News Category: Cervical Spine

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.

Japanese scientists have come up with a possible answer to a sticky problem. Patients with cervical myelopathy often have trouble walking because of damage to the spinal cord in the neck area. Finding a way to rate the severity of this condition can’t rely on walking tests. Some patients can no longer walk, while others aren’t safe doing a walking test. So, they devised and tested a sitting foot tapping test. This study presents the results of testing the new performance test!

Cervical myelopathy refers to any condition that causes degeneration, damage, or pathologic changes of the spinal cord in the cervical (neck) area. This condition can present with many different signs and symptoms. Difficulty walking has been mentioned. Limb spasticity (increased muscle tone) creates balance and walking problems. Other symptoms include neck and arm pain, electric shock sensation down the arms (called Lhermitte’s sign), clumsiness of the hand(s), and difficulty with finger motion to name just a few.

Cervical myelopathy can develop as a result of a disc protrusion pressing on the spinal cord. Changes in the alignment of the vertebral bodies such as occur with spondylolisthesis can also contribute to this problem. In spondylolisthesis, there is a fracture and separation of one of the supporting columns of the vertebra. The affected vertebral body shifts forward over the bone below it. As this shift occurs, the spinal canal narrows between the two vertebrae and traction (pull) is placed on the spinal cord and spinal nerve roots.

Age-related factors are another category of factors leading to the development of myelopathy. For example, thickening and/or ossification (hardening) of the spinal ligaments within the spinal canal takes up space normally needed for the passage of the spinal cord. Degenerative changes of the vertebral bodies with bone spur formation and narrowing of the joint spaces compress the vertebral bodies. The result is a narrowing of the spinal canal. Any time the spinal canal space is decreased, the condition is called spinal stenosis. Spinal stenosis is a big reason why older adults develop cervical myelopathy.

So, why is a performance test really even needed for this group of patients? It provides a way to measure progression of the disease (i.e., is the patient getting worse and by how much?) and it gives a before and after measurement of results from surgery. Both of these measures are important when trying to provide evidence that a particular treatment is effective and should (or shouldn’t) be recommended. Surgeons are also trying to decide when is the best time for patients with cervical myelopathy to have surgery. A test of this sort might help researchers pinpoint an answer.

The authors first proposed the triangle step test (TST) about 10 years ago. They’ve been testing it ever since and have some results for us now. They call it the triangle step test because of the way it’s performed. No walking or upright balance is required. The patient sits in a chair and uses one foot to tap the three corners of a triangle (one corner after another). The number of steps or taps completed in 10 seconds is recorded. The test is repeated using the other foot.

By testing healthy adults (the control group), they were able to determine norms for comparison with the cervical myelopathy group. They also compared results using the triangle step test (TST) before and after surgery. Surgery was done to take pressure off the spinal cord and stabilize the spine. The TST showed rate of recovery after surgery. They tested the same patients using several other tests already available to check the validity of the TST. The other tests included the Nurick score, the finger grip and release (GRT) test, and the Japanese Orthopedic Association (JOA) score. Statistical analysis showed that the results of the TST correlated well (matched) the results of these other tests.

In summary, the triangle step test (TST) is a safe and simple test of lower extremity (leg) function. It can be used to test the severity of spinal cord compression in patients with cervical myelopathy. It takes less than one minute to complete and it doesn’t require any equipment or cost anything. Even patients who can no longer stand up safely or walk can be tested using this tool. Those are all major advantages of this new performance test. The TST is also a sensitive measure of change from before to after surgery. In fact, it looks like the TST can be used to predict when surgery might be helpful. They found that patients who could complete 20 or more steps in 10 seconds would benefit from surgery.

The authors aren’t quite ready to launch the test for general use with myelopathy patients. They say there are some things yet to consider. For example, many of the patients with age-related cervical myelopathy also have spinal stenosis of the lumbar spine or arthritis affecting the hips, knees, and lumbar spine. These comorbidities (additional problems) can cause pain and weakness, resulting in difficulty lifting the feet. Poor eyesight or dementia affecting the ability to follow directions can also affect the results of the TST. The authors plan to analyze how much each of these factors affects test results as their next research step.

Time marches on and sooner or later you realize it is marching across your face. That’s a popular quote made by Dolly Parton in the 1989 movie Steel Magnolias. And as we all know, the passage of time affects many other parts of the body. In this study, surgeons take a look at the effect of time on spinal segments above and below an area that was fused 10 years ago. The patients all had a procedure known as an anterior cervical decompression and fusion (ACDF). Fusion at one level stops motion but may increase the load on the next (adjacent) segment. This study attempts to find out how often this happens and how bad is it?

Using magnetic resonance imaging (MRIs), researchers compared two groups of adults over a period of 10 years. The first group had cervical (neck) spinal disorders that led to the ACDF procedure at one or two levels. Some had bone spurs; others had discs that were protruding. In all cases, there was pressure on the spinal cord and/or spinal nerve roots causing significant neurologic symptoms.

Conservative (nonoperative) care did not help, so surgery was done to remove bone, disc material, and any other soft tissue or bone blocking the nerve tissue. That’s the first surgical (decompression) step. The next part of the surgery used bone graft to fuse two or more vertebrae together. Fusion is necessary to stop the pain and help stabilize the affected segments.

The second (control) group was made up of healthy adults who had no symptoms of neck pain or neck problems. The groups were matched by age (ranging from 17 to 68) and sex (equal numbers of men and women). By including a group of normal, healthy adults, it was possible to observe the physiologic effects of aging without fusion. The idea of making comparisons with this group is that it helps answer the question of whether disc degeneration at adjacent levels is related to the increase in stress caused by the ACDF — or if changes observed in the discs is just a result of time and the effects of aging. Or maybe it’s both! Let’s see what they found out.

MRIs were reviewed by two experienced neuroradiologists who knew nothing about the patients or control subjects. They paid specific attention to signal intensity of the disc, presence of any disc protrusion, narrowing of the disc spaces, and any signs of foraminal stenosis. The foramen is the opening in the bone through which the spinal nerve roots pass as they travel from the spinal cord down to the arms (or legs in the lower extremities). Stenosis means narrowing. So foraminal stenosis refers to a narrowing of the openings for the spinal nerve roots. Pressure on the nerves at this point is what causes neck pain, headaches, numbness and other symptoms suffered by these patients.

Analysis of results showed a definite increase in the incidence of adjacent segmental disc degeneration in the ACDF group compared with the control group. The upper segment adjacent to the fusion was affected more often than the lower adjacent segment. Some areas of the neck seemed more likely to present with problems. For example, narrowing of the disc space was more common at C3-C4 and C6-C7 in the ACDF group. Protrusion of the disc occurred at all levels in the ACDF group with the exception of the C5-C6 segment.

The control group did show evidence of aging over time affecting the spine. Posterior disc protrusion was seen most often (72 per cent), followed by decrease in MRI signal intensity (59.7 per cent), disc space narrowing (30 per cent), and foraminal stenosis (nine per cent). In both the ACDF patient group and the control group, positive MRI findings indicating degeneration were not always accompanied by symptoms of any kind. When symptoms did occur, patients in the ACDF group were much more likely to be the ones affected.

The authors concluded that disc degeneration progresses faster and more often in patients who have had the ACDF surgical procedure when compared to normal, healthy adults who are only subjected to the affects of aging over time. The results may seem obvious but this is the first proof that ACDF speeds up adjacent degeneration when added to the normal effects or physiologic aging.

The exact reasons for this remain to be discovered. It’s possible there are environmental and genetic factors that cause the initial advanced disc degeneration in some, but not all, adults. The authors intend to keep studying this problem in hopes of finding out why some people develop disc degeneration while others don’t. They will also extend the follow-up with these patients beyond the first 10 years to get a look at what happens much later in time. This study gave a hint that perhaps some spinal levels are at greater risk than others for disc damage, degeneration, and progression of disease. They plan to take a closer look at that as well.

You probably don’t give it much thought but the head sits on a stack of little, tiny bones called the cervical spine. Kids fall and bonk their heads, get up and keep going. They seem practically made of rubber. But in our older years, a fall even while at ground level can fracture one of those upper cervical vertebrae and cause serious problems. The treatment of odontoid fractures of the upper cervical spine is the subject of this article.

At the very top of the cervical spine is the atlas bone labeled C1. Directly underneath the atlas (C1) is the axis bone, also known as C2. The axis (C2) has a knob sticking straight up from it called the dens or odontoid process. The dens pokes up through the opening of the atlas. A series of complex ligaments holds the skull on top of the atlas. You can nod, shake, tilt, and turn your head — all done as the skull moves around the pivot point of the upper cervical spine.

A fracture of the odontoid process (dens) can create instability of the head on the spine. A type II odontoid fracture extends through the base of the dens. It is the most common type of fracture in this area. Without treatment, difficulty breathing, paralysis, and even death can occur.

What’s the best way to secure this broken bone in someone who is 70 years old or older? There are two basic choices: a rigid neck brace that holds the spine still until the fracture heals or surgical fixation. Surgical fixation means that screws are used to hold everything together while the bone knits itself back together.

The bracing option is really more for the younger crowd. Studies have shown that the complication rate is so high for older adults treated this way, it’s just not worth it. So that leaves surgical fixation as the best practice. But it’s a pretty small area at the top of the spine just under the base of the skull. How many screws are needed? Should the procedure be anterior (done from the front of the spine)? Or is a posterior approach better? Each method has its own problems and potential complications.

To answer these questions, a group of neurosurgeons did a chart review of their patients treated for odontoid fractures over a period of 15 years. Their search turned up 42 patients who were treated and followed long enough to record results of treatment. They were all over age 70. Direct anterior fixation of the odontoid fracture was used with each one of these patients.

The authors say they chose the anterior approach for all of these patients because it helps preserve motion at the C1-C2 segment, decreases the amount of trauma to the surrounding soft-tissues, and doesn’t require bone grafting to provide the stability needed. This approach also reduces the time it takes to perform the operation and that’s important for this age group. There is also less risk of damage to the nerves and blood vessels compared with the posterior approach.

There are two major downsides to an anterior spinal procedure. And that’s the fact that the patient can end up with difficulty swallowing called dysphagia, which can lead to aspiration. Aspiration refers to inhaling food into the lungs. The result can be pneumonia, a potentially life-threatening complication in this age group.

The surgeons hoped that by looking back at how their surgeries were done and the final outcomes, they would be able to see who had the best results and why. This type of information can help shape treatment decisions for future patients who develop odontoid fractures. In order to assess their results, they reviewed patient X-rays, recorded how each surgery was done, and compiled data on postoperative complications.

They found that the patients who were treated with two screws (two-thirds of the patients) did better than those who only had one screw put in place (one-third of the group). The decision about whether to use one or two screws is left up to the surgeon at the time of the operation. If it’s possible to connect the broken bone together with one screw, then why disrupt the soft tissue and bone by using two? But the results of this study will bring that approach back under review.

The authors recommend using CT scans before surgery in order to assess the strength of the bones and their ability to hold screws. The procedure should be pre-planned to place the screw(s) through the densest (strongest) portion of the bone. A careful preop review of the patient’s anatomy is needed to find the best path for fixation. Sometimes the final decision about surgical methods used can’t be made until the surgeon is in the operating room.

And there are some times when surgery just can’t be done. The patient may be too fragile medically. Those who have severe dementia and won’t be able to follow postoperative directions aren’t good candidates for this type of surgery. Sometimes the family or even the patient refuses surgical treatment. In such cases, the surgeon must be prepared to discuss other treatment options. Each case must be reviewed and decided individually based on all patient factors and potential risk factors.

For these patients who did have surgery, there were some serious complications including nine per cent of the patients who died. Heart, lungs, or intestinal issues were reported as the primary cause of death following fixation surgery. One-third of the group had difficulty swallowing after the procedure. This was treated with a soft diet or temporary feeding tube. Quite a few patients (19 per cent) also developed pneumonia.

X-rays with the head bending forward and backward were used to assess stability. Only slightly more than half of the remaining patients (57 per cent) had a stable union of the bone fracture at first. Some of these patients had a second surgery to place a longer screw or fuse the spine. It was observed that over time, the number of patients who fused gradually increased to 76 per cent.

Reflecting back on the results, the surgeons commented that these are complex patients with a serious problem. Surgery to stabilize the C1-C2 spine and prevent neurologic (spinal cord) injury can be very successful. But the transformation of a fibrous union to a bony union takes a long time (months to years) in this age group. Patients must be forewarned about the potential for various complications. Follow-up should continue until the spine is stable with a solid fusion.

The cervical spine, in other words, the neck and uppermost part of the spine, is normally able to move quite freely. You can bend your neck up or down, and turn it quite far either to the right or the left. Because the neck is a complicated body part, it’s important that researchers and doctors understand how it works when it is healthy in order to diagnose problems when they occur. With this in mind, the authors of this article measured the kinematics, or motion, of the cervical spine using three-demensional analysis.

Up to now, some research has been done on cervical spine kinematics, usually including measuring using compasses and other mechanical devices, x-rays and scans. However, this type of measurement doesn’t involve the third dimension needed to better understand movement. They also cannot measure more than one movement at a time, velocity of movement, and continuous patterns. The few studies that did involve three dimensions usually only looked at primary movements of the neck, not complicated or combined movements.

Researchers recruited 70 men and 70 women who did not have any problems with their neck. These groups were subdivided into seven groups of 10 men and 10 women each, by age. Using an infrared measurement system, the researchers looked at active range of cervical (neck) motion as the subjects rolled their heads while keeping their eyes closed. The head-to-neutral head position was also measured, which involved repositioning the head back to its natural (neutral) position after it has been positions as far as possible at a different angle. Head-to-target measurement was done to see how the subjects actively repositioned their head in a memorized position.

When analyzing the results, the researchers found that there was no obvious difference found between men and women, and their ability to move about – with one group exception. Among the 70 to 79 year olds, the men were not as able to move their neck as the women. Earlier studies had found that women were more mobile than men at various ages. Looking at the results by age, there were limitations to mobility as the groups were older, again, similar to findings in earlier studies. The subjects had also been tested about their awareness of their motions, the proprioception. There was a difference in this only in one sense. As the groups aged, some subjects had more difficulty with horizontal movements.

When someone develops cervical compression myelopathy, this means some vertebrae (bones) in the neck are pressing together, causing pain and other problems. The standard treatment for this problem is a surgery called cervical laminoplasty. The surgery has a fairly good success rate and long-term outcome. However, recovery can be slow. The authors of this article investigated the recovery process to determine the length of time and other issues that may arise.

Researchers studied 98 adult patients who had the surgery for cervical compression myelopathy (69 men). The patients were divided into two groups, according to age: under 70 years old and 70 years old or older. The patients were followed for between five and 12 years. The cause of the compression included cervical spondylosis (arthritis) in 60 patients, cervical disc herniation (slipped or bulging discs) in 20 patients, and ossification of a ligament (hardening into bone) in 18 patients.

The testing consisted of measuring items according to the Japanese Orthopedic Association score, 10 seconds grip and release test for hand coordination, and grasp strength. The tests were done just before surgery and repeated at three, six, nine, 12, 18, 24, 36, 48, and 60 months after surgery. The results showed that the Japanese Orthopedic scores improved at five years after surgery with half of the patients recovering well at this point. For 80 patients, the maximum score was reached within a year. The score plateaued though, stayed even, after about 8.8 months, while the grasp strength continued to improve until an average of 25.6 months after surgery. Patients in the older group took longer to recover than the younger group. As well, patients who had symptoms for less than one year recovered much more quickly than those who had symptoms for one year or longer.

The authors concluded that recovery from this type of surgery can take up to two years and is affected by both age and how long the problem has been symptomatic.

A pinched nerve causing neck and/or arm pain is one thing. But when the spinal cord in the neck area gets pinched or compressed, that’s more serious. Permanent paralysis can develop if the problem isn’t corrected. One of the most popular surgical procedures to decompress the spinal cord is called an open-door laminoplasty. This study takes a look at why the procedure fails for about 10 per cent of patients and what to do about it.

The lamina is a ring of bone around the spinal cord to protect it. And it works very well in doing so until outside forces create a stenosis or narrowing of the spinal canal. And then suddenly, that protection becomes a problem. Aging and the degenerative changes associated with getting older are the most common reasons for spinal stenosis. For example, disc degeneration brings vertebral bones and spinal joints closer together. Closer proximity of the bone and joint surfaces without a healthy disc to hold them apart can cause bone spurs and other bony changes to develop.

The posterior longitudinal ligament (PLL) along the back of the spine thickens and takes up additional space inside the canal. Disc degeneration and arthritic changes cause the vertebral bones to shift or collapse slightly. Even a minor shift in the vertebral bone alignment can put pressure on the spinal cord.

A laminoplasty involves cutting through the lamina on one side and swinging the bone away from the spinal cord. It’s much like swinging a door open, which is why it’s called an open-door laminoplasty. The surgeon places a laminoplasty plate on the opposite side to help hold the door open. It’s a popular procedure because patients get pain relief without causing harm or injury to any of the soft tissues or spinal structures. Recovery from neurologic symptoms following an open-door procedure is as high as 72 per cent.

But sometimes the procedure fails. That’s where this study comes in. The surgeons wanted to take a look at why failures occurred and figure out what to do about it. They reviewed the medical records of 130 patients who had a cervical laminoplasty over a 10-year period of time. An after-the-fact review of this type is called a retrospective study. The authors believe this is the first and only study to report on what happens after a failed open-door laminoplasty.

By carefully analyzing the data available on these patients, it was clear that there were three major reasons why the procedure failed. Surgical technique was the most common cause of failure affecting 25 per cent of the cases. In particular, the use of the suture anchors used at that time to hold the door open was not successful. In other cases, it was a matter of the underlying problem (arthritis, degenerative changes) continued to get worse, causing more stenosis. This cause is referred to as disease progression. And in a few cases, there just wasn’t enough decompression to relieve the spinal cord compression.

In all three cases, symptoms got worse and a revision surgery was needed. The type of revision procedures that were done varied. For some patients, the surgeon just removed the lamina. This procedure is called a laminectomy. If enough of the lamina bone was removed, then the spinal segments were fused together to provide stability. Fusion procedures can be done in a variety of different ways depending on where the surgeon enters the spine (anterior from the front, posterior from the back, or circumferential around two or more sides). To highlight what can happen, the authors presented four individual cases and showed MRIs and X-rays to illustrate the various problems.

The authors now use laminoplasty plates instead of suture anchors to keep the lamina door open. This is especially important for anyone who has poor head control, which was the case in two of their failed cases. One patient had excess head and neck movement due to cerebral palsy and the other had low muscle tone and poor head control because of Down syndrome.

They conclude that open-door laminoplasty is still a good surgical procedure to use when there is spinal cord compression in the cervical (neck) region. It is a motion-preserving technique that usually works quite well. But patients should be advised that the procedure isn’t always 100 per cent successful. There is a slight chance that they could end up with only partial relief from their symptoms. Or the symptoms can get worse over time when there is disease progression.

A second (revision) surgery (usually a fusion) may be necessary. The type of fusion performed depends on the underlying cause of the failure. The authors use posterior fusion when the lamina door has closed, anterior fusion when symptom relief isn’t enough, and a circumferential approach when there are spinal deformities present or when the door hinge breaks and doesn’t heal (nonunion). More studies are needed to find out how successful are revision surgeries and when it is best to use each type of approach (anterior, posterior, circumferential).

Bioabsorbable plates are fairly new to the spinal fusion scene. For a long time now, surgeons have used an approach called the anterior cervical discectomy and fusion (ACDF). Anterior refers to the location of the incision and the way surgeon enters the spine (front of the neck). Anterior fusion is performed through the front of the spine to avoid the spinal cord and spinal nerves. Cervical refers to the neck and discectomy is the removal of the disc from between two vertebrae.

Most surgeons use bone graft material to fill in the space left by removal of the disc and a metal plate to hold the spine in place while the bone graft material fills in. The use of a metal plate and screws to hold it in place is called instrumentation. Stiffness is the desired outcome of fusion in order to provide stability. Fusion rates have improved greatly with this surgical technique.

But even as successful as this approach has been, there can still be problems. Sometimes the screws back out and/or the plate shifts its position. Because the plate is along the front of the spine, swallowing can be impaired. Too much stiffness is a potential problem when using a metal plate system but there is general agreement that fusion without instrumentation is less effective than with instrumentation. And X-rays can’t penetrate the metal plate, so it’s difficult to assess the fusion site.

That’s why bioabsorbable plates that eventually break down and become absorbed into the fusion have been developed. The plate and screws hold up well for the first six months, providing full strength. But then they start to break down bit by bit. The body absorbs the by-product as it dissolves. By the end of the first year, the plate is only at 32 per cent of its full strength. And by the end of 18 months, it is completely resorbed. The plate is translucent so that X-rays taken anytime during the postoperative period pass through the plate and show the status of the fusion site.

But even with all of the technical advances with this procedure, there can still be problems. In this study of 30 patients with cervical fusion at one level (between C3 and C7 using these new plates), the fusion rate was good (92.3 per cent), but the rate of subsidence was still high for the bone graft used in the procedure. Subsidence means the extra bone used to fill in sinks down into the vertebra, leaving it less stable than a solid fusion. Neck deformity called kyphosis (too much forward curve in the spine) occurs when subsidence develops.

Major complications (e.g., infection, bleeding) were about the same for the bioabsorbable plates as with the standard metal instrumentation. Some patients still reported neck and arm pain. Loss of function or failure to resume normal everyday activities accounted for a 41 per cent rating of poor-to-good (rather than excellent). Slightly more than half (59 per cent) of the patients had excellent results.

The authors of this study suggests that bioabsorbable plates stabilize the spine better than having no plate but there are enough problems that further study and improvements in this technique are required before it can be recommended instead of metal instrumentation for ACDF procedures. Long-term study is also needed to see how patients (and the graft site) fare years down the road. Unlike permanent plates, with the dissolving kind, there won’t be any plate-related complications years later as there have been with metal instrumentation.

Sometimes when there’s bone or disc degeneration in the cervical spine (neck), fusion is needed to stabilize the area. Over the years, one procedure in particular has gained popularity because of its effectiveness: the anterior cervical discectomy and fusion (ACDF).

The authors of this article on the treatment of cervical myelopathy originally presented the results of a study comparing disc removal and replacement versus spinal fusion for this condition back in November 2008. Now, they offer a detailed look at the surgical technique and pitfalls of cervical disc arthroplasty (disc replacement in the neck), along with an update on this procedure.

Cervical myelopathy refers to a narrowing of the spinal canal, the opening formed by the vertebral bodies when stacked on top of one another. The spinal cord travels through the open spinal canal. Anything that narrows this opening (e.g., disc protrusion, bone spurs, hardening of the spinal ligaments) can put pressure on the spinal cord and cause serious neurologic problems.

At the time of the 2008 study, there was a question about whether disc replacement versus spinal fusion was the best treatment approach to the problem of cervical myelopathy. Disc replacement preserves motion but might cause ongoing microtrauma to the spinal cord if the implant puts any pressure on the spinal cord. Fusion eliminates any ongoing microtrauma but limits motion and may increase stress and load on the vertebral segments above or below the fused level.

There were no direct studies comparing the two methods, so the authors looked at the results of each procedure separately and compared final outcomes. The results were measured using patient reports of neck and arm pain, function, gait (walking ability), and self-reported general physical and mental health. They found that either treatment worked well and the myelopathy did not get worse after disc replacement. Treatment was restricted to one spinal segment and patients were only followed for two years.

Since that time, cervical disc arthroplasty (replacement) has continued to be used in younger patients who don’t have a lot of degenerative changes seen in older adults. When pressure is placed on the spinal cord because of disc protrusion, then disc replacement is the treatment of choice. Cervical disc arthroplasty is not recommended when the patient has bone spurs, significant wear and tear on the facet (spinal) joints, or other age-related changes.

Other contraindications to cervical disc arthroplasty include fracture, unstable segments due to rheumatoid arthritis, or previous surgery to remove the lamina, a supporting column of bone that’s part of the vertebra. Contraindication means reasons why something should not be done, in this case, the disc replacement. Anything that might compromise the stability of the spine is considered a contraindication. Infection, extreme obesity, osteoporosis (brittle bones), or other arthritic conditions that limit spinal motion are also contraindications to cervical disc arthroplasty.

In this article, the authors (three spinal surgeons from the Midwest) provide a detailed review of the standard technique used to perform a cervical disc arthroplasty. Patient positioning, approach and incision, and surgical instruments used for osteophyte (bone spur) removal are discussed. Photos of the proper patient position needed to ensure perfect placement and alignment of the implant are included. X-ray photos of improper implant alignment help the surgeon see what happens when this aspect of the procedure is not taken care of properly.

Intraoperative photos of the disc space and endplate preparation are also published. Results of decompression (refers to removal of osteophytes and anything else putting pressure on the spinal cord) are checked using CT scans. Additional photos of the implant in place during the operation are accompanied by a description of problems that can develop if the implant is wedged in too tightly (can limit motion) or the soft tissues are too loose (can create spinal instability). Implants no longer come in a one-size-fits-all, so the surgeon must carefully measure and choose the right sized implant for each patient.

And finally, the authors list for surgeons, the many possible pitfalls of this procedure. Most are technical details again related to patient positioning, disc space preparation, obtaining adequate decompression (but not too much!), and proper implant size selection and placement.

For example, too large of an implant will distract (separate) the two vertebral bodies too much resulting in an unstable segment. Not enough decompression may result in rubbing of the implant up against the spinal cord reproducing the same problem as when the disc was present and doing the same thing. Everything done to prepare for the implant must be symmetrical such as even and level edges of the bone all the way around. And the implant must be placed in the middle of the prepared disc space to avoid asymmetrical motion of the spinal segment.

Without direct studies comparing these two treatments for cervical myelopathy, surgeons are left to rely on case studies and personal experience when deciding the best approach to this condition. The 2008 comparative study was based on a large number of patients in both study groups but a direct study is still needed. In the meantime, the authors of this article bring their knowledge from reported studies and personal expertise to offer an up-to-date review of cervical disc arthroplasty.

There’s a move on now in the medical community to find reliable, valid ways to classify a problem and then decide how to treat it. In this study, orthopedic surgeons from St. Louis University School of Medicine check out the Cervical Spine Injury Severity Score (CSISS) for its user friendliness and accuracy. The CSISS is for patients with neck injuries involving the lower cervical spine (C3 to C7). This is an area of common injury. Predicting who might need surgery to stabilize the neck is the main goal of the CSISS approach.

Other classification models for the lower cervical spine focus on how the injury occurred (called the mechanism of injury). But the CSISS uses X-rays and CT scans to take a look at four anatomical features of the cervical spine and score them based on injury present (e.g., fracture, dislocation).

The scoring system takes into account the location of the injury, severity (nondisplaced vs. displaced fracture), and neurologic damage. Four columns of the cervical spine are evaluated separately: the two facet (spinal) joints, the vertebral body, and the posterior area of the spinous process. You can feel the spinous processes of your spine by rubbing your fingers up and down the back of your neck. The largest bump near the top of your spine is the spinous process of C2. At the base of the neck where the cervical and thoracic spines join together, you’ll feel another large spinous process. That’s C7.

These bony knobs are the place where the two lamina bones join together at the back of the spine. There is a bony ring that attaches to the back of the vertebral body. The ring forms an opening for the spinal cord to travel from the brain down to the end of the spine. This ring has two parts. Two pedicle bones form a short column of bone that connects directly to the back of the vertebral body. Two lamina bones join the pedicles to complete the outer rim of the ring.

The authors provide a CT scan photograph to show the reader where the four columns are (right and left facet joints, vertebral body, posterior ring with spinous process) and how the fractures are scored (from zero to five). Each column is scored independently and then the scores are added up for all four columns. Zero indicates no fracture or dislocation is present. A score of one is given for a mild (one to three millimeter) nondisplaced fracture. A score of two means there is a one to three millimeter displaced fracture. Three is for a three to five millimeter displacement. And anything more than five millimeters is scored as a five.

The scores reflect not only the amount of displacement (the higher the score, the more severe the injury), but also give the surgeon an idea of how stable/unstable the fracture site is. A CSISS score of seven or more is a sure sign that surgery is needed to stabilize the spine. In research terms, a score of seven has a specificity of 100 per cent and a sensitivity of 73 per cent. Specificity shows the ability of a test to determine a true negative for the condition (i.e., the spine is not fractured). Sensitivity reflects the ability of the test to show a true positive (i.e., the spine is fractured/unstable).

In the study, 15 physicians (junior residents, senior residents, attending spine surgeons) looked at the X-rays and CT scans of 50 patients with known lower cervical spine injuries from trauma. All physicians had specialized training in the treatment of traumatic spinal injuries. Without any specific instructions, they used the CSISS scoring system on each of the 50 cases. A month later, they attended an instructional lecture on how to use the CSISS scoring system. A month after the lecture, the same 15 surgeons reassessed the same 50 patients using the CSISS. The results were compared from before to after the instructional lecture to show whether or not this system can be taught easily. And the results were compared to the actual patient cases. This is a measure of how accurate, valid, and reliable the CSISS classification system is.

The authors report that the CSISS is both reliable and teachable. Physicians with a wide range of orthopedic training can use it. Scores were definitely better after the instructional workshop. So before using the CSISS classification system, it is advised that some training should be provided. The scoring system is easy to use and may become the universally accepted classification system needed to assess lower cervical spine injuries.

The unpredictable nature of these types of injuries and the difficulty of seeing ligament injury with imaging studies makes treatment planning difficult. Having a classification system like the CSISS to analyze the fracture type and plan treatment would be very helpful for trauma orthopedic surgeons. It would also make communication easier between and among spinal surgeons and trauma specialists if everyone were using the same assessment tool to talk about the injury.

The authors conclude by saying that their study provided an independent look at the CSISS, since they were not part of the group who did the original research and design of this tool. The CSISS passed their scrutiny and found to have excellent reliability and reproducibility at all levels of experience and training. Now, other groups need to do the same thing to verify these findings before the CSISS can be adopted universally by all. Using an instructional lecture to improve scoring is advised.

Have you ever heard the expression What’s good for the goose is good for the gander? It’s an English idiom (figure of speech) that suggests if something is good for one thing, it can be useful for something else as well. In the world of spine surgery, bone substitutes called bone-morphogenetic proteins (BMPs) have been used successfully in lumbar spinal fusions. That’s what they’ve been approved for by the Food and Drug Administration. They replace human bone grafts that are hard to come by, don’t always take, and can leave the donor site more painful than the fusion site when the patient donates his or her own bone for the procedure.

The problem with BMPs is that some surgeons have extended their use to fusions of the cervical spine (neck). This practice is referred to as an off-label use (i.e., not for what it was intended). And suddenly, what was good for the goose (lumbar spine) was no longer good for the gander (cervical spine). Unexpected complications arose — too much bone growth resulted in swelling of the airway, compression of the airway, difficulty swallowing, hoarseness, and poor wound healing. These complications are not minor, but serious enough to potentially be life-threatening.

Not to be an I-told-you-so kind of guy, but the surgeon who originally researched the use of BMPs and eventually got them FDA approved has said all along that these bone substitutes have only been tested in the lumbar spine and that’s the only place they should be used. Using new technologies like bone growth factors in similar but not exactly the same ways is legal, just not always advised.

At least one study showed that BMP is safe for use in the thoracic spine and posterior cervical spine. The real problem appears to be use of BMPs in the anterior cervical spine. Anterior means the fusion is done from the front of the neck. That approach avoids contact with the spinal cord and reduces the potential for neurologic damage. Clearly, the complication rate was much higher (50 per cent higher) when BMP was used in the anterior cervical spine compared with posterior cervical spine or the lumbar spine.

So why isn’t the FDA protecting the public on this issue? Well, again, as mentioned — it’s not illegal to use products off-label. Drug companies can’t advertise or promote off-label use without adequate trials and safety studies. But there’s nothing stopping a surgeon from seeing that something works well in one situation and giving it a try in another different, but similar application. And that’s what happened with BMPs in anterior cervical spine fusions.

Only what worked well for the lumbar spine didn’t pan out for the cervical spine. The natural question is Why not? It’s not entirely clear just yet. There’s some speculation that when the surgeon took the product (packaged for the lumbar spine procedure) and used it in the cervical spine, rather than throw half of the expensive BMP away, he or she used it all. That resulted in overgrowth of bone in an area with little room for additional bone with the trachea, esophagus, nerve supply, and soft tissues contained in a small, limited space of the throat and neck.

As a result of these unexpected complications, there’s been a call for closer supervision of new technologies like BMPs. Surgeons are pointing fingers at the FDA and saying safety should be under their umbrella and products shouldn’t be released without full and satisfactory testing. Others are suggesting the FDA has a role in close surveillance in after market results but that medical societies and surgeons themselves must be responsible for follow-up reporting.

Actually, for those surgeons who attended annual spine meetings and conferences, there was plenty of discussion about the early results of BMPs for anterior cervical spine fusion. But those who didn’t attend the meeting didn’t get the memo, so-to-speak. So this off-label use of BMPs continued with some devastating results that went otherwise unreported. Now, those who are in the know say that at the very least the use of BMPs in anterior cervical spine fusions should be halted until further studies deem it is safe to use and guidelines are provided for how best to use it for that purpose.

The natural history of cervical spondylotic myelopathy (CSM) is the topic of this article. Natural history refers to what happens to a person with this type of problem as time goes by. Do they get better, worse, or stay the same? CSM is a degenerative condition that occurs with aging. Adults affected most often are 50 years old and older. The term myelopathy refers to any problem that affects the spinal cord. Cervical tells us the area affected is the cervical spine (neck region). Spondylotic or spondylosis describes a narrowing of the spinal canal where the spinal cord is located.

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

There is a wide range of changes associated with aging that contribute to spondylosis that leads to symptoms of myelopathy. For one, the vertebra themselves lose height and push down on the discs and facet (spinal) joints. Pressure around the joints from rubbing together causes the vertebral body to form bone spurs that reduce motion and cause additional pain.

This kind of compression affects the spinal nerves more than the spinal cord but both can be involved directly or indirectly. As these structural changes take place, thickening, hardening, and buckling of the ligaments occur along the spine. And that is a common factor in the development of cervical spondylotic myelopathy. Anyone who has a narrow spinal canal from birth is especially susceptible to these age-related problems.

So, what is the natural history of cervical spondylotic myelopathy? Can a person outgrow it? If it comes with aging, does it get worse as we get older? If we know how a condition is going to respond over time, it’s easier to predict which types of treatment would work best and which subgroups of patients would respond to those treatment approaches.

After a thorough review of studies published with good-to-high quality of evidence, it would seem that cervical spondylotic myelopathy can go any number of ways. In some cases, there is a slow decline over time. The patient seems to get worse, plateaus (stays the same) or may get slightly better, then declines even more. This pattern is referred to as a stepwise decline. In other cases, the patient is symptom-free or perhaps experiences no change in symptoms over a long period of time.

Is there some way to predict who will progress and get worse and who will stabilize/stay the same? For that matter, is it possible to predict if anyone with this degenerative problem will get better? After all, if it is age related, we can’t reverse the effects of aging or stop the aging process.

After looking at all the articles published, the authors found 17 studies that met their criteria (i.e., to be of good enough quality to offer reliable evidence). They provide a nicely organized table to summarize key findings for each study. After listing the authors’ names and year the article was published, they wrote a short description of each one with results, level of evidence, and conclusions. Here are a few of the key points they made after reviewing all the evidence.

1) The natural history of cervical spondylotic myelopathy is mixed and somewhat unpredictable.
2) Those who have this condition get worse over time.
3) As the spondylosis (narrowing of the spinal canal) gets worse, the risk of damage and even death of the spinal cord cells increases.
3) Younger adults (less than 75 years old) seem better able to adapt and improve without surgery.
4) For those patients (of any age) who got better with nonoperative (conservative) care, they are able to maintain these good results for three
years or more.

Most of the studies don’t include patients who have severe symptoms. This leads to a bit of skew in the results. Results aren’t as poor as they might be if everyone from mild to severe were included. In other words, the results might be different if those folks labelled severe were included. The fact that the natural history of cervical spondylotic myelopathy has a mixed picture and that not all patients were included in the study alerts us to the fact that we need better studies. The authors point out the need for high-quality random controlled trials to sort this all out.

Finding subgroups who respond (or don’t respond) to treatment and finding predictive factors to help spot folks who will have one outcome (poor result/good result) over the other takes time and effort. Studies with this focus would be very helpful indeed. For now, this study has shown us that there isn’t enough evidence to answer the question of why some people get worse and others don’t, or why some people develop this problem and others do not.

The lack of understanding around the natural history of cervical spondylotic myelopathy makes it difficult to plan treatment or management programs. Knowing that patients won’t get better who have severe symptoms that have been present a long time makes it difficult to include them in clinical studies, yet there’s a need to find ways to treat these patients. The authors of this study point out this dilemma but make no suggestions as to how to deal with it.

However, they do make several helpful recommendations based on current evidence regarding cervical spondylotic myelopathy. First, younger patients with this condition should be offered all treatment options (both conservative and operative). All efforts should be made to manage symptoms early on to avoid progression. This is especially important because research shows that the positive results can last a long time. Patients should be told up front that this condition is likely to get worse over time. They should be told to expect long periods without problems followed by sudden flare-ups of worsening symptoms.

Anyone with severe symptoms is in danger of permanent spinal cord damage. And they are not likely to get better without treatment. Therefore, decompression surgery is recommended to take pressure off the spinal cord. Testing with electromyography (EMG) should be done to see if there are abnormal motor responses (slow, delayed or absent muscle contraction). This is another sign that surgery to decompress the spinal cord is needed.

That concludes the findings from this review of the natural history of cervical spondylotic myelopathy. Researchers have been alerted to the need for some quality studies in the future. Hopefully, we will see the results of those studies translated into treatment guidelines in the not-too-distant future.

Physical therapists often treat patients with neck and arm pain from cervical radiculopathy. A variety of modalities are used. Modalities are treatment tools. For cervical radiculopathy these modalities include traction, postural education, exercise, or manual therapy. In this study, physical therapists attempts to find out if manual therapy and exercise work better when cervical traction is part of the treatment plan.

Cervical radiculopathy is another term for a pinched nerve in the neck. Pressure on the nerve roots as they exit the spinal column causes cervical radiculopathy. The most common problems leading to spinal nerve root compression are cervical disc protrusion, bone spurs, spinal joint degeneration, and other age-related changes in the cervical spine.

Any condition that puts pressure on the nerves where they leave the spinal column can result in cervical radiculopathy. Cervical radiculopathy occurs most often around age of 50 years old and older. As the spine ages, several changes occur in the bones and soft tissues.

The disc loses its water content and begins to collapse, causing the space between the vertebrae to narrow. The added pressure may irritate and inflame the facet joints, causing them to become enlarged. When this happens, the enlarged joints can press against the nerves going to the arm as they try to squeeze through the neural foramina. Degeneration can also cause bone spurs to develop. Bone spurs may put pressure on nerves and produce symptoms of cervical radiculopathy.

Spinal instability is another cause of cervical radiculopathy. Instability means there is extra movement among the bones of the spine. Instability in the cervical spine (the neck) can develop if the supporting ligaments have been stretched or torn from a severe injury to the head or neck. People with diseases that loosen their connective tissue may also have spinal instability.

Spinal instability also includes conditions in which a vertebral body slips over the one just below it. When the vertebral body slips too far forward, the condition is called spondylolisthesis. Whatever the cause, extra movement in the bones of the spine can irritate or put pressure on the nerves of the neck, causing symptoms of cervical radiculopathy.

One of the goals of research is to find homogenous groups of patients with cervical radiculopathy who respond well to a specific treatment. Homogenous means they are alike in some way. The best way to match up homogenous groups with successful treatment techniques is to identify clinical prediction rules (CPRs). A clinical prediction rule for treatment identifies the best combination of signs, symptoms, and other findings that predict a high probability of a successful outcome.

There have been some efforts to find a CPR for the diagnosis of cervical radiculopathy but the research is still in its infancy. Making sure the patient really has a cervical radiculopathy is essential in testing for successful treatment approaches. So far, a diagnostic CPR for this condition has been defined, but it hasn’t been tested enough to be validated yet. The authors used the current CPR while letting the reader know the present status of this portion of the research.

Patients with single-sided arm pain, numbness, and tingling with or without neck pain were tested for cervical radiculopathy. A physical therapist performed the diagnostic testing using the current CPR. There are four tests in the diagnostic CPR: Spurlings test, distraction test, upper-limb tension test, and neck rotation test. Patients who had a positive test on three out of the four tests, were considered to have cervical radiculopathy and were included in the study.

They divided the patients into two groups. One group was treated with manual therapy, exercise, and intermittent (on and off) cervical traction. The second group had the same treatment but the traction was a sham (pretend) treatment. Everyone received two treatments a week for four weeks. There was no control group — in other words, patients who received no treatment.

Manual therapy involves moving the cervical (neck) spinal joints gently using a technique called mobilization or with force, a technique called manipulation. Postural exercises focused on strengthening neck and upper back muscles and pulling the head and neck back toward the spine, a movement called cervical retraction. This is a movement like turtles use to pull their heads back into their shells. The effect is to take pull and pressure off the spinal cord and spinal nerve roots.

Intermittent cervical traction pulls the head away from the spine and distracts (pulls apart) the vertebral bones. The machine cycles through on/off phases with a set amount of pull or traction. Traction force was started at 10 per cent of the patient’s body weight and increased each visit in the treatment group. For the sham group, the machine was set to deliver a five-pound weight pull.

The results were measured using three areas: pain, function, and disability. Specific tests included the Numeric Pain Rating Scale (pain), Patient Specific Functional Scale (function), and Neck Disability Index (disability). Other tests administered included grip strength, patient satisfaction with treatment, and fear avoidance beliefs.

Patients in both groups got better equally. They experienced pain relief, improved function, and reduced disability. The results suggest that adding traction to manual therapy (spinal mobilization/manipulation) and exercise doesn’t really add any value to the outcomes.

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

Second, it’s possible that the tests used to measure results might not be the best ones for this condition treated with this treatment. Third, the sham traction still applied some force to the head and neck. This subtherapeutic traction force could have had a positive treatment effect. And finally, without a control group, there’s no way to know if everyone would have gotten better after four weeks without treatment anyway.

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

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

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

In this study, surgeons at the Hannover Medical School in Germany take a look back at 29 patients who were fitted with a halo vest after an upper cervical spine injury with fracture. They wanted to know if there is a difference in results using the halo vest based on age. The patients were divided in two groups: age over 65 and age under 65.

Different types of upper cervical spine fractures are treated using a halo vest. Burst fractures, hangman’s fractures, odontoid fractures, comminuted fractures or any combination of these types will need the external fixation the halo vest provides. Burst fractures are a type of crush or compression injury that fractures the vertebral body so that it spreads out in all directions. They are usually the result of a car accident or fall.

Hangman’s fractures are named for the type of injury (forcible extension of the head and neck from hanging). Fracture of both pedicles or pars interarticularis (supportive column of bone) of the axis vertebra (C2) occurs. Today we see hangman’s fractures in sports injuries and traffic accidents.

Odontoid fractures occur when the odontoid (a vertical bony peg of the second cervical vertebra (C2)) breaks. The odontoid fits up inside the open hole formed by the first cervical vertebra (C1). Together these two vertebrae stabilize the upper cervical spine and form the connection for the skull to attach to the spine.

A comminuted fracture refers to the bone breaking into many tiny little pieces. Usually this type of fracture is the result of a high impact force or stress but bones weakened by osteoporosis or cancer can also develop comminuted fractures.

There are some problems that can develop while wearing a halo vest. The pins or screws can get infected or come loose. In rare cases, a brain abscess can form. The halo ring can break or dislocate. Sometimes patients develop sores under the vest. And probably most distressing is when the fracture fails to heal. In those cases, surgery is needed to fuse the spine with bone graft and instrumentation (metal plates and screws).

The patients in this study were treated over a period of four years and ranged in age from 17 to 82. Most of the fractures in the younger years were the result of car, motorcycle, or bike accidents. Older adults were more likely to suffer injuries from falls.

Once the halo vest was applied, patients were helped to get up and start moving again. X-rays and CT scans were used to check the position of the halo and assess the status of the fracture. The average time for wearing the vest was 15 weeks. Some patients had it removed as early as nine weeks after it was applied. Others had to wait as long as 29 weeks (seven and a half months).

When they looked at the ages of patients in relation to the time it took to heal, there was a tendency for older adults to take longer to heal. Analysis of the data didn’t show that the difference was really statistically significant. There were some complications with pin infections, ring dislocation, and failure of the fracture to heal. Again, these were evenly distributed between the two groups. Age did not seem to make a difference.

The authors point out that some of the complications with pin loosening or infection can be avoided with proper care. Patients are shown how to clean the skull screws. They are told to do this everyday. They are supposed to see the surgeon on a regular basis for check-ups. Screws are tightened at these follow-up visits.

Ring dislocations are more difficult to prevent. These usually occur as the result of some other trauma (e.g., asthmatic coughing attack, fall after a stroke). Usually, the halo device can be reattached easily. Failure of the fracture to heal (called a nonunion) was not a factor of age as much as it was related to more severe injuries to begin with in patients who smoked. Use of tobacco products has been shown in many studies to delay and even prevent wound or bone healing.

Based on the results from this study, the authors say that using a halo vest is not limited by age. This study was limited by its small number of patients (total of 29) and the fact that it was a retrospective study. That means the data was collected and analyzed after patients completed their treatment. The biggest finding was that complications could be prevented with better patient self-care.

Anyone who suffers from migraine headaches or knows someone who does will be interested in the information presented in this article. The authors (two physicians from The New York Headache Center) review the known or suspected pathology behind this painful condition. And they discuss the role of foods as triggers and supplements as treatment for migraines.

Migraines can be inherited but they can also be caused by environmental factors. The exact way in which these two factors bring on a migraine isn’t known yet. The bits and pieces we do know suggest that in genetically-linked migraines, there is a lowered resistance to certain triggers such as skipping meals, certain foods, changes in weather, or caffeine intake.

When exposed to these triggers, the nervous system hits the panic button. A cascade of chemicals is released that ultimately results in pain perceived by the brain. There’s even some evidence to suggest that improper use of oxygen at the cellular level plays a role in migraines. This helps explain why some nutritional supplements can prevent migraines.

Although it is difficult, giving up certain trigger foods can really help prevent these very disabling headaches. Everyone has different triggers, so it’s a good idea to keep a food diary to identify specific individual triggers. The most commonly reported food triggers include alcohol, chocolate, cheese, caffeine, and monosodium glutamate (MSG).

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

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

In some people, caffeine in the chocolate is the trigger. Caffeine is present in chocolate, but also in coffee, tea, soda pop, and many over-the counter or prescription drugs. Many people have a love-hate relationship with caffeine. The very same symptoms that caffeine reduces (headache, irritability, tremors) can be reversed by sudden caffeine withdrawal (alertness becomes insomnia, energy becomes anxiety, headache pain comes back).

Alcohol as a trigger for migraines or a separate type of headache called alcohol hangover headache (AHH) may be caused by a variety of substances in the alcohol. Some people react to the sulfites in red wine. But white wine can also trigger a migraine, which suggests the tyramine, flavonoids, and histamine as potential triggers. Tyramine is a substance that is also found in aged cheese, cured meats, smoked fish, beer, fermented food (anything with vinegar in it) and yeast extract. Any of these foods can also trigger headaches.

AHH seems to occur more often after drinking dark-colored alcoholic beverages (e.g., bourbon or whiskey). These drinks are the natural byproduct of alcohol fermentation (conversion of carbohydrates into alcohols). But exactly why they have this effect is still being studied.

No matter what your trigger(s) are, lifestyle modifications and the use of nutritional supplements may be the answer. Eating small meals evenly spaced and avoiding foods known to be triggers heads the list of lifestyle modifications.

Limiting (even gradually eliminating) foods and beverages with caffeine may be necessary. Anyone who develops alcohol-induced headaches should eat before drinking, drink in moderation, and stay hydrated with non-alcoholic beverages, especially water or other noncaffeinated, clear liquids.

Vitamins and other recommended supplements include magnesium, Petadolex (Butterbur), Feverfew, CoQ10, vitamin B2 (riboflavin) and alpha lipoic acid. Nutritional counseling with a specialist is advised when choosing the right supplement and determining the correct dosage. More study is needed but valerian root and ginger may also have beneficial effects.

Women with migraines who are sexually active or who could get pregnant must avoid feverfew and butterbur as these can harm the developing baby. There are nondrug, nonsupplemental treatments approaches that might help instead. These include biofeedback, regular exercise, and avoiding known triggers. Magnesium supplements to prevent or treat migraines are safe during pregnancy and while breast-feeding. Again, appropriate medical guidance is advised under these circumstances.

In summary, the reported studies on the effectiveness of oral supplements for the prevention and treatment of migraines open up new options for patients who suffer from this problem. Changing diet and altering lifestyle often takes a lot of discipline. Even the threat of a painful headache doesn’t always keep someone from indulging in certain foods or drinking problem beverages. Having nutritional supplements as a fallback option or even as a main prevention/treatment strategy is a welcome relief for many migraine sufferers.

Cervical myelopathy doesn’t always present with obvious signs and symptoms. Sometimes people have this condition and don’t even know it. Cervical myelopathy is a degenerative condition that occurs with aging. Adults affected most often are 50 years old and older. The term myelopathy refers to any problem that affects the spinal cord, but especially compression of the spinal cord. Cervical tells us the area affected is the cervical spine (neck region).

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

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

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

In this study, those clinical tests are the focus. The authors wanted to see how often those tests are positive in people with and without apparent cervical myelopathy. The main clinical tests used to look for cervical myelopathy include the Hoffman sign, inverted brachioradialis reflex, clonus, and Babinski. These are called provocative tests because the examiner applies some type of stimulus to the patient to evoke an abnormal response.

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

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

The test results of two groups of patients were compared. The first group (the cervical myelopathy group) had a history of symptoms, positive MRI for cord compression, was treated with surgery to take pressure off the cord, and improved after surgery. Improvement in signs and symptoms after surgery is an important confirmation that the diagnosis of cervical myelopathy was correct. The second group (control group) had neck pain that went down the arm but no symptoms of myelopathy. Their imaging tests were negative for cord compression.

After performing the four provocative tests to patients in both groups, the authors compared the results and reported their findings. Patients who had visible cord compression on MRI studies were also more likely to have positive provocative tests. But they found that overall, these signs were not very sensitive in detecting myelopathy. Almost one-fourth of the group with cervical myelopathy who improved after surgery had no positive signs of cord compression.

The Hoffman sign was the most sensitive but still not very high (59 per cent). The inverted brachioradialis test had 51 per cent sensitivity. Babinski and clonus were very low in sensitivity (13 per cent). The more sensitive a test is, the more likely it is an indication of a true positive test. However, when the tests were positive, it was a good indicator that cord compression was present.

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

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

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

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

In this article about cervical myelopathy, a new surgical method is described and results using it without spinal fusion are reported for a select group of adults. Cervical myelopathy is a degenerative condition that occurs with aging. Adults affected most often are 50 years old and older. The term myelopathy refers to any problem that affects the spinal cord. Cervical tells us the area affected is the cervical spine (neck region).

What kind of changes are we talking about? Well, pretty much anything that can narrow the space where the spinal cord travels down through the vertebrae. This space is called the spinal canal. Narrowing of the spinal canal is referred to as spinal stenosis. The cause of the stenosis could be bone spurs, thinning of the supportive discs, thickening of the spinal ligaments, or loss of vertebral bone height.

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

In addition, there can be debilitating pain. It’s the pain that usually drives the patient to get treatment. What’s the best way to treat this problem? Well, that is still being tested, debated, and discussed. The main thing is to take pressure off the spinal cord before the signs and symptoms become permanent. Conservative (nonoperative) care can be tried first, but many patients end up having surgery.

Anterior decompression is the most common procedure performed. The surgeon enters the spine from the front of the patient and removes the discs, bone spurs, or other soft tissues affecting the spinal cord. Often the surgeon must remove part (or all) of the vertebral bone that might be pressing on the discs. If the lamina (column of bone) is removed, the procedure is called a laminectomy. If the main body of the vertebra is removed, it’s called a corpectomy.

Once any of these supportive structures have been removed, the spine must be stabilized with bone graft material, rods, screws, or other types of instrumentation. This type of surgery is major and has many potential complications.

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

With a multilevel oblique corpectomy (MOC), a portion of the vertebral body is removed on a diagonal. The result is to widen the spinal canal, thus giving the spinal cord more space. The surgeon uses an anterolateral approach, reaching the vertebra from the front and side. The surgery is done from the most painful side where the compression is the worst. From this angle, the surgeon can also take the pressure off any pinched nerves as they exit the spinal canal.

The surgeon uses fluoroscopy, a special real-time form of X-ray that allows accuracy and enables the surgeon to avoid cutting blood vessels or nerves. As with the classic anterior decompression, any bone spurs encountered along the way are removed. The posterior longitudinal ligament (PLL) that tends to get thick as we age, buckles, and presses on the spinal cord or spinal nerves is also removed.

Some patients in this study had the oblique corpectomy done at just one cervical level. Most of the patients had two or more levels resected (removed). In all cases, the surgeon tried to take out less than half of the bone. This is called a limited bone resection. Because all other elements of the vertebral body and two of the three supportive bony columns are left intact, this procedure can be done without fusing the spine at the level of the decompression. And it can be done at multiple levels — all without needing fusion.

But there is concern about the effectiveness and safety of this procedure. That’s where the results of this study come in. The surgeons report on the results of over 500 levels surgically treated in the cervical spines of 268 patients. They found that using multilevel oblique corpectomy without fusion for cervical myelopathy was both safe and effective. Long-term results showed that patients were able to achieve stability without the fusion portion of the procedure.

They used a couple of different ways to measure the results. They assessed each patient’s neurologic function before and after surgery using the modified Japanese Orthopaedic Association Scale. Pain intensity and duration was measured using the Neck Disability Index (NDI). The NDI also measures the effects of pain on daily function. X-rays, CT scans and MRIs were taken before and after to show the diameter of the spinal canal, alignment of the vertebrae, and position of the carotid arteries.

Almost 90 per cent of the patients reported improvement of symptoms and function with canal expansion following multilevel oblique corpectomy (MOC). Patients maintained spinal stability with only a few patients getting worse instead of better.

The main complication after MOC was Horner Syndrome from damage to one of the nerves that controls eye movement. Using an anterolateral approach for the incision leaves this particular nerve at risk for damage from moving it out of the way to get to the spine. Fortunately, this was a temporary problem for most of the affected patients. Eyelid drooping on one side is the primary symptom, which went away over time (usually within three months).

The authors conclude that lower overall complications and none related to bone grafting make this procedure worth considering. It does take some additional training and careful surgical technique. But for patients with diabetes, poor bone structure limiting fusion, and for heavy smokers, it offers a safe and effective way to treat painful, disabling cervical myelopathy.

Even with multiple levels of vertebral bones partially cut out, spinal stability is still present. Patients can get up and move early after the operation and without bracing or immobilization of any kind. The key to a successful result is to choose the right patient for the procedure. There can be no spinal instability (one vertebral body slipping or sliding around). Surgeon can expect to have fewer complications over time as they become more familiar with the technique.

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

The costs of such an injury (both direct and indirect costs) are substantial. So much so that researchers are looking for ways to predict who might develop WAD. The goal is to prevent this from happening. Past studies of WAD have not been high-quality or did not collect data in the same way, thus making it difficult to combine information and look for predictive factors.

In this systematic review and meta-analysis, the authors did an extensive search of the published literature on WAD. They limited their search in order to look for consistent factors that might predict who would develop chronic symptoms following a whiplash injury.

For example, only studies published after 1995 were included. That was for two reasons. First, it postdated (came after) the Quebec Task Force (QTF) publication. That was the first systematic review on whiplash-associated disorder. The authors of this study knew from the QTF that the work done up until that time offered very little information in the area of risk and predictive factors of disability. Second, the Quebec study reported that up until 1993, there were no high-quality studies to depend on for information on WAD.

For this new review, only patients for whom data was collected within three weeks of the injury were included. And then only those patients who were followed for at least six months were part of the study. Some length of time in follow-up is really necessary to identify patients with WAD-related symptoms and/or disability.

In order to evaluate studies for quality in design and methodology, a special scoring tool was developed. Each study was evaluated using this scoring tool. It helped the researchers look at how the studies were done, how they were analyzed, and how the results were interpreted. Consideration was given to such things as how missing data was handled, differences in facilities treating whiplash injuries (e.g., emergency departments, specialist clinic, primary care clinic), and geographic location (country where the article was published).

Not every study reviewed gathered the same data or even looked at the same predictors. The scoring tool made it possible to compare the results despite the inconsistencies. In fact, there were over 200 predictors studied. Types of predictors followed included age, gender, general health before the accident, education, occupation, income, marital status, type of insurance, pain intensity, body mass index, seat belt usage, neck range-of-motion, and use of medication before the accident.

When they sorted through all the possible predictors, there were 25 that appeared in more than one study. A closer look placed these 25 predictive factors into one of four categories: 1) patient demographics (characteristics), 2) information about the collision, 3) previous patient history, and 4) patient symptoms.

In the end, they found that there were nine significant predictors of pain and disability after whiplash injury. Health-care professionals examining patients following a whiplash injury can look for any of these factors when establishing a prognosis: high school education, female, history of neck pain before the accident or injury, neck and/or headache pain rated as 55 or more out of 100, no seat belt use at the time of the accident, and catastrophizing.

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

The authors provide a table with a summary of their key findings. They were able to breakdown the results into variables with strong evidence of a significant effect, variables with moderate evidence of a significant effect, variables that just miss significance, and variables with strong evidence of no effect.

This kind of information is helpful in planning treatment that can focus on significant variables. Most of the variables with strong evidence of no effect had to do with the collision (rear-end, no head rest, vehicle not moving when hit). The strongly significant predictive factors included high level of neck pain and headache at the first evaluation and no higher education level than high school. A high rating of neck pain intensity present from the start increased patients’ risk of chronic pain/disability by six times.

Two things are not evaluated by this study. First, because patients were assessed within the first three weeks of their injury, legal factors were not included. Not having insurance or hiring a lawyer were not significant factors predicting outcome. If data was collected later in the process, these two factors might figure more prominently in the long-term prognosis.

And second, no attempt was made to determine how multiple factors present at the same time might affect patient prognosis. Most patients do have more than one risk factor. Whether multiple risk factors add to the risk or even multiply the risk remains unknown. It’s possible that certain factors when present together could double or triple the risk of developing chronic pain and disability.

The authors make several recommendations based on their findings from this study. Anyone examining a patient with a whiplash injury should make note of any variables with moderate-to-strong evidence of a significant effect. This study can be used in an evidence-based practice when determining a patient’s prognosis. This type of information is helpful when seeking reimbursement from insurance companies. And when documenting the presence of these factors, it should be remembered that this evidence is based on only single (not multiple) risk factors.

Everyone loves a good massage — especially if you have neck pain. But does it really help? Are the effects long lasting or effective enough to make it cost-effective? That’s what these researchers from the University of Washington in Seattle set out to study. Given the fact that many adults suffer neck pain every year, these are important questions.

They compared two groups of adult patients (ages 20 to 64). Everyone had neck pain that lasted more than three months. Most of the participants actually had pain much longer than that. Eighty per cent had it for at least a year. The average length of time was 7.6 years. So this was truly a group of patients with chronic neck pain.

The cause of the neck pain was not serious such as a tumor, infection, or fracture. The type of neck pain was labeled mechanical, which means it is related to the human movement system (joints, ligaments, other soft tissues). Anyone with a more serious cause of neck pain (cancer, stenosis, fracture) was not included. Anyone who might not be a good candidate for a massage was also excluded from the study. People in this category had unstable physical or mental health issues.

One group received 10 massages (once a week for 10 weeks). There are different types of massage. This is the first study to look at massage as it is commonly practiced in the United States. The licensed massage therapists applied a wide variety of the possible massage techniques. These included friction massage, clinical gliding, Swedish gliding, traction, trigger point therapy, and kneading massage. Areas of the body massaged included the neck, upper back, chest muscles, and upper arms.

The second group got a self-care book for chronic neck pain. The book was written by a physician by the name of Jerome Schofferman. The title was What To Do for a Pain in the Neck. The book has chapters on causes of neck pain, headaches, and what to do after a whiplash injury. Other information in the book included postural and strengthening exercises and what to do for a flare-up of symptoms.

There was also a section on conventional versus complementary therapies for neck pain. Conventional care includes antiinflammatories or analgesics (pain relievers), physical therapy, rest, and activity modification. Massage is considered a complementary treatment. Other examples of complementary care include chiropractic, acupuncture, Reiki, Yoga, or Tai Chi.

Patients in both groups were allowed to seek other forms of treatment such as chiropractic care, their primary care physician, or in the case of the book group, a massage. Subjects in both groups received some type of nonstudy treatments during the 10-week period of time. People in the book group sought out care from others more often than the massage group (21 per cent for the book group versus 13 percent for the massage group).

Results for both groups were measured using self-reported questionnaires. The Neck Disability Index (NDI) was one. The numerical rating scale (NRS) was another. The Copenhagen Neck Functional Disability Scale, Short Form-36, and some additional questions designed by the authors of the study were also included.

Everyone completed all questions before starting the study. The information gathered at the beginning is called the baseline. The same questionnaires and questions were filled out and answered at four, 10, and 26 weeks after starting the study. The difference between the answers was compared after each of the time periods tested.

The authors report a significant decrease in pain and improved function for the massage group at the four-week time period. The treatment group held on to their improvements through the first 10 weeks. But by the end of 26 weeks, there was no difference between the two groups.

There was one major difference at the end of 26 weeks, and that was in the amount of medications used by the two groups. The massage group was still using the same amount of pain relievers as reported at baseline. But the book group’s use of medications had increased significantly.

Given the fact that the massage group used less medication, fewer treatments outside of massage, and reported improved pain and function in the first 10 weeks, the authors conclude that at least in the short-term, massage for neck pain has merit.

Other studies using shorter massage treatments have not reported as good of results as this study. Studying dose and type of massage used in this study was helpful in showing that a longer period of time may be needed to get the desired results. Other studies comparing massage with acupuncture or sham laser treatments found better motion-related improvements with these treatments over massage.

The authors admit that their study did not figure out why massage worked better than self-study with a book on neck pain. It could have been any number of factors such as the physical touch, specific type of massage, interaction with the massage therapist, or patient expectations. In evaluating a single modality such as massage, it’s important to keep the research pure and just study one part at a time. That’s one of the strengths of this particular study.

Future studies are needed to examine patients with more severe neck pain, to follow-up for more than one year, and to study a larger number of patients. Eventually, it will be necessary to look at patients who are most likely to seek the services of a massage therapist. This would include patients who were left out of this study — those who had a previous surgery, anyone who was in a car accident or involved in a lawsuit, and anyone receiving other kinds of treatment for their neck pain.

Athletes participating in collision or contact sports are at risk for stingers. Usually it’s a temporary injury but it can put a player out permanently. In this article, doctors from the University of Washington (Seattle) review the controversies around this injury. Decisions about diagnosis, treatment, and return-to-play are discussed. The need for equipment modifications to prevent stingers has been questioned and debated. The pros and cons of such a move are also presented.

Stingers refer to the burning, electrical, or shooting sensation a player feels after forceful contact to the head and/or shoulder by another player. The injured player’s neck is bent away from the side of the injury. At the same time, the shoulder on the injured side is depressed forcefully. The combination of rapid, forceful movement and direct pressure pulls and presses the nerves in the neck area.

The symptoms are brought on by trauma to the nerves in the neck and don’t usually last long. Cervical nerve root(s) in the neck or the brachial plexus further down between the neck and the shoulder are affected. The exact site of the problem remains a hotly debated topic. Is it really the cervical nerve roots that are affected? Or is it the brachial plexus? Maybe it’s both. Maybe some players have one type and others have a different type. There’s some evidence that younger players are more likely to end up with a brachial plexus stinger. Older players seem to be at greater risk for nerve root compression.

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

That’s where these authors hope to help sports medicine doctors figure out what to do on and off the field. Obviously X-rays aren’t available on the field. Imaging studies may be done later if the symptoms persist or if the player reports muscle weakness of the neck or arm.

Players who have had two or more stingers should consider having an X-ray to check for instability. There could be a narrowing of the spinal canal or the space where the nerve root exits. This narrowing is called stenosis. There could be a protruding or herniated disc pressing on the nerve root. Such findings would change the entire picture. Any of these problems can put the player at increased risk for significant nerve injury. A more thorough diagnostic evaluation will be needed to decide if the player is safe to return-to-play. And as you can imagine, this is a big decision for most players whose life is sports.

Even with diagnostic X-rays, CT scans, or MRIs, the findings aren’t always very clear or helpful. Further assessment may be needed with electrodiagnostic studies (EDX). These tests can help identify which nerves are affected and check the function and integrity of the nerves. They are ordered two to four weeks after the injury when the symptoms of a stinger have not gone away. The hope is that the tests will be normal indicating a good prognosis for recovery. If the tests show abnormal nerve function, they can be repeated again later to look for signs of improvement indicating slow recovery.

In the meantime, what should the athlete be told? Can he return-to-play while waiting for nerve function to return? Is it safe to do so? The authors say this isn’t a cut-and-dried decision. Many factors must be taken into consideration. They provide a table of return-to-play criteria to use when making recommendations for the season. For example, one stinger with rapid return to normal is easy: no diagnostic tests are needed and the player is safe to return to the game as soon as the symptoms are gone.

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

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

Players who take a long time to recover (even after only one stinger) or who have anatomical deformities such as stenosis or disc herniation should be advised to stop playing (permanently) in sports that involve potential collisions or contact.

Some experts have asked if wearing a special collar would help prevent these injuries from occurring in the first place. There are cervical collars that limit how much the neck can be pushed into extension (backwards) or into lateral flexion (bent to the side). There have even been a couple of studies in the lab with different types of cervical collars to start looking at this issue. The studies were fairly limited — for example, they were not tested during live play.

Even so, early results showed that the collars restricted some motion needed to play safely without really limiting motions that result in stingers. It doesn’t appear that adding a cervical collar to the standard football uniform and equipment is the answer. There isn’t a good solution yet to preventing stingers. For now, quick action at the time of the injury to protect the player from further injury may be the best that can be offered. Careful assessment is needed when making the out-of-the-game virus return-to-play decision.