News Category: Cervical Spine

Doctors have different techniques for assessing the neurological, or nerve, function in your body. For example, when an infant is being examined during a well-baby check-up, one thing that is performed is the Babinski sign or reflex. Until the age of two years, if the doctor or nurse strokes the sole of the baby’s foot firmly, the biggest toe, or the great toe, should bend and the rest of the toes should spread or fan out. In adults, if this happens, it tells the doctor that there is something wrong.

Most people who have studied biology or child development know about the Babinski sign, but there is another sign that is lesser known, called the Hoffmann sign. To do this test, the doctor or nurse taps the patient’s nail on the third or fourth finger. Normally, nothing should happen. However, if there are problems with the neurological system, the test will be positive and the patient will involuntarily bend, or flex, the end of the thumb and index finger.

The authors of this article found that there wasn’t any information on how the Hoffmann sign may be used when examining patients with cervical myelopathy. Patients who have cervical myelopathy have a problem in the part of the spinal cord that passes through the neck, because of changes in the spinal canal from tumors, diseases, or injury. Because the nerves must pass through this part of the spinal cord, if there is a problem, it can affect the rest of the body as the nerves either can’t get through properly. How serious it is depends on how seriously the nerves are affected. The problem can be mild or it can be severe enough to affect a patient’s ability to breathe.

To do their research, the authors reviewed 225 medical records of patients who underwent decompressive cervical spine surgery for cervical myelopathy between January 2003 and December 2006. They then studied how often the Hoffmann sign was present in 617 new patients who were seen for lower-back pain and/or symptoms of leg pain or numbness.

The first group included 125 men and the average age of all the patients was 57.4 years. The researchers found the Hoffmann sign in 154 of the patients and the Babinski sign in 75 patients. In the second group, 290 patients had only lower back pain or leg pain, and 36 had a positive Hoffmann sign. Twenty-five had the sign in one hand, and 11 in both hands. After the test was found to be positive, 31 of the patients underwent a magnetic resonance imaging (MRI), a method of allowing doctors to see three-dimensional images of inside the body. Among those who had the sign in two hands, 10 of the 11 were found to have compression in the spinal area of the neck. Among the patients who had the sign in one hand, 20 also had compression.

When analyzing the data, the authors found that the Hoffmann sign could be more able to detect neurological problems from cervical myelopathy before the Babinski sign can. This means that if a patient comes in with subtle signs of the disorder, using the Hoffmann sign, doctors may be able to make the diagnosis earlier than if waiting to rely on the Babinski sign. The authors did point out, however, that there may be other reasons for a positive Hoffmann sign, such as in people with hyperreflexia, where the reflexes are much more active than in the general population. As well, patients with diabetic neuropathy, a condition where the nerve endings can become quite painful, also had positive Hoffmann signs, even if there was no other neurological problem.

The authors concluded that they felt if patients had the Hoffmann sign in both hands, they had a higher chance of having problems with pressure in the neck.

Whiplash-associated disorders are medical problems that result from having had whiplash, which is caused by having your head suddenly pitched forward forcefully and then jerking backwards at the same rate. Whiplash, of course, results in severe pain, as well as weakness in the arms for some people.

Another painful neck disorder, cervical radiculopathy, is a condition where there is a herniated or bulging disc in the neck that is pressing on the root nerve, causing severe pain. This type of condition is probably the most common neuropathic (nerve-related) pain issue that involves the neck and arms.

Researchers have thought that generalized sensory hypersensitivity (extra strong sensitivity) is the result of how pain is processed in our brain and different sensations are associated with different nerve dysfunction. Now, there is some evidence that people with whiplash-associated disorders and cervical radiculopathy may be experiencing the same type of pain and, therefore, similar pain processing.

The authors of this article wanted to compare patients with chronic whiplash-associated disorders to those with cervical radiculopathy, using a test called Quantitative Sensory Testing. To do this, they recruited 50 patients who had complaints of neck pain for between three months and three years as a result of a motor vehicle accident. According to the whiplash classification called the Quebec Task Force Classification criteria of WAD II, the patients had no loss in muscle power or reflexes. Thirty eight patients with cervical radiculopathy were also included. These patients had to have pain or other symptoms such as numbness past the elbow and sensory or reflex problems that corresponded with the nerve in the neck that was affected. Finally, 31 health volunteers participated as a comparison, or control, group.

The researchers measured the patients’ pressure pain thresholds (PPTs) using an instrument called an algometer. Cold pain thresholds were measured using a device that was applied over the skin on both the neck and the hand. The brachial plexus provocation test was also done. The brachial plexus is a network of nerves that go from the neck part of the spine, running down to the shoulder, arm, hand, and fingers.

Other tests included vibration thresholds (VT), thermal (hot, cold) detection thresholds, and current perception thresholds (CPTs). All patients and volunteers completed a questionnaire called the Neck Disability Index (NDI), which measures pain and disability. They also completed the Symptom Check List. At the beginning of the study, all the patients (not the control group) had physical exams.

When gathering the results, the researchers found that there weren’t any significant differences between the two pain groups when measuring from side to side for any of the measurements. In the radiculopathy group, the patients had higher detection thresholds for several of the tests on the sides with the injuries, but there was no difference between the radiculopathy and whiplash groups on the sides without the injury. However, both groups had higher detection thresholds (pain, temperature) than the control group.

The authors wrote that it was clear that the two injuries were similar in how the sensitivity was felt. An interesting finding was that people with more severe pain showed greater levels of central pain processing.

Disability caused by neck pain can be measured using the Neck Disability Index (NDI). In this study, the NDI is translated into the Catalan language and tested with whiplash patients. The goal was to understand how chronic neck pain from a whiplash-associated disorder (WAD) can affect a patient’s life. Secondary goals were to assist in planning treatment and measuring progress over time.

The NDI has been translated into many other languages. It is used primarily to assess disability in patients with neck pain. It has not necessarily been used with patients who have neck pain from a chronic whiplash disorder. The Catalan language is spoken by about nine million people around the world. It is most common in Spain, France, Italy, and Andorra.

A group of 150 whiplash patients from 10 rehab centers in Tarragona were included in this study. Tarragona is a city in the south of Catalonia (Spanish province) by the Mediterranean Sea. Each patient filled out the NDI and the Spanish version of the Beck Depression Inventory (BDI).

The NDI has 10 items that help describe how neck pain affects daily life. These include pain intensity, personal care, lifting, reading, headaches, concentration, work, driving, sleeping, and recreation.

Most of the patients were the drivers who experienced a whiplash injury. Almost three-fourths were women. The direction of the collision was from behind in more than half the cases. Side and front collisions accounted for one-third of the accidents.

Results from the data collected showed that the NDI had a two-factor structure. One subscale contains items that show how pain interferes with a person’s cognitive function. Items that measure concentration and reading are in this category. The second subscale was labeled functional disability. These items measure how much neck pain affects physical activities such as work or lifting.

The authors suggest that the Catalan version of the NDI can be used to measure disability caused by neck pain from a whiplash injury. The two specific scores (subscales) help define areas of concern. With this information, treatment can be directed toward specific disabilities right from the start.

There are some things missing from the NDI for whiplash patients. For example, the effect of whiplash-related pain on sleep, emotions, and coping is not measured by the NDI. It may be necessary to find another way to measure these variables. Future studies are needed to focus on these targeted areas.

Whiplash injuries have been around even before the car was invented. Modern studies are ongoing to find ways to prevent an acute injury from becoming a chronic pain condition. Keeping up with the latest research results is important for healthcare professionals treating these patients.

A group of scientists from the Back Pain Research Group (Australia) have reviewed recent data and findings on the course and prognostic factors of whiplash. They performed a systemic review and meta-analysis of all studies published through April 2007.

Of the thousands of studies done, 67 articles were selected for review. The authors were looking for ways to predict recovery rate following an acute whiplash injury. Alternately stated, they were trying to identify prognostic factors linked with poor recovery.

They chose studies that were of high quality. All studies focused on adults with neck pain present within six weeks of an automobile accident. Outcomes were measured by pain, disability, and recovery rates. Recovery was measured by the Neck Disability Index, pain levels, and asking the patients if they felt all better.

The authors found a wide range of results for rate of recovery. They suggested this was as a result of different ways studies defined, measured, and reported recovery and recovery rates. Overall, it looks like most people get better during the first three months after the accident. If they haven’t improved by then, they are likely to become chronic pain patients.

Many prognostic factors were tested. These included age, gender, initial pain intensity, prior neck pain or headaches, and direction of impact. Other potential factors reviewed included psychologic distress (e.g., depression, anxiety), presence of neurologic symptoms, and social function. Coping strategies, quality of life, and fear avoidance behaviors were also assessed. All together, there were 42 possible factors tested for strength of association with prognosis.

The authors were unable to pin down the most important prognostic indicators of a poor recovery. The studies done had a wide variation in the ways the information was assessed and reported. The best they could tell, high levels of pain right after the accident is an indicator of poor recovery.

Psychologic factors such as anxiety and depression are likely important prognostic factors. Gender (male versus female) did not appear to be a factor. Older age and crash-related factors (direction, speed) were not related to recovery either.

Future studies are needed that consistently use quality methods and techniques of measures. It is advised that researchers use a validated instrument to measure recovery. The Quebec Task Force made this same recommendation more than 10 years ago when they did a systematic review of whiplash. They even listed measurement methods proven to be valid and reliable at that time.

For now, the results of this review suggest it looks like the early recovery period after a whiplash injury is very important. More successful treatment strategies to address this group of patients are needed.

Prevalence of chronic neck pain is thought to be 60 percent in persons five years or longer after an initial episode. Thirty nine to 67 percent of chronic neck pain is thought to be from facet joints. Facet joints are rich with nerves, pain receptors, and mechanoreceptors. Facet joints can also refer pain to the head and upper extremities.

Various techniques have been employed to treat chronic neck pain from facet joint origin. These include intraarticular injections, medial branch blocks, and radiofrequency neurotomy. Reviews of the literature for treatment of cervical facet joint pain show limited evidence for intraarticular injections, moderate evidence for medial branch blocks, and strong evidence for radiofrequency neurotomy.

The authors chose to study the effectiveness of local anesthetic cervical medial branch blocks with and without steroids. Subjects had to have non-specific neck pain of at least six months duration. Diagnosis of facet joint involvement was verified with diagnostic blocks in a two step process.

One hundred twenty subjects were assigned to one of two groups. Each group was further divided into those that received Sarapin mixed in with the injection, and those without. Group one subjects received medial branch blocks with injection of bupivacaine. Group two subjects received medial branch blocks with bupivacaine and betamethasone, a steroid. All medial branch blocks were performed under fluoroscopy. They were repeated based on the response when increased levels of pain were reported by greater than 50 percent, or relief had deteriorated to below 50 percent.

Outcomes were measured using the Numeric Pain Scale, Neck Disability Index, work status, and opioid intake. These were assessed at three months, six months, and twelve months after treatment.

Improvement in the Neck Disability Index was 50 percent or greater in 63 percent of group I, and 68 percent in group II. Of the subjects eligible for employment, total employed changed from ten persons at baseline to 22 at the end of twelve months in group I, and changed from eleven to 18 in group II. Eighty three percent of patients noted significant pain relief at one year after the study. Duration of pain relief per procedure ranged from 14 to 16 weeks. Subjects noted 46-48 weeks of significant pain relief during the twelve month period.

The authors feel that there is equal effectiveness of local anesthetic with or without steroids. There was also equal effectiveness with or without Sarafin. Therefore, they suggest that it is not necessary to add steroids to the anesthetic during cervical medial branch blocks.

There’s an ongoing debate about adjacent segment disease (ASD) after fusion of the cervical spine. ASD refers to the degenerative changes seen in the disc and vertebra at the next spinal level. The changes may not cause painful symptoms but they are visible on X-ray. If asymptomatic, the condition is referred to as adjacent level degeneration. Once symptoms develop, the label changes to ASD.

It’s clear that after fusion, the next vertebral level starts to degenerate, too. The question is: does this happen as a result of changes in force and stress from the fusion? Or would this happen anyway because of the natural progression of degenerative disease?

The answer to these questions is important because disc replacements for the cervical spine are now approved for use by the Food and Drug Administration (FDA). The goal of these implants is to preserve motion, reduce stress, and decrease the chances of developing ASD. But maybe these efforts aren’t needed. Maybe ASD is going to occur no matter what course is taken.

The authors of this review looked at studies on ASD published from 2006 to 2007. They reported the incidence and outcomes of ASD after fusion. And they offer some conclusions on this topic.

Studies report between 25 and 92 per cent of patients with cervical spine fusion develop ASD. That means that at least one in four (and maybe more) are affected by ASD after fusion. But not all patients with ASD require further surgery. And the rates of ASD after fusion aren’t higher than after combined discectomy and fusion or after discectomy alone.

As time goes by, the rate of ASD increases after surgery. This usually happens at an average of seven years. The cause may be altered stress at the disc spaces above and below the fusion level. With a loss of motion at the fused site, increased stress is placed on the next available mobile unit.

What’s the source of this stress? That remains the subject of many studies. Loss of motion at the fused site may transfer load to the adjacent level. Disc replacements may help prevent this from happening by preserving motion at the diseased segment. But some scientists point out that ASD occurs without fusion. This has been observed in patients who have decompressive surgery. In this procedure, bone is removed from around a spinal nerve to take pressure off it and reduce neck pain.

Another possible cause of the stress may be the location of metal plates used to hold the segments in place until fusion takes place. Plate position placed too close to the next disc may create problems.

Researchers have also looked at the possibility of cervical kyphosis creating a problem at the next level after fusion. Kyphosis is a forward curve of the vertebral bones. The position puts increased stress on the anterior (front) portion of the vertebrae. So far, it looks like patients who had kyphosis before the fusion surgery tend to stay stable. It’s the patients who develop new kyphosis after fusion that also go on to develop ASD.

But while some studies conclude that using a disc replacement will prevent ASD, others show mixed results. In some studies, there was no difference in rates of ASD two years after fusion versus after disc replacement. Experts point out that there are various factors that might influence study results. For example, disc replacement doesn’t change the condition of the nearby facet (spinal) joints.

Bone spurs and hypertrophy (thickening) of the articular joint cartilage of the facet joints may alter the biomechanics of the joint. The end-result could also be ASD. And in studies comparing ASD after fusion versus after disc replacement, the presence of pseudoarthrosis may alter the results. Pseudoarthrosis means there’s enough motion at the fused segment to create a false joint.

Right now, after looking at all the data, it appears as though ASD occurs despite newer treatment methods and surgical techniques. It may just be that a disc under stress (for any reason) is going to respond to stress over time with degeneration at the next level. Discs above or below the fused level that are stiff before surgery tend to degenerate faster after surgery.

The answer to what causes ASD will be discovered over time. Long-term studies of artificial disc replacements will show if motion saving implants are the answer. If ASD is really a multifactorial problem, then further steps will be needed to prevent ASD.

The Hoffmann sign is used by examiners assessing patients with symptoms of myelopathy (spinal cord compression). The test is done by quickly snapping or flicking the patient’s middle fingernail. The test is positive for spinal cord compression when the tip of the index finger, ring finger, and/or thumb suddenly flex in response.

But what we don’t know is if a positive sign correlates with the severity of the compression. Is it a better indicator of cervical (neck) myelopathy than some of the other signs such as the Babinski sign. A positive Babinski sign is seen as downward flexion of the big toe and fanning outward of the toes when quick pressure is applied to the bottom of the foot from the heel to the toes.

To answer these and other questions, two groups of neurologic patients were studied. The first group had decompressive surgery for cervical myelopathy. Decompressive procedures remove whatever is pressing on the spinal cord. This could be a thickened ligament, herniated disc, or bone spurs.

The second group came to the clinic because of low back and/or leg pain. They didn’t have any neck apparent problems. Patients in this group were tested using the Hoffmann test. Anyone who had a positive Hoffmann’s sign then had an MRI taken of the cervical spine. The MRI was reviewed for any signs of cord compression.

Both groups were also tested using the modified Japanese Orthopaedic Association (mJOA) scale score. This is a measure of severity of cervical myelopathy based on function. Points are given for ability to eat, walk, and bathroom without difficulty.

Results showed a positive Hoffman sign in 68 per cent of the patients in group one (the surgical group). Only 33 per cent of the same group had a positive Babinski sign. Function measured by the mJOA was higher in patients with a positive Hoffmann sign (compared with patients who had a positive Babinski sign).

Some patients (12 per cent) in group two had a positive Hoffmann sign. In some cases (25 patients) it was unilateral (present only on one side). Less often (11 patients), there was a bilateral Hoffmann sign (present on both sides).

The presence of a positive Hoffmann’s sign in this group may point to the fact that the patient has spinal stenosis. In spinal stenosis, there is a narrowing of the spinal canal, which surrounds the spinal cord. Anything that narrows this space can put pressure on the spinal cord causing myelopathy. Patients with lumbar pain from stenosis often have similar changes in the upper spine that have not been identified yet.

The authors report these results show that the Hoffmann sign is more likely to be positive in patients with less severe neurologic involvement. It is also present more often in patients with cervical myelopathy than the Babinski sign. Bilateral Hoffmann sign in patients with low back pain was strongly linked with unknown compression of the cervical cord.

Therefore the Hoffmann sign is a reliable way to test for early signs of cervical myelopathy. The presence of Hoffmann sign on both sides strongly suggests the presence of spinal cord compression in the cervical spine. This is very helpful information when assessing patients with very few other objective findings.

However, the test is not foolproof because patients who don’t have cervical myelopathy can have a positive Hoffmann sign. A positive Hoffmann sign can be observed in patients with hyperthyroidism, anxiety disorders, and other problems that involve increased deep tendon reflexes.

Sometimes patients with true cervical myelopathy don’t have a positive Hoffman’s sign. Although less reliable early on, when the Babinski test is positive, there is almost always a real neurologic problem.

The authors suggest performing the Hoffmann test on patients with low back and/or leg pain, especially when lumbar spinal stenosis is present. A positive sign on both sides warrants imaging of the cervical spine. Anyone with evidence of cervical cord compression but no outward symptoms should be followed regularly. Routine neurologic exams every six months are advised.

Over the past 10 years, the way whiplash injuries is classified has changed. Chronic tenderness, pain, and stiffness from a whiplash injury is now labeled as a whiplash associated disorder (WAS). There are four grades of WAD based on severity of symptoms.

With Grade I WAD, there are painful symptoms but no objective physical signs of pathology. Patients with Grade II whiplash have painful symptoms and musculoskeletal signs of involvement (e.g., decreased motion). Grade III means there are neurologic changes such as muscle weakness, numbness, or tingling. And Grade IV is used to describe patients with a bone fracture or dislocation.

When examining the neck, the physician must differentiate between upper cervical spine problems and lower cervical spine. Symptoms of whiplash must be distinguished from fibromyalgia and chronic cervical syndrome.

In this study, the authors showed that trigger points of specific muscles in the upper neck point to WAD. Trigger points of the lower neck and upper shoulder are more common in people with fibromyalgia, nontraumatic chronic cervical syndrome, depression, and even in healthy subjects. All five diagnoses were represented among the subjects chosen for participation in this study.

A careful examination of the upper and lower cervical spine was done on each participant. Trigger points of six specific muscles were identified. The six muscles included the semispinalis capitis, trapezius pars descendens, levator scapulae, scalenus medius, sternocleidomastoid, and masseter.

These particular muscles were chosen for testing based on the fact that they are often affected after a whiplash injury. They are all easy to find and palpate. Each one has a specific pattern of referred pain to the head, face, neck, and arms. A physical therapist trained in trigger point exam and manual diagnosis performed all of the exams.

Any signs of tenderness, taut bands, referred pain, or nodules in the muscle belly were reported. The presence of three of these four criteria was judged as a positive trigger point. Other tests were also performed for neck range of motion, posture, and shape and motion of the spinal column.

The authors say they were expecting to see a higher number of trigger points in the semispinalis capitis and masseter muscles in the whiplash group. Results for the whiplash group were compared with the other groups.

Patients with whiplash do show a different distribution of muscle (trigger point) involvement. In particular, the upper neck muscle (semispinalis capitis) was affected in whiplash more than lower neck and shoulder muscles. This is consistent with findings from other studies that show injury at the C1-C2 facet joints after whiplash. The semispinalis attaches at the base of the skull just above C1-C2.

There was no difference in the masseter muscle response among the various groups. This result differs from previous studies that suggest a significant involvement of the masseter muscle in whiplash associated disorders.

Other findings included similar trigger points in other muscles in whiplash, fibromyalgia, and chronic cervical syndrome. Fibromyalgia patients who usually have tender points did have as many trigger points as patients with whiplash and chronic cervical syndrome. For healthy subjects (the control group) and patients with depression, the trapezius muscle was affected most often.

The information gained from this study will help physical therapists and physicians treating patients with WAD. Focus on the muscles of the upper cervical spine (especially semispinalis capitis) may help patients with this condition.

Rheumatoid arthritis often targets the cervical spine. Changes in the structure of the vertebrae can cause significant and dangerous myelopathy (damage to the spinal cord). Surgery may be needed to stabilize the spine and protect the nerve structures. Cervical fusion is a common procedure to accomplish these goals.

One of the problems surgeons run into in this group of patients is a thin column of bone called the pedicle. Fusion with screws through the pedicles can cause problems. If the screw goes all the way through the bone, it can cut into the vertebral artery (VA). And in up to 80 per cent of patients, the VA takes a right-hand turn at the C2 level.

In this study, researchers studied the risk of VA injury with C2 pedicle screw fixation. They used computer assisted three-dimensional (3D) views of the spine to map out the anatomy of this area. Two groups of patients were compared. One group had diagnosed rheumatoid arthritis (RA). The second group (same age and sex) did not have RA.

They found that 60 per cent of the RA group had narrow pedicles. Only 13 per cent of the non-RA group had similar findings. Normally pedicle size depends on body size. But in the RA group, the C2 pedicle was small in men compared to their body size. These results suggest that men with RA who need cervical fusion with pedicle screws are at even greater risk of VA injury than women with the same diagnosis.

And the location of the vertebral artery loop is a major consideration. Care must be taken when the artery travels through the area where the pedicle screw will be placed. Conventional CT scan images may not be enough to guide the surgeon. These authors suggest a 3D approach is needed when planning surgery for RA patients involving pedicle screw fixation of the upper cervical spine.

Whiplash is defined as a sudden extension of the cervical spine (backward movement of the neck) and flexion (forward movement of the neck). Rear-end or side-impact motor vehicle collisions are the number one cause of whiplash with injury. Soft tissues affected can include the muscles, ligaments, tendons, joints, and discs of the cervical spine (neck).

Chronic pain may result from a whiplash injury. This is especially true if the head was turned to the side at the point of impact. Scientists are trying to figure out just what causes this lingering pain for some people.

Animal studies point to a strain on the capsular ligament around the facet joint. There is an electrical response in the facet joint when a mechanical load is applied to the joint. This finding suggests that the capsular ligament has a threshold for pain. This means that pain occurs when the load (strain) placed upon it is above a certain level.

In this study, researchers take a look at human capsular ligaments in cadavers (bodies preserved for study after death). The main interest was in finding out why a head-turned posture during a low-speed crash increases the risk for chronic whiplash pain.

Mechanical testing and motion analysis were performed on 13 cervical spine segments. Special 3-D markers were used on the facet capsular ligament to estimate the amount of strain placed on the ligament. Loads were tested similar to a rear-end impact at eight kilometers per hour (about five miles per hour).

The maximum principal strain (MPS) was measured for each load up to the point of capsular ligament failure. The effects of vertebral motion such as compression, posterior shear, and rotation were also measured. They looked at the distribution of strain in four separate locations of the capsule (top, bottom, front, back).

Most of the strain occurred in the superior (top) and anterior (front) portions of the capsule. The capsule affected was on the same side of the neck toward which the face was turned. The strain on the capsule with the head turned was twice what it was with the head face forward at the point of impact.

When shear forces were added, strain on the same area of the capsule increased even more. Even before shear loads were applied, there was a large increase in strain on the capsule with the head turned. During the tests, 15 per cent of the specimens failed under the strain.

With the head in just the right position and with just the right amount of force, the ligament tensile strength may be overcome by the load. The result is injury to the ligamentous capsule. When the face is turned to the right, the right capsular facet is affected. When the face is turned to the left, the left side is injured.

The authors are still wondering why don’t the high strains placed on the facet capsule during normal head turning cause injury. They suggest that maybe the capsule’s shape and give (slack) during normal motion is enough to allow natural head turning without maximal strain. Perhaps the added strain of a whiplash-load is just enough to overload the ligament causing tissue failure.

It’s likely that there are other explanations as well. The capsular ligament may have different mechanical tolerances at different locations within the ligament. So for example, multiaxial loads may affect the top front portion of the capsule more than the lower bottom half.

The authors suggest ways to continue testing capsular strain during whiplash injury. This first study only begins to scratch the surface of this topic. Other types of load must be examined. Results may differ between males and females. Results may vary with different speeds. And it will be important to figure out why some specimens failed but others didn’t.

The authors retrospectively studied 200 subjects that underwent anterior cervical discectomy, ACDF, and fusion with the use of recombinant human bone morphogenetic protein-2 (rhBMP-2). This is an osteoinductive protein that is placed at the fusion site in a sponge. The Federal Drug Administration has approved rhBMP-2 for use in lumbar spine fusion. It has been found to reduce time in surgery, blood loss, and shorten hospital stay. It also avoids the need to harvest bone from the iliac crest, or use bone from cadaver. The authors used this protein off-label in the cervical spine. Complications, particularly hematoma and cervical swelling have been as high as 27.5 percent in reports using rhBMP-2 in the cervical spine.

Of the 200 subjects studied, 193 were included in the study. Ninety six of the subjects had single level ACDF, 62 had two level fusions, 36 had three level fusions, and six had four level fusions. The authors rated outcomes as good to excellent in 85 percent of the subjects, fair in 12.4 percent, and poor in two percent of the subjects. All of the subjects had solid fusions, verified with dynamic X-rays and computed tomography, CT, scans.

These subjects were divided into three groups, those with a total dose of 21 mg of rhBMP-2 per level, those with 1.05mg per level, and those with 0.7 mg per level. Sponges were soaked in the rhBMP-2. In all the subjects the rhBMP-2 soaked sponge was placed within a polyetheretherketone (PEEK) spacer. No sponges were placed outside the PEEK spacer.The authors did not feel that there was a significant difference in complication rate between the three groups. Other surgeons have opted to place the rhBMP-2 on the exterior of the graft or use cages for grafts, rather than PEEK spacers. The authors concluded that rhBMP-2 in the anterior spine is likely related to an increased rate of significant swelling when used in the cervical spine.

The authors reported complications in seven percent of their patients. This is significantly fewer than previous reports. Only two percent required repeat surgery due to hematoma or seroma. Eleven percent of subjects experienced dysphagia. Multi-level ACDF tended to be a risk factor for greater incidence of dysphagia, and more severe dysphagia. The authors noted that the rate of clinically significant dysphagia in one and two level ACDF with low dose rhBMP-2 is similar to the rate of dysphagia seen in ACDF without rhBMP-2. However, with three and four level fusions, the total amount of rhBMP-2 exceeded 3mg, and the dysphagia rate was increased.

The addition of rhBMP-2 may raise the cost of operation significantly. However, it appears to reduce the risk of pseudoarthrosis compared to allograft fusion, particularly in smokers and those with osteoporosis. Complication rate when using fhBMP-2 was similar to other surgical procedures when it is placed within a PEEK spacer.

Since magnetic resonance imaging is able to detect small syrinx cavities in patients, it is important to be able to determine the presence and degree of deficits caused by the syrinx. Whether or not to proceed with surgery can be a difficult decision. The authors sought to determine what electrophysiological testing could be used to better evaluate the degree of neurological deficits in syringomyelia. The authors studied 37 patients with known syringomyelia, and 28 healthy controls.

Symptoms among the study subjects included protopathic pain, hypesthesia, spinal ataxia, paresis, headaches, autonomic dysfunction, secondary scoliosis, and swallowing difficulties. Pain and change in sensation are first recognized with syrinx. Neurological deficits are usually slower in onset.

Somatosensory evoked potential (SSEP) and motor evoked potential (MEP) recordings were done on all subjects. This testing monitors nerve fiber integrity of the corticospinal tract. The authors also evaluated silent period testing which evaluates integrity of the spinothalamic tract fibers. The spinothalamic tract fibers lie closer to the inside of the neural tube. This is the area where syringomyelia are found.

The silent period is evaluated by measuring the electrical activity of slow conducting larger nerve fibers after repeated cutaneous stimulation of small sensory fibers. Early onset, as well as long duration of the silent period was considered to be a physiological change seen in the population of patients with syringomyelia.

The authors concluded that silent periods were more sensitive than SSEPs and MEPs in detecting abnormalities in the spine due to syringomyelia. This could be helpful in making the decision for surgery.

Many people with neck pain seek help from chiropractors. Chiropractic care may vary depending on the underlying problem. Applying the right treatment for each patient is every chiropractor’s goal.

In this study, chiropractors from The Netherlands try to find ways to tell which neck pain patients will respond to their care. They evaluated 29 possible factors that might predict treatment results. Each patient answered a series of questions before, during, and after treatment. They were followed for up to 12 months.

Some of these patient characteristics included age, general health, level of education, gender, and working status. Questions were also asked about other symptoms, medication used, prior episodes of neck pain, and workers’ comp or sick-leave status. Fear or apprehension about treatment was also measured.

Over 500 patients participated in the study. As a group, the patients were mostly middle-aged women with a high school degree. They were employed, reported chronic neck pain that comes and goes, and were pretty healthy overall. Many reported other symptoms such as headaches, confusion, ringing in the ears, and fatigue or dizziness.

Not all the patients were treated in the same way. Each chiropractor involved in the study determined what type of treatment to give. The number of sessions was also left up to the chiropractor.

Other studies have shown which factors can predict a poor outcome (negative predictors). This study focused on positive prognostic factors. In other words, which clinical and/or social variables point to a good result with chiropractic care for neck pain?

The authors report the shorter duration of painful symptoms was the best predictor of overall beneficial effect of treatment. The sooner patients came in for treatment, the more likely they would receive benefit. On the other hand, the longer patients waited to receive treatment, the more likely it was that he or she would have a poor outcome.

They also found that patients who weren’t on sick leave or workers’ comp had better results. So did patients with a higher level of education and less fear or anxiety about the treatment. In fact, patients who expected to get better were more likely to improve with chiropractic care. Patients who didn’t have pain in the morning were also more likely to have a favorable outcome.

This study showed that chiropractors can tell during the first patient appointment whether improvement or recovery is possible with chiropractic care. There are both positive and negative predictive factors that can be reviewed before planning the specific treatment.

Neck pain and pain across the top of the shoulder is called trapezius myalgia. Myalgia simply means muscle pain. The upper trapezius muscle (the one that shrugs the shoulders) is involved. The problem is common in women who are office workers.

Studies have shown that strengthening painful muscles helps relieve muscular pain. In this study, the level of muscle activation of the upper trapezius was measured for five selected (commonly used) exercises for chronic neck pain. Surface electromyography (EMG) was used to measure activation level of neck and shoulder muscles. Exercises included shoulder shrugs, one-arm rows, upright rows, reverse flys, and lateral (arm) raises.

The trapezius muscle was most active during shrugs and lateral raises. The other exercises were not as effective. But they were able to challenge the trapezius muscle at a level that would increase strength. These findings were important for two reasons. First, the study showed that a broad range of exercises can be used to strengthen the trapezius. This is important in the rehab treatment program for trapezius myalgia.

Second, for patients with poor grip strength, holding weights during shoulder shrugs can be difficult. This study showed that there is an alternate exercise that works just as well. Lateral raises along with the other exercises can also be used for patients with back pain who can’t hold the weight needed to resist the trapezius muscle during shoulder shrugs.

The researchers also found that shoulder shrugs can replace lateral raises and upright row exercises. This will be useful information for physical therapists. Shoulder shrugs can be used with patients who have good grip strength but rotator cuff (shoulder) problems along with chronic neck pain from trapezius myalgia.

A 51-year old patient with chronic neck pain and clunking sensation went to see a physical therapist for treatment. She reported a history of two car accidents. She was rear-ended in both accidents. The second time she had her head turned to one side at the time of the impact.

The therapist performed an exam of motion and found her active neck motion very reduced. The clunking was present during active movement. It was also reproduced during testing of the alar ligament. The patient also reported dizziness, unsteadiness, fatigue, and anxiety.

The alar ligament attaches the skull to the first vertebra (C1). Its short, tough fibers keep the head from sliding too far to one side when the head is turned. Whiplash injury can cause overstretching and even rupture of this ligament. This is especially true when the face is turned to one side when the impact occurs.

Previous standard X-rays had been taken and reported as “unremarkable”. The therapist suggested MRI to examine the neck for upper cervical ligamentous disruption. The MRI showed a grade II left alar ligament disruption. The patient was referred to a neurosurgeon for a treatment plan.

Surgery was not recommended because of the risk from surgical fixation to repair the problem. The patient returned to physical therapy for treatment to stabilize the cervical spine. Care was taken to prevent further disruption of the C1 segment.

After 16 weeks, the patient was able to complete all daily activities. The clunking was much better and she reported less pain and less fatigue.

There are two different commonly used surgical procedures for cervical fusion. The older method was developed in the 1950s and involves fusion from the front of the neck. This is called anterior cervical discectomy and fusion (ACDF). Most surgeons have advocated the use of a rigid collar after fusion without instrumentation. Problems associated with this surgical procedure include graft migration and nonunion. Because of these problems, some surgeons opted to perform anterior fusion with additional fixation using a plate. One of the advantages of fixation with instrumentation is that it usually eliminates the need for a rigid neck collar during the post-operative period.

The authors studied 170 patients that were able to be contacted following single-level anterior cervical fusion. The surgeon used cadaver bone graft material for the fusion. Patients were offered the option of wearing a soft cervical collar for comfort. The use of rigid cervical collar was not used Patients were encouraged to resume normal activities as soon as tolerated after surgery.

Fusion rate was determined using postoperative flexion and extension films at 12 months following surgery. Focal and segmental alignment and disc space height was evaluated using lateral Xrays.

The authors report a fusion rate of 94 percent and favorable neurological outcomes in 96 percent of patients. These outcomes are felt to be similar to those following ACDF with plate instrumentation. The authors feel that ACDF without instrumentation and without the use of a postoperative collar is feasible in treating cervical spondylosis.

Although rare, a herniated disc can cause paralysis on one side of the body. The condition is called the Brown-Séquard syndrome. This is a case report of such an incident. Only 25 total cases have ever been reported.

The Brown-Séquard syndrome was first described by Dr. Charles E. Brown-Séquard back in the 1840s. It’s caused by compression of one side of the spinal cord. The affected individual develops paralysis on one side of the body with pain and loss of sensation on the other side of the body. The symptoms develop as a result of the pressure placed on a specific area of the spinal cord.

In this case, an otherwise healthy 46-year old man developed symptoms of Brown-Séquard syndrome. A CT scan and an MRI were done showing a large disc herniation in the cervical (neck) spine. The entire left side of the spinal cord was impinged by the disc material.

The patient had neck pain, left arm numbness and weakness, right upper leg weakness, and decreased sensation on the right side of the chest and belly. Since there was no known trauma, arthritis, or history to explain the symptoms, the imaging tests were done.

Microsurgery was done immediately to remove the disc and fuse the spinal segment. The patient was put in a rigid cervical collar called a Philadelphia collar for eight weeks. Results were good with elimination of pain and restoration of sensory function. At the end of a month, there was still some mild motor loss present in the left arm and leg.

This case report demonstrated the importance of a rapid diagnosis and treatment when unusual neurologic symptoms develop. MRI was very instrumental in making the diagnosis quickly. Spinal cord decompression gave favorable results. Although the problem is rare, surgeons should be aware that central disc protrusion in the cervical spine is a possible cause of Brown-Séquard syndrome.

The authors reviewed 45 articles and one textbook while conducting a literature review of cervical facet joint dysfunction. Cervical facet joints are joints that are formed by processes that extend from the bottom of the vertebral bone above with processes that extend from the upper portion of the vertebral bone below. They are surrounded by a fibrous capsule, are lined by synovial membranes, and contain articular cartilage and menisci. Cervical facet joint pain is generally from trauma, or degenerative changes.

Prevalence of cervical facet joint pain ranges from 25 percent to 66 percent based on diagnosis using two medial branch blocks, MBB. The first MBB is done with short-acting local anesthetic, and the second with long-acting anesthetic. Those who had a longer duration of pain relief with the long-acting anesthetic were considered being positive for facet joint dysfunction. While some researchers feel that diagnosis can be made based on physical examination, particularly by a skilled manipulative therapist, the research is not consistent.

Cervical facet syndrome is difficult to diagnose as symptoms are similar to those with spinal stenosis, cervical strain, and diskogenic pain. Cervical facet joint pain can radiate to the base of the skull, upper back and shoulders, or midback. Ten regions of referred pain from the facet joints in the cervical spine have been identified by one of the researchers are similar to results of other studies.

Imaging studies that are used to assist in the diagnosis of cervical facet joint pain usually begin with plain radiographs. Flexion and extension films to detect instability, and open mouth view to detect dens fracture are recommended. Advanced imaging such as computed tomography and magnetic resonance imaging can also be used to diagnose facet joint pain. One study showed that degenerative changes in the cervical spine found on advanced imaging were asymptomatic 75 percent of the time in patients in their seventh decade. Therefore, findings on imaging studies need to be considered based on the patient history, physical exam, and symptoms. Single-photon emission tomography, SPECT scan, while currently not recommended, may help determine which patients are good candidates for intra-articular facet joint injections. Some studies demonstrate that those patients with a positive SPECT scan were more likely to have significant improvement in pain and function short-term and long-term following facet injection. Also, fewer facets were injected, reducing the cost to the patient.

No studies were found that analyzed the benefit of conservative care such as medication, physical therapy, heat or cold, or spinal manipulation in the management of cervical facet dysfunction specifically. Cervical facet injections to include intra-articular blocks or medial branch blocks show conflicting benefit. The studies involving radio-frequency neurotomy are limited, but show that it can provide pain relief from cervical facet joint dysfunction for several months.

There are likely many factors that might contribute to the development of late whiplash syndrome, LWS. Age, gender, initial pain intensity, collision characteristics, and psychological factors have all been studied. The authors chose to evaluate available literature on the potential role of psychological aspects in the development of LWS.

The authors reviewed available literature to assess the role of psychological factors in the development of LWS. Twenty-five articles were included. Fourteen of the articles were rated as low quality, and 11 were rated as adequate quality. Data on 21 psychological risk factors were included.

Some of the psychological risk factors included coping, presence of previous psychological problems, personality traits, distress, catastrophising, fear-avoidance, self-efficacy, wellbeing, and psychosocial work factors.

The authors concluded that no association was found, or there was limited or inconclusive evidence to support the role of psychological factors in the development of LWS. They feel that there is a great need for rigorous and well-designed research in this area.

A sudden or traumatic blow to the base of the skull or upper neck can result in a shear force that fractures the odontoid process. The odontoid process is a peg-like structure of bone that’s part of the C2 vertebra. It sticks up inside the C1 vertebra, which is shaped like an open ring.

When the odontoid process breaks, there’s nothing to keep the C1 ring-shaped vertebra from sliding forward or back. This type of movement causes excessive load and pressure to the spinal cord. The result can be serious neurologic damage, including paralysis.

One serious complication to injury of the upper cervical spine can is a nonunion fracture of the odontoid fracture. This means that despite treatment, the fracture doesn’t heal. Severe motion pain and instability of the cervical spine occur. Surgical fusion with screws, wires, and bone graft may be required.

In this study, surgeons from Vienna, Austria report the long-term results of C1-2 fusion in nine patients with nonunion odontoid fractures. Another term for fusion is arthrodesis. The authors described the surgical procedure used with each patient. The posterior approach (from behind the neck) was used in all cases.

Radiographs (X-rays) and CT scans were used to evaluate the results. Radiographs of the neck during flexion and extension movement were taken three and 12 months after the operation. Imaging like this can be used to find out how solid the fusion is. Movement at the fusion site can be seen if present.

The final results showed that all nine patients had good fusion with improved symptoms and neurologic function. There were a few problems getting good fixation with the screws but these were corrected. After one full year, patients were able to return to their preinjury level of activities and were satisfied with the results.