News Category: Cervical Spine

Every 10 years or so there’s a giant leap forward in the world of spine surgery. The most recent leap ahead has been development of the artificial disc. This new treatment may be as important as the first joint replacements done years ago.

Researchers around the world are studying disc replacement. Some scientists are looking at its use in the the low back, or lumbar spine. Others are exploring its use in the neck, or cervical spine. In this study, an orthopedic surgeon used the artificial disc in seven patients. Each patient had pressure on the spinal cord in the neck from changes in the bone. This condition is called cervical spondylotic myelopathy.

In the past, doctors would work from the front of the spine to take pressure off the spinal cord. The procedure is called anterior decompression. In anterior decompression, the disc is removed, and the doctor puts traction on the neck to pull the space open further. The spine is then fused with bone graft and a metal plate and screws. This is called a strut graft fusion. Problems with this method of treatment led to the development of the artificial disc.

In this study, anterior decompression was still done first. Then one or more artificial discs were put in place. The author of this study reports good post-operative results. All seven patients showed improved arm and neck symptoms. Good neck range of motion was seen on imaging studies. Smokers in the group had the same good results as nonsmokers. For all patients, the disc height wasn’t as high as when using a strut graft fusion.

The authors think cervical decompression with artificial discs may usher in a new era for care of the cervical spine. Long-term results will be reported as more research is done. The use of artificial discs for more than one level at a time will be explored next. For now, we know these devices can be used when there is pressure on the spinal cord in one or two levels of the neck.

A herniated disc in the neck can cause pain and loss of motion and strength. Surgery to remove the disc and fuse the problem part of the spine is one way to help relieve pain and improve function.

A group of doctors in Finland studied patients after anterior cervical discectomy and fusion. This surgery is done from the front (anterior) of the neck. A painful disc is removed, and the vertebrae just above and below are fused.

Physical therapists measured muscle strength, range of motion, and grip strength. All measures were taken before and after surgery. Two groups were included: a group of patients who had the surgery, and a control group. There were 53 people in each group. The control group had subjects of the same age, sex, weight, and height as the patient group. Control subjects didn’t have any neck pain or disc problems.

Before the operation, 89 percent of the disc patients had altered sensation in the arms. Other signs of nerve compression were also reported. After the discectomy the patients had much less motion and neck strength than the control group. Almost half had continued pain. There was no difference in grip strength between the two groups.

The authors conclude that loss of motion wasn’t just caused by pain. They think the fusion (designed to limit motion at that segment of the spine) added to the loss. It’s possible that other disc problems and wearing a collar after the operation also reduced neck motion.

Just over half of the patients (57 percent) recovered after disc surgery. This left many patients still suffering from chronic neck pain. They had decreased neck motion, strength, and function. The researchers think early screening may be needed. And they suggest that the benefits of a rehab program for these patients needs to be studied.

Mild whiplash injuries usually heal quickly. But some whiplash patients develop headaches, dizziness, pain, and vision problems that can go on for a long time. Balance control is especially affected. Balance control is complex. It involves the eyes, the inner ear, nerves, connective tissues, and muscles. Doctors would love to have a test to help determine whether balance problems are caused by whiplash or by some other condition. Many whiplash patients were injured in car crashes or on the job. That means insurance companies and employers would like to have a test, too.

These authors wanted to see whether whiplash patients walk differently than healthy people. The authors have done studies that showed differences in the walks of older people and patients with Parkinson’s disease. So the authors put whiplash patients and healthy people through the same tests. Everyone did specific walking, balancing, and climbing tasks. Some tasks involved moving over and around objects. Some tasks involved rotating the head while walking. The tasks were done with eyes open and closed.

When the authors studied the motion patterns, they found some major differences. Whiplash patients had more body movement while they walked up and down stairs. The whiplash group had more sway while they balanced in certain positions with open eyes. When they walked while rotating the head, they had less sway. The whiplash group also rotated their heads less.

The idea behind the head movements was to create extra visual information for the body to process. The results suggest that whiplash patients have problems coordinating information from their eyes with information from the rest of the body.

The authors judged the tests to be very accurate in identifying whiplash patients. They had different walking motions than healthy people. Whiplash patients also had different walking motions than elderly people and people with Parkinson’s disease. This may be a first step in finding a test to pinpoint the balance problems of whiplash.

Have you ever heard of neurogenic cervicobrachial pain? You may not recognize it in medical terms, but in plain English you know it as neck and arm nerve pain. If you have it, all you really want to know is how to get rid of it.

Physical therapists can help by applying controlled movements to your neck joints. These motions are thought to free up the painful nearby nerves. Studies to measure the effect of this type of movement on nerve injuries are rare. Therapists at the University of Queensland in Australia have made an attempt.

During any movement of the neck and arm, the nerves slide and glide through the soft tissues around them. When the nerve gets stuck or bound down, it’s called neural entrapment. The result can be nerve pain and loss of motion.

The goal of this study was to measure the immediate effects of two different treatment methods for patients with neck and arm pain from nerve entrapment. One method included controlled movement of the neck joints called mobilization. The other method used ultrasound, a form of deep heat applied to the sore tissues.

After each treatment was applied, elbow motion (extension) and pain levels were measured. The authors report major differences in results between these two treatments. No improvement occurred with the ultrasound. However, increased elbow extension and decreased neck and arm pain were noted after the mobilization treatments.

The authors suggest that even small amounts of pressure on the nerve can cause painful symptoms. Loss of motion in the neck may be to blame for these symptoms. Restoring the motion of the joints within the neck is thought to free up the nerve, allowing for normal nerve function.

By improving neck movement with mobilization, pain is reduced and arm motion is increased. The authors conclude that mobilization is an effective treatment for patients with neck and arm pain, even when neck motion is limited at one or more levels.

Doctors in Germany have found a new way to do surgery on some neck problems. They use a tiny incision and a special device that gives them a 3-D (three-dimensional) view. This minimally invasive operation is done on the back (posterior) side of the neck. Disc degeneration and stenosis are the main problems treated with this surgical method.

Disc degeneration describes changes within the disc from wear, tear, and aging. Stenosis is a narrowing of the spinal canal, the opening through which the spinal cord passes. Bone spurs and a thickening of a nearby ligament can narrow the spinal canal. These are common changes with aging.

This new operation allows doctors to spare the muscles from damage. A small opening is made in the skin and tissue under the skin. The soft tissue on either side of the cut is spread apart gently. Then a special tool called a channel is inserted into the opening.

The channel comes in three lengths. It can be redirected and tilted to give the doctor a better view–all in 3-D. The neck muscles remain intact. This means that the patient doesn’t need any type of neck support after the operation.

Neck movement can begin as early as four hours after the surgery. Early mobilization means fewer problems. In this study, four patients had total recovery from their symptoms after the operation. The other eight patients were better. They noted less pain and fewer neurological problems.

The authors report that this new approach gives the doctor a good view inside the neck. There is no damage to the muscles or nearby soft tissues. It only takes about an hour to operate on each segment. And only one suture is needed to close the opening.

The new minimally invasive approach to posterior cervical spine stenosis expands new options for surgeons who perform neck surgery. The authors of this report suggest that severe stenosis continue to be treated with the usual open incision.

Would you like to know what the medical world uses for a crystal ball? It’s called predictors of outcome. In some cases, it’s possible to tell ahead of time who’s likely to have a good result after surgery and who isn’t. Having some kind of ability to predict outcomes is important for operations that often have a poor result. This study reports the predictors for anterior neck fusion.

This operation is done from the front of the neck. Part of the bone is removed, and the spine is fused at that level. This procedure is called anterior cervical decompression and fusion (ACDF). Two ways of doing the operation were included in this study. Many patients still have symptoms after an ACDF no matter how it’s done.

The researchers first looked at ways to predict pain relief. They also included predictors of improvement. They gathered data on gender, pain, and use of drugs for pain. Information on pain included how long the patient had pain, location of pain, and levels of pain. Smoking history, age, education level, and type of work were also recorded.

The results show that older men who werenonsmokers and had a larger kyphosis have the best chances of pain relief after ACDF. Kyphosis is another word for a forward curve of the spine. Sometimes severe kyphosis is known as a hunchback.

Improvements were also based on schooling, pain level, smoking status, and grip strength. Patients with more schooling, lower pain level, and stronger grip strength had better results. Nonsmoking patients also had better outcomes. There was also a strong link between pain intensity before and after surgery with what the patient could do after surgery.

The authors conclude by noting how important it is to preview patients before doing ACDF. Each patient must be screened for factors linked with failure or poor results. Improving patient selection in ACDF is the goal. The patient’s pain is the most important factor for predicting overall result.

The top two bones of the neck fit together like a horseshoe around a spike. The upper bone is in the shape of a ring. It fits around a cone-shaped projection in the second vertebrae, called the dens.

The skull rests on top of the spine with two contact points. The connection between the head and the neck is called the occipitocervical junction. Most of the strength and stability of the occipitocervical junction come from the interlocking of the cervical bone around the dens. A network of ligaments gives added support.

Damage or injury to the dens or surrounding ligaments can cause serious problems. When the junction becomes unstable from disease or injury, it can cause paralysis, disabling pain, and even death. Surgical fusion to relieve pain and provide support is often needed. There are many ways to fuse this area. An operation is done to insert a plate, screws, rods, cables, wires, or a bone graft.

Researchers are looking for a better way to get rigid fixation. Doctors want something that can be used anywhere along the cervical spine. Scientists from the Biomechanics Laboratory at the Mayo Clinic in Rochester, Minnesota, report several studies in this area. The most recent one looks at a new rod and screw system.

The new rod system was compared to two standard methods of securing the occipitocervical area. The study was done using 12 cadavers (bodies preserved after death). Total range of motion and amount of stiffness were measured for each vertebral level. Six different loading conditions were used.

The authors report that fusion of in this part of the neck is a challenge. The best way to do fusion depends on the type of problem and cause of instability. The quality of the patient’s bone is also a factor. They conclude that the new rod-based system is equal to or better than the plate-and-screw or rod-and-cable systems already in use.

Ever wonder what goes through the mind of some scientists? It’s often more than the average person can follow, but sometimes the results can still benefit us. These researchers in Rhode Island asked three questions they wanted to see answered.

Their work centered on the best way to fuse the neck. Bone graft, bone graft with a metal plate, a supportive cage between the bones, and cage with a plate were all compared.

Here’s what the researchers looked for:

A group of doctors in Turkey found a vertebral artery loop formation (VALF) in a patient with neck and upper arm pain. When they started looking for this problem in every patient with both neck and arm pain, they were surprised by what they found.

The vertebral artery is a main blood vessel on either side of the neck. It brings blood to the deep muscles of the neck, the spinal cord, and the cerebellum in the brain. The vertebral arteries are aligned straight up and down, but a kink or loop can form that reduces blood flow to the area. Some people with VALF don’t have any symptoms at all. But some patients experience neck and arm pain and, sometimes, dizziness, numbness and tingling in the hands, or a loss of balance.

Previous studies report that two or three people out of every 100 people have VALF. The cause is unknown. It could be the result of trauma, atherosclerosis, or high blood pressure. Some people may just be born this way.

The authors of this study think the rate of VALF is much higher (about 7.5 percent) in patients with painful neck and arm symptoms. They suggest a closer look at patients with neck and arm pain or symptoms. VALF may be the hidden cause of their problems.

Three-dimensional magnetic resonance angiography (3-D MRA) is the best way to diagnose VALF. Surgery isn’t always needed. Treatment with physical therapy for each VALF patient and drugs for those with hypertension show a positive outcome.

Who do you see for neck pain and stiffness? Many people rely on chiropractors to adjust (manipulate) the spine and get relief. Before manipulating the neck, the chiropractor tests the joint motion. Manipulation is a common form of treatment that is used when the joint doesn’t have full motion.

Various health professionals, including chiropractors, medical doctors, and physical therapists, use a term called endplay to describe the motion in a joint at its end range. When a joint doesn’t move smoothly all the way through its full motion, we say the joint’s end range is restricted. The clinician uses his or her hands to feel the joint motion. If there is end-range stiffness or loss of motion, joint manipulation may be used.

This study questions this method of deciding when to manipulate a joint. Chiropractors in private practice teamed up with the research department of Western States Chiropractic College in Oregon. They divided patients into two groups: a study group and a control group.

The study group received manipulation based on endplay. The control group also received manipulation, but the decision was based on a pretend computer exam. In the control group endplay wasn’t used as a test measure. Each patient was treated by a chiropractor one time. Neck pain and stiffness were measured before and after manipulation. Another follow-up was done at least five hours after treatment.

There was no difference between the groups. Both had improvement in neck pain and stiffness. The authors conclude that manipulation has a general effect to relieve symptoms. The success of the treatment may not always depend on joint motion.

Ever wonder how it is you can nod your head, tilt your face to the sun, turn and look behind you, and hold the phone between your ear and shoulder? Half of your head’s ability to turn and a good portion of your ability to bend and extend the neck come from the atlantoaxial (AA) joint. That’s where the first vertebra (C1) meets the second vertebra (C2) at the base of the skull.

Anything that can affect the joints or ligaments in this area can seriously disrupt motion. Too much motion in this area is called atlantoaxial instability. (AAI). The most common causes of AAI come from:

This is the first study to look at the number and type of problems after neck injections using a fluoroscope. In fluoroscopy, a video X-ray image guides the doctor in placing the needle. By injecting a dye into the covering that surrounds the spinal cord, the doctor is able to guide the needle into the exact spot and not the nearby tissue or blood vessels.

All patients had neck pain that goes down the arm. This condition is called cervical radiculopathy. For these patients, the cause of their symptoms was either a herniated disc or cervical spondylosis. Cervical spondylosis is a general term for joint damage in the neck that occurs over time from osteoarthritis. The nearby ligaments, soft tissues, and discs are also affected.

Each patient had one or more steroid injections. Most patients had two injections. Problems occurred in just under 17 percent of the patients per injection. Increased neck pain at the injection site was the most common symptom after injection. Other symptoms included headache, difficulty sleeping, and facial flushing. Rarely, meningitis, breathing problems, or arm weakness occurred.

According to this study, none of the complications was linked to patient age or the number of injections. Whether a lawsuit is pending doesn’t seem to affect the outcome either. No one had more than one complication per injection. All problems went away without the need for a hospital visit or further treatment.

The authors conclude that fluoroscopically guided injections to the epidural space of the cervical spine are safe and effective. Used for patients with cervical radicular pain, these injections have a low number of problems that generally go away without treatment.

Whiplash injury after a car accident remains a mystery. Some people have it; some don’t. What’s the difference between these two groups? Researchers in the Netherlands conducted a study to see if the difference has to do with styles of coping. They identified four different coping styles: social support coping, palliative reaction coping, expression of emotions coping, and active-handling coping.

Social support coping occurs when the victim seeks social comfort and understanding after the accident. This person shares concerns with others and tends to a have shorter duration of neck pain.

The palliative reaction style describes people who seek distraction and avoid thinking about their problems. They may try to feel better by smoking, drinking, or relaxing. People in this group typically have neck pain for a longer time.

Victims who show their anger have longer duration of neck pain. They fall into the expression of emotions coping style. The palliative reaction and expression of emotions styles are linked by feelings of fear and inadequacy.

An active-handling coping style is the style chosen by people who deal with a stressful event by getting right back to “business as usual.” They don’t let symptoms stop them from normal activities.

The researchers report the following results from this study:

In the real world, most people get whiplash injuries in a surprise rear-end collision. In the laboratory, most subjects know that a crash is coming. Does this make any difference in the results? These researchers designed a study to find out.

The subjects in this study were divided into three groups. All groups knew they were taking part in a whiplash study. But one group got a countdown to the rear-end crash, the second group knew a crash would happen sometime in the next minute, and the third group got crashed into before they expected it.

The researchers measured the muscle response and head movement of all the subjects. The results showed that the surprised group showed much less muscle tensing and much more head movement than the other groups. And women tensed their muscles less and ended up with worse whiplash then men.

The results fit in with what doctors see in real-life whiplash injuries. Women tend to have worse whiplash injuries, and people who see the crash coming tend to have fewer injuries than people who are caught unaware. The results also suggest that past studies may underestimate the extent of whiplash that happens in real collisions, since those subjects all expected a crash.

This study is important because doctors don’t completely understand the way whiplash affects the spine in the neck. It could help researchers design studies that better reflect the way whiplash really happens in the real world.

Much debate continues about the best way to do surgery on the neck (cervical spine). Should the surgeon go through the front (anterior) or back (posterior) of the neck? This study reports the pros and cons for both and reviews the results of 19 patients treated with the posterior method.

Neck, arm, and hand pain can occur as a result of problems in the cervical spine. Aging or injury can cause damage to the discs between the bones (vertebrae) of the neck. The disc may push out of its space and press against the spinal cord or spinal nerve roots. Besides severe pain, the patient may have numbness, weakness, and loss of hand and arm function.

When all other treatments fail, surgery is an option. The disc can be removed and the neck fused in place. This is when the doctor must decide to work from the front or back. The anterior approach works well for the middle section of the cervical spine. But positions high up (near the skull) or down low (at the shoulder level) pose some problems. Soft tissues and blood vessels in these areas must be moved out of the way.

The posterior approach has been given “thumbs down” by some doctors for several reasons. There is a chance the neck could become unstable and even end up in a deformity where the neck bends too far forward. There is also a greater risk of infection or puncture of the lining around the spinal cord with this method.

Many doctors and studies support the use of the anterior approach to cervical spine surgery. However, the authors of this study report excellent results using a posterior approach when the disc presses out to one side. The “back door” method gives the doctor a better view of the area and more room to work. If less than 50 percent of the joint is removed, the neck remains stable. They conclude that the posterior approach is both safe and effective for some patients.

Disc herniation in the neck can be treated with surgery. There are different ways to approach this problem. Doctors generally agree that the disc must be taken out, but then what? Should the disc be replaced by bone graft or artificial bone?

Just removing the disc and leaving the neck as it is can cause bone collapse and other problems. Bone grafts to help fuse the spine are risky. Besides infection in the neck, there can be pain and infection at the site where the bone graft was taken from (usually the pelvic bone).

In the last few years, doctors have worked to find some answers to these problems. New materials to replace the disc are the center of today’s research on neck surgery. These new materials are called interbody implants or “cages.” The cage comes in various shapes and heights. It may be made of metal, graphite, or bone. Most cages are designed so they can be packed with bone chips or a suitable bone graft substitute.

In this study, doctors in Geneva, Switzerland, used a new carbon material and left the cages empty. This method is safe and prevents problems with bone grafting. The researchers found that bone grows through and around the cage. The bone isn’t as dense as bone from a graft site, and there was some settling of the cage into the bone above.

Use of implants or cages for neck fusion after disc removal is likely here to stay. The authors of this study are already planning the next step. They plan to increase the size and support of the cages and compare it to other methods used for this operation.

Many adults suffer pain and loss of stability in the neck (cervical spine). When surgery is needed for this problem, surgeons often recommend a procedure to fuse two or more neck vertebrae together. Fusion holds the bones in place and takes pressure off the nerves.

A spine fusion is held together with bone graft and metal plates. Pieces of bone may be shaved off the pelvis bone to form the bone graft. However, the spot on the pelvis where the bone was taken may develop problems such as pain, fracture, nerve damage, and infection. Doctors in this study tried to find an acceptable substitute for bone graft material.

Calcium carbonate can be taken from sea coral plants. Scientists are able to change this hard substance into a compound and use it as a bone substitute. The bone substitute is called ProOsteon 200. In this study, doctors compared fusion of the neck using patients’ own bone versus fusion using the bone substitute.

They found that patients were equally satisfied in both groups. However, X-rays and CT scans showed that the ProOsteon didn’t hold up. In fact, the study was ended early with no more patients allowed in the bone substitute group.

Authors of this study found that ProOsteon is a brittle material that has only 2.2 percent the strength of bone. Less than half the grafts took hold. One-third of the bones that were to be fused collapsed. They suggest that until better bone substitutes are found, bone taken from the patient’s pelvic bone is preferred for cervical spine fusion.

When the discs in the spine start to wear out, treatment may be needed. This is also true for the neck (cervical spine). Removing the front portion of a spinal vertebra (the vertebral body) is called corpectomy. Two or three vertebral bodies are typically removed in a corpectomy procedure.

Doctors may insert a section of bone graft into the space where the vertebral bodies were taken out. They may also use metal plates to hold the spine together so the bone graft will heal (fuse) in place.

A new method was devised in the mid-1990s. Square, mesh cages made of titanium can be inserted to replace the bones. The cages are packed with bone graft to make them rigid. Locking plates hold the cages in place. One method is to use mesh cages made of titanium. These titanium cages are often used at one or more levels in the neck.

There are some problems that can happen with this approach. Doctors at Tulane University studied 21 cases of corpectomy with cages over a five-year period. They found that one-third of all patients had some problems after the surgery.

No deaths occurred, but in some patients, the cages moved or the screws loosened. Sometimes, the plates would stick out too far. Other troubles involved single events that only affected one person. The patients with more than two bones removed seemed to have more problems–but only removing half of a bone caused the most trouble.

The authors feel that a 33 percent complication rate with titanium cages is high but not surprising. Removing a section of bone, inserting cages, and attempting to hold them in place is a major undertaking. Add to this neck movement, muscle loading, and fatigue, each of which add forces to the weakened area. Doctors are looking for better ways to perform this surgery. Titanium cages may only be a middle step before something better is found.

Every day, most of us turn, bend, and twist our necks without thinking about it. The joints of the neck move smoothly while we wash our hair, read a newspaper, or tie our shoes. For people with neck problems, these actions aren’t easy. Arthritis, aging, and other diseases can change the way we move during everyday activities.

Physical therapists know how much motion is present in the healthy, adult neck. What they want to know is how much neck motion is needed for certain activities. A new study reports the results of measuring neck motion in young, healthy adults. Various daily activities were studied.

Each person in the study was measured while talking on the phone, crossing the street, and backing up a car. Neck flexion, extension, twisting, and bending sideways were measured. A total of 13 daily activities were included. The tasks that needed the greatest full neck motion were tying shoes, backing up a car, and washing hair in a shower.

Surprisingly, some tasks didn’t require as much motion as expected. Activities such as reading a newspaper, reaching overhead, and writing at a table were in this group. Some tasks used a combination of movements. For example, while pouring from a pitcher, the neck is bent to the side, rotated, and flexed forward.

Physical therapists help patients with neck problems to regain movement and function. They use their knowledge of normal motion to do this. Adding information about motion needed for daily activities will help them know what’s required and reasonable.

Neck injuries are fairly common in sports such as football, rugby, skiing, boxing, and gymnastics. Most of these neck injuries aren’t serious. But doctors are still concerned about injuries that affect the spinal cord. Such injuries include stingers (which cause a burning sensation down an arm) and temporary paralysis or weakness in two to four limbs. The worst symptoms usually go away within minutes, but pain and weakness can last for awhile.

Doctors can easily identify these injuries. But it is uncertain how quickly the athletes should return to their sports. Can they go right back to the game after the symptoms are gone? Or should they sit out the game and get some tests later? These authors looked at the research and existing standards. Then they wrote up their own conclusions about how to handle stingers and temporary paralysis or weakness in two to four limbs.

Their plan treats these neck injuries with caution and common sense. For those wanting specifics on how these injuries should be handled, this article is a must-read. The authors pull together today’s information and combine their clinical experience to provide a detailed decision tree for how to handle these neck injuries.