News Category: Cervical Spine

Surgeons from around the United States who are members of the American Academy of Orthopaedic Surgeons gathered together in 2010. Their goal was to review and analyze data from studies on the treatment of one particular spine problem. That condition is spinal fractures (in particular compression fractures) caused by osteoporosis.

Osteoporosis is a thinning of the bone associated with aging and other factors. The bone becomes brittle and fragile. Cracks in the bone further weaken the structure. The weight of the body on the spine is enough to cause the body of the vertebra (spinal bone) to compress down. That load combined with the weak bone structure leads to compression fractures.

In this article, the 13 members of the Academy panel who reviewed the results of treatment for symptomatic osteoporotic spinal compression fractures present their recommendation. There are 11 recommendations in all.

Symptomatic fracture is a key distinction here as many older adults have spinal compression fractures that are painless. In fact, they usually don’t even know they have a fractured vertebra. The diagnosis is made when an X-ray is taken for something else and the damaged bone is seen for the first time.

Strength of evidence determines how strong the recommendation is. For example, high level evidence (level I) from high quality studies yields a strong, conclusive recommendation. Low-quality studies often provide inconclusive results and weak or inconclusive guidelines. Some studies produce mild-to-moderate strength of evidence to support a specific treatment recommendation.

And that’s exactly happened with these guidelines. After looking over all the data and evidence so far, this panel found only one strong recommendation. There were four weak-to-moderate guidelines. More than half of the recommendations ended up being “inconclusive” — just not enough evidence to say one way or the other.

Let’s take a look at some of the specifics. The strong recommendation was against using a procedure known as vertebroplasty to treat the problem. Vertebroplasty is designed to restore the strength of the fractured bone, thereby reducing pain.

The surgeon squeezes special liquid cement into the broken bone. The cement hardens and strengthens and stiffens the vertebra. But this procedure doesn’t restore the original height of the broken vertebra. Nor does it prevent the kyphosis (hunchback) deformity that sometimes results from compression fractures.

There were two high level (level I) studies comparing vertebroplasty to a sham (pretend) procedure. Three level II studies (no sham group) showed similar results: vertebroplasty did not give any better results in terms of pain relief when compared with a pretend treatment.

Instead of a vertebroplasty, the evidence supports the use of calcitonin. Calcitonin is a non-sex, non-steroid hormone. Calcitonin binds to osteoclasts (the bone cells that reabsorb bone). It decreases osteoclast numbers and activity levels. The end result is that it prevents bone from melting away. It doesn’t build up missing bone but it at least keeps the bone that’s there from being broken down and reabsorbed.

Calcitonin is available in a nasal spray and should be used for osteoporotic spinal fractures within five days of the injury. Calcitonin has been shown to relieve pain when tested in four different positions (e.g., in bed, sitting, standing, and walking).

If you know about vertebroplasty, you may be wondering about a similar procedure called kyphoplasty. For a kyphoplasty, the surgeon inserts a deflated balloon into the fractured and collapsed vertebral body.

Hydraulic pressure is used to inflate the balloon. The balloon is inflated until the vertebral body height is restored to normal or until the balloon is fully inflated. The balloon is then collapsed and removed. The empty space left by the inflated balloon is quickly filled in with cement that is injected into the area.

Does this procedure work better than a vertebroplasty? Is it among the practice guidelines? There was only weak evidence to support the use of kyphoplasty for symptomatic osteoporotic spinal compression fractures.

That’s not necessarily because the procedure doesn’t work — the weakness of the evidence comes from the fact that the studies available were so different. The study design and measurement of outcomes looked at different things (e.g., acute versus chronic fractures, short versus long-term results, pain versus function), so they couldn’t really be compared directly.

The other clinical practice guidelines for treatment of this condition had to do with other (nonoperative) approaches. Methods evaluated included the use of bracing, bed rest, complementary and alternative care, pain relievers, nerve root blocks, medications to slow/stop bone resorption, electrical stimulation, and exercise.

Most of these had weak evidence or inconclusive findings. The recommendation for most of these was the same: “We are unable to recommend for or against treatment” with X, Y, Z (insert name of modality here).”

With so little evidence to support so many different approaches to the problem, there’s room for many future studies. Good, quality research is clearly needed in this area. Surgeons evaluating and treating patients with pain from vertebral compression fractures need to know what works and when to use it.

There’s plenty of evidence that pain doesn’t necessarily come from these fractures. Many people with confirmed compression fractures (as seen on X-rays) don’t have any pain at all. It’s not clear that the bone fracture is the true cause of pain for anyone with this condition who does have pain.

While we wait for proper, reliable evidence, patients are looking for some answers. Surgeons want to provide them with fast and effective pain relief that will improve their function and help them maintain their independence. Trial and error may continue as the main means of finding the best treatment for each person until better evidence is available.

Patients who have serious neurologic symptoms (numbness, weakness, paralysis, even death) from pressure on the spinal cord or spinal nerve roots need more than hope for future research. They need immediate emergency care. Unfortunately, the panel was unable to recommend for or against any specific treatment for these folks either.

There’s an interesting expression in the English language that goes something like this, I hope he has his head screwed on straight.” The hope is that the person in question is using sound judgment in making decisions. In the world of orthopedic surgery, having your head screwed on straight can have a completely different meaning.

In this article, surgeons from the University of Washington Medical Center (Seattle, Washington) review modern posterior fixation for patients with an unstable occipito-cervical spine. That’s where the skull meets the upper cervical spine (neck).

Instability severe enough to require surgical fixation occurs as a result of trauma, congenital malformations, or bony destruction from diseases such as cancer, arthritis, and infections. The upper cervical bones are collapsing from underneath the skull. Without support of some kind, the risk of pressure on the spinal cord is too great to leave the problem untreated.

Modern rod-and-screw fixation techniques have replaced the earlier (internal) wire fixation and (external) casts, collars, and halo vests. They are literally using metal plates, screws of various types, and rods to hold the base of the skull attached to the back of the cervical vertebrae.

Preshaped rods and contoured plates have increased the technical difficulty of the surgery. But these devices can be angled specifically to meet each patients needs. And the improvements in design have reduced problems with the plates pulling out or screws backing out.

Different types of locking screws are used and placed in different positions or parts of the spinal bones. The surgeon is literally screwing the head on straight and stable. Specific motions (side bending or rotating the head) can be prevented according to the patient’s pattern of instability.

Such stabilization devices are needed when there has been significant disruption of the ligamentous structures, vertebral bodies, and spinal joints. All of these parts support the spine and hold the head in place on top of the spine.

The surgeons who wrote this article provide in-depth advice to other surgeons regarding preoperative planning, patient positioning during surgery, collaboration with the anesthesiologist, and surgical technique.

For example, MRIs are studied to make sure the surgeon knows exactly where the major blood vessels and nerves are located (and to avoid cutting into them). Bone thickness of the skull as well as the vertebrae are taken into consideration in choosing the right type of fixation and finding the best place to secure it (i.e., screw it in).

They include discussion of the various types of fixation devices including transarticular screws, C1 lateral mass screws, C2 pedicle screws, C2 pars screws, C2 translaminar screws, and bone grafting. Each of these methods of fixation has its own indications, benefits, problems, and limitations.

Careful surgical technique requires a very detailed knowledge of skull and cervical vertebrae anatomy. The surgeon tries to avoid blood loss, prevent blood clots, and minimize damage to the soft tissues. Each surgical step is performed slowly and deliberately with checking and double-checking holes and screws before making the final placement.

The authors conclude that with careful planning, surgeons can anticipate what is needed before attempting an occipito-cervical fusion with fixation devices and bone graft. One-hundred per cent (100%) accuracy in placement of the plates and screws can be achieved. Solid fusion is the final goal with patient safety a high priority throughout the procedure.

Surgery to take pressure off the spinal cord in the neck area continues to progress and change. New and better surgical techniques have the potential to improve results for patients suffering from pressure on the spinal cord.

In this study, surgeons from Emory Spine Center in Atlanta, Georgia use a special plate as the only fixation device after performing a laminoplasty for cervical myelopathy. Cervical refers to the neck and myelopathy means damage to the spinal cord. This condition can cause disabling neck and arm pain. Laminoplasty is a surgical way to cut the bone from around the spinal cord to take the pressure off.

But without the bone to support the spine, instability can result. So surgeons have found various ways over the years to give the spinal cord some added room while stabilizing the vertebrae (spinal bones). For one thing, they found they could cut through the lamina (pillar of bone that forms an arch around the spinal cord) and make a hinge to move the bone away from the spinal cord without removing the bone.

Then using spacers made of bone or ceramic, the hinge-door could be propped open. This step keeps the hinge-door from collapsing or closing back on the spinal cord. Over time, they found that the spacers could pop out or fall into the spinal canal. And the technique of using the spacers required advanced surgical skills much like a master carpenter.

The use of metal plates to hold the lamina hinge-door in place is the newest development. Plating can be done with or without the bone spacers called struts. The 54 patients in this study with cervical myelopathy had a laminoplasty with plate-only fixation.

Two advantages of a plate-only approach are the cost savings (it’s much more expensive to add bone struts) and the shorter time under anesthesia required for a plate-only procedure. A shorter operative time also saves money but even more importantly, reduces the risk of complications for the patient.

CT scans were taken at three, six, and 12 months after surgery to see how the healing was progressing. CT scans take pictures in series a slice at a time horizontally across the spine. The CT-slices give a visual representation of what’s going on at each level of bone. It’s possible to see bone bridges being formed, bone remodeling, and bone healing.

The results were very good. There were no cases where the plates broke, shifted, or failed in any way. A couple patients had a screw back out but it didn’t cause any problems. Healing was complete after three months in more than half the patients (55 per cent).

Three-fourths of the patients had complete healing at the end of nine months. And by the end of the first year, 93 per cent were healed. The remaining seven per cent were considered “nonunions”. The area filled in with fibrous scar tissue rather than bone but the spine was still stable.

Even though there were only 54 patients in the study, the total number of laminoplasty procedures with plating was 217 because many patients had more than one level done. The longest laminoplasty was done from C3 down to T1. Most of the patients had a laminoplasty from C3 to C7. No one had any further neurologic problems from the surgeries.

In a side note, the surgeons saw that a laminoplasty with plating healed the fastest when done at the C6-7 level. One reason given for this outcome is that the bone where the hinge is made tends to be thicker at this level than anywhere else. More bone stimulated and releasing growth factors creates faster healing.

The CT scans showed the expansion around the spinal cord formed by making a hinged-door and propping it open with the plate was a complete success. Since only plates were used without additional bone grafting, the results of this study also show that adding bone graft isn’t really necessary. And that’s good news because sometimes patients have more problems at the graft site than at the surgical site. Of course, there’s a cost savings there as well.

In summary, this is one of the first studies to report on the use of plating only when performing laminoplasty for cervical myelopathy. The high success and low complication rates without the use of supplemental bone grafting suggests this technique to expand the spinal canal may become a standard procedure in the future. Patients have immediate spinal stabilization and can move after surgery right away. The cost savings is an added feature to consider.

What’s the best way to treat the condition doctors refer to as cervical radiculopathy (better known to patients as a pinched nerve in the neck)? This condition causes symptoms of neck and arm pain that come from pressure on the nerve roots as they exit the spinal column. There can also be sensory and motor changes. In particular, how is cervical radiculopathy treated when it comes from degenerative changes in the cervical spine (neck)?

In this article, the North American Spine Society (NASS) offers an evidence-based clinical guideline that focuses on cervical radiculopathy from degenerative disorders. More than a dozen medical experts worked on this document. The panel included surgeons, medical doctors, and imaging specialists.

Drawing from all the studies published on this topic, they answered 18 questions about the natural history, diagnosis, and treatment of cervical radiculopathy. The focus was on radiculopathy as a result of degenerative changes in the cervical spine. After reviewing the evidence in studies up through 2009, they offer specific ways to approach treatment for this condition. The North American Spine Society (NASS) board reviewed the guidelines and published them here for your consideration.

Let’s start with a brief explanation of the changes that occur with degenerative cervical radiculopathy. First and most common is a deterioration of the discs between the vertebrae (bones of the spine). The discs thin out, lose fluid, and compress down. Just that change alone results in a series of other changes as well.

Disc disease means the pressure and load on the vertebrae increases. It also means the facet (spinal) joints move closer together. Compression and added load there can cause bone spurs to form as the body responds to the added friction and shear forces.

A smaller space between the vertebrae also affects the spinal ligaments with resultant increase in stiffness of the spine. All of these factors together reduce the size of the foramen (hole through which the spinal nerve travels as it leaves the spinal cord and travels down the arm). And over time, with thinning of the bones and compression, the front of the vertebral bodies get pushed down. Vertebral compression fractures can develop. These are two more anatomical factors that can contribute to narrowing of the foramen.

The final result? Pinching or pressing on the spinal nerve root(s) and cervical radiculopathy. Of course, a proper diagnosis must be made to rule out other more serious problems like infection, fracture, or tumors. Clinical tests commonly used to test for cervical radiculopathy (e.g., Spurling’s, shoulder abduction test) only got a grade of C (low evidence to support the use of these tests).

A better way to diagnose the problem is with X-rays and CT scans (B grade). This still isn’t a top A grade because of the number of people with evidence of degenerative disease who don’t develop any symptoms, patients with severe degeneration but mild symptoms, and patients with mild degeneration and severe symptoms. That means the tests aren’t 100% reliable or accurate.

Other diagnostic tests including MRIs and electromyography (EMG studies) didn’t have enough evidence to come to a firm conclusion. Nerve root blocks have also had varying diagnostic results. Sometimes the symptoms suggested a particular nerve was the problem but the block didn’t change the symptoms. At the same time, when a nerve was blocked that wouldn’t ordinarily cause the symptoms, pain relief was obtained. That’s why nerve blocks got a grade C.

Once the problem is clearly defined, we are back to the question of what’s the best way to treat this problem given the degenerative changes that brought it on in the first place? And maybe even before that: is treatment even needed?

The consensus of the group was that patients with cervical radiculopathy get better over time. Despite all the degenerative changes, the body seems able to adapt and heal. For that reason, this condition is considered self-limiting. This is the natural history of degenerative-induced cervical radiculopathy.

For those who pursue conservative (nonoperative) care, what works best? The choices are medications, physical therapy, chiropractic care (manipulation), and steroid injections. The group came up with I meaning insufficient evidence. There just haven’t been enough studies; there are limited findings, or conflicting findings to come up with any solid recommendations. This is certainly an area where further study and examination would be a good idea.

Okay then — for those who don’t get better despite efforts with conservative (nonoperative) care, what are the treatment options? That leaves surgery as the next potential step. First question, does surgery work better when conservative care has been given first? That’s another gray area rated as I — insufficient information or “unknown”. There is moderately good evidence (grade B) that surgery provides better relief than doing nothing.

If you are tracking here with us, then your mind has already jumped to the next question: what kind of surgery has the best outcomes? But beyond that there is actually yet another variable to factor in: single-level versus multilevel procedures. Is there one particular surgery that works best when treating just one spinal level? And same question for the surgical treatment of more than one spinal level.

Here’s what the evidence suggests. Posterior decompression (taking pressure off the spinal nerve by removing bone around it) with or without fusion is used most often for multilevel radiculopathy. There weren’t even enough studies on single level segments to see any conclusions. And most of the time, cervical radiculopathy from degenerative processes only affected one spinal level. Multilevel problems were usually the result of inflammation, tumors, or infection (rather than degenerative disease).

The more popular procedure (anterior cervical decompression) for single-level problems got a grade B. In fact, decompression combined with fusion worked equally well. The key here is the time frame: these positive outcomes applied to the short-term, acute phase of the disorder. Long-term results (four years or more after surgery) weren’t so favorable (grade C).

In summary, physicians evaluating patients with cervical radiculopathy will be aided by this document. It will guide them in making a proper diagnosis and forming the most effective plan of care. The treatment plan will be current based on the best evidence available. Researchers will see the need for future research to further clarify the process.

For anyone who would like to see the complete list of recommendations, the North American Spine Society (NASS) has put these on-line for viewing at www.spine.org. But don’t think this is the final word! The authors warn that this topic will be reviewed and the guidelines revised (if necessary) based on any new findings that come up in the near to distant future.

Surgeons from the Spine Institute of Louisiana who wrote this article received the 2010 Outstanding Paper award for Surgical Science. The award was based on their study of adjacent segment degeneration (ASD) following artificial disc replacements (ADRs) in the cervical spine (neck).

There have been many reports that after a spinal fusion for disc degenerative disease, the disc at the next level (usually the one above the fused segment) is the next to degenerate. The loss of motion and adjacent segment disease were two reasons why scientists developed the artificial disc replacement (ADR).

At first, disc replacements were only available for the lumbar spine. But now, artificial disc replacements (ADRs) have been designed for the neck as well. Many studies have shown that disc replacements do indeed preserve joint motion, so the first problem has been solved. Naturally, surgeons (and patients) want to know if the artificial disc replacement also takes care of the problem of adjacent disc degeneration.

In this study, 93 patients with disc disease in the neck failed a minimum of six months of conservative (nonoperative) care and ended up with surgery. Conservative care included medications, physical therapy, chiropractic care, and steroid injections.

Half the group had the fusion procedure. The other half had an artificial disc replacement. The fusion technique used is called anterior cervical discectomy and fusion (ACDF). The name ACDF describes the approach (anterior is from the front), the location (cervical spine), and the actual procedure (discectomy removes the disc and fusion uses bone graft to fill in the hole where the disc once was).

The patients were randomly assigned to one or the other surgical treatment. Random assignment means a computer generated names for each group. The patients didn’t even know what type of surgery they had until after the fact.

In the group of patients who had a disc replacement, 43 patients had a one-level procedure and 16 had two-levels replaced at the same time. Three different types of FDA-approved disc replacements were used. In the fusion group, 28 patients had a fusion at one level and six patients had a two-level fusion. Data on bone density and the presence of lumbar disc degeneration was collected and compared for both groups.

Success of each procedure was determined by measuring before and after changes in pain (or other symptoms) and improvements in function (as measured by the Neck Disability Index).

X-rays were compared before surgery and at regular intervals after surgery for up to four years. Any sign of adjacent segmental disease was noted. Lack of improvement, new (or worsening) neurologic symptoms, and the need for more surgery affecting the operated area(s) were used as measures of failure.

The mid-term results (after a median of three years) showed no difference between disc replacement and fusion. Both groups experienced an equal number of cases of adjacent segment degeneration (ASD). Between 15 and 18 per cent of all patients were affected by ASD. The period of time free from this problem was about three years for both groups.

There did not appear to be any link between age, sex (male versus female), tobacco use, or number of levels of surgery with the final outcomes. One key finding in this study was the fact that patients who had lumbar disc degeneration were more likely to experience segmental disc degeneration in the cervical spine.

In summary, motion preservation technology has led to the development of artificial disc replacements for the cervical spine (neck). This was the first study to examine patients receiving cervical spine disc replacement(s) for adjacent disc disease. Artificial disc replacements are safe and effective in reducing pain and neurologic symptoms. It does not appear that this new technology preserves the disc segment above and below any better than fusion surgery does.

The patients will continue to be followed in order to see what happens over a longer period of time. The surgeons will also keep track of patients who experience implant failure for any reason and report on that in future publications. The finding that disc degeneration in the lumbar spine predicts adjacent segmental disease in the cervical spine following disc replacement will also be studied more closely.

A group of physical therapists from the University of Iceland posed the question, Does neck pain from shoulder problems differ from neck pain associated with whiplash injuries? This is an important question when working with patients who may have altered muscle function depending on the etiology (cause) of their neck pain.

They compared two groups of patients with neck pain. One group had been involved in a motor vehicle accident (MVA). The second group had neck pain but no history of MVA. There was actually a third (control) group who had no neck pain and no history of MVA. Most of the participants were women. Everyone was right-handed. And the groups were carefully matched by age, size, and activity level.

Comparisons were made by measuring pain intensity and function versus disability. A special tool called the Neck Disability Index (NDI) was used to measure function. This survey includes questions about personal care, reading, lifting objects, working, driving, sleeping, concentration, headaches, and recreation.

But the main focus of interest was on movement of the scapula (shoulder blade) with arm elevation. We know that the muscles that control shoulder motion and in particular scapular motion can have a direct effect on the neck. Evaluating scapular motion and comparing among the three groups might give some clues about the best way to treat neck pain.

If scapular motion (and therefore muscle timing, rhythm, and control) is different depending on the etiology (cause) of neck pain, then treatment might vary accordingly. In order to examine scapular motion in relation to the neck and arm, each participant wore a special set of sensors. Three sensors were placed: one on the clavicle (collar bone), one on the acromion (part of the scapula), and one just above the elbow.

The subjects were asked to raise the arm over head three times. Data on the movement pattern was sent to a computer for analysis. With each position of the arm, the position of the scapula was recorded. Using this method of measuring scapular orientation during arm movement, they found a general pattern that was the same for all three groups.

The pattern was described as clavicular elevation and retraction with arm elevation. At the same time, the scapula rotated in an upward direction. The scapula rotated inwardly during the first 90 degrees of arm motion, then rotated externally as the arm moved from 90 to 120 degrees.

There were some differences in movement in the group with neck pain from a whiplash-associated disorder (WAD). The clavicle lifted up higher when the arm was elevated (raised) 90 degrees compared with the other groups. Scapular posterior tilt was decreased in the WAD group compared with the other two groups.

The WAD group also had less clavicular retraction on the side of their dominant hand compared to the other (nondominant) side. There was no difference in movement patterns from side-to-side in the normal, healthy (control) group.

What does all this mean really? Well, several things: first, everyone with neck pain had a different scapular orientation during arm movement compared with normals. This suggests some type of movement impairment that needs to be addressed in treatment. Unless everything moves in proper alignment, uneven pull on the neck from altered dynamic stability of the scapula will cause continued neck pain.

Second, patients with neck pain from whiplash-associated disorder (WAD) have similar muscle patterns as seen in patients with true shoulder problems (moreso than when compared with neck pain of unknown cause).

There is an uneven pull between the muscles of the neck and shoulder contributing to clavicular elevation and scapular tilt. Altered movement patterns is an area physical therapists excel in treating. Knowing which muscles contract at greater intensity for longer periods of time than normal helps direct treatment.

Other studies have shown that neck pain might be part of the reason why there is altered activity in the scapular muscles. It’s not clear if the altered muscle activity is to compensate for muscles that aren’t working or to prevent painful muscles from contracting and causing further pain. This is an area for further study.

The authors concluded that identifying patterns of muscle impairment with different types of neck problems (e.g., post-whiplash versus unknown cause) may guide physical therapists when treating patients with neck pain. Getting normal motor function and alignment may be the key to preventing ongoing or recurring neck pain whatever the cause.

If you follow sports at all, you know there’s a renewed debate about head and neck injuries on the field. How soon should these players be allowed to return to play? Players who suffer an undiagnosed concussion, compression to the spinal cord or spinal nerve roots, or other neck injury are in danger of long-term consequences. Early diagnosis and treatment may prevent serious complications.

When the symptoms are mild, the athlete may “shake it off” and fail to report it to the coach or trainers. More serious symptoms such as loss of sensation and the use of the arms are harder to mask. One of these conditions affecting the neck is the topic of this article. It is called neuropraxia or cervical cord neuropraxia.

The term neuropraxia describes symptoms of bilateral (affecting both sides) burning, numbness, loss of sensation, and muscle weakness of the arms and hands. The symptoms are caused by pressure on the spinal cord in the cervical spine (neck). It is like having a concussion to the spinal cord (instead of to the brain). The symptoms can last minutes up to hours.

Full recovery is expected — if the player doesn’t go back on the field and experience another high-energy contact injury to the head and/or neck. And if there isn’t an undetected fracture of the vertebra or damage to the disc. Only an examination and X-ray, MRI, or CT scan to rule out this type of trauma will answer that question.

The information in this article is meant to help sports officials determine when athletes suffering high-energy contact injuries to the head and neck are safe to return to play. A group of spine surgeons, neurologists, and orthopedic surgeons who specialize in trauma joined together to form a panel to discuss this topic.

After reviewing all the literature already published and examining the data, the panel concluded that there isn’t enough high-level evidence to make strong recommendations. They had to rely upon their own clinical expertise and expert opinion in suggesting the following guidelines:

A sensation of the head “clunking” with movement, headaches, and neck pain that go down the arm are symptoms of an unstable upper cervical spine. Neck and arm pain with numbness and tingling down the arm are more indicative of lower cervical spine problems. And some patients report difficulty swallowing or the sensation of a lump in the throat when there are disc protrusions as part of the mix.

Most of these symptoms go away with conservative care to address the contributing postural components, muscle weaknesses or imbalances, and other soft tissue issues. But with degenerative conditions that don’t respond to nonoperative treatment, surgical intervention to stabilize the unstable segment(s) may be necessary.

In the past, the only real choice was neck fusion. And that worked “okay” (pain and other symptoms are relieved, the neck is stabilized) but there are problems with this approach. The biggest drawback is the fact that the patient loses neck motion at the fused level.

The subsequent problem is the increased load and force placed on the spinal segment above and below the fused level. The added stress speeds up wear and tear and can cause a condition called adjacent-segment degeneration. What’s the answer to this dilemma?

Well, the next development in this area has been an artificial disc replacement. The procedure is referred to as a cervical disc arthroplasty or CDA. In theory, the implant is designed to stabilize the neck AND maintain motion without transmitting load to the adjacent segments.

How well is that working? That’s what the investigators of this article set out to determine. They researched all the studies reported so far on the results of cervical disc arthroplasty (CDA).

This type of report is a technological overview using a systematic review. In reviewing all articles on the topic, they found over 2,000 on the subject. That number tells us there is enough published data now to conduct a systematic review and see what’s what.

They posed four questions and tried to see what the study results showed to answer these questions. Results for cervical disc arthroplasty were compared with cervical fusion for each of the following four questions:

Traumatic injuries of the brachial plexus refer to stretching, avulsion, or rupture of a group of nerves that come from the spinal cord in the neck. Avulsion tells us the nerve root is torn from the spinal cord where it attaches.

Rupture refers to a complete tear across the nerve dividing it into two or more parts. The upper part is still attached to the spinal cord. Plexus refers to the entire group of nerves as they first start out with several main branches that divide to form a much larger number of nerve groups. The plexus starts at the neck but travels under the clavicle (collar bone) and down the arm.

These nerves provide both sensation (pain, temperature, touch, vibration) and motor function (muscle contraction) for the entire upper extremity including the shoulder, arm, wrist, and hand.

Brachial plexus injuries are usually caused by some type of trauma such as a car accident, fall onto an outstretched arm (especially if the head and face are turned away from that side), and stretching or pulling on the hand, wrist, or forearm. Gunshot wounds, knife lacerations, and other blunt open injuries are also likely causes of nerve avulsion or rupture.

Surgery is often needed to reconstruct the nerve. Surgical techniques have improved quite a bit in the last 10 years. The author of this review (an upper extremity orthopedic surgeon who specializes in trauma) has put together a summary of what the surgeon needs to know in making the diagnosis and establishing a plan of care for these patients.

The first step is making the diagnosis. Typically, any medical diagnosis depends on understanding the history (what happened) and carrying out an examination. With trauma to the nerves, the mechanism of injury is important because it often dictates whether surgery is needed and how soon. For example, a sharp injury that cuts the nerve will require immediate surgical treatment, whereas, forced traction (e.g., from a fall) may recover with time and conservative care.

To take that a step farther, the type of surgery may also be determined by what happened. Nerves that are avulsed close to the spinal cord are treated differently than nerves torn farther down the arm.

The decision isn’t made just on the basis of the patient’s history. Additional tests are given to find out as much as possible about what is and isn’t working with each nerve. CT scans, MRIs, and electrodiagnostic tests add important information.

Electrodiagnostic tests include nerve conduction studies and electromyography (EMG). These tests provide information about the sensory nerve cells’ and motor nerve cells’ function. The results of the test help surgeons predict if recovery will occur and how long it might take.

With nerve avulsion, there’s very little chance the nerve will repair itself and recover. The risk of scar tissue interfering with surgery pushes the date of surgery up considerably (within three to six weeks of the injury). For injuries further down (away from the spinal cord), there’s a chance that (with enough time) the nerve can repair and recover. This can take up to six months or more so surgery can be put off a bit longer.

When surgery is done, the surgeon must choose among several different approaches, each with their own specific surgical techniques. When there is a clean cut through the nerve, it is possible to stitch the two ends of the nerves back together in what is referred to as a direct repair.

But most of the time, there are multiple nerves that involve both sensory and motor function. In these cases, it may be necessary to perform nerve grafting, nerve transfers, or even muscle transfers. The nerves used depend on the location of the primary (main) nerve injury and the muscles (motion) affected.

The brachial plexus has many nerves that branch off to each part of the arm from the shoulder on down to the fingers. Nerves selected for grafting or transfer differ according to whether the injured nerve is up high affecting the upper arm or down lower creating problems in the forearm, wrist, or hand.

The author describes each nerve affected and the possible replacements that can be used. Choosing the donor nerve can be challenging. It’s best to use one that is above the lesion and therefore has not been affected by the injury.

Data on outcomes from studies already published are reviewed. Over time these studies have provided some valuable information about which nerves work best as donors to replace the damaged brachial plexus. It is even possible to take selected nerve tissue from the opposite arm as a donor graft for the injured arm.

A muscle transfer is another new technique developed over the last few years. Surgeons have figured out which muscles can be used to replace muscles that have permanently lost nerve innervation. Function is the goal, so restoring elbow flexion or touching the fingers together is often what surgery tries to achieve.

And finally, the newest surgical technique under investigation for nerve injuries is the use of a nerve conduit. A nerve conduit (also referred to as an artificial nerve graft) uses synthetic materials to create a guided pathway for nerve tissue growth. The nerve ends and gap between the ends are enclosed within a tube composed of biological or synthetic materials.

The nerve conduit is being tried for patients with large distances between the two ends of the torn nerve. The distance is too great to use direct suturing of the two stumps of a severed nerve without tension. This approach has worked for small sensory nerves that have been injured but its use with mixed (sensory and motor) function is still being studied.

In summary, brachial plexus injuries can be complex, difficult to treat, and devastating for the patient. Every effort must be made to establish a correct diagnosis (which nerve is affected, location of the lesion, severity of the lesion) in order to plan treatment specific to that problem. Recent advances in the surgical repair and reconstruction of traumatic brachial plexus injuries has opened up treatment options and improved results.

Disc degeneration in the cervical spine (neck) can create pain, loss of motion, loss of function, and disability. Surgeons are now able to replace the damaged disc with an artificial unit. Artificial disc replacement is rapidly replacing spinal fusion. But the question has been raised: does it really do anything more than fusion?

The intended advantage of artificial discs is that they allow the spine to move normally. This concept is referred to as preservation of motion. Neck range of motion is saved at the diseased segment but also in the overall cervical spine. And, if each individual cervical segment is working well, the hope is that further adjacent disease (degeneration above or below the already damaged disc) can be prevented.

One way to see how well disc replacements are working is to measure neck range-of-motion before and after surgery. By looking at various patient and technical factors, surgeons can identify what might be needed to assure good motion after surgery.

In this study, surgeons from South Korea followed 39 patients who received an artificial disc replacement for one level in the cervical spine (neck). Everyone got the same unit (the Bryan Artificial Cervical Disc Prosthesis made by the Medtronic Company in the U.S.). One surgeon did all the procedures using the same methods and techniques for each patient.

Data collected and used to compare before and after results included patient age, sex (male or female), and neck range-of-motion. Technical data collected included amount of bone removed during the surgery, angle the disc was inserted into the disc space (after removing the damaged disc), and how far into the space the disc was inserted (depth).

What’s your guess? Is it more likely that range-of-motion is affected by patient factors or technical factors? Let’s see what they found. If you guessed “both”, you would be right. Range-of-motion before surgery, age, and sex were all patient factors linked to improved motion during the follow-up period. Disc insertion angle was the technical factor most closely linked to post-operative results.

Men were more likely to have better motion than women. Patients of either sex who had the most motion before disc replacement had the best results after surgery. They found that by using this particular disc replacement system, bone resection wasn’t a significant factor. A special machine makes all the cuts giving even, equal amounts of bone cut from each end.

The disc insertion depth didn’t turn out to be statistically significant in relation to post-operative neck motion. But the authors still believe that it’s a good idea to set the artificial disc in as far back as possible. That way, it restores the normal anatomy more closely, opens up the spinal canal, and takes more pressure off the spinal nerve root and spinal cord.

The authors concluded that if maintaining neck motion is the main goal of artificial disc replacements, then measuring motion before and after surgery should be a way to see how effective cervical disc replacement is. This study is unique in that it also looks at what might be affecting motion — beyond just the fact that the damaged disc has been removed and a new unit installed.

By identifying which patients have the best results, surgeons can select patients more carefully for this procedure. Knowing which technical factors make a difference helps surgeons improve their operative technique for this particular procedure.

One final note: only one specific type of artificial disc replacement was used in this study. Each manufacturer has designed their units with specific stiffness, biomechanical factors, and other features. The results here represent important patient and technical factors affecting motion for just the Bryan prosthesis. Future studies are needed to make the same comparisons between different artificial devices.

Benjamin Franklin was credited with saying, In this world nothing can be said to be certain, except death and taxes. But there is one more thing that could be added: change. Whether it occurs quickly or slowly, change is a constant in our lives. This is especially true in the world of medicine.

Medications change, procedures change, treatment methods change, and so on. In the field of orthopedic surgery, length of hospital stays are shorter, surgical tools and techniques are improved, and the kinds of patients who qualify for surgical procedures have been expanded.

In this article, national trends in anterior cervical decompression and fusion (ACDF) are reported. ACDF is one of the most common surgical spine procedures in the U.S. Whenever a treatment approach becomes popular, it is considered a good idea to observe results carefully and see if that popularity is warranted.

In this procedure, the surgeon makes an incision in the anterior (front) of the neck, performs a discectomy (removes the disc) and fuses the two vertebrae together. A fusion simply means that two bones grow together.

Usually, when two vertebrae are fused together, a small piece of bone called a bone graft is inserted between the two vertebrae where the disc has been removed. This bone graft serves to both separate the vertebrae and to stimulate the two bones to grow together – or fuse. The fusion procedure usually involves the use of hardware, such as screws, plates, or cages to keep the bones from moving.

To evaluate the performance of this procedure, we ask: Is the procedure having the intended effect? Are the outcomes successful? Who can benefit and are there other people out there who could really use this treatment? Is it safe and effective for all age groups, both sexes (male and female), and for each diagnosis for which it was used?

Right now, anterior cervical decompression and fusion (ACDF) is favored for degenerative disc disease. It is fairly easy to perform, patients recover quickly, and studies from the 1990s show good results overall. But that data is already over 10 years old. What are the current trends?

Using data collected by the Centers for Disease Control and Prevention (CDC) as part of the National Hospital Discharge Survey, the following trends were observed:

It’s possible now to have a disc replacement in the cervical spine (neck). But the “kinks” aren’t fully worked out yet. One of those kinks is the problem of heterotopic ossification (HO) (extra bone formation).

With heterotopic ossification, there is additional bone formed outside the skeletal system. The extra bone usually forms in the surrounding soft tissues, especially the nearby muscles. It’s a problem because the artificial disc replacement (ADR) is designed to maintain joint motion. The heterotopic ossification reduces soft tissue mobility and causes increased stiffness.

But how often does this really happen? Is it enough to raise a red flag to suggest something should be done to prevent it?

According to the results of this study, it happens more often than expected. In a group of 170 patients treated in Korea, 40 per cent developed heterotopic ossification. And it was serious enough to reduce the life of the implant to an average of only 27 months (less than two and a half years).

The natural question to ask is: What causes this to happen? Can it be prevented? Are there certain patient factors that could be identified ahead of time signaling which patients might be at risk for the development of heterotopic ossification?

By collecting, examining, and analyzing data on this group of patients, the authors were able to provide some (but not all) answers to these questions. First of all, it’s important to recognize that they only studied three of the many different types of disc replacement currently available for the cervical spine (neck). Differences were determined using the Bryan disc, the Mobi-C, and the ProDisc-C.

These three were chosen because they are different in how they are made (material) and how they work (motion system). The Bryan disc is made of titanium and polyurethane. Polyurethane is a resilient, flexible, and durable manufactured material that can be stretched, smashed, or scratched, and remain fairly indestructible.

The Mobi-C implant is composed of titanium and polyethylene (plastic component). And the ProDisc is cobalt chrome and polyethylene. On a continuum of motion provided by each artificial disc, at one end, there’s the Bryan disc, which provides the most movement with the least constraint. At the other end, is the ProDisc device with the least motion. The Mobi-C falls somewhere in between.

X-rays were used to look for heterotopic ossification (HO) during the follow-up period after the joint implants were put into place. The length of time between surgery and the development of HO was also recorded.

Though this sounds like an easy task, there were some problems. For example, X-rays show bone formation in the front of the vertebra (anterior) much better than in the back (posterior). Sometimes it was difficult to tell the difference between bone spurs large enough and long enough to form a bridge and heterotopic ossification.

But the overall results showed there was more bone formation than expected and that the type of implant did make a difference. Occurrence rate was highest in the ProDisc-C group and lowest in the Bryan disc group. What made the difference? And what patient factors might account for no heterotopic formation in 60 per cent of the patients?

This study didn’t provide all of the answers to those questions. There’s plenty of room for future studies to explore both patient characteristics and implant factors that could account for the problem of bone formation.

For now, it looks like type of implant does make a significant difference in when heterotopic ossification develops. Implants that fit well up against the endplate seem to avoid the problem of bony overgrowth. The endplate is a circle of cartilage between the disc and the vertebral body.

As far as possible patient factors, the authors propose genetic traits might be at work. Specific patient characteristics (age, gender, lifestyle, body size, level of implant, diagnosis, type of surgery, and so on) were not compared.

The debate about neck collars has been going on for decades. Some surgeons never have their patients use them — even to stabilize the neck after a fusion procedure. Others use them to provide support and security for the patient but don’t consider them really necessary. And when asked in a survey at least half of the surgeons fell somewhere in between those two opinions.

The debate continues beyond just whether or not to use collars. The next question is then: soft or rigid? Studies have clearly shown that soft collars don’t restrict motion at the end ranges. That means if the person really wants to turn the head all the way to one side or the other (or fully flex or extend the neck), the collar doesn’t prevent it. Tests show that rigid collars don’t fully restrict motion either.

In fact, many patients still have up to half their normal motion even when inside a rigid neck brace. And given the fact that rigid neck collars can be hot, cause skin rashes and sores, and restrict swallowing and breathing, they can be difficult to get used to. If they don’t really do any more than a soft collar, why bother using them?

That’s what the authors of this study finally concluded after comparing neck motion between soft and rigid collars. They used a special tool called an electrogoniometer to measure neck motion in 10 normal, healthy adults. The measurements included neck flexion, extension, side (lateral) bending, and rotation. Range of motion measurements were taken before and after wearing first the soft neck collar and then the rigid collar.

All participants had normal cervical spine (neck) motion. No one had a history of neck problems and there were no reports of neck pain at the time of the study. To assess functional neck motion (motion needed to do everyday activities), neck motion was measured while doing 15 different tasks.

The activities included things like standing up from a sitting position, backing up a car, tying shoelaces, walking up and down stairs, and eating. Other activities normally carried out everyday were also monitored such as shaving (men), putting on makeup (women), washing hands, and reading a magazine or book held in the lap.

A motion analysis of the data was designed to look at two things: 1) how much soft and rigid collars really restrict neck motion, and 2) the effect of these collars on functional motion. All the people who were in the study were young (in their mid-20s).

The idea was to see what a normal, healthy person could do in these collars. It was assumed that using younger subjects would give the best and fullest range of motion measurements since neck motion decreases with age. Measurements were taken for each person without a brace, with a soft collar, and with a rigid collar while performing each of the 15 tasks.

After a detailed study of all the comparative measurements, here’s what they found:

Neck pain affects many people around the world. In the Netherlands, between 9 percent and 22 percent of the population complain about neck pain at some point. One third of Dutch adults have neck pain during a one-year period. Of these, 5 percent to 10 percent will develop a chronic pain disorder. Unfortunately, when people with neck pain visit their doctor, many times, there is no specific cause that can be found. This type of pain, which can also be aggravated by psychological and social factors, is then labelled nonspecific neck pain or neck pain of unknown origin.

In treating nonspecific neck pain, the usual approach is through exercises, manipulation, massage, physical methods, mobilization, and even biopsychosocial techniques. However, there is not a lot of information in the medical literature that backs up the effectiveness of any one of these treatments or management strategies.

Increasingly, doctor are managing patients with subacute neck pain with behavioral treatment, which seems to be effective for patients who are afraid of bringing on more pain or worsening pain, which results in less movement and activity. With this knowledge, researchers have developed a behavioral graded activity program. The authors of this article studied to if such a program would be at least as effective among patients with psychological factors that influence their subacute neck pain as is manual therapy (exercises).

Researchers randomized 146 adult patients who complained of nonspecific neck pain. Half the group was assigned to behavioral graded activities. These included learning skills and increase healthy behavior, having an active role in managing the pain, using and therapist as needed, and working towards preset goals, a gradually increasing exercise program. The manual therapy group were given exercises to restore restricted movement and increase the patients’ level of activity and participation. If health costs were taken into account, the manual therapy group used fewer resources with an average of 5.2 treatments per patient compared with 8.2 treatments in the behavior group. This also is found in visits to the general practitioner. The manual group visited the doctor a mean of 0.5 times, compared with 0.8 times with the behavior group. However, this changed when it came to specialist visits. The manual group mean visits remained at 0.5 while the behavior group dropped to 0.03 times. Lost days of work averaged 2.1 days in the manual group, but 4.3 days for the behavior group.

While examining the study outcomes, the researchers found that the physical therapists who ran the programs did not always follow the protocols of the behavior management activity program (only 52.1 percent did), while 80 percent of the manual therapy programs consisted of manipulations or mobilizations, with or without exercises.

Taking into account all the findings, the researchers noted that after one year, the success rate regarding pain and disability of the behavior program was 89.4 percent and for the manual program, 86.5 percent. The authors concluded that the differences, while present, were marginal and not statistically significant to warrant changing programs from one in favor of another.

Cervical spine injuries are injuries to the high upper back and neck, the cervical column. This part of the back consists of seven vertebrae, bones, that are connected with tough tissue called ligaments. Cervical spine injuries are usually the result of a trauma, such as a fall or a blow. Most often, they are found in young adults because of their activities, such as sports, or accidents, such as motor vehicle accidents. However, the elderly also may sustain this type of injury and, although they may not injure their upper spine as often as younger generations overall, they are at highest risk for doing so in a blunt trauma, such as a fall. And, when and if they have a cervical spine injury, the elderly are at a higher risk of death.

Researchers have been working on identifying this problem, particularly if the cause of death among the seniors are pre-existing health conditions (illnesses or disorder that exist before the injury), the injury itself, or the treatment used to manage the injury. The authors of this article reviewed the literature for studies on this topic, choosing to focus on the reporting of baseline characteristics (how the patients were when the injury occurred), follow-up, cause of death, and analysis of risk factors for mortality in studies that focused on specific treatments for cervical spinal injuries in the elderly.

Upon reviewing the literature, researchers found 26 studies that met their criteria. The combined number of elderly patients in the studies totaled 1550 subjects. Twenty-one studies (81 percent) were retrospective case series, looking back at files. Four (15 percent) were retrospective cohort studies, looking back at studies that compared the subjects, and one study (4 percent) was a prospective cohort study, a study that actively followed subjects through the study period.

The studies focused on the following injuries:

– Odontoid process fractures, a fracture of a piece of the second vertebrae in the back of the neck
– Upper cervical injuries
– Cervical spine injuries

Each study but one had patients who had other injuries along with the cervical spine injury. Of those 25 studies, 24 noted if there were spinal cord injuries and they were identified in one of several ways:

1 – complete versus incomplete injury
2 – Frankel classification, a scoring system related to how severe the neurological (nerve) loss is
3 – tetraplegia versus paraplegia, complete paralysis below the jaw versus versus paralysis below the waist
4 – ASIA International Standards for Neurologic Classification of Spinal Cord Injury classification
5 – neurologic level of injury
6 – noting presence or absence of injury in general

Only nine studies reported any comorbidities, pre-existing health problems.

Reports of causes of death found that 335 subjects died (22 percent), but four studies did not report if they were deaths soon after the injury or later on. In the other studies, 170 of the subjects, or 51 percent, died during admission or while the subjects were receiving treatments that did not involve surgery. Sixty-four subjects (19 percent) died during long-term follow-up. Unfortunately, for the group that died during admission or treatment, 15 studies do not report how long a time period this was.

In 155 of the cases (out of 335), no cause of death was reported. Among those that were reported, the cause of death couldn’t be identified as it was listed as
unknown cause, unrelated cause, or medical conditions. For the subjects whose cause of death was recorded, most (116, or 34 percent) died of heart-related causes (cardiovascular), most often heart attacks.

The result of this review showed that there was no consistency in reporting on the issue of the elderly and the effects of cervical spine injury. This results in lack of information that could help health care providers identify the risks of this patient group when they present with a cervical spine injury. The authors recommend that further, consistent studies be undertaken to help this population as the baby boomer generation reaches older age.

Have you ever heard the expression, Hindsight is 20-20? It means that looking back, we can see perfectly what we should have (or could have) done. Surgeons use this concept to examine patient results and plan better ways to perform procedures. In medical research, a look back at patient records is called a retrospective study.

In this retrospective study, the records of 23 patients of one surgeon were reviewed by two independent surgeons. Each patient had a procedure to reconstruct the cervical spine (neck) following a previously failed surgery.

The reconstructive surgery was called a hybrid decompression. The surgeon removed the disc and the affected cervical bone then fused the segment together. In every case, the surgery was done from the front (anterior approach) of the spine.

More than one vertebral level was treated this way. So the full name of the procedure is multilevel anterior cervical hybrid decompression. In some cases only two levels were decompressed and fused. In others, up to seven levels were involved.

It might help you understand what this procedure was all about by taking a look at the results of the first surgery. The first surgery was a cervical laminectomy. In a laminectomy, a portion of the vertebral bone (the lamina) is removed to take pressure off the spinal cord.

In these 23 patients, the bones collapsed after the laminectomy. Instead of a nice curve in the neck (called lordosis), the bones lined up either too straight or curved in the opposite direction (called kyphosis). The risk of pressure on the spinal cord or spinal nerve roots and possible paralysis is too great to just leave the patient with this postlaminectomy kyphosis.

The reason this particular procedure is so unusual is two-fold. First, removing the rest of the bone (corpectomy) means there’s nothing connecting the spine at that level except soft tissues. The surgeon used a metal plate and screws along the front of the spine to stabilize it. The screws were used to distract the bones and re-establish a more normal alignment of cervical lordosis.

The second unusual aspect of this procedure is that the back side of the vertebrae was not stabilized with any type of fusion materials, plates, or screws. Most patients with this type of problem would have a circumferential fusion — one that goes all the way around front to back. A circumferential approach requires two procedures: one from the front of the spine and one from behind (posterior). The risk of spinal cord damage increases with this type of surgery. In these 23 patients, bone grafts were only placed along the front of the vertebrae to stabilize the spine.

How did everyone do with this type of hybrid decompression and reconstruction? Well, there are several different ways to measure the results. X-rays and CT scans were used to see if the fusion was solid. Before and after signs and symptoms were measured for pain levels; neck and arm pain, weakness, and numbness; bowel and bladder problems; and problems walking.

Everyone had some improvement in their symptoms. More than one-third (39 per cent) had a complete recovery from all pre-operative symptoms. Fusion in at least a neutral position (alignment) was solid for everyone. And the position was maintained for up to 10 years in some patients.

The problem of postlaminectomy cervical kyphosis is a complex one and treatment can be challenging. Although things went well with good results, there were some problems. About one-fourth of the patients developed complications such as difficulty swallowing, graft loosening, infection, pneumonia, and screws backing out.

The authors concluded that this hybrid approach (removing the disc and front side of the vertebral bone) to cervical postlaminectomy kyphosis can be done successfully. Fusion only along the front of the spine can stabilize the spine as well as correct the kyphosis deformity. Long-term results showed significant improvements in all areas. There were some complications but these were decreased from previous studies done by the same surgeon.

But this isn’t the final word on the subject. The authors point out that their sample group was small and no one had the circumferential fusion to compare results with the hybrid and anterior fusion approach.

Future studies are needed with two different groups of similar patients treated with this hybrid procedure compared with the circumferential fusion. Results might be the same or significantly better with one procedure over another. But the only way to know that for sure is to compare them directly.

It’s been just slightly more than 10 years since the first cervical disc replacements were done on a group of patients in England. These first generation implants had design problems that have since been improved. In this article, surgeons from Washington University in Washington D.C. offer a review of the cervical disc arthroplasty (replacement) procedure.

In the beginning, cervical disc replacements were used when all else failed. Fusion had created more problems at the adjacent levels. The hope was to save the affected segment. But things have progressed far enough along that there is talk about expanding the use of cervical disc arthropathy (CDA).

Until now, degenerative disc disease has been treated first, nonoperatively. If and when conservative care failed to reduce pain, improve motion, and restore function, then a procedure called anterior discectomy and fusion (ACDF) was the gold standard of treatment.

In the ACDF procedure, the spine is entered from the front of the body (anterior). The diseased disc is removed (discectomy) and the segment is fused. The main advantage of spinal fusion is that it provides stability for the affected level. The main disadvantage is that motion is lost. Over the years, the ACDF (fusion) procedure has yielded better and better results. Studies report long-term results in the 90 per cent range for excellent outcomes.

So you can see that surgeons might be reluctant to use a disc replacement when the ACDF procedure has been so successful. But still, the ACDF does not preserve motion and that’s an important loss to consider. And long-term studies have confirmed that with the fusion procedure, one-fourth of all patients end up having another surgery for adjacent disc disease.

With loss of mobility at one level (the fused level), biomechanics of the spine are altered. Load is transferred through the spine to the next (adjacent) level. The added wear and tear speeds up the degenerative disc disease process. If this complication could be avoided with cervical disc replacement, more surgeons would consider switching from fusion to disc replacement.

Early results from studies of cervical disc arthroplasty are limited in scope. Although the outcomes look good, the data only extends up to four years at the most. Any information about five or 10-year outcomes will be forthcoming but isn’t available now. However, so far, the early (two to four year) success rates with cervical disc replacement are equal to the results for cervical fusion.

Rates of reoperation for adjacent disc disease are much lower for disc replacement (one per cent) compared with fusion (3.4 per cent). But again, these statistics are gathered within the first two years of the procedure. Long-term results just aren’t here yet. Likewise, there isn’t any long-term data available on durability and wear rates for cervical disc replacements.

What about the complication rate between these two procedures? How do these compare? We’ve mentioned the adjacent disc disease as one complication. Other possible complications include dysphagia (difficulty swallowing), infection, length of time in surgery (greater with disc replacement), and time to return-to-work (longer for fusion patients).

Dysphagia is more likely to occur with disc replacements but the actual rate of occurrence is unknown. Infection is always a concern with any surgery. Infection is potentially more likely with disc replacement because of the longer time needed to perform the procedure.

The authors conclude by saying that cervical disc replacement has a good early showing. More time and more studies are needed to know if it will eventually be able to replace fusion as the gold standard for cervical disc disease. With more and more surgeons using these implants, we should have an answer to the question in the next few years.

You’ve probably heard the old expression, If you’ve got your health, you have everything. Well, that’s true, of course. But there are some simple things you can lose that can impact your life in a profound way. Take for instance the ability to bend your elbow.

Picture all the things you can’t do without elbow flexion — wiping your nose, putting on a pair of glasses, scratching your back, eating! These are just a few of the activities you lose control over when the brachial plexus is injured.

Brachial plexus injuries refer to stretching, avulsion, or rupture of a group of nerves that come from the spinal cord in the neck. Avulsion tells us the nerve root is torn from the spinal cord where it attaches. Rupture refers to a complete tear across the nerve dividing it into two or more parts. Plexus refers to the entire group of nerves as they first start out with several main branches that divide to form a much larger number of nerve groups.

These nerves provide both sensation (pain, temperature, touch, vibration) and motor function (muscle contraction) for the entire upper extremity including the shoulder, arm, wrist, and hand. Brachial plexus injuries are usually caused by some type of trauma such as a car accident, fall onto an outstretched arm (especially if the head and face are turned away from that side), and stretching or pulling on the hand, wrist, or forearm. Gunshot wounds, knife lacerations, and other blunt open injuries are also likely causes of nerve avulsion or rupture.

No two brachial plexus injuries are alike. And because of the complexity of diagnosing and treating them, the hand surgeons from Mayo Clinic who wrote this article attempt to help sort out all of the features of this injury. The goal is to help in setting up a plan of care for each patient and foster the best possible recovery. Most patients don’t get full use of the arm again but new microsurgical techniques have helped improve the prognosis.

The first thing the surgeon does when a patient arrives with a possible brachial plexus injury is get a good history of what happened, how it happened, and when it happened. Then a physical exam is performed including all sorts of special tests designed to figure out what got injured, where, and how bad is it. Identifying specifics about the nerve injury help provide the prognosis and treatment plan.

Imaging studies starting with an X-ray of the head, neck, spine, and upper arm may be followed up with CT scans, MRIs, and electrodiagnostic studies. There are even some specific tests that can be done to look for damage to the nearby blood vessels (common with some brachial plexus injuries) and that show avulsion injuries right at the level of the spinal cord.

Once all the information has been gathered, the best treatment for the injury is decided upon. Timing is everything because giving the nerve some time to rest and recover may yield spontaneous healing. Waiting too long (more than six months) may be too late as there can be irreversible changes that mean the nerve will never fire again. If that happens, then the muscle the nerve innervates (controls) will no longer contract. That’s how elbow flexion (or other motions) becomes difficult or even impossible.

Surgical procedures to reconstruct nerves that have been damaged can include nerve transfers, muscle or tendon transfers, nerve grafting, and arthrodesis or fusion of the affected joint(s). The authors of this article provide detailed descriptions of nerve reconstruction surgery. They discuss which nerves can be used in transfers and grafts for each of the nerves affected.

The surgeon must work with both the sensory and the motor sides of nerve function. Without proper sensation, the patient can be at risk for other burns or injuries. If enough time has passed since the injury (more than six months) and there hasn’t been much (if any) recovery of muscle function, it may be necessary to do a muscle transfer. The details of which muscles can be used and how to do the transfer are provided in this review article.

Surgery isn’t the end of treatment. After surgery there can be weeks and months of rehab to restore arm and hand function. If there’s been a loss of shoulder stability, the patient could also lose hand function. That’s when a shoulder fusion may be necessary. Hand function is very complex with muscles needed that can help us hold onto something (grasp) as well as release it. Fingers must be able to flex (bend), extend (straighten), and grip (pinch).

Some surgeons have tried using nerve tissue from donors (patients who have died and donated body parts) instead of reconstructing the injured patient’s damaged brachial plexus. This has not worked out as well as they had hoped. Many have returned to brachial plexus reconstruction for the best results.

Patients with brachial plexus injuries should be warned that the injured arm will probably never be good as new. A team of specialists who really understand these complex injuries will be needed to see the patient through to recovery.

It’s been 10 years since the first artificial disc was implanted in the cervical spine (neck). That event took place in Europe and quickly caught on in the United States. Now we have the four- and six-year results from a multicenter study looking at patients with degenerative disc disease who were treated with the Bryan Cervical Disc Prosthesis. The Bryan implant is made by a well-known company (Medtronic).

Anyone who is thinking about having a disc replacement in the cervical spine will be interested in the outcomes from this study. Everyone in the study had radiculopathy (nerve pain down the arm) or myelopathy (pressure on the spinal cord). The underlying problem was usually a disc protrusion or herniation. Most of the 89 patients involved had a single-level disc replacement. But a few (nine) had implants placed at two levels. Conservative (nonoperative) care was tried first but without success. Cervical disc replacement is a fairly new procedure; so understandably, it’s not the first treatment choice for patients with these kinds of problems.

So, how successful has it been for these patients so far? Early results were reported as very positive after the first two years. The researchers have continued recording any adverse responses as well as any out right failures. X-rays were used to view the neck, discs, and motion at each involved level. The patients filled out several valid and reliable surveys to indicate how well they are doing (motion, function, neck and arm pain or other neurologic symptoms).

Now after six years, the results have been tallied once again. There was a high incidence of adverse events — things like pain in the neck and arm (shoulder to wrist), numbness and tingling in the arm, and hoarseness of the voice. A few odd events were reported such as low back pain and a soft tissue tumor in the neck. Those problems weren’t likely caused by the implant but all complications are being investigated. The real area of interest (used as a measure of success or failure of the implants) was the number of second surgeries (reoperations).

Any time the device migrated (moved or shifted), put pressure on the spinal cord, or had to be removed for any reason, it was counted as a failure. Once removed, the neck was fused rather than trying another disc replacement. Some patients had a second surgery but it wasn’t to remove the implant or correct problems related to the first procedure. These additional surgeries were to treat disc problems at other levels in the cervical spine. Overall, the number of second surgeries was low and the success rate reported as 93.9 per cent.

Comparing the results after six years with the early two-year outcomes, it looks like most patients were still doing well. Any reports of pain or discomfort at the end of two years were even better after six years. There were some changes in sensation noted around the end of the fourth year. No one was quite sure what that was all about or why it resolved over time, so it’s something they will continue to investigate in future studies.

By continuing to follow this group for a full 10 years, it will be possible to observe any late complications and/or late surgical reoperations. Since all patients receiving a disc replacement hope to keep it for the rest of their lives, these long-term studies are important. Surgeons will continue to compare results of disc replacement against the more traditional approach to this problem (fusion).

Although disc replacement allows continued motion at the involved segment, no one wants to face serious problems with this procedure if they can be avoided. And, if in the end, motion is lost, then perhaps a fusion is still the best way to go. These are all things researchers are looking at and will continue to follow for the next 10 years at least.

Cervical spondylotic myelopathy is a common neck (spinal cord) problem among people who are over 55 years old. It occurs when the spinal cord becomes compressed because of changes to the spine and sometimes because of bone spurs that form. When the condition progresses to moderate or becomes severe, surgery is usually the only option to provide relief and improve movement.

Opinions on the type of surgery used to treat cervical spondylotic myelopathy differ between specialists. Some feel that the best approach is from the front anterior cervical discectomy and fusing the bones, while others feel that a corpectomy, removal of some of the vertebrae and fusion is the way to go. Yet other surgeons go for an approach from the back of the neck, a posterior surgery that includes laminoplasty (repositioning of the vertebrae) or laminectomy (removing part of the vertebrae), along with fusing the bones together. Because the population in the United States is aging and people are living longer, these types of surgeries will become increasingly common. For this reason, it is important to know which, if any, approach is better, to increase the chances of good outcomes. The authors of this study reviewed the different approaches to see if one was better than the other, in order to help surgeons with their decisions regarding the surgery to be done.

Researchers went through the medical literature to find studies that looked at the targeted surgical procedures, from 1980 to 2008. A separate review was done of 10-year follow-ups. Seven articles were found that were used for this review and three for the 10-year follow-up review. None of the studies included a randomized controlled study, where neither the patients nor the investigators know what type of surgery is being performed. The follow-up articles were case studies.

Four studies compared corpectomy to laminoplasty. Following the surgeries, the reports showed similar results from both surgical procedures in terms of neurological (nerve) damage and recovery rate, but two studies did find a significant difference in the range of motion after surgery. The patients who had undergone a laminoplasty had better range of motion than those who had a corpectomy. There was also a difference in pain outcomes. Patients reported more pain after laminoplasty than corpectomy (40 to 60 percent versus 15 to 19 percent). In reviewing complications, more were found in the corpectomy group and seemed to be related to where the surgery entry was (anterior or posterior). However, there were also complications in some patients related to the grafting or the bones not joining. The complications seen with some laminoplasties involved nerve damage, but all were resolved.

Two studies compared anterior cervical discectomy and laminoplasty. The only differences found between these procedures was a higher rate of spondyloptosis (vertebrae slips forward) in the patients in the first group. Only one study compared laminectomies with laminoplasties. In this study, the only significant differences were a decreased range of motion after surgery with the laminectomies, compared with the laminoplasties, and five patients in the laminoplasty group had non union of the bones. There were eight serious complications among the laminectomy group including two patients getting worse, two patients experiencing a breakage of instruments, one patient requiring further surgery, one having a deep infection, and one having graft site pain. No complications were reported in the other group.

When reviewing the studies involving the 10-year or more follow-ups, the researchers looked at three case series. All showed that limited range of motion and neck pain continued to be a problem among some patients who had undergone laminoplasties. Some patients who underwent a corpectomy also had continued neck pain, but not in as high a number as the laminoplasty group.

The researchers concluded that the laminoplasty is a good option for treatment of cervical spondylotic myelopathy, with generally fewer complications than the other surgeries described in this article. However, there is also a higher incidence of neck pain among this group.