FAQ Category: Cervical Spine

Doctors debate this question, too. When fusing the spine, should the vertebrae above and
below the fused area be fused to prevent future problems at those levels? Some
researchers say the next level should be fused only if there are abnormal findings on the
X-ray at the time of the first operation.

Other researchers say too many levels fused puts a lot of stress and strain on the bone
graft. It may not hold up even when metal plates and screws are used. Movement at the
fused site can occur causing even more problems.

Most doctors take into consideration the patient’s age and activity level when making this decision. X-ray findings are important, too. Many patients get better without surgery using conservative treatment. If and when conservative care fails, then further surgery can be considered as an option.

It’s true that disc degeneration can occur at the levels above and below the first area fused. The result can be disc pressure on the spinal cord in the neck or on the spinal nerve roots as they leave the cord.

Many studies have been done on this topic. The results vary from as little as seven
percent to as high as 50 precent years later. A recent study from Japan has shed some light on this problem. It seems that breakdown is more likely when damage is already present at the disc level above or below the level fused.

It appears the problems later are just a natural progression of the same disease. The disc degeneration is already present but the patient doesn’t have any symptoms yet. Many patients get better with physical therapy and drugs. A second surgery is only needed
about six percent of the time.

Spinal discs are made up of two basic parts: the outer covering called the annulus and the inner part called the nucleus.

A herniated disc means the nucleus has protruded out of the walls of the annulus. In the neck, when the disc pushes out of its normal space, it can go straight back and put pressure on the spinal cord. Pain or symptoms from this kind of pressure is called
cervical myelopathy.

Damage to the spinal cord can upset joint position sense. The body’s ability to sense its position or to sense movement is called proprioception. Studies show that
compressive myelopathy can alter proprioception. Clumsiness of hands and even problems walking can be caused by a change in proprioception.

You may be describing two things. The first is a problem called cervical
myelopathy. Myelopathy is a condition of impaired spinal cord, which can be caused by disc protrusion in the neck (cervical spine). The second is proprioception.
Proprioception is a term used to describe a joint’s sense of where it is in space, how fast it is moving, and in what direction.

Pressure on the spinal cord can impair knee proprioception. It’s not likely that exercise for the legs will change the sense of proprioception until the underlying cause (disc protrusion) is taken care of first.

See your doctor before attempting any exercise program. A change or worsening of symptoms with disc protrusion requires medical attention.

It’s likely your symptoms improved for both reasons. Damage to the soft tissues of the neck from injury, stress, or overuse takes about six weeks to recover. Exercise helps improve blood supply to areas trying to heal and repair.

When it comes to neck motion and function, a little pain reduction goes a long way. When you combine pain relief with improved activity, you feel much better physically and mentally.

Studies show that long-term outcomes are often the same between groups who exercise and those who don’t. But most people agree they’d rather get pain relief sooner than later. Exercise is often the key to helping many parts of the body get back to normal.

Let’s step back to when you first started your exercise program. Did you take a baseline measurement of your pain, function, and activity level? If you did, look at those measures and compare them to how you feel and what you can do now.

Many times people improve so gradually they aren’t aware that the pain level is better. In some cases there’s still as much pain, but they are able to do more. They may be less tired at the end of the day.

At this point it’s probably a good idea to get the opinion of an expert. Check with your doctor or physical therapist for the best program to follow. Most likely, the therapist will take measurements of strength and motion. He or she will review the program you are currently following and advise you based on the results of testing.

The fact that you’ve stuck with an exercise program for a year is very commendable. You’re right to want one that works.

Several studies have come up with the same results. Exercise helps chronic pain patients get pain relief and more function after six weeks of strengthening. Six months to a year later, they have about the same results as patients who are just given advice.

Some patients may find the exercise program is worth the time and money. Individual suffering is less early on. There may be less time lost at work. They may be able to resume normal activities sooner.

For many people quality of life is an important factor. For them investing time in an exercise program is worth the earlier payback.

Whiplash injury usually occurs with rear-end impacts. The neck is forced into flexion and
then into extension. The sudden movements take place in a matter of seconds. Many studies
have been done using live subjects, crash dummies, and computer simulation to define the
steps of events that occur with whiplash injury.

The results are not very clear. Studies in the U.S., Canada, and Australia have shown
both results: increased cases of chronic neck and back pain with and without the use of
seatbelts.

The main conclusion is that seat belts save many lives each year. The life-saving ability
of seatbelts far outweighs the risk of increased injury during a rear-end collision. The
bottom line is: you should always wear your seatbelt.

Rear-end or side collisions often produce what is referred to as a whiplash
injury. Muscles, ligaments, and cartilage in and around the neck can be injured by the
sudden thrust of the head and neck forward and back.

Usually soft tissues of this kind take four to six weeks to heal. But it’s not uncommon
for two people in the same car to have different degrees of injury. Healing time can vary
quite a bit. About one out of every three people in an auto accident has chronic pain
months later.

Factors that can affect the injury include: the angle of the collision, the speed and
size of the vehicles involved, and road conditions. Other things to consider include the position of the head and direction of the face at the time of the injury. Women seem to be at greater risk for injury than men. Anyone with other health issues can delay healing.

After years of study it looks like the cause of pain after a whiplash injury is damage to
the neck joints. The muscles seem to recover but the cervical joints may need to be
“reset” in their ability to detect and fine tune motion.

Of course there may be other important factors. For example, psychosocial effects such as
nervousness and loss of sleep may play key roles. One study showed that a prior history
of head trauma and headache leads to a worse result after an injury.

It’s not really clear why some people have a worse result than others. Studies continue
to look for factors to predict the outcome. This may help us reduce the risk of injury
after an accident.

Hoarseness is common after anterior neck surgery or any surgery that requires an endotracheal tube down the throat to keep the airway open. Most patients find their voices returning to normal several days after the tube is removed.

Hoarseness and difficulty swallowing can also be caused by injury to the recurrent laryngeal nerve during the operation. This is the nerve to the vocal cords. In about 15 percent of the cases hoarseness only lasts about 24 hours. In a smaller number of patients (2.5 percent) permanent hoarseness can occur.

A concussion occurs when an injury to the head causes the brain to bounce against the skull. Concussions are divided into three groups based on signs and symptoms.

Grade 1 is a mild concussion and occurs when the person does not pass out. He or she may seem dazed. Grade 2 is a more severe form. This occurs when the person does not lose consciousness but has a period of confusion and does not remember the event. Grade 3 is the most severe form. It occurs when the person loses consciousness for a brief period of time and has no memory of the event.

The signs and symptoms of a concussion include severe headache, dizziness, and vomiting. The doctor will look for uneven pupils in the eyes. A sudden weakness in an arm or leg is another red flag. The person may be restless, agitated, or irritable. Often, the patient has memory lapses or seems forgetful.

Symptoms may last for several hours up to several weeks. A CT scan or MRI is needed for a sure diagnosis. Any loss of consciousness or amnesia after the head injury should be seen by a doctor.

Head injuries in soccer are common. These include collisions with goal posts, head butting or heading between two or more players, and blows to the head. Illegal high kicking and/or low heading account for many injuries.

Concussions are more likely among girls and women than among boys and men. Head butting the ball increases the risk of concussion. There are reports that head injuries add up to 22 percent of all soccer-related injuries. Severe head trauma or death is rare. The extent of other injuries is less clear.

Some parents want protection for their children from head contact with goal posts, the ground, and other players’ heads, elbows, and knees. Protective head gear and a mouth guard are suggested. Using a softer ball during practices is another good option. Talk to your daughter’s soccer coach about your concerns. Sometimes it’s up to parents to do what’s best for the players.

Whiplash or flexion/extension injury is a soft tissue injury to the neck. Whiplash is also called neck sprain or neck strain. Symptoms may occur right after the injury or they can be delayed by several days, just as you’ve described.

Pain occurs because of the sudden movement forward (flexion) and then back (extension). Neck stiffness, headaches, and dizziness are common. Some people also have upper back, shoulder, and arm pain with numbness and tingling down the arm.

Exactly which structures are injured is not really known. It’s likely that the ligaments or muscles are stretched and torn between the vertebrae. There may be some small areas of bruising and swelling within the spinal cord itself. Symptoms are delayed until enough swelling and inflammation occur to press on sensitive nerve endings. This can take anywhere from 24 to 48 hours.

Basically, trauma to the recurrent laryngeal nerve (RLN) causes hoarseness among other symptoms. How the trauma comes about can vary from patient to patient. Sometimes the
nerve is injured indirectly. This can happen when it gets pinched between the surgeon’s instrument and the endotracheal tube holding the patient’s airway open.

The nerve can also get stretched when the surgeon uses retractors to pull the muscles and tissues out of the way. In a few cases there’s no known cause.

The best way to avoid damage to the RLN is for the surgeon to locate the nerve early in the operation and protect it. Making sure the nerve doesn’t get stretched, pulled, or pressed is important. It’s also important to make sure the blood supply to the nerve doesn’t get cut off at any time.

Doctors and other health care professionals use several models to help explain and monitor chronic problems. One popular model is the Nagi model.

In the Nagai model impairment refers to the loss of normal body function. If the neck doesn’t move, or the kidneys don’t make urine, or the heart doesn’t beat normally, there is an impairment.

Disability is any restriction or lack of ability to perform an activity normally. The disability shows how the impairment affects a person at home or at work. A person may have heart disease but there’s no disability because he or she can still do everything normally. In that case there’s an impairment but no disability.

In the case of neck pain, you may have limited range of motion but can still bathe using a bath brush and shoulder motion. The neck is impaired but you aren’t disabled.

Not all disease leads to impairment. Likewise not all impairment leads to disability. Doctors and therapists must look at both as part of your overall exam and treatment plan.

According to a recent study from the University of Hong Kong patient satisfaction seems to be linked with many factors. Pain, loss of motion, weakness, and loss of function are all important to a happy result. Each one should be a part of the treatment focus at some point.

Your therapist knows that treatment success depends on finding out what’s causing your painful symptoms. Treatment is usually based on the therapist’s findings and the patient’s goals.

The therapist should look at all the pieces of the puzzle–patient’s pain, level of satisfaction, physical function, and disabilities present. It wouldn’t hurt to ask what your therapist is thinking. Ask about the treatment plan and what his or her strategies may be for your complete recovery.

Spinal fusion works well but there are reports of repeat operations needed at the level above or below the fusion site. Of course the main disadvantage of fusion is the loss of function. That is offset by the primary advantage of fusion: spinal stability.

Other complications after fusion include failure to fuse, fracture, and loosening of any hardware used (screws, plates).

The artificial disc was first used in the early 1960s. Since then technology and design have changed. Improvements in surgical technique have also helped return the use of an artificial disc replacement (ADR) as an option.

The main benefit from an ADR is restored, pain free motion. The nearby bone is preserved with less trauma during the operation. The downside may be in how long the implant lasts. During simulator testing the wear rate for some ADRs was 40 to 50 times less than the usual wear rate for a knee or hip implant.

ADRs don’t prevent further disc disease at the level above or below. Researchers aren’t sure yet if removing the disc at one level is directly linked with later degeneration at other levels. It may be that nearby levels would deteriorate anyway.

You can start a schedule of decreased wearing time. Take the next week to 10 days to gradually wean yourself off the collar. If you are wearing it during your waking hours, put it on 15 minutes later in the morning. Take it off 15 minutes earlier at night. Repeat this formula every day. If you feel comfortable, increase the time you delay/stop to 30 minutes each day.

At the same time you need to continue your program of exercise and strengthening exercises. Your rehab program will help you expand your limitations and over come your physical and mental dependence on the collar.

See your surgeon if you have trouble adopting a weaning schedule. An exam may be needed to ensure the stability of your surgical site.

The artificial disc replacement (ADR) is still fairly new. Its use in the lumbar spine has been tested and reported on. Early studies on its use for the cervical spine (neck)are more limited.

There was a recent study from Yale University with a small number of patients (16). Results showed improved function, reduced pain, and less use of pain drugs in the first three weeks. Range of motion increased between three weeks post-operative and one year later. X-rays also showed increased disc height and motion.

The authors of the study noted the absence of any significant problems or complications. This was true during the operation and afterwards for the device used and the type of surgical technique used.

Short-term results look promising but long-term outcomes are equally important.