News Category: Cervical Spine

When it comes to finding out what causes late whiplash syndrome (LWS), researchers have come up empty handed. A group of social scientists reviewed all the studies they could find on LWS. They were looking for psychologic risk factors that might predict who develops this condition.

Of the 25 articles already published, 14 were rated as low quality. There
was poor consistency from one article to another. It wasn’t possible to combine the data together for a better analysis. Most of what was reported was inconclusive.

Of the 21 possible psychologic risk factors, there was some (limited) evidence pointing to two potential factors. These included low self-efficacy (belief you can do something) and post-traumatic distress. Both were mildly predictive of chronic painful symptoms months after a whiplash injury.

Personality traits, stress unrelated to the injury, cognitive function, and stress in response to the injury did not appear to be linked with LWS. Previous history of neck pain may influence perception of pain. And older age may affect the ability to recover from neck pain.

The authors suggest better quality research is needed in this area. Finding prognostic factors could help screen for patients at risk for LWS. If the risk factors can be changed or modified in any way, prevention programs might reduce the number of LWS cases.

Scientists, doctors, and therapists are struggling to find reliable and predictable ways to treat neck pain. Researchers want a model that can be tested and reported on. They want to find out what works and what doesn’t.

Toward that end, the World Health Organization’s (WHO) Task Force on Neck Pain has come up with a new model for neck pain. The committee members of this task force met 18 times with many phone calls in-between over a period of six years. The result was a model for the classification of patients with neck pain.

The authors of this article review and summarize this new model. The first part of the model gives us a clear picture of the anatomic area considered as the neck. Diagrams with areas shaded in gray guide our understanding of who should be in these groups.

Members of the Task Force agreed that neck pain isn’t a single event with a permanent solution. Neck pain is best understood if viewed as a condition that can come and go over time. Many personal and environmental (outside) factors influence when and how this happens.

These can include genetic traits, age, social, and economic factors. There can also be health, workplace, and cultural issues at play. Research is needed to pinpoint which factors are likely to affect treatment for each patient or for groups of patients. The goal is to find modifiable (changeable) factors that can be altered to prevent neck pain or to reduce pain and disability when recovering from neck pain.

The next step is to classify patients in a way that helps guide management. In this model, a four-grade subgrouping is proposed for all types of neck pain. This model is based on neck pain severity. It includes traumatic and nontraumatic causes of neck pain. The key difference among the groups is whether or not the pain interferes with daily function.

For research purposes, patients are also viewed according to settings. These settings are broken down into work setting (sports, general, specific occupation), health care setting (emergency room, walk-in clinic, primary care doctor), and type of claim (insurance, worker’s compensation, personal injury).

Classification can also be done according to duration (how long the symptoms have been present) and the pattern of neck pain over time. Some of the categories include single episode (no previous neck pain), recurrent episode (recovery in-between), and persistent (no recovery).

This new model will help health care providers and patients measure short- and long-term outcomes of various treatment methods used for neck pain. There are benefits of this model for patients, clinicians, and policy makers. They may help guide us in providing more effective care for patients with neck pain.

The World Health Organization (WHO) keeps a close eye on health concerns around the globe. Epidemiologists (people who study statistics and trends) from the WHO have alerted us to the increasing number of musculoskeletal disorders in adults.

Rising rates of joint diseases, back pain, and bone fractures was just one of the concerns. Disability due to high-intensity neck pain was another. In January 2000, they set up a special program called the Bone and Joint Decade. This program was designed to focus worldwide attention on musculoskeletal problems.

The decade is almost over, so it’s time to take a look at what’s happening. To this end, the WHO put together a special Bone and Joint Decade Task Force on Neck Pain. More than 50 experts from nine countries were involved in reviewing the evidence gathered so far. Eight universities and 14 different clinical and scientific groups were on the committee.

The Task Force reviewed all the studies published on neck pain and disorders linked with neck pain. This entire supplemental issue of the Spine journal is devoted to summarizing their findings. There are chapters on risk factors for neck pain, diagnosis and treatment, and prognosis. Treatment includes conservative (nonoperative) and invasive (surgical) care.

With the vast number of people affected by this problem, prevention has become a new focus. In particular, there is a search on for cost-effective prevention and treatment. The importance of patient education and participation must not be forgotten. More research is needed to understand musculoskeletal disorders to help in these efforts.

In this article, a Task Force reports on its findings from an extensive review of studies involving whiplash-associated disorder (WAD). The course of recovery and expectations for recovery are reviewed. Factors that predict who will recovery quickly and who will have a delayed recovery are also presented.

Studies that sort out prognostic factors for recovery can be very helpful. If factors are present that will delay healing and return to normal function, then maybe it may be possible to prevent a poor or prolonged recovery. The results of these studies help in planning effective treatment and health care policies related to WAD.

The authors report that collision factors don’t seem to be the reason patients fail to recover after WAD. Collision factors refer to the position of the patient in the car at the time of the accident. It doesn’t seem to matter if the face is straight ahead or turned at the time of the impact. Likewise, use of the headrest and type of headrest wasn’t significant.

Many people in the general population report neck pain at some time in their life. Half of all patients with WAD still have neck symptoms a year after their injury. It’s possible that these neck symptoms aren’t related to the injury but just a reflection of neck pain that would have occurred without the injury.

There is a wide range of age, gender, and health at the time of accidents or injuries leading to WAD. Studies reported various results linking these factors to final outcomes or showing no relationship at all. As a result, no firm conclusions were made.

More severe whiplash injuries with greater symptom intensity do predict a longer course of recovery. The best evidence points to the fact that recovery from WAD is multifactorial. In other words, it’s likely that each patient has a different group of factors affecting their healing and recovery. Course and prognosis can be predicted for some, but not all, patients.

Is there an exercise program that would help patients for the same cost (or less) than usual physical therapy care? A group of researchers from the Netherlands say No — at least for the group of patients used in this study and with the type of program prescribed.

Two groups of low back pain (LBP) patients were included. One group received usual care with a physical therapist. The second group received intensive training with exercise, back school, and behavioral principles. Both programs were supervised by a physical therapist. Everyone in the study was followed for a full year.

Results were measured on the basis of pain, function, and quality of life. Direct and indirect costs were totaled up for both groups as well. Work absenteeism and the cost of health care were part of the cost analysis. Health care included medications, visits to traditional or alternative specialists, and the intervention groups used in this study. The health care costs were labeled as resource-use.

There was no difference in total costs between the two groups. Direct training costs were higher in the intensive training group. This was related to two factors: 1) the cost of the intervention, which included 10 individual sessions and 20 group sessions with the therapist. 2) Patients in the intensive training program used more alternative resources while waiting for their training group to start up.

The authors conclude that there weren’t enough cost savings to recommend the intensive training program with all LBP patients. This is not to say that the program shouldn’t be used wherever it is already in place. There may be some work settings where the cost savings in reduced worker absenteeism outweigh the cost of the program.

Getting started with this type of training program right away and following it more closely might also make a decided difference in cost savings. More study is needed to understand all the economic factors in treating chronic LBP.

If you are suffering from chronic neck pain, there are many treatment approaches to choose from. There are medications to relieve pain, exercise, heat, electrical stimulation, and collars. Physical therapists and chiropractors offer manual therapy (joint mobilization and manipulation). And there’s acupuncture, laser and magnetic therapy, or a combination of any of these methods just listed.

Which one works best? Which combination is the most effective? Patients rely on their doctor to guide them. But how does a doctor decide? Researchers conduct a best evidence review of all the articles published on a topic such as neck pain. They summarize the data and offer conclusions and guidelines.

Physicians and other health care providers depend on systematic reviews such as this one. They look for advice on best practice. They are especially interested in cost and cost-benefit when helping prevent and manage conditions such as neck pain.

The authors of this review looked at all the articles on the course and care of neck pain published between 1980 and 2006. Treatment was always conservative. This means it was noninvasive (did not involve injections or surgery). Here are a few of their key findings:

Diagnosing the cause of neck pain can be a difficult and expensive process. There are many tests and procedures that can be done. Doctors need to know what tests to use with each type of neck pain patient.

A large group of doctors, physical therapists, chiropractors, and other health care specialists were part of a committee to conduct a systematic review of neck pain assessment. The focus was on diagnostic tests to use. Surveys used for self-reported disability assessment were also reviewed.

A systematic review is very helpful to doctors and other clinicians. It gives them a summary of the important findings of all the quality studies published. It saves them time and helps them find out which recommendations are evidence-based and worth paying attention to.

The committee carefully reviewed 95 articles on diagnosis of neck pain. Test research in each paper was evaluated for usefulness, validity (accuracy), and reliability. After presenting the present clinical practice used in diagnosing neck pain, current research results were offered.

Emergency and nonemergency situations were included. Assessment of emergency patients must include ruling out bone fracture, dislocation, and/or spinal cord injury. Immediate imaging studies are used more often in emergency cases than in nonemergency care.

Nonemergency neck pain patients are examined for motion, strength, trigger points, and function. A careful patient history is also taken. Blood testing, electrodiagnostic testing such as electromyography (EMG), and imaging studies may be ordered for some patients. A review of each testing procedure was provided.

The authors list evidence-based statements for the screening of emergency neck patients. There is strong evidence that using a standard screening protocol is a good idea. It alerts the doctor when there is a high risk of cervical spine fracture. It’s less likely that a serious injury will be missed when using a screening protocol. Findings regarding the use of X-rays, MRIs, and other imaging studies were also presented.

A list of findings for clinical assessment of the nonemergency neck pain patients was also presented. Again, these suggestions are based on the best evidence found after doing a systematic review. The authors report how much evidence was found for each one (e.g., none, limited, some, and consistent evidence).

The committee concluded that tests should only be used when they have been proven to be accurate. Doctors should know what are the benefits and limits of each test used in the diagnosis of neck pain. There is a great need for further studies to establish the reliability, utility, and validity of many test procedures used when diagnosing patients with neck pain.

When conservative care doesn’t help with neck pain, then doctors and patients may turn to injections or surgery. But no one wants invasive treatment if it’s not going to help. It’s best to know what type of surgery to perform and when to do it.

In this review article, the authors answer these questions and summarize findings on both types of treatment. A committee of medical doctors, chiropractors, and physical therapists studied the results of over 1200 studies on the treatment of neck pain by surgery or injections. Only high-quality, scientific studies were included in the review.

All studies included patients with common kinds of neck pain and/or neck and arm pain. Anyone with structural problems such as dislocation, infections, or tumors was not included. Some patients had disc problems or ligament tears, but most had no obvious cause for their neck pain.

Treatments studied included steroid injection, radiofrequency neurotomy, and surgery. Methods of surgery included percutaneous (through the skin) or open (with incision). Decompression, fusion, and disc replacements were the most commonly studied types of surgery. Complications from each type of treatment were described. These ranged from allergic reactions and infections to serious spinal cord or brain injury.

Evidence from the research does not support the use of steroid injections into the facet (spinal) joints for neck pain. Neurotomy may be helpful but there were no studies with high enough quality to report the results from. Neck pain alone (without arm pain) should not be treated with anterior cervical fusion or artificial disc replacement.

There was some indication that steroid injections of the nerve root or into the epidural space are helpful in the short-term. But these injections did not prevent patients from ending up with open surgery. Surgery may help improve pain but doesn’t always restore function. And surgery is not recommended for ligamentous damage after a whiplash injury.

Future studies should focus on minimal acceptable outcomes. This means finding out (before surgery) what the patients consider is the minimum improvement in pain, medication-use, and recovery after surgery to make it worthwhile.

This research committee also made some recommendations for future studies. Cases series of common procedures and small trials are not advised. Studies should have high quality design, standardization across studies (measure and report the same way for similar patients), and report early and late results. Patient satisfaction should be assessed rather than the surgeon’s subjective report of results.

The standard treatment approach to nonspecific neck pain is with the use of nonsteroidal antiinflammatory drugs (NSAIDs). Hands-on care such as chiropractic or physical therapy manual therapy (joint mobilization and/or manipulation) is a close second. Exercise is always suggested as well.

Despite all the research that’s been done on specific treatments for neck pain, it’s still not clear which one is best. It may depend on the patient’s goals. Is it strictly pain relief? Pain relief and improved neck motion? Or perhaps the goal is to return to full function that was present before the episode of neck pain started.

Each method of treatment has its benefits and harms. Patient satisfaction and quality of life should be considered. In this study, results from five different types of treatment were evaluated. The main measure was the effect of treatment on changes in life expectancy and quality.

Patients receiving care for neck pain from a physician, physical therapist, or chiropractor were divided into five treatment groups. Treatments included NSAIDs, selective Cox-2 inhibiting NSAIDs (Coxibs), exercise, manipulation, and mobilization.

The harm and benefit of each treatment approach were reviewed for each patient. A decision-making model was used to track patients over a full year’s time. The data was broken down into 13 four-week cycles.

The authors used information from other studies to calculate the risk of adverse events for these patients. The specific studies and measures were explained. Rates of hospitalization for heart attacks and serious GI bleeding, heart failure, and stroke were reported. These problems occurred as a result of taking NSAIDs.

The authors found there were no risks of harm in doing exercises or receiving joint mobilization. Mortality (death) and life expectancy did not change with these two treatments. There was a small risk of decreased life expectancy with NSAIDs and manipulation.

Using quality of life and life expectancy as the measures of outcome, there was no difference in effectiveness of the five treatments discussed. The authors could not recommend one single treatment above the others for the treatment of nonspecific neck pain. Patient attitudes and preferences should be taken into consideration when deciding on the best treatment approach.

Neck pain that doesn’t go away can be very disabling. Understanding causes, risk factors, natural course, and prognosis of chronic neck pain can help direct treatment.

The World Health Organization’s (WHO) Task Force on Neck Pain has spent the last five years screening 31,000 journal titles and reviewing 1,200 articles to bring us the most up-to-date opinions on the prevention, diagnosis, and treatment of neck pain.

In this executive summary, the authors provide us with a bulleted list of key findings from the Task Force. They review the results of new research and present a new model for classifying neck pain.

There are many factors that impact patients with neck pain. Some may be preventable, others can be modified (changed), and the rest are unmodifiable (can’t be changed). Treatment to reduce pain and disability and return workers to the job place has varying results.

Analyzing all these factors may help us find better ways to prevent and treat neck pain. For example, age, gender, and genetics as contributing factors can’t be changed. But exposure to tobacco products and level of physical activity and exercise can be modified. And making positive changes in either of these categories has been shown to make a difference.

Workplace stresses, repetitive motions, and sitting for long periods at a desk or in front of a computer also contribute to neck pain. But changes in these risk factors don’t seem to reduce neck pain in workers. On the other hand, lack of insurance for neck pain and suffering from whiplash injury is linked with faster recovery and improved outcomes.

It’s safe to say that most patients with neck pain don’t ever get 100 per cent better. Up to 85 per cent still have neck pain five years later. Older age, poor health, and a previous history of neck pain are negative risk factors for prognosis. This means patients with these risk factors aren’t as likely to get better compared with younger patients in good health with no previous history of neck pain.

If would be helpful if workplaces, insurance companies, and patients understood the likelihood of chronic pain from neck injuries. Changes in expected recovery rates and outcomes are needed along with more effective treatment for these conditions.

Classifying neck pain by severity of symptoms and function may help us in choosing treatments that are effective and measurable. Patient’s personal preferences should always be considered when choosing treatment options with potential adverse side effects.

The ultimate goal is to prevent neck pain. When it does occur, then reducing disability is the next step.

Studies show that the number of people affected by neck pain every year is on the rise. Health care providers want to offer the best treatment for each condition. But how do doctors keep up with current ideas and information for this condition?

In this article, members of the Task Force on Neck Pain and its Associated Disorders tell us the process by which they came up with the best evidence for treatment of neck pain. They used asystematic review as their basic approach.

A systematic review means the Task Force looked for studies on neck pain and then summarized their results. Over a period of six years, the Task Force found over 31,000 citations (mentions) of articles about neck pain. Only 1,200 were considered relevant for the first step of this review. After looking them over more carefully, 552 were included in the best-evidence category.

A similar systematic review was done in 1995 but it was just related to whiplash injuries. This new review included neck pain in anyone from any traumatic, occupational, or other work-related causes. Anytime a first systematic review is published, it’s considered a baseline. This means it’s a place to start. Future studies can be compared to the baseline to look for changes.

The purpose of such studies is to publish guidelines for everyone to follow when treating patients with neck pain. The hope is that these recommendations will lead to more effective prevention and management of neck pain. Meeting these goals would also reduce the financial, social, and emotional cost of neck pain to society.

The Task Force on Neck Pain was made up of a large group (over 50 people) from around the world. Scientists, clinicians, and other experts to guide the process were included. There was an Advisory Committee to keep the process going and on track.

A list of questions was decided upon and used when reviewing each article. For example, who gets neck pain? What is the risk for work-related strains or injuries? What determines who gets better and who doesn’t? What evidence is there that a specific treatment was successful? What’s the best way to evaluate or diagnose neck pain?

Studies were included if there were more than 20 human subjects with neck pain. Cases of neck pain from a serious medical problem such as infection, fracture, or tumor were not included. Each one had to be published in English, French, and Swedish sometime after 1980. Opinion articles, letters to the editor, and studies that didn’t have proper reporting or data were not included.

A critical review of the included studies also focused on the study design, how the study was conducted, how the data was collected and analyzed, and follow-up rates. The study was not included if it was not consistent with best research practices.

The final results were published in a series of nine topic-specific reviews in this edition of the Spine journal. Clinical and research implications of the evidence are presented whenever possible.

People who experience whiplash, an injury caused by a sudden jerking movement of the head – usually the result of a motor vehicle accident – can go on to experience persistent pain and disability. This can happen in up to 40 percent of people with whiplash. The disorders caused by whiplash are grouped into Whiplash-associated disorders, or WAD. These include hypersensitivity (too strong) reaction to stimulation, either mechanical (touch), thermal (heat or cold), and/or electrical.

It has long been thought that psychological distress affects the amount of pain and the persistence of pain among patients with whiplash.

The authors of this study wanted to investigate the how psychological factors can affect the responses to stimuli. To evaluate the responses, researchers recruited 33 patients, 23 of whom were women, who had had neck pain for a minimum of 3 months, as the result of a motor vehicle accident. The patients’ average age was 37.7 months. This group was compared with a control group (no neck pain) of 32 subjects.

To assess the subjects, the researchers used the Neck Disability Index (NDI) so the patients could measure self-perceived pain and disability associated with their neck pain, the Visual Analog Scale (VAS) so the patients could rate their pain scales on a level of 0 to 10, with 10 being the worst imaginable, the General Health Questionnaire-28 (GHQ-28) to measure emotional distress, and the Pain Catastrophizing Scale (PCS).The researchers also measured the pressure pain thresholds and heat pain thresholds.

Five subjects – 3 from the whiplash group and 2 from the control group – complained of severe pain at a rate of 8 out of 10 without stimulation, so they were not included in the results, leaving a total of 30 patients in the whiplash group and 30 in the control group.

In comparing the subjects’ results, the researchers noted that there was no difference between the two groups when looking at the right and left sides, so the results were pooled together,left and right.

The researchers found that the subjects in the whiplash group had lower pain thresholds in tolerance to cold than did those in the control group. However, the whiplash group also had a higher level of psychological distress when measured through the questionnaires. In other areas, there were no differences between either group with the heat pain threshold, for example.

The authors conclude that although catastrophization among the whiplash group did result in a hypersensitivity to cold stimuli, it did not seem to have an effect on the other forms of stimuli. Therefore, the authors write, although psychological distress may play a role in some physical distress, it is not necessarily one of the main causes of pain.

Myofascial pain syndrome (MPS) is a common cause of neck and back pain. In this condition, tight muscles with increased tone or tension result in trigger points (TrPs).

Trigger points are defined as tender points in the muscle that trigger or set off a pain pattern in the affected area. This could be anywhere in the body including the neck and back.

In this study, scientists at Stanford University report on the use of botulinum toxin type A (BTX-A). Another well-known name for botulinum toxin is BOTOX. Patients in this study had neck and upper back pain from MPS.

Two groups of patients with MPS were compared. The treatment group received one injection of BTX-A in TrPs of up to two muscles. Specific TrPs were injected based on palpation of tender points.

The control group received a saline (salt water) injection as a placebo. Placebo means the injection has no known effect but the person believes it works and gets better because of it.

Results were measured based on neck pain, body pain, function, and disability. The treatment group reported decreased bodily pain and improved mental health. The greatest improvement was seen at two and four months after injection.

Changes in neck pain were not different between the two groups. Both groups had less neck pain after injection. There were no differences in post-injection side effects or problems between the two groups.

The authors point out that both groups seemed to experience a placebo analgesia effect. This was the interpretation of the results since both groups had decreased neck pain and disability.

The results of other studies have led some experts to conclude the pinprick from the needle is what makes the treatment successful. Future studies are needed to target other areas of the muscles. Results should be compared to patients in a control group and patients receiving a TrP injection.

Physicians use range of motion (ROM) of the neck to determine functional status of patients with degenerative spine disorders. Although several studies involving the spine have been done, most focus on the lower back, rather than the upper back and neck. In those studies, however, there have been findings that patients with degenerative changes in the spine do have a reduced ROM.

The authors of this study sought to assess the effects of age, gender, degeneration, and the degeneration of adjacent levels and the relationship with ROM of the upper back and neck.

Researchers accessed the records of 195 patients (133 females), ranging in age from 15 to 93 years, who had presented with complaint of pain in the cervical spine. X-rays were examined of the patients in a standing natural posture position and of the neck bent upwards and downwards.

The x-rays were assessed by a musculoskeletal surgeon, an orthopedic surgeon, an a spine surgeon. ROM was assessed by a spine surgeon and two orthopedic fellows.

The study findings revealed that patient age was associated with a decline in ROM to the about five degrees every 10 years. Degeneration seemed to be responsible from 0.8 to 1.2 degrees in change depending on the level.

The authors write that these findings help provide “a framework with which to counsel patients about cervical ROM and a benchmark from which procedure specific changes can be compared.”

In this article, the procedure called cervical laminaplasty is discussed in detail. It is a relatively new procedure for cervical disease. The first operation was done in 1982 with good results. Laminaplasty is an indirect way of taking pressure off the spinal cord.

The lamina is a thin layer of bone located between the spinous process and the pedicle. The spinous process is the bone that projects out from the vertebra. It can be felt along the back of the spine and is referred to as the backbone. The pedicle is a bridge of bone between the vertebral body and the arch that forms a circle of bone around the spinal cord.

Laminaplasty is done by opening the lamina just on one side. This creates a hinge joint that makes more room for the spinal cord inside the spinal canal. The procedure has been changed many times over the last 25 years.

One of the more popular modifications is the French door approach. A thin trough or channel is made in the lamia on each side of the spinous process. Then the spinous process is split down the middle. The two sides of the lamina (each with half a spinous process attached) open outward like French doors. The doors are held open by metal plates and ceramic spacers.

There are many advantages and disadvantages of the laminaplasty technique compared to the anterior approach. Anterior means the operation is done from the front of the spine rather than the back.

With a laminaplasty, the patient does not have to be put in a brace afterwards. No bone graft is used so there’s no risk of graft failure. There are no problems with swallowing or loss of vocal cord control. Both of these complications are possible with an anterior approach.

Laminaplasty may be better than a laminectomy where the lamina is removed. With laminaplasty, the bone is still there to protect the spinal cord. There’s less chance for deformity of the cervical spine (neck) after laminaplasty compared with laminectomy.

The main disadvantages of laminaplasty are neck pain after the operation, nerve damage, and poor cosmetic appearance. Neck pain occurs because the muscles are stripped away from the bone.

The authors provide a detailed description of the procedure. Photos of the patient’s position, traction and frame used, and dissection of the tissues are included. Videos are also available to show surgical technique and modifications of the procedure.

Pearls and pitfalls of laminaplasty are listed to guide the surgeon. Tissue closure of the wound is discussed along with specifics of postoperative care.

Patients can expect to stay in the hospital for up to 48 hours. Range of motion is started right away. Rehab continues at the time of discharge. Full return to normal activities (including aerobic exercise) is possible by the end of six weeks.

Whiplash injury, often caused by motor vehicle accidents but also from other accidents, such as falls, is a common neck injury that can cause neck pain and stiffness, headache, shoulder pain, arm pain, tingling, numbness, and other neurological effects.

Up to 75 percent of patients with whiplash may see their symptoms go away on their own, however, many patients require treatment for their discomfort. No treatment, including nonsteroidal anti-inflammatory drugs (NSAIDs), muscle relaxants, injections into trigger points, surgery, and others, has proven entirely effective and some are controversial.

The use of botulinum neurotoxin type A (BTXA, also known as Botox) has been investigated, however usually after a long period of time following the initial injury. The authors of this study believed that earlier intervention, at 3 months, would be more effective and prevent the pain from developing into chronic pain.

Twenty patients with a history of whiplash injury and myofascial pain, pain caused by a trigger point, were enrolled into the study. The injury had to have occurred between 2 to 48 weeks before the study onset, the pain had to be restricted to the neck only, 4 to 8 spots had to be considered to be tender spots, or trigger spots, and there could be no spinal or neck abnormality.

The patients were asked to assess their pain before the treatments using the Visual Analog Scale (VAS) of 0 to 10, with 10 being the worst pain. They also noted use of pain relievers. They were reassessed at 3, 6, 9, 12, 18, and 24 weeks following the injection of Botox.

Besides the VAS scoring, the patients were also asked to use the Verbal Rating score to measure pain, and the SF-36 questionnaire to measure quality of life. The physician measured the patients’ ability to move at the neck and determined pressure pain by applying pressure to the trigger points.

Results of the study found that although there was improvement in all values among the patients who did receive the Botox injections, the differences were not statistically significant. The authors point out that although they wanted to have the patients receive injections at 3 months following the injury, it was another 2 months before treatment because the patients preferred to try less invasive treatments before proceeding to the study treatment. The authors feel that this could have played a role in the study outcome.

In conclusion, the authors state that there appears to be some efficacy with the use of Botox in the treatment of whiplash symptoms, however further study is needed.

In this study, surgeons from the People’s Republic of China report on the use of a microscope to perform an anterior cervical discectomy and fusion (ACDF). This technique is called an endoscopic approach.

The authors provide intraoperative photos showing the insertion of a working channel. The channel allows the surgeon to use surgical tools without cutting a large opening. A tiny TV camera on the end of the microscope (endoscope) showed the removal of the damaged disc. Taking the disc out removes pressure from the nerve tissue. This operation is called a decompression.

A fusion cage was inserted in the open space left by the disc that was removed. Another photo showed the fusion cage in place. X-rays and CT scans taken before and after the ACDF helped show the results. Pain levels, motion, and function were also used to measure the outcomes.

The endoscopic method of decompression and fusion has been used for a long time in the lumbar spine. The small area and closeness to the vocal cords has kept this from being used routinely in the cervical spine (neck).

Surgeons must have special training to do microendoscopic discectomy. The procedure is best done at C45 and C56 levels. The jaw gets in the way of inserting the working channel any higher. Blood vessels to the thyroid are at risk of injury if working any lower.

Some patients are not good candidates for anterior cervical endoscopic surgery. For example, narrowing of the spinal canal (called stenosis) makes it difficult to get full decompression. Likewise, hardening and thickening of the posterior longitudinal ligament (OPLL) requires an open incision.

The good-to-excellent results in this study suggest this procedure works well in carefully chosen patients. The fusion rate was 100 per cent. The rate of complication was very low. Anyone with a blood clotting disorder or cervical dislocation is not a good candidate for anterior endoscopic microsurgery.

The authors hope that future improvements in surgical tools and techniques will expand the use of this procedure for more patients. A device is needed that can apply traction to pull the vertebral bones apart. Special tools to help get around anatomical barriers are also needed.

Until recently, surgery for cervical disc degeneration has been with fusion. But 25 per cent of those patients end up with further problems in the next 10 years. Artificial disc replacement (ADR) may help change that.

This study was done in order to compare the results of fusion versus ADR. ADRs are designed to restore normal neck motion. Another goal is to get patients back to daily activities and work quickly.

Complications and problems usually linked with fusion are not a problem with ADR. For example, bone graft is not required with ADR. So there is no risk of graft site fracture, infection, nerve damage, or pain. And with cervical fusion, there is always the risk of motion recurring from a pseudoarthrosis (false joint). This doesn’t happen with ADRs.

Data from three centers carrying out FDA-approved research on the Bryan ADR combined the results of 99 patients. All patients had a diagnosis of cervical degenerative disc disease. Neck and arm pain from pressure on the spinal cord or spinal nerve roots was the main cause of disability.

Half the patients had an ADR at one level. The other half had a single-level anterior cervical discectomy and fusion (ACDF). Follow-up was for a full two years. Outcomes were measured using pain levels, X-ray results, and range of motion. Function (both mental and physical) was also assessed.

Patients in both groups improved compared to before surgery. Blood loss and length of hospital stay were slightly more for the ADR patients. But pain and disability after two years were less than for the fusion patients.

Current studies (including this one) show that ADR is comparable to the gold standard of fusion for cervical disc disease. The two-year ADR results were very favorable. Only time will tell if the long-term results are better for ADR compared with fusion. The hope is for less adjacent level degeneration that occurs so often with fusion procedures.

A disorder called crowned dens syndrome (CDS) is frequently given different names, resulting in the need to clarify the clinical features of the disorder. The authors of this study reviewed the records of 40 patients, aged 48 to 83, with the syndrome to evaluate the test findings and treatment outcomes.

CDS is characterized by the presence of calcium deposits around the odontoid process, the small area that sticks out from the second vertebrae of the neck; the first vertebrae rotates around the odontoid process. As the calcium builds up, it causes pressure and acute pain. The patients in this study had gone to the emergency room within 1 day of the onset of pain, which had spread to the both sides of the neck at the base of the skull. The patients scored their pain on the Visual Analog Scale , which rates the pain from 0 to 10, with 0 being no pain and 10 being the most severe. The average score was 8.3, ranging from 7.5 to 9.4). All patients had difficulty moving their necks.

Upon examination, all patients had an increase C-reactive protein level in their blood, an indicator of inflammation somewhere in the body, 10 patients had a higher than normal body temperature, and 13 patients had a slightly higher than normal white blood cell count. Patient histories showed that 22 patients had a history of pseudogout and 26 had a history of articular chondrocalcinosis .

X-rays did not show calcification in most patients, but the calcification was detected by computed tomography imaging, or CT scans. Twenty patients had calcium deposits in the posterior section, 11 around the posterolateral section, 5 had a circular pattern around the area, 2 in the front (anterior) and 2 patients had tuberous calcification masses on both sides.

The patients received either prednisolone (a corticosteroid), a non-steroidal anti-inflammatory (NSAID) or both for treatment. On average pain was relieved within 4 days, with some patients as early after 1 day of treatment, others as long as 9; the patients who took both medications did report quicker pain relief.

After an average of 9 months of follow-up, 9 patients relapsed and needed repeat treatment.

The authors point out that when they were reviewing records to find study subject, among all the patients who presented to the emergency with neck pain scores of over 7, 2/3 were ultimately diagnosed with CDS. They suggest that the syndrome is more common than originally thought, with the condition more common among elderly women.

They conclude that patients with CDS do have a good prognosis and treatment does effectively eliminate the pain within a few weeks.

Surgery to take pressure off the spinal cord in the cervical spine(neck) can cause problems. In order to reach the bone over the spinal cord, the muscles are first stripped away. Even though the muscles are reattached, patients lose the natural lordosis (curve) of the neck.

In this study, surgeons from Japan compare two different methods of doing a laminoplasty for cervical myelopathy. Laminoplasty refers to the removal of part of the lamina. The lamina is a bridge of bone that forms a protective covering around the spinal cord. Myelopathy refers to any damage or disease to the spinal cord.

Two groups of patients with cervical myelopathy were surgically treated with cervical laminoplasty. Group A had the standard operation with stripping of the extensor neck muscles, removal of part of the bone, and repair of the muscles.

Group B had a dome laminotomy or a laminectomy. In the dome laminotomy, the lower half of the lamina is removed. The entire lamina is taken out during laminectomy. The muscles are not cut or disrupted.

Results were measured using X-rays of the cervical lordosis before and after the operation. Differences between men and women were noted. Loss of nerve function and neurologic recovery were also reported.

The authors report loss of cervical lordosis only in the Group A women. They saw that the extensor muscles were atrophied (wasted away) at the time of the operation. They could not be repaired successfully. It appears that preserving these muscles (even when atrophied) prevents loss of cervical lordosis in men and women.

The dome laminoplasty can improve outcomes for patients with cervical myelopathy. The procedure is not recommended for anyone with ossification of the posterior ligament (OPLL). OPLL is a hardening of the ligament along the back of the spine.