Comparing Cost Effectiveness and Outcomes Between ACDF and CDR

The gold standard of treatment for symptoms including long term neck pain, neurological deficits and radiculopathy stemming from the degenerative changes of the neck is an anterior cervical discectomy and fusion (ACDF). It has a very high clinical success rate but is also associated with some negative long term side-effects including loss of cervical range of motion, increased degenerative changes at segments adjacent to the fusion level and an increased reliance on future need to solid bony fusion. An alternative to ACDF was developed for this reason. A cervical disc replacement (CDR) procedure can result in symptomatic relief while preserving range of motionand decreasing degeneration at adjacent segments.

A recent group of large randomized clinical studies investigated long term outcomes comparing ACDF to CDR. They looked at measures including perceived neck function, general health, neurologic improvement and avoidance of future secondary surgical needs. All reported improvement in all outcomes with both CDR and ACDF, with no significant difference between to two procedures. Since CDR is just as beneficial as ACDF but does not come with secondary side effects such as loss of range of motion and increased risk of future deterioration of adjacent segments, it may be the new ‘gold standard’, however another important variable to consider is cost-effectiveness, both short and long term.

Utilizing a patient population targeting individuals over the age of 40 with acute disc herniation and associated radiculopathy, ACDF and CDR were compared with 6 possible outcomes of each procedure: well after primary surgery, nonoperative complication, well after revision, complication after revision, adjacent segment revision, and death. Transitions between the above listed health states were estimated from current literature which included seven studies and over one-thousand total patients. Estimated costs in dollars for each procedure were generated using 2010 Medicare reimbursements for 2010 and quality-adjusted life years (QALYs), were also estimated .

The study found that CDR generated a five year total cost of $102,274, compared to ACDF total cost of $119,814. Furthermore, CDR resulted in 2.84 QALYs while ACDF generated 2.81 QALYs. The cost-effectiveness ratio using these two measures was $35,976/QALY for cervical disc replacement and $42,618/QALY for anterior cervical discectomy and fusion. CDR is less costly and more effective when compared results in a 5 year follow-up span.

Assessing Cost-effectiveness of Surgery for Cervical Degenerative Diseases

Value based health care is swiftly becoming a thing of the present and substantiation of treatments for spinal conditions will be necessary. Optimal treatment options need to be identified in value-based health care, where optimal can be defined as greatest gain in quality of life at the lowest cost to the patient and society. Overall there are very limited cost-effectiveness studies in spine surgery literature with cervical conditions being most neglected. A recent systematic review looked to identify if there is evidence present on the cost-effectiveness of operative treatment of cervical degenerative disc disease (DDD) conditions. Ultimately they stated that no definitive conclusion can be made secondary to the great limitations present in the small amount of current research on this topic.

Answers to four questions of interest were sought in performing this review to examine cost effectiveness of surgical treatment for cervical degenerative conditions. The first question looked at whether there was evidence present to suggest surgical intervention is cost-effective as compared with non-operative treatment for degenerative spinal conditions specifically cervical myelopathy (compression of the spinal cord within the neck) and cervical radiculopathy (compression or irritation of the spinal nerve roots in the neck). It was found that no full economic review existed relative to this question. The second question focused on evidence to suggest anterior cervical discectomy and fusion (ACDF) is cost-effective compared to cervical disc arthroplasty (CDR) for cervical myelopathy or radiculopathy. Only two economic evaluations were available which demonstrated that CDR is more cost-effective than ACDF for a patient with single-level cervical DDD and radiculopathy or myelopathy. The third question looked at whether evidence is present to suggest that surgeries based from the front of the neck were more cost-effective as compared to surgeries performed using a technique from the back of the neck for cervical myelopathy. Again only two economic evaluations were available. Surgery performed from the front did demonstrate increased cost-effectiveness at one-year postsurgery for patients with cervical myelopathy. The last question examined if evidence was present to suggest that surgeries performed from the front of the neck were more cost-effective as compared to surgical techniques performed from the back of the neck for cervical radiculopathy. In this case only one economic evaluation was available for analysis and this demonstrated that surgical techniques from the back are less costly than ACDF for patients with single-level radiculopathy.

There were several limitations found in this systematic review. Drawing conclusions off of only one or two studies is challenging and thus it was concluded that these questions must be further validated by additional high-quality investigations. Different types of surgical techniques (i.e. performed from the front or back) typically have a different subset of patients thus any conclusion made on cost-effectiveness may be influenced by patient demographics. Recent studies have further defined health utility indices in the study population as well as long-term complications. A repeat cost-effectiveness comparison utilizing this new information is still lacking.

Overall it was suggested that further analysis should adopt a standardized cost-utility methodology, which should include both comprehensive long-term follow-up costs and valid quality of life outcome questionnaire data. The authors of this review also recommended that the analyses should directly compare either non-operative versus operative intervention or two different surgical interventions using a cost-effectiveness ratio and being specific about whether it is a patient with myelopathy versus radiculopathy versus neck pain alone receiving treatment. They also felt that other surgical interventions should be explored and lastly that longer-term follow-up is necessary so that aspects such as adjacent level surgery, failure rates and clinical outcomes can be further defined.

Is My Neck Getting More Stiff Every Year? An Analysis of Cervical Spine Range of Motion Changes Over Forty Years.

One’s neck mobility seems to gradually get worse as we celebrate birthdays and suffer our share of accidents and uncomfortable hotel pillows. The garden variety pain or achy stiffness in the neck, categorized in the healthcare world as ‘nonspecific neck pain’ sends a lot of people to their care providers for some sort of treatment and medical relief. In order to best assess neck complaints, providers perform an examination of the spine. The physical therapist (or other provider of choice) will measure their range of motion (ROM), as in many cases one of the goals for patients with nonspecific neck pain is to improve the neck’s mobility. Normative values for the neck’s mobility are memorized by clinicians during their respective education, so relative stiffness measured in degrees, documented and treated for hopeful improvements. For example, we learned in PT school that the “normal” neck flexes and extends about 60 degrees, rotates 90 degrees and side bends 45 degrees. But, “normal range of motion” changes with age, and thus ‘normal’ for a 20 year old is quite a bit more generous than the age-reduced ‘normal’ for a 60 year old.

Enter the work of Dr. Swinkels and his team of researchers from the Zuyd University’s Department of Physiotherapy in the Netherlands. They recently published a paper on their investigation on the range of motion differences in the cervical spine as we age. They studied four hundred people without neck issues and quartered the data set with 100 for each decade of age from 20 years to 60 years and in each quarter subgroup. Each subgroup also had an even balance of genders with 50 males and 50 females. The mobility of the neck was measured with a special cervical range of motion device called the ‘CROM’. Swinkels’s team crunched the nitty-gritty analyses of variance, linear regressions and even further dredged the data with Scheffé post hoc tests to investigate the differences in neck mobility between the decades of age and any possible relationships of age and/or gender.

As one may expect, they found that age does have a significant effect on active ROM of the neck. Recall the “normal” ROM for neck flexion we committed to memory was 60 degrees. This normal mobility of 60 degrees in Swinkels’s study was assessed as typical for 20-somethings, but each decade men and women evenly lose a degree or two, until the 50-something decade. 50 years and older, active ROM declines greatly in all directions except neck extension and side bending. Neck flexion on average is reduced 12 percent (seven degrees) to 53 degrees. Clinically this is relevant, as we in the physical therapy profession tend to council a lot of people on improving their stiff neck’s mobility. In all due fairness, the “new normal” should be on an age-adjusted sliding scale when goal setting for target neck mobility.

Results of Double-Door Laminoplasty for Neck Pain

Problems in the neck that can cause severe pain, numbness down the arms, and sometimes even paralysis are referred to as cervical myelopathy. Cervical myelopathy can be caused by several changes that occur over time. The first is ossification (hardening) of the ligament that goes down the back of the spine (posterior longitudinal ligament or PLL). Another is the herniation of several discs in the cervical spine (neck) with resultant spinal canal stenosis (narrowing caused by disc material pushing into the canal).

A successful treatment for this problem is laminoplasty surgery to take pressure off the spinal cord and stabilize the spine. In this study, surgeons from Korea examine the effect of doing a double-dooor laminoplasty in 58 patients diagnosed with cervical myelopathy. This type of surgery splits the spinous process down the middle and then opens them up like french doors or two windows that open toward you. The spinous process is the bone along the back of the vertebra that you feel as a “bump” down the spine.

The effect of this procedure is to allow the spinal cord to shift backwards or “move away” from the front of the spine. Many people who have cervical myelopathy have a cervical spine that is too straight referred to as kyphotic. The natural (normal) alignment of the bones in the neck is a slight backward (lordotic) curve.

With these other degenerative changes (disc herniation, ossification of the ligaments), the straighter-than-normal (kyphotic) cervical spine can put enough pressure on the spinal to cause cervical myelopathy. But not everyone has cervical kyphosis associated with symptomatic cervical myelopathy. Some patients have the more normal neck curve.

The question this group of researchers asked was whether or not this kyphotic alignment would compromise surgical results. There is less room for the spinal cord in the canal when the spine is so straight. The posterior shift made possible by the laminoplasty may place the already (posteriorly) shifted spinal cord too far back to achieve (and maintain) the positive benefit of the procedure.

They studied 58 patients with cervical myelopathy who were all treated with this double-door laminoplasty. Patients ranged in ages from 32 to 74 years old. X-rays were used to measure the amount of cervical spine curvature. The patients were divided into two groups: those with cervical lordosis (normal curvature) and those considered “nonlordotic” (abnormal curve).

Two methods of classification (Cobb angle and Toyama classification) made by radiographs were used to determine who was considered lordotic and who was nonlordotic. Comparing how cervical lordosis is measured was a second feature of this study. The patients with 10 to 15 degrees of lordosis were in the lordotic group. Angles less than 10 degrees were nonlordotic.

Anyone with more than 15 degrees of kyphosis was not included. Other tools used to measure outcomes included the Japanese Orthopedic Association (JOA) score (for function), neck disability index (NDI), and visual analog scale (VAS) (for pain).

They found that the degree of lordosis or the method of measuring didn’t make any difference in results. In other words, preoperative cervical alignment was not a factor in how well patients maintained the benefits of the double-door laminoplasty procedure.

The authors noted that there are many different ways to perform a laminoplasty to decompress the spinal cord in the presence of cervical myelopathy. This posterior approach has more advantages than disadvantages when there are protruding discs at several levels. Likewise, this posterior laminectomy works well when there are bone spurs along the front of the vertebral bones or a stiff, tight ligament along the back of the vertebrae. With the posterior decompression, discs, spurs, and ligaments remain untouched.

In summary, cervical nonlordosis (i.e., the presence of kyphosis or reverse cervical curve) was once considered a reason to avoid the double-door laminoplasty. The results of this study suggest preoperative alignment may not be as important as some other factors. For now, it looks like laminoplasty can be done on patients with milder forms of cervical kyphosis.

Future studies are needed to confirm the findings of this study as well as look at other reasons why long-term results may not be maintained (e.g., age, number of levels involved, presence of ligamentous ossification).

Swan Neck Deformity of the Cervical Spine

If you look at the average person from the side, the neck appears straight up and down. But, in fact, there is a backward curve called lordosis that helps keep the head and neck in perfect alignment. Injury, deformity, or arthritis can change this head-neck relationship causing a condition referred to as swan neck deformity.

In this study, surgeons report on the results of fusion surgery to correct the malalignments that occur when there is chronic atlantoaxial (A-A) dislocation. Atlantoaxial dislocation refers to the abnormal movement of the head (skull) over the first cervical vertebra. Ligamentous damage causing laxity (looseness), vertebral fracture, or deformity from rheumatoid arthritis can lead to this type of instability.

As a result of the cervical spine changes associated with a swan neck deformity, the upper portion of the neck becomes kyphotic (develops a forward curve of the neck opposite of lordosis). The lower portion of the cervical spine then compensates by becoming hyperlordotic. These changes occur as the head, neck, body complex attempts to keep the head balanced over the neck and the eyes on a straight plane to protect vision.

Surgery to fuse the head and neck (C0-C2) is done to stop the abnormal movement of the atlantoaxial junction. This is the first report published for a series of patients (total of 68 people ages four to 68) who had this procedure under the care of one single surgeon. The goal was to see (and report on) changes in overall neck alignment with this procedure. X-rays viewing the cranium (skull) and neck and change in function and neurologic status were used to measure before and after results.

The surgery was successful for all but two patients who continued to have painful and neurologic symptoms that continued to get worse over time. In all the other patients, posterior fusion of the upper cervical spine actually resulted in the body auto-correcting the lower (subaxial) cervical spine (below the level of the fusion). This was a hoped for but uncertain favorable outcome.

The authors concluded that reversal of subaxial cervical alignment does occur in patients with atlantoaxial dislocation that is stabilized with posterior fusion of C0 to C2. The amount of change in the lower cervical spine (C2-C7) was significantly and directly linked with the amount of change at the C0-C2 levels.

This is the first study to report on the effect of such a correction in patients with this complex swan neck deformity. The type of fusion hardware used (screw and plate system) has been approved in China but not by the United States Food and Drug Administration (FDA).

Auto correction and reversal of the swan neck deformity in these severe and complex cervical spine deformities may occur as a result of the body attempting to achieve global (overall) alignment or to maintain visual orientation required for upright posture. Future studies are needed to determine the exact mechanism by which the subaxial alignment of the lower cervical spine improves when the upper cervical area is surgically fused.

Important Way to Compare Results Between Disc Replacement and Fusion

There are many ways to evaluate the results of treatment for severe neck pain and instability following cervical fusion or disc replacement. Change in symptoms (numbness, pain, loss of motion, loss of function) is a common source of information about what works well and what doesn’t.

In this study, the authors chose rate of reoperation after five years as the main means of evaluating and comparing results between disc replacement and neck fusion. The type of disc replacement system they used was the ProDisc-C. The type of fusion procedure was the anterior cervical discectomy and fusion (ACDF). ACDF involves removal of the diseased disc with a bone-packed spacer (bone graft) placed in the space left by the missing disc. The use of hardware (plate and screws) along the front of the spine provided support and stability until healing took place.

Just over 200 patients with single-level disc disease between C3 and C7 were randomly divided into two separate treatment groups. Half (103 patients) received the disc replacement. The other half (106 patients) had the fusion procedure. The main difference between these two treatment types is the effect on neck motion. Fusion prevents movement at the level that was grafted together. Disc replacement allows for motion (though not usually full, anatomic motion).

Besides the five-year reoperation rate, they also took a look at the effect of the two procedures on the next vertebra. The incidence of adjacent segment disease (ASD) has been known to be increased after fusion compared with disc replacement. ASD refers to increased pressure in the disc spaces next to the fusion site. There can also be increased motion at those levels observed with ASD.

The concern is that fusion (or perhaps disc replacement) will increase the speed at which the next disc/vertebra starts to degenerate and break down. By comparing the five-year results in two groups of matched patients, it is possible to compare the durability of the disc replacement and the rate of adjacent segment disease with both procedures.

Although disc replacements help maintain spinal motion, they are devices that can break, shift, or sink down. Any of these problems can result in return of painful neck and/or arm symptoms and the need for a second surgery (referred to as a reoperation). Other studies have shown that the fusion procedure does have a much higher (two to six times higher) rate of reoperation compared with disc replacement.

Let’s look at what happened with these 200+ patients. Data was collected at six weeks after the surgery and again after six and 12 months. The last collection point was after five years, although the authors intend to recheck everyone seven years after the primary (first) surgery.

A dozen patients in the fusion group had at least one additional surgery (three of those 12 had more than one reoperation). There were problems with pseudoarthrosis (movement at the fusion site creating a “false joint”) and movement of the hardware (plate) lifting off the spine. This “lift-off” of the plate then caused pressure on the esophagus resulting in difficulty swallowing.

Only three of the ProDisc-C had revision surgeries. Two of those three had the disc replacement removed and the neck fused after all. None of the implanted discs broke or failed. Overall, fusion procedures had a much higher reoperation rate (five times more reoperations). The two main reasons for reoperations in either group were persistent pain and significant adjacent-segment disease (ASD).

The authors concluded that the advantages of disc replacement continue to exceed those of the fusion procedure, which has always been the “gold standard” for treatment of degenerative disc disease. In time, if motion is spared with the disc replacement, there is less adjacent segment disease, and lower reoperation rates, disc replacement may replace fusion as the “gold standard” treatment.

These results support similar findings in other studies comparing these two treatment approaches for degenerative disc disease in the cervical spine (neck). Watch here for continued (seven-year) results of this study in two more years.

Neck Fusion: Is It Worth the Price?

The average single-level cervical spine (neck) fusion costs around $15,700. With the rising costs of health care, the question comes up: is this surgery really worth that much money? One way to measure the economic value of this procedure is to calculate the cost per quality-adjusted life year (cost/QALY) gained. Proving cost-effectiveness is necessary in order to justify payment for these procedures — especially for patients on Medicare.

Here’s what cost per quality of life year (cost/QALY) really means. The actual cost of the procedure is the $15,700. But if the procedure works and the patient is pain free and able to return to work and regular daily activities, then there is a clinical benefit of the procedure each year following the surgery. That value can be measured in dollars and cents.

If there are no additional surgeries or added costs, then even a high-cost procedure like cervical spine fusion can gain even more value over time. And any surgical procedure that gains between $50,000 and $100,000 is considered “worth it” (cost-effective).

In this study, surgeons calculated the cost/QALY over a five-year period. There were 352 men and women between the ages of 22 and 73 years old in the study. They each had a single-level instrumented anterior cervical discectomy and fusion (ACDF) procedure. Instrumented means that hardware such as metal plates and screws were used. Bone graft material was also used to help create a solid spinal fusion.

After analyzing all the data for these 352 patients (including direct costs for additional medical procedures for complications), they found the cost/QALY gained in the first year was $106,000. That figure meets the cost-effective criteria. In the next four years, there was a continued added benefit though it wasn’t as high as the first year. For example, in the second year after the surgery, the cost/QALY gained was $54,000. In the third year, it was $38,800 and in the fourth and fifth years, it was between $24,000 (fourth year) and $29,000 (third year).

The conclusion of the study was that single-level neck fusion using the instrumented anterior cervical discectomy and fusion (ACDF) approach has lasting clinical benefit. The five-year favorable cost/QALY provides evidence that the ACDF is cost-effective and durable. In other words, the gains in health benefit are maintained over time adding value with each additional year without problems.

About 18% of the group needed follow-up care. The types of additional surgeries needed by some patients included implant removal, fusion revision, adding a posterior fusion, and removing hematomas (pocket of blood collected in the surgical area). The cost of these procedures was calculated as $20,000 per patient. But even with these added costs, the value added was greater than the additional costs, so the ACDF procedure was still considered cost-effective.

What’s the Latest on Cervical Spine (Neck) Disc Replacement?

Disc replacements were first designed for the low back (lumbar spine). Their success in restoring pain free motion led to the development of a similar device for the neck (cervical spine). Although not everyone qualifies for a cervical intervertebral disc replacement, they seem to work well for those patients who are good candidates.

In a recent review of cervical disc replacements (CDRs) by two surgeons at the William Beaumont Hospital in Michigan, we are brought up-to-date on the current status of these implants. There are now five different models and designs to choose from. Some are made of a titanium-ceramic material. Others are a titanium-alloy outer part with a polyurethane (plastic) core. Shapes vary and include saddle-shaped, triangular, round, square, and square with rounded edges.

The goals of a good fitting design are first to maintain the space between two vertebra (in other words maintain disc height). Preserving motion at that segment is equally important. And providing shock absorption while keeping the proper spinal alignment is important, too. The implant should be durable (last a long time) with few (hopefully no) complications or problems.

A good fit can depend on how the device sits in-between the two vertebral bones. Different methods of “fixation” have been tried. Some implants are serrated while others have teeth or keels to help them grab hold of the bone and stay where placed. Screws and cement have been used to aid fixation.

But the method with the best results (fewest complications, minimal debris, lowest rate of adjacent segmental disease) has yet to be determined. Studies are ongoing comparing cervical disc replacement with the standard treatment (anterior cervical discectomy and fusion or ACDF). And now with five CDR devices to choose from, research is being done to compare the results among the currently available implants.

Overall, research results show that patients who are treated with either fusion (the ACDF procedure) or cervical disc replacement (CDR) all get better. They all have less neck and arm pain and fewer neurologic symptoms (e.g., pain, numbness, or tingling down the arm).

There is always a concern for adjacent segment disease or ASD. ASD is defined as degeneration of the disc at the level next to the fusion or disc implant. This seems to be improving with cervical disc replacements. These results may be explained by the fact that the implant preserves motion, so there is less pressure on the discs above and below the surgical level.

Other benefits of the cervical disc replacement (CDR) (over fusion) include fewer revision (second) surgeries, faster return to work, overall greater improved function, and maintenance of the improvements in pain and function over time. Longer-term studies (two years or more) tend to show fairly equal results between fusion and CDR as time goes by.

At first, cervical disc replacement was only done at one level. But now, with improved implant design and increased surgeon experience, multilevel procedures are being done. Even with the increased risk of complications with multiple level implants (up to three levels), survivorship of the devices and patient satisfaction are high (95 per cent).

Reported complications with either procedure include difficulty swallowing, vocal cord paralysis, penetration of the esophagus or dura (lining around the spinal cord), infection, and hardware failure. In the case of disc replacement, there have been rare episodes of device migration (disc implant shifts or moves significantly), spinal cord compression, and bone spur formation around the implant. Some of these problems required removal of the disc implant.

Long-term concerns include adjacent segment degeneration and wear debris from tiny flecks of metal getting into the area from the implant. There have been some questions raised about the long-term safety of disc implants from studies that showed chronic inflammation around the implant and in the spinal cord. All metal implants have an increased risk of a hypersensitivity (serious allergic) reaction.

One final area the authors of this review article considered was the cost of cervical disc replacement (CDR) versus the fusion (anterior cervical discectomy and fusion or ACDF). At $2500 for a fusion compared with $4000 for the implant, fusion surgery is less expensive in the short-term. But if a second surgery after fusion is needed later because of increased wear and degeneration at the next segment, then in the long-run, disc replacement is less expensive.

Some insurance companies are refusing to pay for the implant surgery until the benefits of disc replacement (over fusion) are clearly proven. Long-term studies are needed to evaluate all factors related to these two very different treatment approaches to disc degeneration. In time, it may become clear which treatment will provide the most treatment benefit.

Five-Year Results Comparing Disc Replacement with Fusion

People with painful, unstable necks from degenerative disease have two surgical options when conservative (nonoperative) care fails to help. The first is still considered the gold standard (preferred choice) : anterior cervical discectomy and fusion or ACDF. The second is a total disc arthroplasty or disc replacement. Disc implants have been around for about 10 years now, so we are starting to get some study results with long-term outcomes.

There are several reasons why surgeons even started looking for an alternative treatment approach to replace ACDF. ACDF had been around since the 1950s. More than half a century of data showed that despite improvements in the procedure, patients still had problems.

Increased pressure on the discs and degenerative disease (called adjacent segment degeneration or ASD) on either side of the fusion site were common. Patients ended up having a second surgery more often than expected.

Other problems developed such as stiffness, nonunion of the bone, and broken hardware (plates, screws, pins) used to aid the fusion process. Complications of the surgery also included difficulty swallowing or speaking due to nerve damage.

In the early part of the 21st century (2002), European surgeons started using cervical arthroplasty devices. A year later, the United States Food and Drug Administration (FDA) approved the use of these implants on a trial basis. Three separate implants are now available on the market: the Bryan Cervical Disc System, the Prestige-ST Cervical Disc, and the ProDisc-C.

In this report, the five-year results are provided for patients who were in a two-part study using the ProDisc-C implant. Spine surgeons from 13 different centers randomly placed patients with single-level painful disc degeneration into one of two groups. Group one had the anterior cervical discectomy and fusion (ACDF) and group two received the disc implant. The first report came out after two years. This is the five-year report.

At the end of two years, it was reported that the ProDisc-C implant was equal to cervical (neck) fusion in terms of pain relief and function. Now after five years, we see that patients in both groups continue to report high levels of satisfaction. There have been no failures of the ProDisc-C implants so far.

The two significant findings showing the disc implant superior to fusion include: 1) patients with the ProDisc-C have less neck pain (less intense and less often) compared with patients in the fusion group and 2) the reoperation rate is lower among patients with the implant. All other measures (e.g., complications, failures, X-ray results of bone bridging) were equal between the two groups.

The authors conclude that the ProDisc-C implant provides just as good, if not better, results compared with the “gold standard” of spine fusion. Certainly, the disc implant group did no worse than the fusion group.

The surgeons say they expect in time that the value and benefit of disc replacement will be proven. They predict better outcomes than with ACDF and better motion with less chance of developing adjacent segment disease. And the risk of reoperation will remain significantly lower compared with neck fusion.

Concerns After Fusion or Nonfusion in the Cervical Spine

Step-by-step, orthopedic surgeons are finding better ways to treat neck and arm pain from degenerative disc disease of the neck. Severe neck pain and other symptoms down the arm (e.g., pain, numbness, tingling) are the usual reasons patients consider surgery for this problem.

Over the years, advances and improvements have been made in the surgical approach for this condition known as cervical spondylosis. Nearly 60 years ago, in the 1950s, the first anterior cervical diskectomy and fusion (ACDF) was done. This has now become the standard of care for symptomatic cervical spondylosis.

The surgeon removes the diseased or damaged disc and any bone spurs that might be causing problems. This part of the procedure is called decompression. Then the spine is surgically stabilized. This is the fusion part of the surgery. A metal plate is attached to the front (anterior) side of the spine. Bone graft material is used to help speed up the stabilization process.

More recently, ACDF has been replaced with a different surgical approach. The development of a total disc replacement (TDR) has been introduced. Efforts to compare results of treatment between ACDF and TDR are underway. The main effect that concerns surgeons is adjacent segment disease (ASD).

Adjacent segment disease refers to breakdown of the vertebrae next to the fusion or disc replacement implant. At first it was expected that the increased stress and strain from a fusion (no movement at the fused level) would result in adjacent segment disease but not after a total disc replacement (TDR) where movement is preserved.

But so far, no difference has been observed between these two procedures in terms of adjacent segment disease and the need for a second (revision) surgery. Of course, total disc replacements (TDRs) are new enough that results are limited. The number of patients in reported studies is small and long-term outcomes aren’t available yet.

There is much to evaluate when comparing the results of these two procedures. Studies are needed to measure intradiscal pressure, strain distribution across the adjacent discs, and shear forces on the connecting vertebrae. Neck motion is another way to compare outcomes between ACDF and TDR. Changes in motion occur at the fused levels but overall neck motion improves for both ACDF and TDR just from taking away the pain.

In summary, available evidence suggests that cervical disc replacement is biomechanically superior to spinal fusion. In theory, total disc replacement (TDR) should decrease stress and strain on the neighboring spinal segments. But this may not be the reality based on studies done so far. In time with continued long-term follow-up, the results of fusion (ACDF) versus nonfusion (total disc replacement) surgery will be fully known.

The hope is that the number of patients who experience adjacent segment disease will decline in both groups as surgical techniques continue to improve and advance. Changes in design of disc implants will also help eliminate problems and provide better outcomes.

Can You Really Get Normal Spinal Motion After a Total Disc Replacement?

It is agreed that if you have a disc replacement, it’s better than a fusion (in terms of motion). Movement of the spine is maintained with the implant (called a disc arthroplasty. But does a disc arthroplasty provide the same kind of spinal movement (called kinematics) as the normal, natural spine? That’s what this study was intended to find out.

The authors conducted a systematic review (collecting all the published materials on this topic) and a meta-analysis (combined all the data together). They compared the results of a disc arthroplasty with anterior cervical disc removal and fusion (called an anterior discectomy and fusion or ACDF). The cervical spine refers to the neck.

The main measure of results or outcomes was change in movement at the spinal level next to (adjacent) the implant. Kinematic (movement) measurements were made by looking at overall (global) neck range of motion. Special flexion-extension X-rays were used to measure changes in cervical spine motion.

They looked at the motion at the spinal segments above and below the arthroplasty and the fusion site. There was interest in knowing if either of these adjacent areas would end up with increased stress, force, and motion.

They also looked at movement of the vertebra (spinal bone) forward over the vertebra below it. This motion is called anterior translation. And they studied changes in the center of rotation of the discs and vertebra above and below the sites of fusion or arthroplasty.

There really wasn’t any significant difference in motion at the adjacent levels between the two groups (arthroplasty versus fusion). The studies followed patients for up to two years after the surgery. Longer-term results might show a difference but this wasn’t evident in the short-term.

Likewise, there were no measurable differences in center-of-rotation or anterior translation motion between the two groups in the first two years. Observing center-of-rotation motion gives us an idea of the quality (not just quantity) of motion. And that’s important because early joint degeneration leading to arthritic changes can occur when the center-of-rotation is off. Uneven load on the spinal joints and increased pressure through the disc can occur when there is a shift in the vertebral center-of-rotation.

What they did notice was a change in alignment in the group with the disc replacement. The cervical spine became more lordotic (backwards spinal curve). But even with this change, the overall (global) neck motion stayed the same among all the patients no matter what kind of treatment they had. Small changes in global motion in both groups were attributed to decreased pain, which allowed for increased neck function.

In conclusion, studies have already shown that compensatory motion occurs at adjacent spinal levels after spinal fusion. This increase in motion is accompanied by other effects such as increased pressure on the discs, a shift in the center of rotation, and increased vibrational stress on the spine.

Total disc replacement helps avoid these effects. But as this study shows there is no major difference in kinematics at the adjacent levels after disc replacement compared with spinal fusion. There were some significant changes in alignment after disc replacement as described above (i.e., increased lordosis in disc replacement group).

The authors offer their suggestions for future studies including: 1) longer follow-up time (more than two years), 2) compare results based on different implant designs, 3) study effects of muscular contraction, pain, and pain relief on results, and 4) effect of ever changing technology in these procedures and their effect on spinal biomechanics.

Studies Come Up Short Comparing Surgical Treatment for Cervical Disc Disease

The authors of this review of surgical treatment for painful cervical disc disease describe their work as “structured” and “rigorous.” And it is truly both! Using a series of carefully layed out tables, they walk us through what they found. They did a very thorough review of published studies comparing the results of cervical spine (neck) fusion with total disc replacement.

Their search was for information on radiographic (X-ray) results and clinical pathology after these two treatment approaches. The specific focus was on adjacent segment disease (ASD) that sometimes comes after this type of treatment for degenerative disc disease.

With ASD, there is an increase in motion above and below the fused level. This occurs because when one segment doesn’t move (the fused segment), the vertebrae above and below the fused area take on more stress and load. Over time the result can be increased wear and tear in the adjacent areas of the spine.

With disc replacement, motion is preserved but adjacent segment disease (ASD) can still develop if the center of rotation for those vertebrae is altered. If the implant is not placed so that normal vertebral motion is restored, uneven wear on the spinal joints and discs can occur.

Comparing the outcomes of these two procedures by looking at the pathology that occurs in the adjacent segments is one way to guide surgeons in making treatment decisions for their patients. Studies like this that take a close look at previous studies and summarize what we know so far are very helpful. The strength of evidence can be presented along with recommendations based on that evidence.

Here’s a quick summary of the information presented through a series of five carefully constructed tables. Each study that was reviewed had to meet the criteria listed in Table one. For example, only studies with adults who had surgery for cervical degenerative disease (e.g., disc herniation, spinal stenosis, pressure on the spinal nerves or spinal cord) were included. If trauma, infection, tumors, or deformities were present in the study subjects, then those studies were excluded (left out of the review). Case series, case reports, and studies using cadavers were not included.

Table two presented more details about each study included. Number of patients, percentage by sex (male or female), follow-up length of study, and level of evidence for each study was listed in table form. There was a total of 14 studies selected based on the criteria listed in Table one.

Table three is a comparison of risks comparing total disc replacement with fusion. Table four shows the risks based on different types of disc replacement implants (e.g., Bryan disc replacement, ProDisc-C disc replacement). These two tables really highlight one of the conclusions the authors made: the studies currently published are low-quality with very few actually comparing radiographic and/or clinical results after these two different procedures. In most of the studies, the information was either not recorded or incomplete.

The fifth and final table is a summary showing the strength of evidence from these 14 studies. Three pieces of information are conveyed: 1) evidence that disc replacement has a lower risk of pathology (i.e., adjacent segment disease) compared with fusion; 2) evidence that other types of surgeries (not fusion and not disc replacement) yield better results with less pathology; and 3) evidence that there is less risk of adjacent segment disease with one type of disc replacement over another.

Their conclusions? First and foremost, studies comparing fusion versus disc replacement for cervical spine degenerative disc disease come up short. Many of these studies are conducted by companies that make the disc replacement devices. So there is a clear need for independent research. Independent means the research isn’t carried out by (or paid for) by companies manufacturing these implants.

There is a moderate amount of evidence that no difference exists in short-term or medium-length follow-up results between fusion and disc replacement. In other words, the development of adjacent segment disease is about the same after either type of treatment. But no specific recommendation can be made to guide the selection of treatment without further studies with stronger evidence.

Likewise, they were unable to offer any firm conclusions about the value or benefit of one disc replacement system over another. There just isn’t enough evidence or enough strong evidence to make such a statement. They do point out that it is difficult to perform a blind study, which would be more objective.

In a blind study, the outcomes would be measured without patients or physicians knowing who had which treatment. Since X-rays are one of the main ways to assess results, it is always clear what type of treatment was provided each patient.

And they also mention that it is not clear whether or not painful symptoms or loss of function experienced by patients after surgery necessarily comes from the adjacent segment disease. There could be other factors or variables at work that we just don’t know about or recognize yet.

This report is very valuable. By critically reviewing studies comparing results of cervical spine fusion with disc replacement, the gaps in current research show up. Recognizing the need for high-quality research with short- to long-term results measured is an important step in moving forward in developing better future studies. Developing evidence-based recommendations or treatment based on patient outcomes is next.

Cervical Fractures in Older Adults with DISH

Diffuse Idiopathic Skeletal Hyperostosis (DISH) is a condition in the spine caused by ligaments that turn into bone. Spinal ligaments along the front and back of the spine that help stabilize the spine are affected.

The ligament along the front of the spine is called the anterior longitudinal ligament. The ligament that attaches to the back of the spine is called the posterior longitudinal ligament. These are the spinal ligaments that can turn into bone in Diffuse Idiopathic Skeletal Hyperostosis (DISH).

As a result of this condition the spine becomes stiff, rigid, and more fragile in the older adult. A fall (even from ground level) can cause spinal fractures affected by this condition. In this study, surgeons from three separate medical centers reviewed their charts for patients who had a diagnosis of DISH, then fell, fractured their cervical spine (neck), and were treated surgically to fuse the spine.

Patient characteristics and results of treatment were key areas of interest. The goal was to understand this problem better and eventually develop guidelines for treatment. As it turned out, there were many surgical and medical complications associated with cervical fractures in patients with DISH. As these surgeons suspected from their experience, this group of patients were at high risk for further problems during surgical management.

All the patients in the study had a spinal fusion because the fractured spine was unstable. Ages ranged from 53 up to 98 years old. Concern for serious neurologic damage (including paralysis from spinal cord injury) was the main reason for fusion as the recommended choice of treatment. Several studies reporting on conservative (nonoperative) care for serious injuries in patients like these have shown poor results.

About half of the 33 patients in this study were fused from the front of the spine, called an anterior fusion. Another one-third had a posterior fusion (from the back). And the rest had both anterior and posterior fusions done. In all cases, more than one level was fused (some patients had as many as eight spinal levels fused).

The type of problems encountered during treatment included pneumonia, pulmonary edema (fluid in the lungs), respiratory failure, urinary tract infections, seizures, blood clots, and even death. The nine patients who died had a spinal cord injury from the cervical fracture before surgery was done. The medical complications and the deaths of all 33 patients were linked with the post-injury/pre-operative neurologic damage.

This study points out very clearly how fragile patients are who have DISH and then sustain cervical spine fractures. Despite surgery, serious disability and often death are the outcomes. Should surgery even be done for these individuals? That is a tough question to answer. Other experts who have studied this problem say these patients are at high risk for poor results but the outcomes are still better than without surgery.

The authors conclude that surgeons counseling patients and their family members must be aware of the high risk for serious complications. A second surgery may be needed. Death is always a possibility with any surgery but especially in this situation. More study is needed to improve the prognosis for this group. Future studies may also help surgeons develop a treatment protocol for managing these kinds of complex cases.

Results of Three Different Surgical Techniques for Cervical Spine Fusion

Patients faced with a fusion procedure of the cervical spine (neck) for degenerative spine disease have several options to choose from. Fortunately, the surgeon will guide each person through the process. But who guides the surgeon in selecting the “just right” or “best” procedure for the patient?

They rely on high-quality studies published in the last few years. By keeping abreast of the latest medical and surgical journals, surgeons can benefit from tips offered by other surgeons or reports of trends in treatment results.

In this study from Prague (Czech Republic) three interbody fusion techniques are compared: 1) autograft stand-alone, 2) autograft with anterior (front of the spine) plate, and 3) polyetheretherketone (PEEK) cage filled with betatricalcium phosphate and supported by an anterior plate. Each of these approaches has its own benefits and disadvantages, which the authors discuss in detail. They also provide a written description of each procedure technique (no photos or drawings included).

The main purpose of cervical spine fusion is to stabilize the spine in order to reduce pain. Each of these three methods accomplishes this task in slightly different ways. And as this study shows — with slightly different results measured at the end of two years. Let’s take a closer look.

Briefly, group one had the disc removed (discectomy) and bone graft from the pelvis packed into the front of the empty disc space. Group two had the same type of discectomy and the same graft technique but with the addition of a metal plate screwed into the front of the vertebrae. Group three had a discectomy and instead of a bone graft pack, a metal cage filled with bone material was placed in the disc space. Group three also had an anterior plate.

In all cases, the fusion was successful. That’s good! But what about the neck pain, neurologic function, and pain that typically occurs at the fusion donor site? Well, at first everything was the same among all three groups. But over time, there were some differences that developed.

For one thing, the stand alone grafts (Group one with no reinforcing anterior plating) started to lose height in the spine. This was compared with at least 10 per cent more height gained and maintained in the other two groups. In general, the overall results in group one (remember, this is the stand-alone graft without plating) were worse with lower patient satisfaction compared with the other two groups.

In group three, the artificial bone graft gave just as good of results as the two groups with real (human) bone material. That is good news because scientists have been working a long time to find a successful substitute for human bone. Substitute bone eliminates the long-term pain and discomfort that often occurs with bone graft taken from the patient’s hip.

And there’s an added benefit of interbody (between vertebral bones) cages. Cages used in between the vertebral bones support the load and maintain spine height. In this study, results were even better with the added plate along the front of the spine (present in groups two and three).

Until a better stand-alone technique is found, anterior plating will continue to be used in cervical spine fusion procedures. The goal for the future is to develop a cage or other fusion device that doesn’t require the additional plating. This would decrease or even eliminate problems with plating such as difficulty swallowing and degeneration that often occurs at the spinal level next to the fused area.

Exercises for Neck Pain

Physical therapists often work with patients who have chronic neck pain from minor injuries. Most often, serious athletes and “wanna be” athletes (also known as “weekend warriors”) are affected. These are folks with minor sprains, strains, or contusions who develop loss of motion and motor control — sometimes without realizing it. Pain and stiffness are the two symptoms noticed first.

Exercises have been developed by therapists to help improve neck mobility, endurance, and strength. In this article, one therapist from the University of Wisconsin – La Crosse provides a written and visual summary of these exercises. Photographs showing specific positions and techniques are included.

The exercises go beyond just the basic pain relief and restoration of motion and function. There are deep neck muscles that can still be misfiring or not contracting at all. Neck stability and even vision depend on the finely coordinated activities of neck muscles, eyes, and cervical vertebrae (neck bones). Exercises to improve recruitment of the cervical muscles to address these more subtle and sometimes hidden deficits are also included.

The therapist will guide individual patients through an exercise program specific to that person. It’s not a good idea to just jump into an exercise routine and go full tilt ahead. The neck is especially a sensitive and delicate area that can be easily over stretched and flared up. The author provides the therapist with some reminders and guidelines for progressing exercise intensity, volume, and frequency.

Other areas must be assessed and addressed, too. For example, shoulder and trunk muscles might be involved requiring attention. Weakness in the muscles of these structures can contribute to neck pain. In some cases, the patient holds his or her head at an angle without even realizing it. They may have lost the natural function referred to as head/neck repositioning acuity. There are exercises to improve these deficits as well.

And finally, the therapist working with athletes will prescribe exercises that are sport specific, in other words, a program that will prepare the athlete for activities required by their sport. Changing speed quickly, agility to sprint easily, and the strength and endurance needed for the entire game or set all require different exercise programs.

In summary, anyone with neck pain (whether a top athlete, weekend warrior, or nonathlete) can benefit from specific exercises to address the problems they are facing. Pain, stiffness, loss of motor control, poor muscle contraction, and even dizziness can be addressed with exercises to improve repositioning acuity and postural stability.

Trigger Points as Pain Generators in Chronic Whiplash

One way to break the pain-spasm cycle of chronic whiplash known as whiplash-associated disorders (WAD) is to treat the trigger points in the muscles. This is the finding of a new study from the University of Granada Department of Physical Therapy in Spain.

Trigger points (TrPs) are hyperirritable spots in the muscle caused by muscle immobilization (e.g., in a cast or splint or in response to pain after an accident) or overuse (repetitive motion). When active, these points create painful muscles and limited range-of-motion. Trigger points develop along with whiplash-associated disorder as a result of something called central sensitization.

Central sensitization is a hyperexcitability of the central nervous system. In other words, when present, TrPs “revv” up the engine of the nervous system and it doesn’t slow down when the foot is taken off the accelerator. But there may be more to it than that as some research has shown a bidirectional mechanism. Input from TrPs to the nervous system increase pain sensitivity and vice versa. Increased sensitivity of the nervous system to stimuli may actually create the TrPs.

To understand more about the role of TrPs in whiplash-associated disorder (WAD), this group of physical therapists compared two groups of patients. Group one had a high level of whiplash-associated disability from a car accident that occurred in the last 30 days. Group two were sex- and age-matched controls who did not have a whiplash injury.

Everyone was tested for TrPs in the neck, face, and upper shoulder areas. Active neck motion was recorded and the participants rated their pain and disability. Pressure pain threshold (PPT) was also measured on both sides of the neck at C56, the second finger, and the tibialis anterior muscle of the lower leg/ankle. Pressure pain threshold is a measure of how much pressure it takes to create a painful response. Small amounts of pressure that result in high levels of pain is referred to as pressure pain hypersensitivity.

They found four major discoveries: 1) People with higher levels of neck pain were more likely to have trigger points and more of them. 2) The number of days from the accident was a factor. 3) Decreased neck motion was linked with TrPs. But which came first (the altered neck motion and then the TrPs or the TrPs and then the decreased neck motion) remains unclear. 4) Higher pressure pain sensitivity over the cervical spine (neck) is linked with more trigger points.

These findings support the idea that active TrPs generate pain in people with neck pain from a whiplash injury. The natural conclusion is that treating TrPs may be one way to reduce pain for individuals with whiplash-associated disorder. Future studies are needed to test out this theory.

Not all face, neck, and shoulder muscles were tested in this study so further studies are also advised to search for all likely TrP areas. Other factors that must be studied in relation to whiplash-associated disorders and trigger points (TrPs) include the influence of the joints, psychologic effects from the accident, and posttraumatic stress.

What’s Happening with Cervical Disc Replacements?

Much has happened in the last few years related to disc replacements for the neck called cervical disc arthroplasty. The first FDA-approved studies on the subject have been published for three different devices: the Prestige System, the ProDisc-C system, and the Bryan disc. Since the first cervical disc replacement didn’t come out until 2007, the results so far are fairly limited. Later implant systems weren’t available until 2009, so research data is fairly limited as well.

What do we know so far? Short- and mid-term results are very favorable. Patients are able to get pain relief and return of motion and function. Results are measured using a specific Neck Disability Index (NDI) and assessment of neurologic function after surgery. A report of any adverse events, implant failures, or need for a second surgery is also reviewed.

One of the key areas of interest in these studies is the rate of adjacent-level degeneration. There is a belief and hope that disc replacement will reduce the risk of deterioration at the spinal level above and below the new disc. Disc replacements allow for continued neck motion so that force and load transmitted through the neck are not transferred to the adjacent segment.

It is believed that this scenario is more likely after a fusion procedure (compared with a disk replacement). But proving that normal neck joint motion prevents or reduces adjacent segment degeneration remains a goal for the industry.

Some experts have even suggested that the natural history of degeneration isn’t stopped by replacing the disc. Patients with degenerative disc disease seem to continue experiencing an ongoing progressive disease process no matter whether they have disc replacements or spinal fusion. It’s possible we may not be able to stop the disease but even slowing it down would benefit many people.

It should be noted that all the studies published so far were paid for and funded by the industry that makes the implants. Results should be analyzed carefully. Most of the studies done so far have compared the results of a disc replacement with the results of discectomy (disc removal) and fusion surgery. Trials comparing the cost and effectiveness of one disc device to another have not been reported yet.

In the future, we can expect to see continued changes and improvements in the technology behind cervical disc replacement. Answers are still needed to the question of whether cervical disc arthroplasty have similar problems to other joint replacements (e.g., wear and debris creating an inflammatory response).

Indications and precautions for the use of cervical disc replacements are also under investigation. Currently, anyone who is a candidate for a discectomy and fusion is also likely to do well with disc replacement. Patients with bone deformities, severe spinal joint arthritic changes, or osteoporosis (brittle bones) may be excluded from having a disc replacement. A history of prior neck surgery, bone or disc infection, and cancer metastases may also prevent a patient from having a disc replacement at this time.

Rate of Reoperation After Cervical Fusion

There is a curious observation about patients who have a cervical spine fusion procedure when those patients are part of a Food and Drug Administration (FDA) study. They have a higher reoperation rate compared with people who have a cervical fusion outside of an FDA study.

To be more specific, the cervical fusion patients in this study received the standard anterior cervical discectomy and fusion (ACDF) procedure. Two groups of fusion patients were compared. One group was part of the FDA investigational studies comparing results of ACDF (the control group) with disc replacement. The second group were patients who had the same ACDF procedure as part of their regular clinical treatment (not as a control group or experimental group).

It is suspected that just being part of an investigational study comparing disc replacement to cervical fusion is enough to produce the difference in results. In other words, being a patient in an FDA study is a risk factor for a second surgery.

Why is that? There are several theories to help explain these differences. First, surgeons working within an FDA study may be quicker to intervene when the results aren’t satisfactory. A second surgery is scheduled sooner than it would be out in a private orthopedic practice.

Second, in the FDA study, the surgeons were only allowed to make corrections at one level, whereas fusion surgeries in real clinical practice could have two or more spinal levels fused. The result is a more stable spine for the group outside the FDA and higher reoperation rates for the FDA participants.

The FDA patients who needed a multi-level fusion but only got a single-level fusion went into the procedure (and came out of the surgery) with greater instability compared with those individuals who only needed a single-level fusion and got it.

What is the value of this information? There is some concern that recommendations made based on FDA studies may direct clinical practice in error. Artifically inflated reoperation rates might lead to investigators recommending disc replacement over fusion. A higher reoperation rate in the FDA fusion group doesn’t reflect or match the reoperation rate after fusion in usual clinical practices. Just being in the control group could be the trigger for poor results. We don’t know for sure yet.

Where do we go from here? There is a need to establish some basic guidelines (“criteria”) for when someone should have a reoperation following spinal fusion. Right now, there are multiple factors that influence the decision to reoperate after the first fusion procedure. For example, the surgeon may respond more to the patient’s complaints of pain and disability than to the results seen on X-rays.

Finding a way to describe a “failed” first fusion procedure that could be used in all studies would be very helpful. If each surgeon identifies what he or she views as a “failure” but it’s not routinely the same from study to study, then the results measured in terms of reoperation rates isn’t possible. Studies are needed to establish “thresholds” for reoperation (i.e., at what point would reoperation always be recommended no matter what study the person is in?).

Although this study does not have all the answers yet, it does raise some interesting observations and suggestions about the use of anterior cervical discectomy and fusion inside and out of the FDA. Further evaluation of these differences are needed.

The Benefit of Supervised Exercise for Chronic Neck Pain

Many people with neck pain never bother to seek help or get treatment for this problem. They just muddle along year after year making the best of their situation. After all, it’s not a condition that will kill you. It takes time to take off work for the doctor’s appointments. And besides that, no one has really found one treatment method that works for everyone. The passive approach (do nothing) ends up being a common way to deal with this condition.

Despite all that, health care providers such as chiropractors, medical doctors, and physical therapists continue to explore ways to help patients with chronic neck pain. Two of the most popular treatment methods for chronic neck pain are spinal manipulation and exercise.

Research has shown us that exercise therapy works well for neck pain. Spinal manipulation is also helpful for neck pain. Would combining the two make a difference? And if so, how much more benefit is there of adding spinal manipulation to an exercise program?

To find out, a group of chiropractors, physicians, and physical therapists treated adults who had chronic neck pain with either supervised exercise therapy (ET), home exercise and advice (HEA), or exercise therapy and spinal manipulation therapy (ET + SMT).

The supervised exercise therapy groups received high-dose strengthening exercises. High-dose means many repetitions with increased resistance (load). The exercises for this group were geared toward the neck and upper body. The home exercise group performed low-dose exercises that were gentle and emphasized motion rather than strength. The home exercise and advice group also received patient education about neck anatomy, posture, and ways to reduce strain on the neck.

Results were compared after a 12-week treatment period. Follow-up was one full year. Neck pain, neck motion, and neck strength were the main measures of outcomes. Everyone in all three groups showed improvements but the exercise groups had the most gains in all areas measured.

Patient satisfaction was highest in the supervised exercise therapy group. And overall results were better for the exercise groups with or without spinal manipulation. This last finding suggests that adding spinal manipulation to supervised exercise therapy for chronic neck pain has little value.

The authors summarize their findings by saying that intense, supervised exercise may be the best way to treat chronic neck pain. Spinal manipulation does not appear to add enough benefit to be helpful in this approach. Since there was a significant response among the patients receiving home therapy and advice (HEA), perhaps it makes the most sense to being with HEA and then try supervised high-dose exercise therapy if the HEA isn’t successful. Spinal manipulation may not be needed at all.

As always, any treatment program should be provided based on each individual’s needs. Exercise therapy with or without supervision requires discipline and a long-term commitment on the part of the patient. But for those who are seeking pain relief and improved function, the results are consistent with exercise.

Patients with Cervical Radiculopathy Should Try ESI Before Surgery

Pressure on the spinal cord or spinal nerves in the cervical (neck) region can cause painful disabling symptoms. This condition is called cervical radiculopathy. Usually, it’s a herniated disc pressing on the nerve tissue that’s causing all of the problems.

Painful symptoms can be managed with medication and physical therapy. But a loss of motor control of the arm and hand (progressing to paralysis) is a signal that it’s time for surgery. For patients with pain but no other neurologic symptoms, epidural steroid injection (ESI) may be helpful and may also eliminate the need for surgery.

As the name implies, epidural steroid injection (ESI) is the injection of a numbing agent (like Novocain) and antiinflammatory (steroid). A long, thin needle is used to inject the medication into the space between the spinal cord and the lining around the spinal cord. The effect of the injection is to block pain messages. It also decreases swelling that is putting pressure on the nerve tissue.

Many studies have reported the effects of ESI for lumbar radiculopathy. There aren’t as many reports on the use of ESI for cervical radiculopathy. This study comes from Korea where 98 patients with cervical radiculopathy were divided into two groups. Everyone in both groups had one or more (up to three total) injections. One group ended up having surgery, whereas the second group did not have surgery.

The differences between the two groups were the areas of interest. Seeing how many patients had surgery and how many did not was one important comparison. Analyzing the patient characteristics between the two groups was the second main focus of the study. Having this information might help surgeons predict who would benefit from ESI before surgery. The various factors they compared included patient age, sex (male versus female), duration of symptoms, number of spinal segments involved (one or more), measure of pain intensity, and neck disability.

They found that 80 per cent of the group did just fine with the steroid injection therapy and did not need surgery after all. Only 20 per cent of the group failed to get pain relief and ended up having follow-up surgery. In some cases, ESI was helpful but either the pain came back or some patients had pain relief but not total elimination of painful symptoms. In those cases, conservative care was prescribed including rest, change in activities, medications, and physical therapy.

There weren’t a lot of differences between the two groups. But two things did stand out: 1) return of radiculopathy pain and 2) severe intensity of pain. Patients with these two factors were most likely to need surgery. None of the other factors (including imaging studies) gave any clues as to who would respond well to ESI therapy and who would need surgery.

Surgery to remove the disc and fuse the spine or replace the disc with an artificial implant was done on average six weeks after the last injection. For some patients, surgery was elected within two weeks of the start of injection therapy. For others, it was six months before surgery was performed. In all cases, the severity of pain and progression of neurologic symptoms were the deciding factors to have surgery.

The authors reported that right now there is no consensus or consistent evidence that ESI is effective for cervical radiculopathy. Their study showed that the majority of patients with cervical radiculopathy who were considered good candidates for surgery actually got much better with a less invasive form of treatment (i.e., epidural steroid injection). Unless there is paralysis or a worsening of pain and/or other neurologic symptoms, patients with cervical radiculopathy should consider ESI therapy before surgery.