FAQ Category: Cervical Spine

CSM is a degenerative condition that occurs with aging. Adults affected most often are 50 years old and older. The term myelopathy refers to any problem that affects the spinal cord. Cervical tells us the area affected is the cervical spine (neck region). Spondylotic or spondylosis describes a narrowing of the spinal canal where the spinal cord is located.

So, basically what we are describing is a narrowing of the spinal canal that puts pressure on the spinal cord. That’s what causes your neck pain, arm pain, and sensory symptoms such as numbness and tingling down the arm. Some patients also report a shock-like feeling down the arms when the head and neck are flexed. Pressure on the spinal cord causes this sensation called Lhermitte’s sign.

So, what is the natural history of cervical spondylotic myelopathy? Natural history refers to what happens to a person with this type of problem as time goes by. Do they get better, worse, or stay the same? Can a person outgrow it? If it comes with aging, does it get worse as we get older?

Understanding the natural history of a condition is important. For example, if we know how a condition is going to respond over time, it’s easier to predict which types of treatment would work best and which subgroups of patients would respond to those treatment approaches. Unfortunately good-to-high quality of evidence, has shown us that cervical spondylotic myelopathy can go any number of ways. In some cases, there is a slow decline over time. The patient seems to get worse, plateaus (stays the same) or may get slightly better, then declines even more. This pattern is referred to as a stepwise decline. In other cases, the patient is symptom-free or perhaps experiences no change in symptoms over a long period of time.

Is there some way to predict who will progress and get worse and who will stabilize/stay the same? For that matter, is it possible to predict if anyone with this degenerative problem will get better? After all, if it is age related, we can’t reverse the effects of aging or stop the aging process. These are very good questions and ones you may have asking yourself. Here’s what we know so far:

1) Anyone who has this condition will probably get worse over time.
3) As the spondylosis (narrowing of the spinal canal) gets worse, the risk of damage and even death of the spinal cord increases.
3) Younger adults (less than 75 years old) seem better able to adapt and improve without surgery.
4) For those patients (of any age) who got better with nonoperative (conservative) care, they are able to maintain these good results for three
years or more.

The fact that this condition does seem to respond to early treatment is a good sign. It means patients can get the help they need to stabilize the condition and keep it from getting worse.

You may have a condition called cervical spondylotic myelopathy sometimes shortened to cervical myelopathy. Disc degeneration and vertebral compression reduce the normal height of the spine. This puts increased pressure on the discs and facet (spinal) joints, which can lead to the formation of bone spurs. The end result can be a narrowing of the spinal canal where the spinal cord is located, as well as a narrowing of the spaces where the spinal nerve roots exit the spinal canal.

These changes in the anatomical structures surrounding the spinal cord and spinal nerve roots results in neck and arm pain, numbness, and tingling from pressure on the neural structures. Sometimes people have these changes (as seen on X-rays taken for some other reason) without any symptoms at all. Others experience enough trouble and loss of function that they need treatment.

In all cases, CT scans have shown changes in the spinal cord. As the spondylosis (narrowing of the spinal canal) gets worse, the risk of damage and even death of the spinal cord increases. There is mild demyelination or loss of the protective covering around the spinal cord. Studies show small holes can develop in the spinal cord with loss of spinal cord cells.

All efforts should be made to manage symptoms early on to avoid progression. This is especially important because research shows that the positive results from treatment can last a long time. Patients are informed that this condition can get worse over time. You can expect long periods without problems followed by sudden flare-ups of worsening symptoms. Studies show that younger patients (less than 75 years old) and those who have not had the problem for very long have the best chance of response to treatment.

Yes! Although the study you mentioned showed no difference in results for patients receiving manual therapy with and without traction, there were quite a few yes buts expressed by the authors.

First, they used 15 minutes of intermittent (on/off) traction. They started with a traction force (generated by the machine) of 10 per cent of the person’s body weight. The treatment was delivered twice a week for four weeks.

It’s possible that a different setting/dosage of traction might work better over a longer period of time. The results of this study don’t really support doing away with traction altogether. More study is needed before that recommendation would be made. The patients received the traction lying down on their backs with their heads in a position of slight flexion. It’s possible that a different head and neck angle would yield better results.

Second, it’s possible that the tests used to measure results might not be the best ones for this condition treated with this treatment. They used the Numeric Pain Rating Scale (pain), Patient Specific Functional Scale (function), and Neck Disability Index (disability). Other tests administered included grip strength, patient satisfaction with treatment, and fear avoidance beliefs.

Third, the comparison group received a sham (pretend) traction of five pounds of force. This subtherapeutic weight still applied some force to the head and neck and could have had a positive treatment effect. And finally, without a control group (patients who received no treatment), there’s no way to know if everyone would have gotten better after four weeks without treatment anyway.

Future studies are needed to follow-up the findings of this study. Because cervical radiculopathy can be so painful, limiting, and disabling, it is important to make sure patients are identified early and receive the most effective treatment. Physical therapists will continue comparing treatment methods until its clear what works best for each group of patients.

You wouldn’t really be able to purchase a traction machine for home use like you use in the physical therapist’s clinic. But home traction units with a head harness or halter that hang over the door are available and seem to help some people manage their symptoms.

Ask your therapist about the possibility of getting a home traction device. They usually take a small amount of effort to set up at home and most people can do it themselves. It is also very important to improve the strength and coordination in the neck and shoulder blade muscles. Make sure you carry out these exercises daily.

Your therapist can also evaluate your workstation or the way you use your body when you do your activities and suggest changes to avoid further problems. Postural alignment is a key ingredient to successful management of cervical radiculopathy (pinched nerve).

The way the vertebral bones, discs, and spinal joints line up can make a big difference. When everything is where it’s supposed to be, the opening for the nerve as it leaves the spinal cord and travels down the arm is wide open. The more space available for the nerve, the less chance it will get pinched or compressed. Traction combined with good posture can help in taking pressure off the nerve, breaking the pain-spasm cycle of neck and shoulder muscles.

Fractures of the upper cervical spine (C1-C2) can be stabilized without surgery by using a special apparatus called a halo vest. The vest is made of durable plastic that fits over the chest with a supportive collar around the neck. Four long, vertical metal rods attach the vest to a crown around the entire head. Metal screws hold the halo portion to the skull.

The halo has a few problems of its own, but it eliminates the need for surgery with all its potential complications. The device is attached under local anesthesia. The patient’s stay in the hospital is much shorter. The patient can get up and move about right away. The downside of a halo vest is the weight and of course, the fact that it cannot be removed. As intended, neck motion is not allowed while the fracture heals. Some say that is the blessing and the curse.

Comfort and personal hygiene are important during the weeks and months the patient must wear the vest. Women may have a more difficult time adapting — especially if they are large breasted. But there are some tricks that patients have shared over the years that we can pass along here.

A T-shirt can be worn under the vest if it’s not too tight or too bulky. Wrinkles must be smoothed out carefully. To get the T-shirt under the vest, you will have to cut along the top shoulder seam on one side. Your daughter will step into the shirt while you help her gently pull it up through the bottom of the halo. Once the shirt is all the way up, she can put her arm through the uncut sleeve and have you safety pin or tape the cut sleeve closed. The shirt can be worn for more than one day but should be exchanged for another T-shirt as needed.

Bathing can be done carefully. Your daughter can sit in a bath with a small amount of water. Make sure you follow every precaution to prevent falls. Place a nonskid bath mat in the tub before getting in. Install safety bars to hold on to while getting in and out of the tub.

You can purchase a thin flannel or silk material from a fabric store to make a wash cloth that can slide underneath the vest. Do NOT use soap unless approved by the physician. Soap residue and build-up from inadequate rinsing can cause skin problems. You can use a similar cloth to help dry the skin but follow-up with a blow dryer on the cool setting to get into difficult to reach areas.

The biggest problem many people have is with infection at the pin insertion sites. It’s important to follow the instructions provided at the clinic. You can put a little saline solution (available at any drug store) around the pin sites whenever there is any oozing or crusting. Gently cleanse from the pin site outward to remove any debris.

Ask the nurse or doctor about applying moisturizer to the area and to the skin. They may have some guidelines for you and a specific recommendation on type of skin lotion to use. Avoiding infections will help minimize scarring once the halo device is removed.

Migraine headaches can occur in children. Usually these migraines are inherited. Studies show that migraines tend to drop off for men and women after midlife. Pregnancy is a unique time of life for many women. Some who have never had migraines develop them as a result of the increased estrogen in the system.

Others who have had a history of migraines may be migraine-free during some or all of the pregancy. This is unpredictable but evidently hormone driven. Food triggers commonly associated with migraines include alcohol, chocolate, cheese, caffeine, and monosodium glutamate (MSG). The list can change or vary during pregnancy and again after the pregnancy ends.

Magnesium supplements seem to help women who have headaches during pregnancy or afterwards during lactation (breastfeeding). Oral supplements (pill form) are available but in some cases, it may be necessary to administer magnexium by intravenous drip.

An added benefit of this supplement in childbearing women is the prevention of premature labor. The rate of sudden infant death symdrome is also lower in children whose mothers took magnesium during pregnancy and lactation.

There are different formulations of magnesium on the market. Some are chelated (combined or bonded with something else), some are combined with oxygen to form magnesium-oxide, and some are slow-release. The recommended daily dose is 400 milligrams but this should be determined for each individual by a nutritional or medical specialist.

Many people suffer from headaches triggered by various food substances. Sometimes the reaction is a delayed food intolerance with a variety of symptoms including headache, joint pain, fatigue, skin rashes, acne, and so on. In other cases, a full-blown migraine can begin.

Some detail is known about how and why these triggers bring on a migraine. For example, phenylethylamine in chocolate causes the release of neurotransmitters in the bloodstream that open up blood vessels in the brain (vasodilation). Too much vasodilation puts stretch and tension on the pain receptors of the blood vessels. The result is a vascular migraine. In some people, caffeine in the chocolate is the trigger.

Headaches can certainly be caused by other health problems such as tumors, infection, atherosclerosis, diabetes, fibromyalgia, and so on. A medical evaluation is always a good idea to establish the cause of any kind of chronic headache pain. Determining food-related headaches is as simple as keeping a food diary.

It may take several months (even several years) to track foods that trigger migraines. That’s because the reaction can be delayed by hours to several days — AND the triggers can change over time. Sometimes it takes a while before the person has been exposed enough times to the substance before the body loses its tolerance and a new food becomes an offending trigger.

Once the list is completed, limiting (even gradually eliminating) the suspected foods and beverages is the next step. For those who lack the willpower to do this, there is another option: vitamins and other supplements. Research shows that certain supplements can help prevent (or treat) migraines.

Magnesium, Petadolex (Butterbur), Feverfew, CoQ10, vitamin B2 (riboflavin) and alpha lipoic acid head the list of potentially beneficial substances. Nutritional counseling with a specialist is advised when choosing the right supplement and determining the correct dosage. More study is needed but valerian root and ginger may also have beneficial effects.

Dysphagia (difficulty swallowing) is not uncommon after anterior cervical spine fusion. In the process of cutting through skin and soft tissue around the throat, damage can be done to some of the nerves in that area. The nerves are tiny and not always visible.

Your surgeon may not have communicated his or her knowledge and understanding of dysphagia as a postoperative complication in a way that would have made a better connection with you as the patient.
Experience has shown that most of these problems are temporary. The nerve tissue regenerates and the function returns.

Greater efforts are being made to study minor and major complications after spinal surgery. A more recent study published a comparison between what surgeons think are problems and how patients view those problems. They found exactly what you described — some things like blood loss during the operation or difficulty swallowing after the procedure were considered minor by the surgeon. Patients tend to see these things as much more major.

There was general agreement between surgeons and patients for events like a heart attack or blood clot. These were viewed by both groups as major events. But there were also some complications that surgeons viewed as more dangerous than patients — like infections. Even a superficial wound infection was viewed as an adverse event by the surgeon. Infections of the urinary tract, deep wound, or arterial line were more likely to be seen by the surgeon than the patient as a major complication.

The bottom line is that your surgeon may not be clear in saying so, but he or she knows what to watch out for, what’s serious and what’s not, what constitutes a minor versus a major event after surgery, and what you will or won’t recover (or recover easily) from.

Artificial disc replacement (ADR) is relatively new. In June 2004, the first ADR for the lumbar spine (low back) was approved by the FDA for use in the US. Replacing a damaged disc in the cervical spine (neck) is a bit trickier. The disc is part of a complex joint in the spine. Making a replacement disc that works and that will last is not an easy task.

The artificial disc is inserted in the space between two vertebrae. The goal is to replace the diseased or damaged disc while keeping your normal neck motion. Disc replacement can be done instead of fusing the neck and losing neck motion.

When a new treatment like disc replacement comes along, it takes a while before it’s clear who should have this surgery. So patient selection is extremely important. At first, it’s just a limited group of patients who qualify for the procedure. That’s okay because surgeons want the best results for their patients.

Who’s the best candidate for a cervical disc replacement? Well, for starters, anyone who is also a candidate for cervical fusion. These patients have obvious cervical disc disease with herniated disc, bone spurs, and/or neck/arm pain from myelopathy or radiculopathy. Myelopathy is any damage to the spinal cord as it travels down the spine. Pressure on the spinal cord can cause significant symptoms and disability. Radiculopathy is pressure or irritation of the spinal nerve roots as they exit the spinal cord and travel down the arms (or legs).

In Europe where disc replacements have been done much longer than in the U.S., there is a broader patient selection. For example, patients with a failed cervical fusion, patients with multilevel degenerative disease, and patients with segmental disease after fusion are also candidates for cervical disc replacement.

Even with expanded patient selection criteria, certain patients still may not be good candidates for this type of surgery. Brittle bones from osteoporosis or other significant diseases may keep a patient from having this type of surgery. Local problems in the spine such as infection or severe degeneration of the facet (spinal) joints are also possible contraindications (reasons NOT to have the operation).

If the spine has already started to fuse itself (autofusion) with bone spurs crossing the disc space, then disc replacement is not advised. And if the patient has an unnaturally straight cervical spine called kyphosis, cervical disc replacement may not be a good choice. The kyphosis can get much worse after surgery. The result can be worse neck pain than before surgery. In time, with the right design and placement, this problem may be resolved. But for right now, preoperative kyphosis is considered a contraindication for cervical disc replacement.

Disc replacement surgery is safe and effective but must be used on the right patients. The best thing to do is go see an orthopedic surgeon who does disc replacements and find out if you are a candidate. There may be some other less invasive, more conservative treatment that might be helpful.

Artificial disc replacement (ADR) have been in use in Europe for many years. But they are relatively new in the United States. The first ADR were approved by the FDA in 2004 for the lumbar spine (low back).

The artificial disc is inserted in the space between two vertebrae. The goal is to replace the diseased or damaged disc while keeping your normal spinal motion. Disc replacement can be done instead of fusing the spine and losing motion. Replacing a damaged disc in the cervical spine (neck) is a bit trickier. The disc is part of a complex joint in the spine. Making a replacement disc that works and that will last is not an easy task.

Choosing the right implant is important. If the disc was collapsed before surgery, the disc space was probably narrow. There might have been limited motion just from that factor. The surgeon might have inserted a narrow implant to avoid overstuffing the disc space. The result can be limited motion.

It’s also possible your brother developed some compensatory stiffness to help with neck instability before the operation. It can take some time and may require some intervention to restore normal motion. A few visits with a physical therapist can help with any muscular imbalances that might be contributing to the problem.

It may not be a bad idea to ask some questions based on your observations. Your concern about being tactful shows that you are already aware of the need to be careful in how this comes across. If you look for the right moment, it may be possible to broach the subject without causing problems and maybe even bringing about a better result in the end for your brother.

Upper cervical spine fractures (C1-C2) are treated using a halo vest when surgery isn’t an option or when the patient wants to avoid surgery. Many patients seem to do quite well with this treatment and have good results. There is some thought that older adults take longer to heal and have more complications. But a recent study from Germany reported no real difference between patients older than 65 and younger than 65.

However, the patient’s health status (such as having diabetes or being a smoker) can affect the outcome. Special care must be taken to avoid infections at the pin sites. Getting proper hydration (fluids), nutrition, and sleep are essential during the healing period.

If she is having trouble making meals for herself, you can help by arranging for meals on wheels (if available in her area). If not, a few friends or volunteer groups from churches might be able to help out with meals for a few weeks at least until she gets settled at home. A consultation visit with a nutrition expert might be a good idea, too. Just having someone review the importance of good food choices and a healthy diet can help keep your mother on track with managing her diabetes. That will be a key element in her healing and recovery process.

Getting enough rest and especially good sleep can be a problem. Sleeping positions are somewhat limited with a halo device. It may be worth the money to purchase the thickest, most comfortable memory foam and mattress topper possible. A bed with adjustable firmness/softness works well, too. If she has private insurance, they may cover this as a medical expense with a physician’s letter of justification.

Some people have gone to using a lower daybed because it’s easier to get in and out of. Others rent an adjustable hospital bed for the necessary time. Over time, it will be easier for your mother to maneuver herself in and out of bed. But at first, she is probably going to need some help. Find (or make) her a small, very soft pillow (or use a covered piece of memory foam) to place between the halo bar and her face for sidelying. It gives a little pillow support without affecting the frame in any way.

Halo vests are put on under a local anesthesia. Most patients are able to go home the same day or soon after. For some older adults, having someone there to help the first few days to weeks may be essential. If family members cannot provide this type of help, there are visiting nurse services, home health aids, private personal care attendants, or even volunteer friends who can help.

Corpectomy refers to the partial or complete removal of a vertebra. The vertebrae are the bones in the spine. Removing the bone may be necessary when there’s been a collapse of the bone or loss of structural integrity that is affecting the spinal cord.

The spinal cord travels through a round tube formed by the vertebral arches just behind the main body (corpus) of the vertebra. This tunnel-like pathway is called the spinal canal. Degenerative changes associated with aging can contribute to pressure being put on the spinal cord as it goes down the canal from the brain to the bottom of the spine.

Oblique corpectomy is the partial removal of part of the vertebral body. The surgeon cuts a portion of the spinal segment out on a diagonal. The result is to widen the spinal canal, thus giving the spinal cord more space.

The advantage of this procedure is that it can be done without fusing the spine. That can mean fewer complications and less risk of vertebral (spinal) instability. It is used with patients who have anterior spinal cord compression. This means the pressure on the spinal cord is toward the front of the spinal canal (closest to the vertebral body).

An oblique corpectomy can be done at just one cervical level. But most of the time, it is used to resect (remove) a part of the vertebral body at several levels. The surgeon tries to take out less than half of the bone. This is called a limited bone resection.

Because all other elements of the vertebral body and two of the three supportive bony columns are left intact, this procedure can be done without fusing the spine at the level of the decompression. And it can be done at multiple levels — all without needing fusion.

Improvement of symptoms and function is experienced by most patient who have this type of spinal canal expansion. Even with an oblique corpectomy at multiple levels, patients maintain spinal stability with very few patients getting worse instead of better. Patients can get up and move early after the operation and without bracing or immobilization of any kind.

It appears that there are many conditions people can have that don’t present with any particular signs or symptoms. It’s not until they have an X-ray, CT scan, or MRI for something else that the problem shows up.

This tells doctors not to rely just on the results of clinical tests. A recent study confirmed this is true for cervical myelopathy. Cervical myelopathy is the technical term for spinal cord compression in the neck (cervical spine).

There are four common provocative tests that can be done to help diagnose cervical myelopathy. The main clinical tests used to look for cervical myelopathy include the Hoffman sign, inverted brachioradialis reflex, clonus, and Babinski. These are called provocative tests because the examiner applies some type of stimulus to the patient to evoke an abnormal response.

The Hoffmann sign is done by quickly snapping or flicking the patient’s middle fingernail. A positive sign occurs if the tip of the thumb bends in response to this flicking. An inverted brachioradialis test is positive if, when the brachioradialis muscle is tapped with a reflex hammer, the fingers flex and the expected reflex is weak or absent.

Clonus is a rhythmic beating of the foot and ankle when the ankle is quickly and forcefully moved into a flexed position. The Babinski sign (when positive) is seen as an extension of the big toe (rather than flexion) and a fanning open of the other toes when the pointed end of the reflex hammer is used along the bottom of the foot from heel to toes.

It’s been proven that doctors can’t rely on signs of myelopathy to make the diagnosis. On the other hand, the lack of positive signs doesn’t rule out the condition either. When the tests are positive, it’s a pretty good indication that cord compression exists. The one group of patients that may not present like others is those who have diabetes.

Signs of myelopathy in adults with diabetes are very low. The reason for this is probably the decreased transmission of nerve impulses resulting in slower (not faster) reflexes. That’s because diabetes affects the peripheral nerves most often.

In general, the appearance of these four signs is not necessarily an indication of how severe the cord compression is since it was possible to have severe compression without myelopathic signs. On the other hand, the more damage that is present in patient’s spinal cords, the more likely it is that they have positive provocative signs.

Since the treatment of cervical myelopathy is often surgery, the decision to operate should be based on not just the presence of these clinical signs, but also the results of advanced imaging. Surgery may be needed even when provocative signs are negative because the MRI shows damage to the spinal cord.

Your physician will probably go over the results of your tests and answer any questions you may have. We can give you a little bit of information, to help you prepare for that meeting. Cervical myelopathy is a degenerative condition that occurs with aging. Adults affected most often are 50 years old and older. The term myelopathy refers to any problem that affects the spinal cord, but especially compression of the spinal cord. Cervical tells us the area affected is the cervical spine (neck region).

There are several reasons why cord compression develops. Sometimes the posterior longitudinal ligament (PLL) along the back of the spine thickens and hardens. Without its normal flexibility, it can buckle and put pressure on the cord. Bone spurs, disc herniation, and spondylolysis can also apply pressure to the spinal cord. Spondylolysis refers to a defect (usually a fracture) in the par interarticularis, a supportive column of bone in the vertebra.

The diagnosis of cervical myelopathy is a clinical diagnosis. That means in order to make the diagnosis, the physician relies on the patient’s history, specific tests performed during the physical exam, and the results of advanced imaging studies. There isn’t a blood test or other simple way to identify this condition.

Patients with cervical myelopathy can experience a wide range of signs and symptoms. There can be difficulty walking, using the hands, bowel and bladder function, or even wasting of the muscles of the hands. When the muscles are affected, motor function, coordination, and muscle mass can change. Sometimes there is also a loss of normal sensation with numbness and tingling of the fingers and toes. In addition, there can be debilitating pain.

There are other conditions that can cause similar symptoms such as stroke or multiple sclerosis. The differential diagnosis refers to the steps (tests and measures) needed to identify which specific cause is present. In the case of cervical myelopathy, the MRI can show changes in the shape of the spinal cord called deformation indicating pressure or compression.

Whiplash injuries occur when the head and neck extend backward and then flex forward in a rapid transfer of energy to the neck. Persistent neck pain, arm pain, headache, and other symptoms following such an accident have been labeled whiplash-associated disorder (WAD). WAD occur most often after rear-end or side-impact collisions.

Often the person affected is at a standstill in traffic and unprepared for the impact. Seatbelt use and the presence of a headrest have both come under scrutiny as possible risk factors for WAD. But a review of all studies since 1995 showed that being unprepared for the crash or sitting in a seat without a head rest were not variables that contributed to a chronic condition from whiplash.

On the other hand, not wearing a seatbelt doubles the risk of developing persistent problems later. But not wearing a seatbelt isn’t the only predictive risk factor of outcome. There are other factors that have a significant effect as well. High school education, gemale gender, and a history of neck pain before the accident can also increase the risk of chronic whiplash-associated disorder.

You may need to seek legal counsel in order to find out what your legal rights are and how to best protect yourself. Each state has its own laws that govern some of these issues. Someone in your area with specific training in situations like this could be very helpful in answering this question.

Cervical spine instability usually means that one vertebral body slides too far forward over the vertebra below it. The degree of instability depends on how far the bone moves. This movement can be measured in actual distance (usually in metric units of millimeters). Or it can be expressed as a percentage based on its location over the vertebra below it. For example, a spinal segment that has slipped forward 25 per cent over the vertebra below it is a Grade I instability.

Grade II describes a vertebral bone that has moved forward over the bone below it by 50 per cent. Grade III is a 75 per cent instability. Grade IV is complete instability and very rare with paralysis and/or death as the outcome.

With all of these instabilities, the spinal cord is involved. As the vertebral bone moves forward, a traction pull is placed on the spinal cord. Patients experience painful symptoms accompanied by neurologic signs and symptoms such as numbness, tingling, weakness, loss of reflexes, and/or bowel and bladder problems.

The problem your mother has been diagnosed with is called cervical myelopathy. It is a degenerative condition that occurs with aging. Adults affected most often are 50 years old and older. The term myelopathy refers to any problem that affects the spinal cord. Cervical tells us the area affected is the cervical spine (neck region).

Fusion is needed to stabilize the bones — that is, put them in as good alignment as possible and hold them there. Bone graft and instrumentation (metal plates, screws, or rods) are used to hold the spine stable. Without this stabilizing procedure, continued pull and pressure on the spinal cord can cause loss of function and severe disability.

Chronic pain and disability from a whiplash injury is still the most common injury after a car accident or other similar (often sports) accident. Whiplash occurs when the head and neck extend backward and then flex forward in a rapid transfer of energy to the neck. Persistent neck pain, arm pain, headache, and other symptoms following such an accident have been labeled whiplash-associated disorder (WAD).

The costs of such an injury (both direct and indirect costs) are substantial. The effect this has had on your friendship is an example of an indirect cost. Research is underway to prevent an acute whiplash injury from becoming a chronic, disabling condition. The focus is on identifying factors that might predict early on who is at risk for a whiplash-associated disorder (WAD).

So far, nine significant predictors of pain and disability after whiplash injury have been determined. These include high school education, female, history of neck pain before the
accident or injury, neck and/or headache pain rated as 55 or more out of 100, no seat belt use at the time of the accident, and catastrophizing.

Catastrophizing refers to irrational thinking that something is far worse than it actually is. Patients who catastrophize see their current situation in a negative light. They tend to think that the worst possible outcome will happen. Catastrophizing is associated with pain intensity, psychological distress, and pain-related disability among individuals with chronic pain.

It sounds like your friend may at least have this one risk factor affecting her recovery. Supportive friends at a time like this are important, but professional help with a behavioral counselor or psychologist may be needed. If you have the kind of relationship that allows for suggestions, you may be able to suggest some outside help for your friend. If not, you may have to set some limits in time spent together or time spent discussing health issues in order to preserve your relationship.

That’s a good question and one you should definitely ask your surgeon. The answer may depend on the type of surgery performed and method of fusion used. With a successful fusion, your neck motion will be limited. Long periods of time with your head and neck bent forward may not be advised — especially at first during the healing phase.

It may be possible to modify your activity. When doing hand work, set a timer for 10 minutes. When the timer goes off, get up and move around. Do one or two of the range-of-motion exercises prescribed after surgery. When working on a project, place a bolster or firm pillow under your elbows and forearms. This will help raise your hands up — rather than bending your neck down.

You may find it necessary to limit the number of hours you sit engaged in this type of activity. Sometimes a surgeon will agree that it is okay to use a soft collar as a reminder not to bend forward. But this must be used carefully with equal amounts of time moving slowly and gently through all available motion to avoid stiffness and loss of motion.

Athletes participating in collision or contact sports are at risk for stingers. Usually it’s a temporary injury but it can put a player out permanently. Stingers refer to the burning, electrical, or shooting sensation a player feels after forceful contact to the head and/or shoulder by another player.

The injured player’s neck is bent away from the side of the injury. At the same time, the shoulder on the injured side is depressed forcefully. The combination of rapid, forceful movement and direct pressure pulls and presses the nerves in the neck area.

No matter which area of nerve supply is affected, most players are able to get back into play during the same game. In some cases, a stinger (or more often, repeated stingers) causes permanent nerve damage. That’s a problem, and one we don’t really know how to predict or prevent. Despite the fact that this is a fairly common injury (up to 65 per cent of college players have at least one sometime — high school athletes may not be quite as common), there are no clinical guidelines for how to evaluate and treat players.

Some experts suggest that players who have had two or more stingers should consider having an X-ray to check for instability. There could be a protruding or herniated disc pressing on the nerve root. Such findings would change the entire picture. Any of these problems can put the player at increased risk for significant nerve injury. A more thorough diagnostic evaluation will be needed to decide if the player is safe to return-to-play.

Stingers refer to the burning, electrical, or shooting sensation a player feels after forceful contact to the head and/or shoulder by another player. The symptoms are brought on by trauma to the nerves in the neck and don’t usually last long.

When the symptoms of a stinger have not gone away two to four weeks after the injury then diagnostic X-rays, the findings aren’t always very clear or helpful. Further assessment may be needed with CT scans, MRIs, or electrodiagnostic studies (EDX). These tests can help identify which nerves are affected and check the function and integrity of the nerves.

Deciding whether or not a player can return-to-play (practice or game play) isn’t always a cut-and-dried decision. Many factors must be taken into consideration. For example, one stinger with rapid return to normal is easy: no diagnostic tests are needed and the player is safe to return to the game as soon as the symptoms are gone.

Two stingers in the same season should be checked by X-ray and in some cases, an MRI should be done. Persisting pain, numbness, weakness, and/or loss of motion are signs that electrodiagnostic tests are needed. The athlete is held out of the game until it is safe to play again. Two or more stingers in different seasons are assessed first by symptom resolution, then by X-rays, MRIs, or electrodiagnostic testing if symptoms persist.

Three or more stingers in the same season or in different seasons put the player at risk for being benched and out for the season (if not permanently). These are the cases where it is clearly in the best interest of the individual to be protected from any further injuries. When is it safe to return to the practice field? When the player has full, painfree neck motion and strength to perform all the sport-specific skills needed to play without any symptoms.