News Category: Cervical Spine

Ossification of the posterior longitudinal ligament (OPLL) of the spine is common as we get older. Treatment for this problem remains a hot topic in orthopedics. Should everyone be treated conservatively without surgery? If surgery is done early, will it prevent worse problems from happening later?

Ossification means the ligament becomes hardened from bits of bone forming within it. The posterior longitudinal ligament is located inside the spinal canal along the back wall of the canal. It runs down the spine from top (cervical spine) to bottom (sacrum). The spinal canal is the round tube formed by the vertebrae where the spinal cord is located.

When the posterior longitudinal ligament hardens, it takes up space in the spinal canal. With decreased space for the spinal cord, myelopathy can occur. Myelopathy refers to any condition that affects the spinal cord. In this case, pressure on the cord from the ossified ligament can cause neurologic problems. Patients may report numbness, arm weakness, clumsiness of the hands, and trouble walking. Too much pressure can lead to paralysis.

But it’s not clear yet whether or not treating this problem can prevent neurologic damage from occurring. Surgeons don’t want to disturb this area by performing surgery if it’s not really necessary. Studies like this one help determine the results of conservative versus operative treatment.

Two equal-sized groups of patients with OPLL were compared. The first group had no myelopathy or only mild myelopathy. Patients with no myelopathy came to the doctors because of neck pain and/or stiffness. Their pre-treatment range-of-motion was less than those patients in the second (surgical) group. Group one received nonoperative care but the authors did not describe what this included.

The second group with moderate-to-severe myelopathy had surgery. The surgeons entered the spinal canal from the anterior (front of the) spine. The main area of hardened ligament was removed. The vertebrae were fused at that spot using bone taken from the patient’s fibula (lower leg bone) or iliac crest (pelvic bone).

Everyone was followed for three to five years. Special tests were performed before and after treatment to assess the results of treatment. The Japanese Orthopaedic Association (JOA) scale was used to measure the severity of the myelopathy. This same scale used after treatment showed changes (improvement or worsening). X-rays (also taken before and after treatment) were used to show how much of the spinal canal was occupied by the ossified ligament.

In the first group who had nonoperative care, those patients who had no myelopathy remained unchanged. Of the remaining patients with measurable myelopathy, half got better. The rest (except for one person) stayed the same. Neck range-of-motion did not change before and after conservative care.

As might be expected, the amount of residual space for the spinal cord was less in the nonoperative group compared to those who had surgery to increase the diameter of the spinal canal and take pressure off the spinal cord. This finding represents improvement in the surgical group.

In looking back over the results from before and after treatment between the two groups, the authors outline a plan for deciding who should have surgery and when to operate. Conservative care is always the first choice whenever possible. This is most likely when there is no myelopathy or only mild myelopathy in older patients with continuous OPLL. Continuous means the problem affects more than one vertebral segment.

Surgical treatment is advised for patients with excessive neck motion and signs of growth activity of the ossified mass (as seen on MRIs). Surgery is also indicated when the MRIs show high signal intensity indicating an increased risk of myelopathy developing or getting worse if already present. The presence of segmental OPLL (affecting multiple vertebral levels) was another indication that surgery was the best treatment choice. Most of the patients who met these criteria were younger (less than 50 years old).

Surgeons can use these guidelines when deciding on the best timing for surgery to treat myelopathy associated with cervical OPLL. The results of this study showed that conservative care is effective even when the spinal canal is narrowed. Patients in this group did not get worse over time, so there was no theoretical advantage of early surgical treatment to avoid a worsening of the problem.

Researchers say the cost of whiplash injuries is far more than ever imagined. It turns out that long-term sick leave and disability pensions for chronic pain from whiplash associated disorder (WAD) cost much more than acute medical care. This could mean that routine medical care right after a rear-end collision could save a lot of money in medical costs later.

Other studies show that as many as four out of every 10 people develop chronic neck pain after a car accident. In this study, work disability after whiplash is assessed. This is a fairly new area of study as it relates to neck pain after motor vehicle accidents (MVA).

The results of studies done so far in this area have had mixed results. Some showed full return-to-work for the majority of patients included. Others reported work disability after whiplash was a major problem. How is it possible to have such different results after studying the same thing?

The authors suggest that perhaps there were different types of patients included in each study — too different to really compare. And it’s possible that the way researchers defined the terms return-to-work and work disability can vary considerably.

Of all the studies done, some showed that being an older woman, performing heavy manual work, or being self-employed were risk factors for poor recovery. Patients with these characteristics were more likely to be permanently disabled after a motor vehicle accident.

To help better understand work limitations on post-whiplash patients, the authors of this study looked at neck pain after whiplash injury and specific work-related factors. Subjects for the study came from a Dutch insurance company. Anyone who filed a compensation claim for personal injury because of neck pain after a car accident was invited to participate.

Surveys were used to ask patients questions about the accident, neck complaints, injuries, past history of neck pain, and work-related disability. Each person was contacted one month after the accident and again six months and 12-months after the accident. Information about the subjects included whether they were white or blue-collar workers, level of education, and whether they were self-employed or paid employees of a company.

The first finding reported by the authors was the large number of people who were affected at work by postwhiplash syndrome after a motor vehicle accident (59 per cent of the entire group). So, in keeping with results reported from other studies, it’s fair to say that work disability after car accidents is, indeed, a common problem.

Over time, neck complaints diminished. At first (after one month), 83 per cent still had pain. But by the end of a year, only about half of this number (44 per cent) still reported neck pain. The results did not differ between blue and white collar workers. As might be expected, people with the greatest amount of pain had the most work disability. Older adults were most likely to still have neck pain a full year after the accident.

They also found that work disability is usually accompanied by restricted neck movements, increased use of pain medication, and impaired concentration. This last factor, cognitive function (concentration), was affected in both blue and white collar workers and especially in higher age groups. The link between impaired concentration and work disability in whiplash-associated disorder is unknown. Anxiety and/or depression may be part of the picture. Further study is needed to understand this connection.

In summary, the authors point out that 1) work disability is a common problem in people with whiplash associated disorders, 2) older age is a predictor of work disability in this group, 3) cognitive impairment is a second preditive factor of long-term work disability, and 4) these findings are true regardless of work or education level (white versus blue collar workers).

These findings suggest that physical treatment may not be as important after whiplash injury as interventions for mental functioning. Age is not a modifiable risk factor, but it is a tip off to watch out for problems. Older adults should be screened carefully after motor vehicle accidents to help identify problems and prevent an acute injury from becoming a chronic and costly one.

Cervical myelopathy is a condition where the neck is being compressed, causing pain and disability. It’s considered to be one of the most common neurologic, or nerve, disorders that is occurring more commonly in the older – or geriatric – population. Usually, the best treatment is surgery, to decompress the area and relieve the pressure on the nerves, but before surgery is decided upon, the surgeon and patient have to take a few things into consideration, including how successful they feel the surgery will be.

In order to judge the severity of cervical myelopathy, physicians have been using various tests and systems. Some ways of grading the severity included measuring clumsiness of the hands, walking and gait ability, and if there are any problems with urinating. The problem with grading those issues is that there is such a huge variety in what people consider as normal and as abnormal, and many other issues may also affect these things.

The authors of this article developed a 10-second step test to measure and to quantify the severity of cervical myelopathy. They then tested their design on a group of 163 patients with cervical compressive myelopathy who were going to have surgery to alleviate the problem. The mean age was about 63 age and 99 of the patients were men. Over one thousand volunteers without cervical myelopathy or any type of neck pain were tested as controls.

The study subjects were asked to take high steps by bending their knee at 90 degrees, making their thighs parallel, or in line with, the floor. They were asked to make these steps in the same place, without holding on to anything for balance, for as many steps as they could do in 10 seconds. If the patients seemed like they were at risk of falling, the test was done close to a hand bar that could be grabbed for balance. A hand test that involved gripping and releasing for 10 seconds was also done.

In gathering the results together, the researchers found that the average number of steps in 10 seconds for the patients was 10.7, give or take 5.3 before they had surgery. They were able to do an average of 16.4 grips, give or take 6.1, in the right hand, and 15.5, give or take 6.2, in the left hand. Seventy-nine patients did the step test twice and the average score was 11.2 steps the first time (give or take 5.1) and 11.5 the second time (give or take 5.5). The researchers noticed a connection between the number of steps that the patients could do and the number of grips they could do.

The healthy volunteers did an average of 19.6 steps, give or take 3.5, and there was a big difference between men and women and changed with age too. As the subjects were older, their number of steps dropped.

Twelve months after surgery, 123 patients were retested. They scored an average of 10.4 steps, give or take 5.9 before surgery, and 14, give or take 5.4 after surgery. Their grips were on average 15.2, give or take 6.2, before surgery and 18.4, give or take 5, after surgery.

The authors concluded that although this type of test wasn’t always easy to do and would require a separate area to do, it was more quantifiable and objective that previous tests for cervical myelopathy severity. The authors also pointed out that the test couldn’t be done by everyone, including people who already have trouble walking or can’t stand on their own without aid.

When someone has problems with the discs in their neck, the cervical discs, surgery is often needed. In the 1950s, two surgeons (Bailey and Badgley) developed a procedure that allowed surgery to fuse the discs together be done through the front (anterior) rather than the back (posterior). There were some problems with this though, as the patients often were limited in their range of motion and how well the fusion worked. Three other surgeons (Cloward, Smith, and Robinson) worked on improving the technique by immobilizing the patients after surgery and using devices to limit the patients’ ability to move the neck as it healed.

Even later on, two other surgeons (Bohler and Gaudernak) began using plates in their surgery to stabilize the neck if there were fracture dislocations. These have been adapted over the years to cause more improvements. Such plates in the cervical spine tended to support the neck for healing and this reduced how often the grafts failed. However, collars to support the neck and limit neck movement have still been used after surgery and the authors of this article evaluated if using the collar improved the surgery outcome.

The researchers analyzed the outcomes of 257 patients who had single-level anterior cervical fusion with plate; 149 had braces after surgery, 108 didn’t. The patients were evaluated before surgery and then again at one and a half months, three months, and six months after surgery and then again at one year and 2 years after. The researchers looked at reported neck and arm pain, neck disability, and neurologic exams. X-rays were also done to check how well the neck had fused.

Results showed that there was no statistical differences between the two groups after surgery, at any point. The only difference was with the SF-36 questionnaire part that asks about quality-of-life, where the non-braced patients scored higher. The average pain scales improved for both groups from 68.6 out of 100 for the braced group and 70.4 for the non-braced group before the surgery to 15.3 out of 100 and 17.3, respectively, 2 years after the surgery.

The authors concluded that using a brace after this type of surgery does not improve fusion rates or the pain and disability levels after surgery. Neither being braced or not being braced had any effect on hardware or graft failures. The authors do point out some limitations to the study, however. The patients weren’t randomized to the groups, so this may have played a role in the success. As well, the fact that the study was on only one level of surgery means that these findings can’t be carried over to multi-level surgeries.

Physical therapists, like everyone else in the health care field, are working hard to find ways to treat patients safely and effectively. Instead of treatment as usual, therapists are striving to find scientific evidence to support (or refute) current treatment approaches.

One of the ways this is done is to compare treatment of a common problem (e.g., acute neck pain as in this study) using one type of therapy versus another. In this study, the use of electro/thermal therapy is compared with thoracic manipulation (joint thrust).

A previous study by the same authors showed evidence that thoracic spine manipulation combined with other treatment is more effective than electro/thermal therapy alone. The results were reported in terms of short-term improvement. Specifically, improvements in neck range-of-motion, pain, and function were observed at the time of immediate follow-up. No long-term studies have been done in this area.

So, taking the same model used in the previous study, the physical therapists repeated the experiment. This time, they compared two groups of acute neck pain patients using the same treatment and reporting on the same results for a longer period (up to four weeks). Repeating results from a previous study helps validate the treatment as an effective way to manage neck pain.

Everyone in both treatment groups had neck pain lasting less than one month. That meets the criteria for acute pain. Everyone was screened carefully for a serious medical cause of their neck pain such as a tumor, infection, or fracture. Certain patient groups were excluded (e.g., fibromyalgia patients, anyone who had a recent spinal manipulation, or anyone with osteoporosis). Only patients between the ages of 18 and 45 were allowed to participate.

Forty-five patients were selected and randomly assigned to one of two groups. The first group received five electro/thermal therapy sessions over a three-week period. This treatment consisted of 15 minutes of superficial heat to the neck area using an infrared lamp. This was followed by electrical nerve stimulation applied with electrodes on either side of the spine at the C7 (seventh cervical vertebra) level.

The second group had the same electro/thermal therapy treatment and three (once a week for three weeks) thoracic spine thrust manipulations. The thrust manipulation was done with the patient in a seated position, arms folded across the chest. The therapist stood behind the patient and applied an upward distraction manipulation by grasping under the patient’s elbows and lifting. One physical therapist administered all of the treatments to all of the patients.

The results concurred with the first study done as well as other independent studies (i.e., not this group of researchers) in this same area of research. Patients improved more with the manipulation procedure (combined with the heat and electrotherapy) than with just heat and electrotherapy alone (nonthrust group). There was a greater reduction in neck pain, better function, and improved neck range of motion. And the results were maintained for the full four weeks of follow-up.

The results of this study represent a step in the right direction. With shrinking health care dollars, the goal of finding the right treatment for each patient or groups of patients has never been more important.

But as the authors point out, this first step must be followed by many others. For example, there is more than one way to perform a thrust manipulation of the thoracic spine. It’s possible that another technique would yield even better results than the one used in this study. At the same time, there are other ways to apply heat and/or use electrical stimulation to treat neck pain. Perhaps there’s a better way to use this modality for improved pain control and increased function.

And finally, having a positive short-term benefit of treatment is good, but it’s not too helpful if the results don’t last and the patient ends up in therapy again later for the same problem. Future studies using other treatment strategies and longer time frames will be extremely helpful in finding optimal ways to manage mechanical neck pain.

This is the first nationwide study to look at the results of multilevel cervical spine (neck) fusion comparing an anterior approach to a posterior approach. Anterior refers to fusion from the front of the spine. Posterior is done from behind the spine.

Data from over 8500 patients with degenerative disease was included. Information entered into the patient database came from 1000 hospital across the United States. The researchers looked at variables such as age, gender, race, and the presence of comorbidities.

Comorbidities refer to other health problems the patient may have such as high blood pressure, diabetes, osteoporosis, and so on. They compared the number and type of complications after surgery between the two approaches. They also looked at cost, number of days in the hospital, and whether or not the patient was discharged home or to some other facility.

In all patients who were included, fusion was done at multiple levels of the cervical spine. Multiple levels means there were between four and eight vertebrae fused together.

They found that posterior fusions were done more often in larger, teaching hospitals. Patients were more likely to be older, Black men with many other health problems. Anterior fusion was more common in younger patients with fewer levels affected.

Posterior fusions were usually Medicare cases. Anterior fusions were usually performed in private hospitals and paid for by private sources. Complications were more likely to occur in posterior fusions. The problems that developed varied and included hematomas (pockets of blood), blood loss (enough to need a transfusion), and even death.

Sometimes there was a cerebrospinal fluid leak. Respiratory and cardiac complications were present in both surgical approaches but were more common in patients who had a posterior fusion. Difficulties swallowing called dysphagia was a more common effect with anterior fusion. Damage to the nerves in the front of the neck is a greater risk with anterior fusion and especially when multiple levels are involved.

Analyzing all the data more closely showed that older age and health status (more comorbidities) kept people in the hospital longer. This group was more likely to need critical care and were especially at risk for death.

Many patients in both groups could be routinely discharged to home. Some required additional services such as home health care. But almost half of the posterior fusion group had a nonroutine discharge. More money was spent for the posterior fusion group on what’s called resource utilization (meaning added services such as longer hospitalizations and discharge to a nursing home or assisted living facility).

In summary, the impact of surgical approach for cervical spine fusion is significant. There is a greater level of complications with the posterior approach. Patients who need multilevel fusions seem to do better with the anterior surgical procedure. The authors advise that whenever possible, this method should be chosen over posterior procedures.

An accurate patient history after motor vehicle accidents is important when planning the best and most appropriate treatment. Anyone with a prior history of neck or back pain may need a different approach. Social research confirms that anyone with a psychologic profile, history of alcohol or other drug use, or mental illness will likely need special attention.

But getting at that information can be tougher than it looks. Despite taking a thorough patient history, patients don’t always reveal important facts from their past. In this study, researchers at Stanford University School of Medicine attempt to see how accurate patient self-report is after an accident.

They compared the information given by patients experiencing chronic neck or back pain following a car accident with data in their medical records on the same patients. They were expecting that the information would match up.

But what they actually found was that patients frequently (half the group) underreported previous bouts of neck and back pain. And they denied ever having treatment for these problems even when the medical records clearly showed they did have treatment at some time in the past.

Not only that, but the patients who were not at fault (the accident was caused by someone else) were much more likely to fail to report previous back and neck pain problems. Patients with a history of psychologic problems were seven times more likely to underreport information on those problems. These patients didn’t just leave out a small portion of their history. Often, they omitted the entire history.

To make sure this wasn’t just a general underreporting of all problems (including health conditions unrelated to an accident), the authors also included two control conditions: hypertension and diabetes. Consistent with the idea that the underreporting was conscious or deliberate, no one failed to tell the examiner about other health concerns of this type.

Why do patients give inaccurate histories? The authors suggest in the case of psychologic issues, the patients may have the feeling that it will be a strike against them. Everyone will think they are faking or exaggerating because they have a mental health history. Whether or not this is true was not tested or proven in this study.

Secondly, other studies done by these same authors have shown that underreporting occurs more often in cases where the patient was not at fault and who hired a lawyer. It’s easy to assume the patient is out for secondary gain (i.e., get all they can from this one accident).

But there may be other explanations for this behavior. For example, maybe the people who underreported past history just couldn’t think straight and didn’t remember past injuries. Maybe they didn’t have the emotional or psychologic strength to deal with all the questions, the finances, and all the paperwork.

Regardless of the reasons, it’s clear that patient histories related to neck and back pain taken after motor vehicle accidents are not valid or accurate. Involvement in a compensation claim may be a key risk factor for this type of underreporting. Health care workers must keep this in mind when trying to interview or help patients who have recently been involved in a car accident.

Other studies show that patients with a previous history of treatment for neck or back pain are much more likely to have a poor prognosis. Management of the problem may be approached quite differently under these circumstances. Not knowing this information could compromise quality of care.

The cervical spine, or the upper part and the neck, can be hurt in many ways, from trauma and injury to osteoarthritis, the so-called wear and tear arthritis. Most often, conservative – nonsurgical treatment- is all that’s needed to help the patient heal, but there are times when surgery is necessary.

Nonsurgical treatments included nonsteroidal anti-inflammatory drugs (NSAIDs) to help reduce inflammation and pain, physical therapy, manipulation, injections of medications such as anesthetics or steroids, and by avoiding activity that can cause or worsen the pain. If these methods don’t work, then surgery is generally the next step.

There are different approaches to surgery of the upper neck and back, and one approach is the anterior approach, coming from the front of the neck rather than the back. This was first done to fuse bones together by two researchers, Robinson and Smith in 1955, and has been adapted and improved upon ever since. Most often, this approach is successful and there are few complications, called adverse effects. However, surgeons are aware that adverse effects are possible and they must do whatever they can to reduce the risks of complications. They must also explain to the patients the types of risks involved in the surgery.

The authors of this article reviewed the different types of events that could affect patient outcome after surgery and/or make it so the patient must undergo more treatment, tests, or monitoring. The authors write that the most common and most likely serious adverse events that occur with these surgeries usually happen either during surgery, within one week of surgery, or between one and six weeks after surgery.

Adverse events that may happen during surgery (intraoperatively include injuries to the esophagus, the tube that carries food from the mouth to the stomach. This is a serious injury that can be life threatening and it occurs in about 0.2 to 0.4 percent of all such surgeries. To avoid the injury, surgeons are encourage to place their retractors (instruments that hold back body tissue so they can access where they are operating) in a such a way that avoids touching the esophagus.

Discovering if the esophagus isn’t always easy as the injury might not be obvious. If there is any doubt, the authors suggest that a general or thoracic surgeon be called in to see if damage has been done and if so, to correct it. Also, if there is any doubt, it’s recommended that a feeding tube be inserted (through the nose down into the stomach) until further studies are done. This would avoid the patient trying to swallow food through a damaged esophagus.

If the injury is missed, the mortality rate can be as high as 20 percent, even if this is discovered early after surgery, within a day. This rises to as high as 50 percent if the injury is discovered and treated later on. If a patient who had this surgery shoes any sign of infection, the surgeon should be suspicious about the esophagus and investigate right away.

Injuring the vertebral arteries is another risk. The vertebral arteries send “clean” oxygenated blood past the vertebrae, the bones in the back, to the back of the brain. This is a very rare complication and can be avoided in many cases by making an opening in the surgical area that seems wider than needed so that the arteries can be found and avoided.

If the surgeon does nick or damage the artery, the bleeding should be controlled by blocking the wound. The problem that may happen though, is that the artery may become blocked and there’s a 3.8 percent risk of this happening if it’s on the left side and 1.8 percent chance if it’s on the right. Because of this, it’s recommended that the surgeon do an angiography (test that allows the surgeon to see if the artery is blocked) while the patient is still having surgery.

The dura mater is the outer fibrous tissue that covers the brain. With anterior cervical surgery, there is a possibility that the dura is damaged or torn. The effects of the tear depend on where the tear is and how easily it can be repaired. If the dura is easily reached and repaired, then damage is limited. Unfortunately, sometimes repairs don’t always hold up so some surgeons may put a drain in just in case, to drain any excess fluid. In some cases, patients are also encouraged to sit upright right after surgery and this seems to help reduce pressure from leaking spinal fluid.

The surgery also puts the spinal cord itself at risk although, again, it’s not common. Such injuries happen in about 0.2 to 0.9 percent of cases. Certain people are at higher risk of spinal cord injury from the surgery. These are people who have myelopathy (problems with the spinal cord itself, cervical kyphosis (“hunched” neck or extreme upper back), spinal cord atrophy (wasting away of the spinal cord), or spinal instability or fractures.

If, during surgery, it’s suspected that the spinal cord has been injured, it must be inspected right away and an x-ray may need to be done. After surgery, the patients should be watched closely for any signs of nerve trauma or damage. If needed, other imaging tests should be done, as well.

The nerves that surround the area but aren’t part of the spinal cord are called peripheral nerves. These may become damaged during the surgery. If this happens, it’s most often from the pulling, or traction, or eve direct pressure on the nerves. This most often can be avoided by proper positioning of the patient for surgery and avoiding being aggressive with traction, holding back parts of the body to access the area that is being operated on.

During the early postoperative period, the first week after surgery, patients could have an acute airway compromise, which means something has affected their airway and ability to get air in and out of the lungs. When this happens, they may need to be re-intubated (have the breathing tube inserted again) to allow them to breathe. It’s estimated that this happens in about 1.7 to 2.8 percent of cases.

Acute airway compromise can have a few causes, such as blood forming into a pool and putting pressure onto the airway, leaking cerebral spinal fluid, hardware or bone graft breaking off or moving from the surgery, obesity, sleep apnea, long surgery time (over five hours), repeat surgery, or tissue swelling. It appears that the highest risk time for this complication is during the second and third days after surgery.

To lower the risk of this complication, surgeons are encouraged to try to keep the surgeries less than five hours long, don’t use too many intravenous fluids and keep the patients intubated until it is obvious that they will be able breathe without difficulty. If they haven’t been able to have the tube removed after a week, the surgeon should consider putting in a tracheotomy (opening in the trachea through the neck) for breathing.

Epidural hematomas are bubbles or areas of built up blood that can cause pressure on surrounding body tissues, nerves and organs. In this case, they would be in the epidural space, which is one of the spaces along the spine. Radiculopathy z(nerve irritation) occurs in about 0.2 to 0.5 percent of cases and is most likely caused by excess traction during surgery.

After the first week, the other complications that could arise include dysphagia (trouble swallowing), dysphonia (hoarse voice or difficulty speaking), bone graft extrusion (bone graft bulging), or infection.

There are also some adverse effects that can occur because of the newer technologies now available to surgeons. This includes off-label use (not approved by the FDA) of a specific protein that helps stimulate bone formation. Surgeons have been using bone morphologic protein with a fair amount of success, but it doesn’t work for everyone and it seems to be as high as 23 to 27 percent of patients.

Arthroplasty, replacement of bones or joints, has been done in the lower back for quite some time, but it’s not yet approved for the cervical spine. They have been used in studies and in Europe, they have an adverse event rate of 6.2 percent.

The authors conclude that the rate of adverse events is low, but they do occur and surgeons may lower risk by learning what actions contribute to the chances of developing the complications.

Researchers from Australia present the positive results of 42 patients with a Type II odontoid (neck) fracture who were treated conservatively (without surgery). Everyone in the study was at least 65 years old. Ages ranged from 67 to 91 years old. This type of fracture is most common in older adults who fall and break off the odontoid in the cervical spine (neck).

The odontoid is a bony knob or upward projection of bone on top of the second cervical vertebra (C2). C2 is also known as the axis. The odontoid process is also called the dens. The dens points up and fits through a hole in the first cervical vertebra (called the atlas). The joints of the axis give the neck most of its ability to turn to the left and right.

A Type II odontoid fracture occurs right where the odontoid process attaches to the C2 vertebral body. Without this piece of bone in place, the first two vertebral bones (the atlas and the axis) can slide apart. This puts a tremendous compressive or stretching force on the spinal cord as it goes down through the spinal canal. The spinal canal is a round opening or hollow tube formed by the vertebrae stacked on top of each other.

Type II odontoid fractures are unstable because they can be displaced so easily. Nonoperative treatment to allow the bone to knit back together can be successful. In fact, this approach is preferred because of known complications that occur when surgery is done for this problem in older adults. If conservative care fails, then surgery to fuse the spine can be done. Surgery is indicated in cases of nonunion instability such as recurrent dislocation or when there is serious neurologic involvement (e.g., paralysis).

If the atlas and axis have not been displaced (moved), then immobilizing the neck for a period of time is an option. The two most common forms of immobilizers used in this study included a rigid cervical collar and a halothoracic brace.

Results were compared for 10 patients who used the cervical collar and 32 patients who were placed in a halothoracic brace. The halo brace is a titanium ring (the halo) that goes around the head. This portion of the brace is secured to the skull by metal screws (pins). Four metal bars attach the halo ring to a vest worn on the chest. This vest offers the weight to anchor the ring and immobilize the neck. Sometimes the halo brace is referred to as a halo vest.

Bracing was used for 12 to 24 weeks. X-rays were taken to see if bone fusion had taken place. Pain and function were two other outcome measures used to compare patient results with conservative care. Function included neck range-of-motion and ability to perform daily activities. Two specific tests of long-term function were used: the Neck Disability Index and the Smiley-Webster Scale.

Nine of the 10 patients treated with a rigid cervical collar had good results. Cervical spine stability was achieved either by bone fusion or by fibrous union. Fibrous union means the fracture filled in with strong enough scar tissue (but not bone cells) to prevent movement at the fracture site. Ratings from the Neck Disability Index and Smiley-Webster Scale for this group showed mild disability in eight of the patients.

In the halothoracic group, stability of the fracture site was achieved in all 32 patients. But the fracture union rate was lower in this group (37.5 per cent) compared to the patients treated with the cervical collars (50 per cent). Function was good-to-excellent in almost all of the patients in this group. Mild-to-moderate disability was reported in 24 or the 32 patients. No one had severe disability.

These conclusions support the results of other studies that show some disadvantages in using cervical collars alone for Type II odontoid fractures. For example, cervical collars don’t always hold the fracture site until healing occurs. Sometimes there is a loss of reduction (the bones slip or displace). The reason for this may be because the collars limit, but don’t prevent, neck motion.

Complications can occur with either choice (cervical collar or halo vest). Pressure ulcers (skin sores) develop with either form of immobilization. Infection can occur at the pin sites for the halo brace. Difficulty breathing leading to respiratory problems has been reported. But some experts think that the respiratory compromise and the other symptoms may really be as a result of inactivity and poor follow-up care.

And the potential complications with surgery are much more serious than with nonoperative care. Bone loss in older adults makes surgery very difficult. The surgeon may have a hard time finding solid enough bone to insert screws to help stabilize the spine. Sometimes, the weak or brittle bone fractures when the surgeon tries to place screws to fix the fracture.

Permanent disability can occur if the spinal cord or vertebral arteries are injured during surgery. And the older patients are, the more health issues are present and the greater the risk for complications from the use of anesthesia.

The authors conclude that surgery doesn’t have to be the first line of treatment for Type II odontoid fractures in older adults. Unless conservative care fails or there is instability in the cervical spine, nonoperative care has good results.

Clinical and functional results were the same whether the patient healed with a fibrous union or a bony union. In other words, a stable, fibrous union was good enough and may mean the freedom to choose nonoperative care. For an older adult with the increased risk of serious complications, that choice is important. All things considered, results of bracing (conservative care) seem to be best when halothoracic bracing was used instead of a cervical collar.

Scientists are still scratching their heads over chronic whiplash injuries. Why is it that some people recover just fine, while others go on to develop a chronic problem? In fact, the problem is common enough that it now has a label: whiplash associated disorder (WAD).

Some experts suggest there are risk factors that predict who might end up with WAD. One of those predictive factors is the focus of this study: local sensitization to noxious stimuli. This refers to how the nervous system seems overly sensitive and responds faster and with stronger pain signals in some people. The theory is that the nervous system is already pretty touchy either before the accident or right after the injury.

A prospective (observational) study was done to test this idea. A prospective study is a research effort that follows a group of people who are similar in some respects but different in other ways. In this study, two groups of WAD patients were tested and compared.

All participants in the study were seen within the first five days after they had a moderately severe whiplash injury. Everyone included was considered high-risk for WAD based on results of previous studies identifying risk factors. Risk factors for poor recovery include female gender, decreased active neck motion, and pain intensity after injury.

One group had recovered fully at the end of one year. The other group still had tenderness in the neck (and other regions) and was unable to return to a full work capacity. The groups were labeled recovered and nonrecovered.

This same group of researchers has done other studies in this area. They have shown that when the body perceives stimulation as painful, it produces muscle fatigue and weakness. The person who becomes highly sensitive has a lower threshold for pain. Not only that, but the pain spreads to other parts outside the area of injury. The affected muscles have a reduced ability to contract fully and also have reduced endurance (lasting power).

If patients who are at risk for WAD can be identified early enough, it may be possible to prevent persistent symptoms and preserve muscle function. The result could be a faster return to full function without loss of work capacity. It is not possible to test people for sensitization before an accident since we don’t know when accidents are going to occur. The next best thing is to do what these scientists did: test patients right after the accident.

Muscle tenderness and mechano-sensitivity were measured 12 days after the whiplash injury and again after three months and at the end of one year. Nine areas of potential muscle tenderness were palpated. These tender points were located and tested bilaterally (on both sides). A score was given from zero (no pain) up to four (unbearable, untouchable) for each area.

A second test was done. This one measured stimulus-response between pressure and pain. In other words, pressure of varying amounts (from 50 kPa up to 800 kPa) was applied to three separate muscles in the body (trapezius/neck and shoulder, masseter/jaw, tibialis/lower leg). The pain response felt with any of the pressure gradients used was then scored from zero (no pain) to 10 (worst pain).

Almost one-quarter of the patients (22.9 per cent) had not recovered at the end of 12 months. Analyzing the data further, the authors made the following observations. There was no difference in type of work done (occupation) between the recovered and nonrecovered groups. Those who were in the nonrecovered group had more intense pain after the injury. They also had reduced neck motion after the injury compared to the recovered group.

Tenderness scores were higher for the nonrecovered group right from the start. Likewise, there was increased sensitivity to mechanical stimulation (pressure) and spread of symptoms in the nonrecovered group within days of the injury.

The results of this study show that there may be pre-injury factors that set a person up for the development of chronic pain after a whiplash injury. The exact mechanism for how and why this occurs remains unknown. Clearly, there is a decreased pain threshold and increased sensitivity to pressure or other stimulus that is then perceived as pain, but why does this happen?

Future studies will continue to look into this question. Scientists will try to understand exactly what’s going on in the nervous system and why some patients seem more susceptible than others to WAD. Identifying predictive patient factors (personal or physiologic) can open the door to finding ways to keep pain signals from escalating in intensity, duration, and frequency. In this way, it may be possible to prevent WAD altogether.

Physical therapists routinely examine patients with neck pain for posture and alignment. There is an assumption that these three things are linked together. In other words, if everything isn’t lined up in a neutral or correct position, then neck pain may develop. Or neck pain gets worse in someone who already has neck pain. In this study, therapists take the first steps toward possibly proving that theory wrong.

The focus of this research was the position of the scapula (shoulder blade) in relation to cervical (neck) motion. In particular, the therapists looked at the effect of a depressed scapula on neck range of motion. A depressed scapula was defined as a shoulder blade that was located below the expected, normal anatomic position (between the second and seventh thoracic vertebra).

Normal, healthy adults were examined. The idea was that studying a young, healthy group of adults would show the effect of scapula position on neck motion in someone who didn’t have neck pain. Two groups of subjects were included. One group had neutral vertical scapular alignment. The second group had depressed scapular alignment. There were equal numbers of people in both groups matched by age and sex. No one in either group had a recent history (last 12 months) of neck, shoulder, or arm problems.

A special device called the Cervical Range of Motion (CROM) was used to measure neck motion. The CROM is placed over the head like a cap. A dial in the middle of the forehead with a needle registers the degrees of motion. The device is known to be a valid and reliable tool for measuring neck motion.

The experiment was set up so that a digital camera could read the CROM and report the results to a computer. That way, no one knew which group the subjects were in when recording motion. This type of study is called a blind study.

The therapists went into this study knowing that neck motion is increased when the normal, neutrally aligned scapulae are elevated or lifted up. They also knew (from other studies) that a loss of cervical (neck) rotation affects function more than a loss of any other neck motion (bending, extending, tilting sideways).

What they didn’t know was whether people with depressed scapulae have the same neck motion as people with neutral scapular alignment. And they didn’t know what would happen to the cervical range of motion in otherwise healthy subjects who have depressed scapulae when the arms are supported to raise the scapulae to a more normal, vertical position.

With that information in mind, they built a special chair for the subjects to sit in during the motion testing. The arms of the chair were adjustable so that the scapulae could be placed in various positions of elevation or depression. Testing was done in two positions for each person.

The first position was with the scapula in the neutral position (between second and seventh thoracic vertebrae). This required the subjects to use the armrests on the chair. Cervical rotation to the left and right were measured and combined together as one figure. The second position placed the subject in his or her normal scapular resting position. In order to accomplish this, the armrests were not used. Each subject sat on the chair with the arms hanging down at the sides. Cervical rotation was measured in this new position.

They found that cervical rotation was definitely increased when the arms were supported. This was true for both groups (neutral vertical scapula and depressed scapula). They also reported that cervical motion was equal between the two groups in either test position.

Without the influence of pain as a factor, this study helped showed that scapular position isn’t necessarily related to neck and shoulder dysfunction. Contrary to previous held beliefs, scapular depression does not appear to negatively influence neck motion.

It is clear that there is a link between scapula position and cervical spine motion in healthy adults. Since only healthy adults were included in this study, specific conclusions cannot be made about the influence of a depressed scapular position on neck pain.

What’s the take home message from this study for physical therapists? First, it should not be automatically assumed that a depressed scapular position is the cause of decreased neck rotation in someone with neck pain. Second, neck motion should be measured with and without upper arm support. This would show the effect of the upper limbs on the patient’s neck motion. And third, neck exercises with the arms supported can be prescribed to help increase neck motion and potentially improve function.

Future studies are needed to verify these findings in patients with neck pain. The benefits of arm support on neck motion are clear, but the effect of this factor on neck pain is still unknown. The influence of other scapular positions on neck motion (and on neck pain) should also be tested.

Despite many studies on whiplash patients, we still don’t know why some people get better quickly while others suffer head and neck pain for months to years after the injury or accident. In this study from the Danish Pain Research Center, previous studies are continued looking for more clues to the problem.

In the past, risk factors for the development of disabling, chronic whiplash-associated disorder (WAD) were identified. These included female gender, number of non-painful symptoms, and total degrees of active neck range of motion. Using these risk factors, the researchers conducted this study. They put patients in one of two groups according to their risk (high vs.low) of developing a chronic whiplash-associated disorder (WAD).

Everyone was in a rear end or front-end car accident and had an acute whiplash injury. Symptoms of neck and jaw pain, headache, and/or decreased neck motion were reported within the first three days of the injury. It’s during this time that scientists think cells called nociceptors become overly sensitive. Nociceptors are pain receptors, cells that recognize and process noxious or irritating, pain-inducing stimuli. When this happens, the patients don’t recover, but go on to develop problems with chronic pain.

The high-risk group was further divided in two parts and labeled recovered high risk and nonrecovered high-risk whiplash patients. It was the high-risk group that was of interest to these researchers. Using tender points and mechano-sensitivity after injury, they tried to see if these two variables were different in the two groups. They asked the question: were the values different enough in the first few days after injury to use them as predictors of patients who would develop chronic WAD?

And they looked to see what happened to these early changes — did they stay the same? Did they get better or worse over the next 12 months? Tender points were assessed by pressing on them and having the patient respond subjectively.

In other words, the patients labeled their pain from zero (no pain) up to four (unbearable pain). Besides the already established sensitive points, four paired (control) points were also pressed. Using points away from the neck helped show if the pain response to whiplash was specific (just the head and neck) or more generalized (all over the body).

A second measurement called stimulus-response between pressure and pain was taken. A special tool called an algometer was used. Pressure was applied using between 50 and 800 kPa. Three muscles were tested: the masseter (jaw muscle), the trapezius (on top of the shoulder), and tibialis (lower leg muscle). Different levels of pressure were applied randomly the first time. The same pattern or order of sequence was repeated each time the patient was re-tested. This is a test of mechano-sensitization (sensitivity of the mechanoreceptors that register pressure).

Non-recovery was defined as inability to return to work or failure to return to work at a level equal to the status before injury. This outcome measure was referred to as reduced work capacity. Decreased work hours, simplified tasks, loss of a job, undergoing retraining for a new job, and being on disability are all examples of reduced work capacity. Work capacity was chosen to define recovery because previous studies showed that high-risk patients were 10 times more likely than low-risk patients to experience reduced work capacity.

The researchers did compare jobs between those patients who did recover versus those who didn’t. This could have been a deciding factor, but it turned out there were no real differences in this regard between the two groups. What they did find was that the non-recovered patients had more tenderness in all muscles tested (local and regional) compared to recovered patients.

They also had more sensitive mechanoreceptors, not at first, but later on at the end of the year. The non-recovered patients had limited neck motion during the acute phase as well as during the months leading up to the progression from acute to chronic pain. Even 12 months after the injury, all the muscles tested were still ultra tender to touch and pressure.

The fact that the nonrecovered patients had a hypersensitivity response early on after the injury (compared to the recovered group) suggests the possibility that something was going on even before the injury. The fact that there may be pre-injury factors that set off the sensitization process is new information. And the discovery that symptoms spread over time points to some kind of dynamic pain process after injury in these patients.

The authors weren’t sure how to explain the spread and referral of muscle pain. There are many possible explanations but no real answers yet. Other research using the stimulus response function to measure pain responses after whiplash injury have proposed the possibility of changes in neurologic systems between the spinal cord and brain. Similar altered sensitization in patients with conditions like fibromyalgia support this idea.

All of these results take us back to the original question: are there other reasons for the chronic pain following whiplash injury than the injury itself? This study confirms what other studies have suggested: the pain sensitization is coming from a central pain control system.

Centralization of pain points the finger to the nervous system as the cause of the problem. Somehow these patients become overly sensitive to stimulus because nociceptive receptors respond to the slightest input of pressure. No more can be said beyond that without further study.

But these results do give us treatment ideas to help high-risk patients early on. Medications, psychologic treatment, or physical therapy may be able to take advantage of the plasticity of the nervous system and change the pain messages during the acute phase of recovery. Plasticity refers to the flexibility of the nervous system (brain and spinal cord) to change, recover, or return to normal function.

Neck pain got you down? You’re not alone. On any given day, 20 per cent of adults in the United States report similar symptoms. And two-thirds of all adults will experience neck pain at some point their lives. Some get better without treatment. Others seek the services of physical therapists.

Physical therapists are working hard to narrow down what treatment works best with which group of patients. In the past 10 years, the results of research studies in physical therapy have changed the way low back pain patients are treated. The results of this study may do the same for patients with neck pain.

Research has shown us two important things about neck or back pain patients. First, it is possible to identify subgroups of patients. These are patients who respond better to one treatment over another. They may have a particular characteristic about them that puts them in that subgroup.

For low back pain patients, the presence of leg pain along with back pain has created a subgroup of patients who seem to respond to manual therapy of the lumbar spine. Manual therapy refers to nonthrust joint mobilization and/or thrust joint manipulation of the spine. In this study, the same idea is applied to patients with mechanical neck pain with and without arm pain.

Mechanical neck pain tells us the problem is within the joints and/or soft tissue structures. It is not caused by tumor, infection, or fracture. Patients with whiplash injuries, stenosis, or previous neck surgery were not included in this study. One group received manual physical therapy and exercise (MTE). The second group had minimal intervention (MIN) therapy.

MTE included joint mobilization or manipulation, muscle energy techniques, and stretching. Home exercise programs were prescribed based on impairments identified during the exam. Impairment areas identified included dysfunction of the cervical spine, thoracic spine, and ribs.

MIN patients received advice, range-of-motion exercises for the neck, and subtherapeutic ultrasound. Subtherapeutic means this form of heat was applied at a low intensity (low enough so it did not actually heat the tissue).

Everyone in both groups was treated for six sessions over a period of three weeks. There were no significant differences in the baseline characteristics of patients in both groups. Baseline factors included age, gender, type of symptoms, use of medications, neck motion, and arm pain.

The one difference that might have made a difference was the duration of symptoms. More patients in the manual therapy and exercise group (74 per cent) had symptoms lasting longer than 12 weeks when compared with patients in the minimal intervention therapy group (48 per cent).

The results were compared using pain, patient satisfaction, and function. There were two significant findings. First, patients in the manual physical therapy and exercise (MTE) group had much better improvement in all areas compared with patients in the minimal intervention (MIN) group. Second, the MIN group was much more likely to seek additional health care services after the treatment period was over. Increased utilization of health care services increases the overall costs.

The authors used a high global rating of change (GRC) to clearly define success. And the success rates lasted as long as two years after treatment. The authors concluded that using manual therapy for neck and/or arm pain caused by specific impairments of the cervical spine (neck), thoracic spine, and rib cage works better than standard minimal care.

The use of specific impairment-based exercises for each patient in the MTE group adds to the challenge of sorting out what worked. Was it just the manual therapy that was effective? Just the exercises? Or both combined together in a multimodal approach? The researchers were able to use specific statistical analyses to measure the effect of each treatment component.

They did this by assessing each patient after manual therapy techniques and before instructing the patient in the exercise(s). They felt this was an effective way to sort out what part of the treatment had a direct effect on the patient.

Although the study did not identify a subgroup of patients most likely to benefit from either MTE or MIN, the results did confirm the value of manual therapy and exercise for patients with neck pain (with or without arm pain). Reducing pain, disability, and overall health care costs is possible in the short- and long-term for patients with mechanical neck pain using manual physical therapy and exercise. The MTE approach is both safe and effective.

What is it about some people who have a whiplash injury from a car accident that causes them to develop chronic neck pain referred to as postwhiplash syndrome? Is it the severity of the injury or the way they view the experience? In this study, researchers from the Netherlands look at the role of catastrophizing and causal beliefs as possible predictive factors in postwhiplash syndrome.

Pain catastrophizing refers to a negative focus on pain, whether that pain is real or anticipated. A person’s pain is increased or amplified and prolonged because of the way they view every physical action as a possible source of pain. This type of thinking becomes a habit and leads to chronic pain and disability.

Causal illness beliefs describe the patient’s ideas about what originally caused the problem in the first place. In the case of a whiplash injury, the patient may have been given the wrong impression about their prognosis.

Information provided at the emergency department or in the doctor’s office may have led him or her to believe there was severe, irreparable damage done to the neck. This impression added to the social or cultural belief that whiplash injuries are permanent could lead to a negative spiral in thoughts and actions.

The patient starts requesting more medical help. He or she constantly scans the body for any new symptoms or to check the severity of the old symptoms. Expecting pain and looking for symptoms can lead to more severe and longer lasting complaints. Intense anxiety and fear of pain are linked with a poor outcome or prognosis.

Social research has also shown that pain catastrophizing actually leads to more dysfunctional causal beliefs. In time, a vicious cycle is set up that creates a pathway from acute to chronic neck pain. In order to test the theory that pain catastrophizing and causal beliefs lead to more severe pain and delay recovery, traffic accident victims were studied.

Everyone in the study had filed a compensation claim for personal injury with an insurance company. Questionnaires were sent to each claimant between the ages of 18 and 65. The Neck Disability Index (NDI), Pain Catastrophizing Scale (PCS), and Causal Beliefs Questionnaire Whiplash (CBQ-W) were filled out and returned by 747 people with postwhiplash syndrome. Postwhiplash syndrome was defined as patients suffering from chronic neck pain after a motor vehicle accident. No one had lost consciousness for more than one minute and no one had a previous history of neck problems.

The Causal Beliefs Questionnaire was developed by the authors for use in this study. As part of the study, they were evaluating its use for validity and reliability in measuring four causal factors. These four factors relate to the patient’s expectation of where the symptoms are coming from (psychological, severity of injury, vertebral bone, muscular).

The results showed that the more severe the pain at first, the more likely whiplash symptoms would persist beyond six and 12 months. Pain severity was linked with pain catastrophizing. And pain catastrophizing was linked with disability. Patients who thought all their neck pain was caused by the whiplash injury were also more likely to still have pain and disability 12 months later.

The authors couldn’t tell if more pain catastrophizing leads to more disability. The research was not designed to answer that question. They could see that believing a car accident will cause a whiplash injury and that a whiplash injury creates pain was a good predictor of a poor outcome (more than even the intensity or severity of symptoms when the accident first happened).

This is the first published study to prove that attributing complaints to whiplash (i.e., believing that whiplash causes neck problems) is a negative prognostic factor in chronic whiplash or postwhiplash syndrome. This information suggests that patient education is a critical feature in the management of the acute injury.

Overcoming culturally embedded beliefs and modifying patient expectations about their recovery process could possibly help prevent postwhiplash syndrome. Given these findings, it may be necessary to rethink our current treatment focusing on the vertebrae and muscles in the early stages of recovery. It may be better to identify people who have high anxiety related to the accident and injury and offer them helpful information to reduce wrong or dysfunctional thinking.

The authors point out that this study only includes one group of people (from the Netherlands) and may not apply to other populations. The fact that everyone in this group was involved in an insurance claim could be an additional factor to consider. Not everyone with postwhiplash syndrome has a compensation claim — maybe it makes a difference.

As researchers learn more about whiplash and whiplash-associated disorders, they have learned about a group of patients who, after sustaining whiplash, end up with chronic whiplash-associated disorders, including hypersensitivity (being too sensitive) and hypoesthesia (a dulled sensitivity to touch).

Earlier studies have shown a connection between high sensitivity to heat, vibration, and electrical stimulation following whiplash and as part of the whiplash-associated disorder. However, although these studies have been done, they were generally done with chronic whiplash-associated disorders, not acute whiplash. One study that ventured into the acute area, done by Kasch and colleagues, did find that people with acute whiplash with high levels of whiplash pain showed signs of hyperalgesia, or increased sensitivity to pain, more than those with lower levels of whiplash pain. They wrote that this could be a predictors of poor recovery from whiplash.

The authors of this study wanted to find out if hyperalgesia occurred in patients with acute whiplash injury, using a quantitative sensory testing (QST), which examines the level of pain experienced with temperature, vibration, and electrical stimulation. To do this, researchers studied 52 volunteers with neck pain following motor vehicle accidents and 31 controls, people who had not injured their neck.

In order to determine the pain thresholds, the researchers used a probe that provided pressure in certain levels of the spine, the elbow, and the abdomen. Cold thresholds were measured using a probe that applied cold directly to the skin on the top part of the hand. Another test, called the brachial plexus provocation test measured pain while the arm was being straightened at the elbow. Vibration sensation and threshold was measured using a vibrometer applied to the hand. Hot and cold detection was measured using another prove on the hand with which temperatures were either increased or decreased, depending on the test. Finally, the electrical stimulation was done with a device that emitted various frequencies and this was applied to various parts of the cervical spine, or neck.

The patients were asked to complete questionnaires about their symptoms, the Neck Disability Index (NDI), as well as the General Health Questionnaire 28 (GHQ-28). All participants then had a full physical examination to be sure that they qualified for the study. At this point, the patients’ group was split into to, with 17 of the patients being assigned to the high-risk group. The study tests were done by the same examiners for all the patients and controls.

The researchers found that there were significant differences between all three groups, the two patient groups and the control group. Both patient groups had higher detection thresholds than the controls but there wasn’t a significant difference between the two patient groups. For the hot and cold detection, there wasn’t much difference in the heat detection threshold between any group, but there was a difference between the patient groups and the controls. The patients had a slower response in detecting the cold sensations and more so in the high-risk group. The electrical stimulation was much higher in the high risk group, followed by the low-risk group, with the controls being significantly lower.

These findings led the authors to conclude that there was an effect of generalized hypoesthesia not only among people who sustain chronic whiplash-associated disorders, but those who have acute whiplash-associated disorders as well.

When it comes to fusion of the cervical spine (neck), there are now many ways to surgically fuse one or more segments. Surgeons are interested in knowing which method provides stability without significant changes in biomechanics.

In this study from Italy, four different fixation (fusion) methods were compared. The research was done in a lab using four simulation models of the C4-C7 vertebral segments. Using models is the first step in this type of research before performing similar testing on humans.

The four models used included 1) stand-alone cage, 2) cage with anterior locking plate, 3) cage with an anterior dynamic plate, and 4) dynamic combined plate-cage device. The models were made to test the segments right after surgery (before bone fusion actually takes place).

The authors describe in detail the surgical methods used to implant each cage and/or plate device. Removal of the discs, preparation of the surrounding ligaments, type of screws used, and preparation of the vertebral body were all considered in the experiment.

All four models used the same type of intervertebral cage made of polyetheretherketone (PEEK; also known as polyketones). This material is an elasticized plastic to give support with some give. Plates used to supplement the cages were made of titanium. Locking plates do not allow motion between the various parts of the device. Dynamic locking plates use a nonbonding contact between the screws and plate and between the surface of the plate and the vertebral bones.

Tests were done by exposing each model to a compressive load. The load was applied in four different directions (flexion, extension, side bending, and rotation). Range-of-motion was measured for each trial at the level of the fusion and the adjacent levels (segments above and below). The researchers also measured how much load was placed on the cage and plate.

They found that the cage with the locking plate had the best ability to prevent motion in all directions at the fused levels. Dynamic plates reduce, but do not stop, motion at the fusion site. The locking plate was able to bear the most load (90 per cent compared to 40 per cent for the dynamic plate).

Amount of motion detected with each model varied. Motion was the greatest with the stand-alone cage. The dynamic plate-cage device (model number four) was the least stable of the combined options. The authors think this may be because this model only has two screws to hold it in place (compared with four screws in the cage with locking or dynamic plate).

All four models showed elevated pressure where the devices come in contact with the upper endplate of the vertebral segment. The endplate is a transition area of cartilage between the intervertebral disc and the next vertebral bone. The stand-alone cage put the most pressure in the endplate area. This is a concern because of subsidence (cages sinking down into the endplate). Cages used with plates seem to spread out the pressure more evenly across the entire endplate.

The authors conclude that even though they could measure differences in the biomechanics of the fused spine, differences in load sharing between the four models, and differences in motion and stability, these are only models. Actual clinical trials with patients randomly placed one of these four groups for comparison is the next step. There is no question that single-level fusions work well. The focus now is really on success and stability of multiple segmental fusions.

Along with back pain, neck pain is one of the most common musculoskeletal disorders in humans. It’s estimated that in one year, between almost 6 percent and 22 percent of people experience some sort of neck pain. While there are many specific causes of neck pain (injury, tumor, arthritis, for example), there are also many times that there is no obvious reason for the pain. This is called non-specific neck pain. This type of pain can be very difficult to treat because the doctors don’t have anything solid to go on.

If you have been diagnosed with non-specific neck pain, there’s a good chance you would be referred for physiotherapy or for spinal manipulation if a wait-and-see approach doesn’t work. While studies have found that physiotherapy and/or manipulation can help relieve non-specific neck pain, there doesn’t seem to be much agreement as to which patients would benefit from these therapies.

The authors of this article wanted to identify which patients would be best for physiotherapy and/or manipulation, and why. To do this, researchers reviewed three earlier studies of patients with non-specific neck pain who were assigned to either usual care, physiotherapy, spinal manipulation, or behavioral graded activity. At the end of the analysis, those who were in the behavior graded activity were not included in the study findings because it is not a commonly used treatment.

The patients who went for physiotherapy were given exercises to improve strength or range of motion of the neck. There may also have been heat applications as well. Patients attended a maximum of 18 sessions, which were about 30 minutes each. Spinal manipulation therapy consisted of several techniques at the level of the cervical spine (the neck) but did not use high velocity thrust techniques. Patients attended a maximum of six sessions of 30 to 45 minutes.

Usual care is the term used for patients who received advice on how to care for themselves to manage the pain and discomfort. The doctors gave the patients a booklet on ergonomic advice and exercises to improve their strength and function. If needed, the patients took over the counter medications to relieve the pain.

The researchers also looked at the differences between the patients and if these differences made it possible to predict if their assigned treatment would be effective. The differences – or variables – included their sex, level of education, if they’d had neck pain in the past, how long they have experienced this episode of neck pain, if the pain was radiating or stayed in the neck area, if the pain was caused by a trauma or injury, their overall health, if they experienced headaches and/or dizziness, if they had back pain, and what their pain intensity level was on a scale of zero to 10, with zero being no pain and 10 being the worst possible. Patients were also asked about which treatment they preferred if they had a preference.

The results of the analysis showed that the variables that had the most effect on predicting if treatment would be successful were the intensity of the pain, the age of the person and that there was no back pain. Patients with these predictors showed up to a 25 percent recovery or improvement. The other variables did not seem to have any play in whether treatment was effective.

The authors concluded that the type of treatment for non-specific neck pain that is provided to a patient should be based on predictors that would indicate if the treatment has a higher chance of being effective.

This study from Japan highlights a problem faced by many Japanese adults. It’s called cervical spondylotic myelopathy (CSM). Cervical refers to the cervical spine or neck. Spondylotic means there is bone involvement. In this case, the vertebral bones with the opening for the spinal cord are the center of attention. Myelopathy tells us the spinal cord is affected.

Myelopathy can be caused by many different things. The most common is a narrowing of the spinal canal (opening for the spinal cord). Anything that causes this narrowing can put pressure on the spinal cord, resulting in neurologic deficits. This narrowing called spinal stenosis can occur as a result of bone spurs or thickening or hardening of the spinal ligament (posterior longitudinal ligament).

Tumors, infection, trauma, and age-related degenerative changes in the spine can also contribute to stenosis. With aging, the vertebral bodies compress and develop a lip around the edge. Even a small amount of collapse alters the position of the facet (spinal) joints.

At the same time, the intraforaminal space where the spinal nerve roots leave the spinal cord get compressed. Likewise, the discs between the vertebral bodies are under increased pressure. All of these factors together create the CSM condition.

But in the Japanese population, it appears that the major cause of CSM is a congenital decrease in the size of the spinal canal. This occurs without an equal decrease in the size of the spinal cord going through the canal. The condition is referred to as developmental stenosis since it is present at birth.

How does this problem affect patients? And what are the results after surgery to relieve pressure on the spinal cord? Those are the two questions posed by Japanese surgeons at the Nara Medical University in Kashihara, Japan. They performed a bilateral open-door laminoplasty on 194 adults with CSM.

An open-door laminoplasty refers to a single incision along the lamina bone of the vertebra with a partial incision on the other side. The lamina is the bridge of bone that connects the spinous process (bony projection out from the vertebra felt as a bump along the back of your spine) to the main body of the vertebra. The lamina is present on both sides of the spinous process.

The surgeon then swings one side of the bone open like a door and away from the spinal cord. Bilateral means the procedure was done on both sides of the vertebra. In this study, the surgeons used a modification of the open-door laminoplasty called the double-door laminoplasty. The surgeon removed the spinous process. The center of the lamina was split and opened like double doors. This technique enlarges the spinal canal more than a single open-door procedure.

After surgery, bedrest was advised for up to one week. A cervical collar was worn for up to two months. Everyone was followed for at least two years (some as long as 15 years). Results were measured using neck range-of-motion, Japanese Orthopedic Association (JOA) scores, and X-ray measurements of the spine. JOA scores provided a measure of function by examining ability to eat, walk, and maintain bladder control.

They compared results between two groups of CSM patients: with and without developmental stenosis. It turned out that half of the patients with CSM included in the study had developmental stenosis, so the groups were about equal in size. Stenosis was defined as a spinal canal diameter less than 14 mm in men and less than 13 mm in women.

Age, duration of symptoms, and recovery rates were the same for both groups. JOA scores measuring function before and after surgery were equal between the two groups. Neck motion was less in the group with developmental stenosis, but this didn’t appear to affect the final outcome.

The authors conclude that the presence of developmental stenosis in adults with cervical spondylotic myelopathy (CSM) does not make a difference in results after surgery. In other words, the stenosis was not an important or influencing factor when doing a laminoplasty to treat this problem.

The authors of this study retrospectively reviewed the charts of 167 patients who underwent cervical spine surgery by one of two orthopedic spine surgeons. Indications and contraindications to lumbar total disc replacement, TDR are established and have been well evaluated. Potential candidacy for cervical TDR has not been well evaluated. The authors of the study were interested in the indications and contraindications for cervical total disc replacement. Of the 167 subjects reviewed, 91.6 percent underwent fusion surgery. Non-fusion surgery comprised 8.4 percent of the subjects.

However, 43 percent of the subjects would have met the strict criteria for TDR surgery. Of the 57 percent that had absolute contraindications to cervical TDR, the average number of contraindications was 2.1. If adjacent segment disease was not included in the exclusion criteria, 47 percent of subjects would have been candidates for cervical TDR. In contrast, 0.5 to five percent of persons needing lumbar surgery qualify for consideration of lumbar TDR.

Presently, anterior cervical discectomy and fusion, ACDF is the standard treatment for disc herniation and degenerative disc disease in the cervical spine. However, studies have shown that fusion appears to hasten the onset of adjacent segment degeneration. This often leads to extension of the fusion, which has greater complications. Cervical TDR is designed to maintain more normal motion at the operative and non-operative segments. It does not require bone grafting. The authors support the removal of adjacent segment disease from exclusion criteria for cervical TDR. Results from long-term follow-up studies after cervical TDR are not available.

Trauma to the upper arm during accidents can result in avulsion (complete tear) of the brachial plexus. In this study, the use of nerve transfers is explored for these injuries in six patients.

The brachial plexus is a group of nerves that start at the spinal cord in the neck area. At this level, the nerves are called spinal nerve roots. The nerve roots branch out and form the three main nerves to the arm. All six patients experienced brachial plexus injuries from motorcycle, skiing, car, or agricultural accidents.

Most of the patients came to the study clinic some time (months to years) after the original injury. They were examined carefully with a wide range of tests and measures. Range of motion, muscle strength, and function were evaluated. Photographs and videos were taken to document their baseline status at the start of treatment. All measurements were compared with average normal values for each area.

Sometimes primary muscles responsible for a movement weren’t working. The patients developed muscle substitution (one muscle doing the job of another). The presence of any muscle substitutions was noted. Shoulder stability was also assessed.

All patients had surgery to find out how badly the brachial plexus was injured. Intraoperative electrical stimulation was used to test the location and status of the nerves. The main focus was on the use of the pectoral nerve. Nerve grafting and nerve transfers were used to restore motor function of the upper extremity.

The surgical technique was described in detail by the authors. Exact locations of the transfers and grafts were discussed. In the basic procedure, the pectoral nerve was divided on one side and then surgically attached to the torn nerve.

Pectoral nerves are used for several reasons. The nerve is broken down into several parts or segments. Usually, not all segments are destroyed. So there is some part of the pectoral nerves that are still working. At the same time, there is segmental innervation of the pectoralis major (chest) muscle. Segmental innervation means that more than one nerve controls the muscle. If one part of the nerve plexus is torn, another part can be used to signal the muscle to contract.

The pectoral nerves also have a large number of motor fibers. This increases the chance of success for reinnervation of the affected muscles.

The nerves are close enough to the area of damage that re-routing them isn’t too difficult. The closer the nerve is placed to the muscle target, the faster the recovery will be. This is important because if a nerve pathway isn’t used, and the muscle doesn’t contract, both soft tissues start to atrophy (waste away).

But with the right placement of nerve graft or nerve transfer, new nerve fibers will grow back to the place where the nerve was damaged. The placement of nerve transfers and grafts for brachial plexus injuries depends on where the nerve root was ruptured and how severe the tear was.

Results from these six patients with their seven pectoral nerve transfers were reported as good-to-excellent for six of the seven nerve transfers. The patients were able to use the donor nerve to contract the muscles. Electromyographic studies and strength of muscle contraction were used as measures of success. Elbow, forearm, and wrist motion was also compared from before surgery to after the procedure.

The authors report that this type of complex brachial plexus reconstruction may be needed when direct repair of torn nerve roots can’t be done. But the results aren’t guaranteed. If the distance between the donor nerve and the muscle it is trying to reach is too great, regeneration can take a long time.

If the new nerve reaches the target muscle, there may not be enough motor fibers to get a good, strong muscle contraction. Even if the muscle is reinnervated, it doesn’t always function normally. And there is a chance that function of the pectoralis major muscle will be impaired. It’s a gamble that with multiple nerves supplying this muscle, if muscle function is lost, it will only be partial — not enough to affect how the arm moves.

In summary, pectoral nerves are dependable sources of nerve grafts for severe brachial plexus injuries. This type of reconstruction is most successful when used on young individuals without a long delay between injury and surgery.