, betamethasone. The authors concluded that the effectiveness was very similar. Therefore, the use of a steroid is not necessary during cervical medial branch blocks.

Changes can occur in the structure and function of the cervical spine as a result of rheumatoid arthritis (RA). Joint degeneration can lead to instability. Pressure on the spinal cord as it travels through the spinal canal in this area can cause significant problems.

In fact, a condition called myelopathy can result in disability and/or death. Myelopathy describes a condition of damage to the spinal cord from any cause (including RA). Surgery to fuse the spine is often needed to avoid such serious problems.

Not everyone with RA has myelopathy or needs a neck fusion. However, it is a potential problem. You may want to ask your rheumatologist or primary care physician about the need for X-rays or other more advanced imaging.

If you aren’t having any neck problems now, a baseline study may not be a bad idea. This gives you an idea of any changes that are occurring later and how quickly they are developing.

There are always risks with any surgical procedure. Some can be reduced and even eliminated with careful surgical planning. Others are nonmodifiable (age, diabetes, heart disease).

In the case of upper cervical fusion, there are several unique risk factors. Some of these may not apply to you. It depends on the type of fixation used. For example, pedicle screws have become a popular fusion technique.

These screws provide high biomechanical strength at the site of fixation. They are inserted through the column of bone called the pedicle along the back of the vertebrae.

In many patients with rheumatoid arthritis of the cervical spine, the pedicles are very narrow. And in 80 per cent of the patients, the vertebral artery supplying blood to the brain is located next to the pedicle at this level. If the screw goes through a thin pedicle, it could penetrate the artery. These are things that your surgeon will address though you may want to discuss them ahead of time.

On a more practical level, if you smoke or use tobacco products, reduce or stop using them as soon as possible before surgery. Tobacco is a known risk factor for poor wound and bone healing. If you are overweight, focus on good nutrition and exercise before surgery. Consult with your physician, physician’s assistant, or surgical nurse for any other suggestions that might fit your situation best.

Good question and one that has been studied by many scientists in the field. It’s likely that there are multiple factors involved. Position in the car is one. The force of the impact on the front seat passenger won’t be the same as the back seat passenger on the same side. And there is a difference in force on impact from one side of the car to the other.

Speed of crash and direction of the impact can also make a difference. The shear force or mechanical load placed on the neck joint(s) will vary with both of these factors. And the position of the person’s head and neck at the time of impact can make a difference. Having the head turned to the left or right increases the risk of whiplash injury.

It’s also possible that there are differences in ligament tensile strength from one person to another. Even within an individual’s neck, there are differences in ligament strength from top to bottom and front to back.

So, depending on how the impact transfers the load, damage may occur at the weakest ligamentous site. Since everyone has a slightly different ligament configuration, some people may have greater risk of injury than others.

Long-lasting pain after a car accident from a whiplash injury occurs in a small number of people. But it can be very annoying, if not disabling. Scientists are actively studying this problem. It even has a name of its own now: whiplash-associated disorder or WAD.

It’s not clear just what the source of pain is in WAD. Studies show that about half the time, the pain is coming from the facet (neck) joint. Injecting a numbing agent into the area relieves the pain. But since this doesn’t explain all cases, there may be some other reasons as well.

Animal studies have shown there is an electrical response in the facet joint when a mechanical load is applied to the joint. This finding suggests that the capsular ligament has a threshold for pain. This means that pain occurs when the load (strain) placed upon it is above a certain level.

Human studies confirm that symptoms are much worse after the injury when the head was turned at the point of impact. This appears to be linked to the fact that the head-turned position puts a strain on the capsule normally. Any extra compression, load, or shear force can be enough to cause failure of the soft tissues.

It’s likely that there are other explanations as well. The capsular ligament may have different mechanical tolerances at different locations within the ligament. So for example, multiaxial loads may affect the top front portion of the capsule more than the lower bottom half.

With the head in just the right position and with just the right amount of force, the ligament tensile strength may be overcome by the load. The result is injury to the ligamentous capsule. When the face is turned to the right, the right capsular facet is affected. When the face is turned to the left, the left side is injured.

Pain, stiffness, and tenderness of the neck are words used to describe symptoms of fibromyalgia and whiplash associated disorder (WAD). And associated signs and symptoms such as dizziness, headache, difficulty swallowing, and blurred vision have been reported with both conditions.

Not only that but fatigue, trouble sleeping, reduced energy, and irritability or depression are all linked with fibromyalgia and WAD. So, it’s no wonder you’re having trouble sorting out what is the underlying problem.

And, in fact, the characteristic tender points of fibromyalgia can be accompanied by painful areas called trigger points that we normally see with chronic pain conditions like WAD.

There is one way to distinguish between trigger points of WAD and trigger points from fibromyalgia. A physical therapist skilled in trigger point assessment can examine you. Studies show that trigger points linked with WAD occur up high in the cervical spine. In particular, the semispinalis capitis muscle will be affected. Trigger points linked with fibromyalgia are more common in the lower cervical spine.

It may not really be necessary to know the difference. The treatment program is the same for trigger points no matter what causes them.

Scientists aren’t really sure what causes painful nodules in muscles referred to as trigger points. Tissue changes associated with trigger points are palpable. There’s usually a taut band of tissue. When the area is pressed or stimulated, a predictable pattern of pain is created.

Lab studies of the cells involved have led scientists to believe perhaps there is a dysfunction at the motor endplate of a skeletal muscle fiber. Mechanical trauma causes a neurotransmitter called acetylcholine (ACh) to be released. When present at the junction between the nerve and muscle, ACh causes the muscle fiber to contract maximally.

The muscle doesn’t relax and remains tightly contracted. Blood doesn’t get in or out of the area so waste from cellular metabolism doesn’t get cleansed from the soft tissues. A downward cycle continues. Failure of the calcium pump occurs in the muscle and stimulates further muscle contraction.

The abnormally increased calcium may cause uncontrolled muscle fiber shortening. This leads to increased metabolism. The muscle fiber shortening also cuts off local circulation. Loss of oxygen and nutrient supply to the muscle completes a vicious cycle. Thus an energy crisis occurs, and taut bands form. It appears that these taut bands are there first before trigger points develop.

You are asking about predictive factors of treatment for neck pain. And since you’ve had the pain for more than three months, it is considered chronic.

There are positive and negative prognostic predictors. These factors help guide the chiropractor when patients and choosing appropriate treatment for selected subgroups. So although there isn’t a crystal ball exactly, there are some telltale signs to help guide the process.

For example, patients who have high levels of pain over a long period of time are more likely to have a poor prognosis. Likewise, those who have delayed treatment, who are older (40 years old and older), and who also have low back pain are at risk for a poor outcome.

But the good news is that there are positive predictors as well. The best predictor of a good result is short duration of symptoms. Other positive predictive factors include no morning pain, higher level of education, and less fatigue. Not being on sick-leave or Workers’ comp also points to a favorable outcome.

The authors of a recent study feel that electrophysiological testing to evaluate the silent period is more sensitive to change in neurological integrity within the spinal cord in persons with syrinx. Somatosensory evoked potentials and motor evoked potentials may be normal and not detect more subtle, early changes that silent period testing can.

The most common complication is dysphagia. This means some people have difficulty with swallowing after surgery. It usually goes away with time. Other complications include formation of hematoma or seroma. Sometimes another surgery is necessary to remove them. Non-union of the fusion is another complication. In a recent study, the use of an osteoinductive protein called rhBMP-2 actually had similar complication rates, but had 100 percent fusion rate in single and multiple level cervical fusions.