News Category: Cervical Spine

It is well known that after spinal fusion, increased stress is placed on the vertebral bones, joints, and discs above and below the fusion. But what happens at all the other levels of the cervical (neck) spine when just one level is fused?

Researchers at the Department of Biomedical Engineering (University of Tennessee) studied seven adult human cadavers to help answer this question. After fusing one-single but different level in each spine, motion testing was done. A total of seven spines were used to test each level of the cervical spine.

A special motion-tracking system was used to track motion for each cervical vertebra. All six motions (flexion, extension, side bending and rotation to both sides) were measured.

The authors report the motion changes observed at each cervical level for all seven fusions. They looked for trends in motion reduction. They found that when the two lowest levels of the cervical spine were fused (C56 and C67), increased flexion and extension motion were measured at the level just above and just below the fusion.

There were differences in how the facet joints were affected. Each vertebra in the cervical spine has two facet joints on each side. Each joint is made up of two parts. The superior segment of the joint (the one on top) connects to the vertebra above. The inferior segment (the one below) joins with the vertebra below.

When the lower part of the cervical spine was fused (C5 to 7), the inferior segments of the facet joint just above were affected the most. When the upper part of the cervical spine was fused (C3 to C5), greater motion occurred in the superior segments.

Movements to the right and left were not equally affected. This may be explained by differences in tissue quality. It could also be caused by the effect of being right- or left-handed. Dominance may change movement patterns unevenly.

The authors conclude increased motion in the spine after fusion does occur and may speed up spinal degeneration at other levels. This is the first study to show specific effects on each facet joint.

In this report, the authors present the results of a series of patients treated for multiple myeloma. Each patient had metastases or cancer that had spread to the cervical spine (neck). Symptoms included pain and spinal instability. Treatment consisted of radiation and/or surgery.

Outcomes of treatment were measured by change in pain, presence of neurologic symptoms, and results of X-rays. X-rays showed if there was any spinal instability. Instability was seen as destruction of the bone and collapse of vertebral bodies. Any deformity caused by these changes was also noted.

Thirty-five (35) patients with cervical spine metastases from multiple myeloma were included. Patients ranged in age from 35 years old to 82 years. Everyone was treated at the M. D. Anderson Cancer Center in Houston, Texas.

Most of the patients (77 per cent) had radiation alone. The rest had radiation and surgery, radiation after surgery, or just surgery. Most of the operations were to fuse the spine. Everyone wore a neck collar to immobilize the neck for at least three months.

Almost all of the patients in all the treatment groups had relief of their pain. The authors point out that significant pain relief was possible with radiotherapy alone. Radiation was able to stop the bone destruction. In some cases, bone healing and bone remodeling took place.

Many patients with terminal cancer have spinal metastases. It is helpful to know that radiation can help reduce pain and stabilize the cervical spine when it is affected in this way. Treatment may be able to prevent fractures and deformity leading to an unstable cervical spine. Surgery may not be needed after all.

Neck pain patients often have chronic disorders of the cervical spine. Whiplash injuries and degenerative changes associated with aging are the most common causes. Treatment is usually focused on decreasing pain and increasing range of motion (ROM). Finding an accurate and reliable way to measure change in ROM is important to assess the results of treatment.

Total neck ROM is made up of six directions including flexion, extension, right and left rotation, and right and left side-bending. In this study, total cervical ROM (all six motions) was tested and retested in two groups of patients. Both groups had chronic disorders of the cervical spine.

Group one (whiplash) and group two (degenerative changes) both had a 25 to 35 percent decrease in total cervical ROM. The results showed a major decline in all directions compared to healthy adults of the same age.

The authors suggested the reason total ROM was less in both groups was because of pain rather than any difference in anatomy or neck structure. They suggest total cervical ROM can be used as a measure of treatment success in both whiplash and cervical spine degenerative disorders.

Any changes observed represent actual change and not an error in measuring. A difference of five to 10 degrees may occur as a testing error. But a 20 to 25 degree change observed in these patient groups is an indication of real limitations.

Predicting who might have a poor outcome after a whiplash injury is the topic of this study. Patients with acute whiplash injury were included.

In a previous study these same researchers showed that pain and disability levels at the time of the accident weren’t enough to predict symptoms six months later. Both physical and psychologic factors were important predictors. More information was needed to guide early treatment. They continued following this same group of patients for another two to three years.

They found that older age, reduced cold pain tolerance, and symptoms of post-traumatic stress syndrome (PTSB) were good predictors of future moderate-to-severe pain levels. More than half the patients had neck pain, headaches, and shoulder/arm pain six months after the accident. Almost 80 percent of those patients were still the same two years later. Only a small group recovered completely. The rest of the remaining 20 percent had mild improvement.

The authors conclude that it may be possible to predict which whiplash patients will fail to recover. Physical and psychologic changes noticed one month after the accident were still present six months later. The same symptoms were still present two or three years later.

Whiplash patients should be assessed right away for the presence of these predictive risk factors. Early management to prevent chronic pain is advised. Treatment should include many options such as drugs for pain management, physical therapy, and counseling.

Managing severe cervical spine (neck) injuries can be improved with a reliable classification system. Such a system would help doctors describe the injury, plan treatment, and predict the outcome. Should the patient have surgery? Are neurologic problems likely? What’s the prognosis?

In this study, a new classification system is presented based on morphology and stability. Morphology refers to form and structure. In the case of cervical spine injuries location and type of injury are described as part of the morphology.

For example anterior or front of the spine injuries include fractures, disc herniations, or disc distraction. Lateral or side of the spine injuries affect the joints called facets. The joints can be fractured or dislocated. The discs may be distracted or herniated to the front, side, or back. Posterior or back of the spine can include bone fractures and trauma to the disc, but also damage to the ligaments.

In order to measure stability after cervical spine trauma, a special tool was developed called the Cervical Spine Injury Severity Score. The score reflects bone and ligament injury. It doesn’t include neurologic function. Each column or side of the spine is scored separately. Then each column is added together for a total sum to describe stability. The more severe the injury, the less stable the spine is.

The authors say the tool is easy to learn, reliable, and can be used with all types of fractures. It can be used in many different settings such as the emergency room, research lab, or during the healing process.

In this report from England, doctors describe the case of an 80-year old woman who lost consciousness from large cervical osteophytes (bone spurs in the neck) pressing on her windpipe and cutting off her air.

She was rushed to the hospital where an MRI showed the cause of the breathing problems. Surgery was done to remove two large bone spurs pressing on the larynx (voice box) and the pharynx (throat).

Complete relief of symptoms gave proof that the osteophytes were the cause of laryngeal spasms. She reported having a history of problems breathing whenever she flexed (bent) her head forward. She had learned to avoid this position. But on the day of the accident she had a severe laryngeal spasm as she was getting out of her car. Her head was flexed and she was without oxygen causing a black out.

The authors report this is the only case study of its kind. Other cases of difficulty swallowing and altered breathing have been reported linked with cervical (neck) osteophytes. Cervical MRI was very helpful in making the diagnosis.

It’s not clear if her symptoms were caused by irritation of the laryngeal nerve and soft tissues around the throat or if the airway was kinked because of the pressure. Either way, her symptoms weere completely gone even up to three months later.

Many treatment methods have been used to help patients with chronic pain for a whiplash associated disorder (WAD). Injections with steroids, BOTOX, or a numbing agent have not been very helpful. This study reports on the use of cervical radiofrequency neurotomy (CRFN).

CRFN is the use of heat generated by radio waves to interrupt nerve pathways and stop painful symptoms. All patients enrolled in the study had been in a car accident. They were all treated conservatively but still had pain at least six months after the injury.

Factors used to measure success of the CRFN treatment included cervical (neck) range of motion and cervical muscle strength. Patients were also asked to rate their own satisfaction with the results. Patients had a decrease in pain level and an increase in motion. The authors suggest that less pain meant a greater release of muscle tension freeing up joint motion.

Overall patients treated with CRFN for chronic neck pain after a whiplash injury had a positive trend of improvement over time. Patients were satisfied with the results because they had improved function. This study agrees with the results of other studies suggesting a benefit from CRFN for WAD.

Successful fusion of the cervical spine remains a challenge for surgeons. In this study, results of fusion with expandable cylindrical cages (ECCs) are presented. Twenty-two patients with cervical stenosis and severe kyphosis were included. The fusion rate at follow-up 18 to 34 months later was 100 percent.

Cervical stenosis is a narrowing of the spinal canal where the spinal cord is located. Many different conditions can cause this to happen. Cancer, car accidents, and disc bulges are three examples from patients in this study. Kyphosis is the forward curvature of the spine. This type of deformity is common with spinal stenosis.

ECCs are a new variation on titanium mesh cages previously used for spinal fusion. Since the ECC is expandable, the size and fit can be adjusted. The ECC matches the hole left when the vertebral bone is removed as part of the fusion operation.

With a 100 percent fusion rate, the authors suggest ECCs are a good choice for anyone having cervical fusion for stenosis and kyphosis. The ECCs are easy to insert and cause less trauma to the vertebral endplates. They can be used for up to three level fusions. However, surgeons are advised to use posterior instrumentation for multilevel fusions.

ECCs cost more but the results are likely worth it — better fusion rates, improved alignment, and fewer problems afterwards.

Anterior cervical discectomy and fusion (ACDF) is one way to treat an unstable cervical spine. The operation is done from the front (anterior) of the neck to avoid the spinal cord and nerves. The disc is removed and bone graft, plate, or cage is used to fuse the spine at that level.

In about six percent of the cases, the fusion doesn’t work. If movement remains at the level of the fusion it’s called a pseudoarthrosis which means a “false joint.” The spine is unstable and may cause problems for the patient. What’s the next step?

In this study surgeons compared two operations for this problem. The first was a repeat anterior (revision) surgery. The pseudoarthrosis is removed. Bone graft taken from the patient and metal plates are used to re-fuse the spine. The second was a posterior (from the back) fusion using wires, plates, or a screw-rod system.

Both of these operations have good and bad points. The anterior revision must cut through the old scar tissue. There’s a risk of injuring nerves and blood vessels. The esophagus and trachea are also at risk. Posterior fusion requires a longer hospital stay. There’s also more blood loss during the posterior fusion operation.

The overall advantage of the posterior fusion is a lower second revision surgery rate. Almost half of the anterior revision group still had a nonuninon. The fusion failed and another operation was needed. Posterior fusion with its high fusion rate (98 percent) and low failure rate (two percent) may be the best way to treat ACDF nonunion.

Minimally invasive surgery (MIS) of the cervical spine (neck) is limited to the lab for right now. The cost of new technology to accomplish this must be matched or exceeded by benefits. In this study scientists use three-dimensional (3-D) fluoroscopy (X-ray imaging) to place cervical spine screws. This technology allows the surgeon to use small incisions through the skin. This is called percutaneous placement.

This type of operation is already being used in the lumbar spine. But using MIS in the cervical spine is a little trickier. Standard fluoroscopy doesn’t always show the details of the bones. The smallest mistake could result in nerve or spinal cord damage. That’s why practicing this technique on cadavers is important before trying it on live patients.

The new 3-D fluoroscopy is combined with computer assistance. It gives the surgeon anatomic views in 3-D to guide the placement of screws. The goal is to improve accuracy and reduce complications. The imaging machine is a C-shape arm that can be rotated in a 190-degree arc around the patient. The surgeon uses a foot pedal to move the arm.

One incision site was used to place screws at two spinal levels. A drill guide was inserted through the soft tissues into the bone using the 3-D technology. Screws were passed through the guide. Intraoperative scans showed that 41 of the 42 screws were accurately placed.

The authors say this new technology has many advantages over standard CT imaging. It is more efficient because it allows the surgeon to skip some steps in the operation. The scan automatically transmits images of all the vertebra instead of one at a time allowed with standard CTs.

Navigation error is reduced with 3-D fluoroscopy because the patient can be scanned in the desired position for surgery. Images are available for viewing right away. Cost and training time are the two biggest drawbacks. More study is needed to define the best use of this new technology.

As with any sport that involves speed, equipment that can fail, and outdoor trails, serious injury can occur with mountain biking. In this study three cases of cervical spine injury and paralysis are presented.

In all three cases, male mountain biker’s went forward over the handlebars. Each one hit the ground helmet first. In one case the impact split the helmet in two pieces. Damage to the helmet was evident for all three riders giving some idea of the severity of the injuries.

Cervical spine fracture with damage to the spinal cord left each biker paralyzed from the neck down. Although the helmet protects the head, it does not prevent injury to the vertebral column.

All three cases could have been prevented. One biker’s front wheel fell off during a downhill ride. Another rider lost his balance. The third rider hit an unexpected and unmarked drop of five feet on the trail without any notice. Warning signs should have been left by the crew working on the trail.

The sporting community must be made aware of the dangers of mountain biking. Acute cervical spine injury leaving riders paralyzed is an unacceptable outcome of recreational or sporting activities. Going too fast for the conditions, equipment failure, riding beyond one’s ability, and inattention are all under the control of the rider. Education may be the key to reducing serious neurologic injuries from mountain biking.

Despite parents’ warnings not to dive into shallow water, diving accidents still happen. Diving injuries affecting the cervical spine are the most common. Most of these accidents are caused by impaired judgment associated with alcohol. In this study doctors review 20 cases of diving injuries that occurred over a 34-year period. Long-term results of treatment are presented.

Diving head first into shallow water can cause an impact injury to the head and neck. Spinal cord injury with paralysis and even death are common after this type of reckless behavior.

The type of fracture, neurologic status, and general health are used to determine treatment. In these 20 cases, four patients had surgery to fuse the spine. The rest of the patients were treated with spinal traction and steroids. The drugs were used to prevent further spinal cord damage caused by swelling in the spinal canal.

There were five deaths in the first month after the diving accidents. One other patient died during the first year after the injury. Half the patients made improvements within five years. The other half remained unchanged. After 10 years one patient improved and one was worse. The rest stayed the same.

This series shows that conservative treatment can lead to improvement early in the recovery process. The final results depend on how severe the initial injury was. The authors stress the need for public education about water safety. Alcohol-related diving accidents are preventable.

Chronic neck (cervical) pain from degenerative disc disease (DDD) is sometimes treated with an operation to fuse the bones together. First the damaged disc is removed, and then the bones are fused. This is called an interbody fusion. The best way to fuse the cervical spine remains under investigation.

In this study 100 patients with 127 cervical levels of DDD were treated and followed for at least 12 months. Patients were divided into two groups. Group 1 (the ICAG fusion group) had a fusion using bone graft taken from the iliac (pelvic) crest.

Group 2 (the RTC group) had a rectangular titanium cage inserted in place of the disc. Usually the cages are filled with bone chips or other material. In this study the cages were left empty.

The results of this study showed that both fusion methods are safe and effective. Both had equally good results with one exception. The ICAG group had more overall pain at the neck and at the donor site. Neck and arm pain were better in the RTC group but neck pain didn’t go away for one-third of the RTC group. The RTC group had no donor site so their overall pain was less making this method slightly more advantageous for the patient.

Neck pain and headaches are common after whiplash injuries. Symptoms can last months to years. The exact injury mechanism is still unknown. Researchers have shown it’s not damage to the muscles or nerves. In this study scientists test the lower cervical (facet) joints as the possible source of chronic pain.

Cadavers were used to compare the load placed on the facet joints at the C4-C5 level. A special testing device was used to extend the neck with compression to mimic normal motion and whiplash injuries. Loading conditions for normal motion was compared to load during whiplash. Motion was measured for these two circumstances, too.

They found that when the neck was extended, the facet joints moved faster and with greater shear force under whiplash load. Although the segment didn’t extend more between normal and whiplash conditions, the amount of facet joint motion increased with whiplash. They also saw that the increased facet joint motion causes greater joint capsule distortion along the front of the spine.

The authors say this is the first study to show in measurable terms the impact of whiplash on lower cervical facet joints. There’s too much shear motion for the amount of extension.

Abnormal loading does affect the joint and the joint capsule. Joint capsule strain can result in chronic, painful whiplash symptoms.

Scientists are working to find ways to replace titanium plates used in cervical fusion. They are looking for something that the body can absorb later. In this report researchers review the current anterior cervical plates (ACP) used. They also give the results of a new bioabsorbable ACP used in seven human cadavers.

Currently titanium plates are used in many cervical fusions. Titanium plates give good stability. Some studies suggest there’s too much fixation with titanium. They say this because increased arthritis occurs on either side of the fused segment when titanium is used. They do have a low rate of infection, fracture, and loose screws. It is hard to get a good MRI scan of the surgical site with the plates in the way.

The authors point out some basics that a new type of plate must have. It must have better fusion rates than when bone graft is used by itself (otherwise, why bother adding the plate?). It must stay in place and not shift or move. The plate must hold up under its share of the load while the fusion is taking place.

Beyond that, a bioabsorbable plate must be resorbed by 18 months. MR imaging must be able to “see” through it. In other words, the implant is transparent. It has to hold up under stress and load while the plate and screws bend and then disappear during the resorption process. Finally nothing should be left to block the segment from moving above or below the fused site.

The MacroPore plate tested was made out of resorbable polylactide polymers. Results were compared to titanium plates and the MacroPore mesh plates. The authors report the new MacroPore ACPs can resist load as well as metal plates and better than the mesh plates. The results didn’t show if the MacroPore ACP can give the same amount of stability as the titanium plates. More studies are needed before results are final.

It’s easy to see that patients with chronic whiplash have less motion than normal, healthy adults. But when does normal neck motion become abnormal? What are the cut off limits? And what is a typical profile for whiplash injured patient? In this study physical therapists try to define typical and unusual or “atypical” neck (cervical) motion in patients with chronic whiplash (CW).

Six cervical motions were measured in 101 patients with CW. The results were compared to 75 healthy adults. The CW patients had much less overall motion. The researchers were unable to find a cut off point between CW patients and healthy subjects.

Atypical patients had very little (less than 10 degrees) of motion in any direction. The results also showed a greater decrease in motion in men and older adults in both groups compared to women and younger adults. Patients with atypical motion had extreme personality and functional changes.

Fear of pain or reinjury may keep CW patients from moving the head to the end range of motion. The authors suggest a complete behavioral test for anyone with atypical motion. This is needed before the best treatment can be decided.

If you’ve already had neck surgery but the pain in your neck comes back, what are your options? Surgeons are starting to look at using artificial discs, an operation called cervical arthroplasty. These are the early results of one study.

Fifteen (15) patients with neck or arm symptoms from cervical disc disease already had at least one operation on the cervical spine. The Bryan artificial disc was implanted. Most patients got one disc but a few needed disc replacement in up to three levels. All discs were inserted anteriorly (from the front of the neck).

All patients did well after surgery. There was an overall improvement in symptoms compared to before surgery. Almost everyone said the surgery was worth it, and they would do it again if given the choice over again. The authors review in detail each patient who had problems of any kind.

The authors conclude that artificial discs can be used for the neck even after previous operations in the same area. Patients who’ve had cervical fusion with new symptoms from the disc above or below the fusion seem to have the best results. Younger patients are ideal candidates for this operation.

Surgeons at the UCLA School of Medicine report on 33 patients who had a failed anterior cervical (neck) fusion. Movement at the fusion site called pseudoarthrosis caused continued neck and arm pain. They all had a second operation to fuse the same level from the back (posterior). Reported results of this treatment for pseudoarthrosis are few and far between.

The first operation done was called an anterior cervical discectomy and fusion (ACDF). The disc was removed and bone graft used to fuse the spine. Motion of the facet joints at one or two levels (seen on X-rays) showed the pseudoarthrosis.

After the posterior operation the authors report a solid fusion in all 33 patients. Everyone had some improvement in his or her painful symptoms. But about half the patients still had pain. Almost one-third of that group reported severe pain.

The authors say the debate goes on about which is better: anterior versus posterior revision fusion. Theirs is the largest study done so far using posterior fusion after ACDF. Although the fusion was successful, patients didn’t always get the pain relief desired.

This report offers a detailed review of rheumatoid arthritis (RA) affecting the neck (cervical spine). Many patients with RA of the hands and feet also develop changes in the neck. Instability of the spine can lead to neurologic signs and symptoms, including sudden death.

Doctors who know about this pattern of disease progression can keep an eye on it with X-rays. Surgery is advised when the patient’s neurologic condition gets worse. Other reasons for surgery include constant, severe pain with spinal instability. The authors also point out specific risk factors that doctors must watch for on X-rays.

Type of surgeries and expected results for cervical problems are reported. Patients with RA are complex because the disease affects many systems in the body. Patients become malnourished and run down, making surgery more difficult

Treatment without surgery is also discussed. A soft cervical collar may help some patients but it doesn’t change the underlying problem. A program of education, physical therapy, collars, practical aids, and drugs may work best.

New drugs to limit the disease may change the course of RA. Studies also show early surgery is better for some people than waiting. Patients with the best preoperative status have the best recovery and results after the operation.

The authors make a final point that surgical treatment of an unstable neck from RA can be very difficult. Patients must be selected carefully. Special surgical methods are used. An experienced spinal surgeon is best for these patients.

Many studies have reported the results of cervical spine (neck) fusion. This is the first report of results from the operation done on an out-patient basis.

Thirty (30) patients were treated at the ambulatory surgery center with an anterior cervical discectomy and fusion (ACDF). The results of their treatment were compared with a control group. The second group of 30 patients had the same surgery in the hospital with an overnight stay.

All patients had a disc problem in the cervical spine. The ACDF consists of removing the disc, putting a bone graft in the empty space, and attaching a metal plate in front of the bone.

The outpatient group had fewer complications. The authors think this is because of the careful selection process for these patients. They conclude ACDF is yet another of the many orthopedic procedures that can now be done on an outpatient basis.