News Category: Cervical Spine

Fusion of the cervical spine (neck) may require metal plates for a rigid result. But the outcomes of this study show that even with a locking plate, motion occurs after anterior cervical discectomy and fusion (ACDF).

The purpose of this study was to measure the amount of motion present after ACDF. A second goal was to find out where the motion was occurring. Anterior plates are used to reduce or stop motion between two vertebrae. This allows for the bridging of bone between the vertebrae.

The same surgeon treated all patients. Allograft bone donated from a bone bank was used as the graft material. A locking titanium cervical plate with an adjustable angle was inserted anteriorly (from the front of the spine).

Special moving X-rays and motion tracking software were used to observe and measure motion after the procedure. Over half of the levels fused had detectable motion two weeks after the operation. Most of that motion occurred at the place where the bone and screw met (bone-screw interface).

Bending of the plate was the second most common source of motion. In a small number of cases, there was movement that originated at the screw-plate interface. It appears that there is enough load repeated in the first two weeks to cause loosening.

Factors that may affect loosening include osteoporosis (decreased bone mass), design of the implant, and post-operative care. It may be possible that patients who do not wear a rigid neck brace after surgery have more loosening than those who do wear the brace. Loosening is also more likely when more than one level is fused.

The authors conclude that efforts to improve fusion results using locking metal plates with ACDF have not been successful. Motion at the fusion site may be complicated by quality of bone, type of bone graft, and even the type of injury (fracture, tumor, disc degeneration).

Surgeons will be able to use this information when planning ACDF procedures. Type of implant used, postoperative care, and patient risk factors must all be taken into account to avoid implant loosening.

Neck pain can be difficult to treat successfully. Neck pain that travels down the arm from pressure on a spinal nerve is called cervical radicuolpathy (CR). In this study, physical therapists look for ways to predict who might get better with treatment for CR.

Baseline testing was done before treatment started. All patients were examined by the physical therapist. They each filled out several surveys about pain, function, and disability. Individual treatment was provided by physical therapists at three different clinics.

Short-term results were measured based on improvement in scores from the tests given before and after intervention. Four factors were identified that might help predict which CR patients would have a successful outcome from treatment. These four variables included:

Fractures of the upper cervical spine (neck) can be very difficult to treat. The bones in the area are small. Swelling and bone fragments complicate the problem.

CT scans taken before the operation don’t show the same anatomical positions that are present during the procedure. This is because the patient is supine (on the back) for the CT scan. But the surgery is done with the patient face down. This position gives the surgeon access to the spine.

A new computer navigation imaging system called Iso-C 3D may help. In this case report, surgeons from India successfully fused the C2 vertebrae in one adult patient using Iso-C 3D-based fluoroscopy. This type of imaging allows the surgeon to see the spine’s position as it is at that exact moment. This is referred to as intraoperative real-time imaging.

The 28-year-old male manual laborer fell and fractured both sides of the pedicles (posterior segment) of his C2 vertebra. The C2 vertebra shifted forward over the C3 vertebra below it. This type of injury is called a Hangman’s fracture. Surgery was needed to realign and reconnect the vertebrae.

The real-time imaging assisted by computer navigation made it possible to get an accurate picture of the spine. The exact entry point was found. The surgeon could use this imaging tool to make sure the position of the screws was correct.

This special imaging aid made it possible to put screws in place without puncturing a blood vessel or entering the spinal canal. This injury could be stabilized without fusing the neck. Fusion results in loss of neck motion.

Successful fixation of this area is now possible with the Iso-C 3D fluoroscopy navigation system. The authors note that the equipment is expensive. It is not available everywhere. Patients may be exposed to more radiation than is desired.

Cervical disc replacement is a rather new treatment option for persons needing fusion of their neck. It is estimated that 70 percent of spinal surgeries in the United States will involvine disc replacement by 2010. While anterior cervical decompression and fusion (ACDF) surgery seems to have successful outcomes long-term, some studies have shown that it is common for the development of wear and tear of the segments above and below the level that has been fused. It is felt that this is due to decreased range of motion at the segment that has been fused. This then causes the adjacent segments to have increased motion and forces on the discs, facet joints and soft tissues.

The authors of this study evaluated range of motion in live subjects rather than cadavers. Ten subjects had ACDF at C5-6. Ten subjects had cervical anterior disc replacement (CADR) at C5-6. Surgery was at minimum six months before the start of the study. The normal group consisted of 10 subjects who had not had neck surgery. Evaluation of forward bending or flexion, backward bending or extension of the neck was done by using special X-rays called fluoroscopy. Motions of each segment to include C3-4, C4-C5, C5-6, and C6-C7 were measured.

This study demonstrated that subjects with CADR had range of motion at all segments close to those in the normal group. However, the CADR subjects had larger range of motion than the normal subjects at the implanted level, C5-6. When compared to the normal and CADR groups, the ACDF group had two to three times more range of motion at both adjacent levels. The range of motion at C3-4 was similar among all groups.

Contact forces were extrapolated from measurements also. Transverse forces were increased in the ACDF group when compared with the normal group and the CADR group. Vertical forces were not significantly different among the three groups.

This study demonstrated that CADR may prevent adjacent segment wear and tear when compared with anterior cervical decompression and fusion. CADR preserves the motion and force patterns of the normal spine. However, the increase in motion at the implanted segment may be a cause for concern. Long-term follow-up studies are needed to determine if CADR can replace ACDF.

The purpose of this study was to explore why dysphagia or difficulty swallowing occurs following anterior neck surgery. Difficulty swallowing is known to occur prior to surgery in some individuals that have large bone growths called osteophytes from the vertebral bodies in the cervical spine. Given this, plate thickness has been thought to be a possible cause of difficulty swallowing after surgery. None of the 64 patients in the study had difficulty swallowing before surgery. The surgeon involved used the same plate thickness for all subjects. Nine of 30 patients in the group who had less protrusion from the surgical plate than they did from osteophytes before surgery developed difficulty swallowing. Five of the nine had difficulty swallowing chronically. Thirteen out of 34 patients in the group who had greater protrusion of their plate after surgery than their osteophytes before surgery developed difficulty swallowing. Six of the thirteen patients had chronic difficulty swallowing.

The authors concluded that from their experience with 64 patients, plate thickness seemed improbable as a source of difficulty swallowing. The authors felt that it was more likely that plates at the upper cervical spine (C3) were the cause of dysphagia. This may be becuase they require more moving and holding of soft tissue around the throat with instruments called retractors. They also felt that when smaller incisions were made, there was more vigorous retraction of the esophagus (the tube that connects the mouth with the stomach). They felt this could have been a cause for the difficulty swallowing after surgery. Surgery lasting longer than 175 minutes seemed more likely to contribute to post-operative difficulty swallowing.

In this study, patients with Chiari malformation type I (CM-I) who had failed results from surgery were examined carefully. The authors found a link between Chiari malformation and hereditary disorders of connective tissue (HDCT).

Chiari malformation is the herniation (downward movement) of the cerebellar tonsils (lower brain). The tonsils move down through the opening at the base of the skull. This opening is called the foramen magnum.

The most common HDCT are Ehlers-Danlos syndrome and Marfan syndrome. Both of these conditions have a variety of signs and symptoms caused by a defect in the connective tissue.

Each patient with failed outcomes from surgery to correct the Chiari malformation had many tests and measures performed. These included information on family history, physical exam, and MRI of the cervical spine (neck).

Some patients had other tests as well. CT scans, barium swallow, sleep monitoring, and cardiac tests were some of the tests performed. A special cervical traction test was done if cranio-cervical instability was suspected. The cranium is the skull and the cranio-cervical junction (CCJ) is where the skull and first vertebra meet. X-rays and CT scans of the CCJ also helped identify instability in this area.

Because connective tissue was involved, joint mobility and tissue fragility were also measured. Excessive joint motion called hypermobility is common with HDCT. Easy bruising, poor tissue healing, and thin scars are common with fragile tissues.

After studying the data, the authors report that 35 per cent of the patients with CM who had a failed surgery also had HDCT. Patients with combined CM and HDCT were more likely to have symptoms of lower brainstem dysfunction.

This included nausea, difficulty swallowing, and throat tightness. Other symptoms such as shortness of breath, facial pain, and double vision were also reported. Some patients had heart palpitations and fainting spells.

The authors report this is the first time CM-I has been linked with HDCT. Patients with both conditions are more likely to have hypermobility of the upper cervical spine. This extra movement causes an unstable spine and allows greater herniation of the cerebellar tonsils.

Patients with CM-I undergoing surgery to stabilize the cervical spine should be tested for HDCT before the operation is done. This helps the surgeon plan the type of surgery and follow-up care to avoid complications.

Pain and muscular fatigue of the neck is increasing in incidence in industrial countries, affecting all ages, resulting in an economic cost in sick days, health insurance, and medications used. Much of neck pain is caused by muscular weakness, particularly in women who, although they have the same mass to support, have only about half the neck muscle forces than of men.

The authors of this study sought to determine if the Biodex isokinetic dynamometer was reliable in measuring the isometric strength of the neck, in order to obtain normal values on which to base evaluations.

Healthy men and women (96) and women with chronic neck pain (30) were recruited to participate in this study. The women without neck pain could not have experienced neck pain in the previous year nor engaged in any type of muscle training that involved the neck within the past 6 months. For assessment, the subjects completed the standardized Dutch Musculoskeletal Questionnaire, which evaluated neck pain.

For the testing, the subjects were placed face down on the examination bed and were asked to flex and extend their neck, against a gauge, to evaluate the muscle strength. Upon evaluation, the researchers noted that there was a significant difference in strength between the health male volunteers and the healthy female volunteers. Thus, only the females were compared against the group with neck pain. The researchers found that the strength of the women with neck pain was considerably lower than that of the healthy group.

The authors conclude that it is important to take the sex of the patient into account when determining neck strength in relation to neck disorders.

Neck pain, a common complaint in the Western world, can have a significant impact on quality of life. Many treatments have been tried, including physiotherapy, which included hands-on massage to treatment with therapeutic devices. Exercise therapy, a common approach to neck pain treatment, can include exercise for mobilization, strengthening, stretching, and endurance, with the aim to improving function, reducing pain, and increasing the patient’s awareness of what triggers the neck pain.

The authors of this study investigated the effectiveness of exercise therapy combined with Qigong, a therapeutic Chinese practice that involves slow movements and breathing exercises, combined with meditation. One hundred twenty two patients with neck pain participated in this prospective, randomized controlled trial. The patients, aged between 18 and 65 years, had non-specific neck pain of at least three months and a Visual Analog Score (VAS) of at least 20. VAS is measured on a scale of one to 100, zero indicating no pain, 100 indicating severest pain. Patients with chronic tension-type headaches, migraines, traumatic neck injuries, neurological signs, rheumatic disease, fibromyalgia, or other severe physiologic or physical diseases, or receiving treatment with antidepressants or anti-inflammatories were all excluded from the study.

Of the 122 patients (86 women), 60 were randomized to qigong and the remaining 62 to exercise therapy. Both groups were seen one to two times per week over a three-month period for a total of 10 to 12 visits. Both groups were also given ergonomic instructions, which included information regarding neck pain.

The patients in the qigong group were seen in groups of 10 to 15, with each session beginning with information about the philosophy of the practice and instruction for the exercises, following a guideline of 14 exercises. The patients in the exercise group participated in individually adjusted programs that involved resistance and repetitions.

All patients were evaluated at the start of the study, after the treatment, at six months following the study beginning and again at 12 months after. They were assessed by VAS for pain intensity and the patients kept a pain diary for the first week. The Neck Disability Index (NDI) was used to assess function and activity; grip strength was assessed by an instrument called the Grippit, and the neck range of motion was assessed with a Murin goniometer. The findings of the 102 patients who completed the study, were as follows: neck pain frequency before treatment was rated in the qigong (Q) and exercise (E) groups on average at seven days per week. After intervention, the average number of days in the Q group was reported as 6.5 and in the E group, four. After six months, five and 3.5 for the Q and E groups, respectively, and after 12 months, five and four days. VAS before the treatments were, on average, 45 and 39 for the Q and E groups, respectively, right after treatment, 31 and 22, respectively, at six months, 26 and 23, respectively, and at 12 months, 28 and 21. Cervical range of motion, was measured at 123 at the start of the study in both groups, 140 after the intervention and at six months, in both groups, and 140 in the Q group, 150 in the E group at six months.

The authors write, “there were no differences in the effect of qigong and exercise therapy in patients with long term [neck pain].” The note that both groups of patients were compliant with the treatment programs. The authors concluded that the patients were able to reduce their pain and improve range of motion with both qigong and exercise, but it still is not known which is a better treatment option.

This study was the first large-scale survey of chiropractors to estimate the incidence of serious effects from cervical spine (neck) manipulation. It is believed that the risk of serious problems from chiropractic manipulation is very low. But there are no studies to support this conclusion.

Chiropractors in England and Scotland were invited to complete a survey with details on treatment and outcomes for their patients. Patients included were 16 years of age or older. Treatment included at least one manipulation to the cervical spine.

One-third of all chiropractors registered in the British and Scottish Chiropractic Association participated in the study. Minor and more serious adverse effects of treatment were reported. Data from a total of 19,722 patients was analyzed.

Minor side effects of chiropractic manipulation were common. This included neck pain, stiffness and soreness, and headache. There were no serious adverse effects reported in this study. Such events might include stroke, hemorrhage, or neurologic problems.

The authors suggest the risk of a serious adverse event after cervical spine manipulation is low to very low. They conclude that this treatment approach is a relatively safe procedure. The risk is low when patients are treated by registered chiropractors.

An outside reviewer of the study pointed out several areas to consider. First, only one-third of the registered chiropractors participated in the study. This means the safety of treatment for patients under the care of the majority of chiropractors remains unknown.

Results for patients who were lost to follow-up or not followed-up at all were not included. Any adverse effects in these two groups were not reported. The researchers also had no way to know if chiropractors underreported negative reactions.

Likewise, patients may have failed to tell their chiropractors about problems after treatment. The outcomes for these factors could change how the data should be interpreted. The reviewer suggested that adverse events from cervical spine manipulation should be reported for every patient every time. This would mimic similar data already collected on every surgical patient.

Patients with syringomyelia with Chiari malformation-Type I (CM-I) were the subject of this study. With CM-I, the lower part of the cerebellum protrudes from its normal location in the back of the head.

The cerebellum is a separate, smaller part of the brain located at the base of the skull. It is just above the cervical spine (neck). It slides down into the cervical portion of the spinal canal. These patients develop syrinx in the cervical spine.

The syrinx is a cyst or tube-shaped cavity that forms within the spinal cord. Syringomyelia is the general term used to describe this cyst formation. The syrinx can expand and get longer. It can destroy the center of the spinal cord.

In this study, neck motion was studied in relation to the degree of severity of the syrinx. It’s possible that motion is restricted with more severe deformity. Although all levels of cervical motion were studied, the focus was on the occipitocervical region. This is where the occiput (base of the skull) and first two cervical bones (C1 and C2) meet.

Patients included all had surgery for CM-I with syringomyelia. A foramen magnum decompression (FMD) was done. In FMD, the bone around the spinal cord is removed. Pressure is taken off the brain and spinal cord.

Range of motion was measured before and after the operation for each patient. The results showed no difference in neck motion between pre- and post-operative measures.

FMD is an effective treatment method for pain relief but doesn’t change motion in patients with CM-I. It does not appear that the severity of CM-I is linked with the loss of motion seen in the occipitocervical region. The authors suggest further study of this question is needed with a larger number of patients.

The authors of the studied reviewed sources of pain, treatment, and prognosis of cervical whiplash injuries. Whiplash describes the mechanism of injury and the associated neck pain caused by it. While soft tissues are usually the source of pain, chronic whiplash and associated pain may have other sources. The authors discussed facet joints, discs, and craniocervical ligaments as sources of chronic pain from whiplash injury. The authors report that clinical studies indicate that 15 percent to 40 percent of persons with acute neck pain after a motor vehicle crash will develop chronic pain. Five percent to seven percent will become permanently partially or totally disabled. Those who report acute neck pain immediately following the MVC are three times more likely to report chronic neck pain seven years later than those who did not have immediate onset of neck pain. Complete recovery in the studies reviewed by the authors is 60 percent to 85 percent. The authors found that the strongest predictor of poor outcome is high initial pain intensity. They also found that patients with better coping seem to have more functional outcomes than those that don’t. Fear avoidance may contribute to the disability of the chronic pain. Baseline psychological factors, litigation, age, sex, and forces generated in the accident did not seem to be predictive of outcome.

Symptoms of whiplash include neck pain, pain in the trapezius muscle, shoulder, interscapular area, arm, and occasionally the face. Studies indicate that there may be a significant incidence of shoulder problems in patients with chronic whiplash. Pain can also be from nerve compression, discogenic or facetogenic sources. Headache is reported as the second most common symptom of whiplash. There are several documented sources for cervicogenic headache such as the C2-3, C3-4 discs, facet joints and the atlanto-occipital joint. Low back pain may occur in as many as 50 percent of whiplash patients, with 20 percent to 40 percent experiencing chronic low back pain. Cervical facet joints may cause chronic pain in 49 percent to 60 percent of patients. The evidence supporting discogenic pain is not as good, but seems likely as a source of chronic neck pain. Radiographic studies show that alar and transverse ligaments may be damaged by whiplash and when found on MRI were more common in patients with a history of whiplash. Patient symptoms and MRI findings did not correlate.

Patients who remained active despite pain fared better. At one year, patients treated with cervical immobilization had a higher incidence of neck pain and disability than those who did not. Exercise is effective pain treatment for chronic neck pain, however stretching is not. Exercise directed at strengthening of the neck and shoulder and upper back area can reduce pain and improve function. Exercise must be continued to maintain gains. Physical therapy may be beneficial initially, but studies show that the benefits may not be apparent at 12 months. Body mechanics training for home, work and recreation is shown to be beneficial. Spinal manipulative therapy results are conflicting.

The most useful drugs among studies were anti-inflammatories, opioids, and muscle spasm agents for up to 14 days after the accident.

Several studies indicate that up to 83 percent of patients report good to excellent results following anterior cervical fusion for axial neck pain following whiplash using the Oswestry Disability Index particularly.

Among the many people in the United States who have spinal surgeries, the most common procedure is called the anterior cervical discectomy and fusion (ACDF). This surgery involves removing a disc and fusing together vertebrae. According to the authors of this study, over 50,000 ACDFs have been done in the US between 1990 and 1999.

Generally, most patients experience good results from the surgery, however, some do experience complications that can be life-threatening. The study’s authors reviewed the files of 549 men and 466 women, all between the ages of 28 and 75 years, who underwent ACDF due to degenerative disc disease, provided they had not undergone previous neck surgery. The goal of the study was to document the potential complications and management issues.

The patients’ files included results of pre-surgical cervical (neck) magnetic resonance imaging (MRI) for all patients and computed tomography scan (CT scan) for 445 patients, x-rays for 670 patients, cervical myelogram (x-ray with dye) followed by CT scan for 224 patients, and tests to check nerve conduction in the arms (called electromyography) in 119 patients.

Grafts used were either autologous (from the patient’s own bone tissue) or allografts, from others, if the surgeons determined that autografts were not an option due to disorders, such as hyperparathyroidism, Paget’s disease, osteoporosis, and others. A history of heavy smoking was also a deciding factor in using allografts over autologous grafts.

The researchers then reviewed the follow-up findings for each patient, searching for any complications noted during the surgery, at 2 and 4 weeks after, and then again at 3, 6 and 12 months after. They found, through x-rays, that at 12 months, fusion was successful in 94.5 percent of the patients. In terms of complications, 9.5 percent of the patients complained of difficulty swallowing, coughing, choking, new-onset of heartburn, or feeling as if their neck was blocked, after the surgery. Of the 97 patients with these complaints, only 5 did not resolve spontaneously within 7 days. They did, however, resolve within the following 4 weeks.

A hematoma (a collection of clotted blood) that caused severe dysphagia, difficulty breathing, or painful swelling in the neck occurred in 5.6 percent of patients. Surgery was needed to remove the hematoma in 2.4 percent of the affected patients. recurrent laryngeal nerve palsy (RLN palsy), which caused hoarseness of the voice, occurred in 3.1 percent of patients.

In 5 patients (0.5 percent), there was leakage of cerebral spinal fluid; in 4 cases, this happened accidentally, in the last case, a surgical procedure opened the area. Three patients (0.3 percent) experienced an accidental opening of the esophagus during surgery, but this was repaired immediately in 2 patients. The third patient’s tear was not noticed during surgery and it was discovered on the second day after surgery when he developed a fever. Despite aggressive treatment, including surgical repair and antibiotics, the patient died after 10 days.

Two patients experienced worsening symptoms of myelopathy, or disease effects to the spinal cord, that appeared to improve after 12 weeks of therapy. One patient developed temporary Horner’s syndrome on one side of the face. The symptoms of Horner’s syndrome include flushing skin but no sweat, a small (constricted) pupil, and drooping eyelid. Finally, one patient presented 16 months following the surgery with movement of the screws from the fusion area. The researchers determined that the screws had not been placed properly during surgery.

The authors concluded that the most common complication is that of dysphagia and hematomas, followed by nerve palsy. Although not common, perforation of the esophagus is life threatening.

One-fourth to nearly one-third of all computer workers worldwide suffer neck and/or arm pain. In this study, researchers from the Netherlands compare the results of three treatment methods in computer workers. All participants had pain or stiffness in the neck, shoulder, arms, hands, or wrists.

The focus of treatment in group one was a change in work style. Intervention included improving body posture and making adjustments to the work place. Taking breaks and coping with the demands of work were also part of the work style group.

Group two combined the elements of the work style group along with training toward increasing lifestyle physical activity. Walking, biking, gardening, chores, and sports were encouraged. Group three received usual care. They did not participate in any of the group meetings.

Groups one and two met once a month for six months. Data was collected, analyzed, and compared. There was follow-up for 12 months. Results were measured by pain intensity, number of days with symptoms, and amount of disability at work.

The authors reported the single work style intervention was most effective in reducing pain and symptoms. Group meetings were successful in providing general information and increasing awareness about work style. Adding physical activity did not change the results.

Changes in work style had the greatest effect in the long-term (after 12 months of follow-up). Significant changes were not observed after six months. It appears that behavioral change takes time. Effects are not easily seen in the short-term.

The lack of improvement in the combined work style and physical activity group was a surprise. The authors suspect a lack of focus may be the reason for this outcome. More than one message given to the workers could be at fault. More study is needed to come to a complete understanding of this phenomenon.

In this study, researchers use sheep to study the effects of surgery on the cervical spine (neck). They looked at structural and cellular changes at the facet joints of the spine. All sheep were treated with anterior cervical discectomy and fusion (ACDF).

There are risks whenever spinal surgery is performed. During the anterior approach to cervical fusion, things can go wrong with screw placement, retraction of the soft tissues, and surgical removal of the disc. Placement of a titanium cage between the vertebrae can also result in patient complaints of pain and neurologic symptoms.

Only one surgeon performed the operations. The procedures were all the same. The disc was removed at the C5-6 cervical spine level. This step is called a discectomy. In ten of the 15 sheep, a rigid device called a cage was inserted in the empty disc space.

X-rays were taken of the cervical spine before and after the operation. Tissue samples from the joints and vertebral endplates were examined. The endplates are located on either side of the disc between the disc and the vertebral bone. They are made up of fibrocartilage.

The facet joints were studied using special light microscopy. Changes suggesting trauma were seen in both the joints and the endplates. This was true for the level operated on as well as the next (adjacent) segment. Degeneration and death of the cartilage cells was observed.

Other signs of injury in these two areas included edema (swelling) and microhemorrhages. There were no observable changes in the vertebral bodies. There were no problems with the position of the implants.

The authors conclude that joint injury does occur during surgery to place stabilizing screws in the sheep spine. If that’s the case, then it’s likely that similar problems occur in humans. The human spine and sheep spine are very comparable.

This could be the explanation for problems that develop weeks to months after surgery in humans. Neck and or arm pain and loss of motor and sensory function occur when there’s no evidence of any apparent injury.

More study is needed to see if the effects of surgery go away after the operation. It’s possible that microinjuries can be avoided with changes and improvements in surgical technique. Further study of this area is also needed.

Despite many studies, researchers still don’t know why some people develop chronic pain after a whiplash injury and others don’t. They haven’t been able to predict who will have lasting pain and who won’t.

In this article on chronic whiplash syndrome, the model of fear-avoidance behavior (FAB) is reviewed. FAB refers to the idea that some people in pain start to avoid movement that they think might cause pain.

The fear of pain results in movement avoidance behaviors. Attitudes and beliefs of this type fall into the category of psychologic risk factors. The FAB model is one that has worked well in understanding and treating people with chronic low back pain.

Perhaps it would help explain the transition from acute to chronic whiplash. Injured patients may get trapped in a downward spiral as pain leads to avoidance, which results in disability and more pain.

But so far, two systematic reviews looking at the evidence haven’t confirmed the role of psychologic factors in chronic whiplash. One other study has shown that an acute injury is more likely to result in FAB compared with patients who had a gradual onset of pain. More research is needed to clear up the inconsistent findings on this topic.

The authors of this review suggest the FAB model has some merit in chronic whiplash. They based this conclusion on their review of all relevant studies. Problems in the design of the two systematic reviews may help explain the inconclusive results reported.

Suggestions for future research include studies over a long period of time to look for factors that predict the final outcome. These factors might include high level of anxiety and early symptoms of acute traumatic stress.

Studying the FAB model in chronic whiplash patients may help guide future research. Screening tools to identify patients at risk after injury may help direct treatment choices for acute and chronic pain patients.

Researchers from the Primary Care Musculoskeletal Research Centre in England have been conducting ongoing studies on neck pain. This article is the third in a series exploring predictors of treatment outcome.

A previous study done by this same group compared the results of three different physical therapy treatments for neck pain. They did not find significant differences in the results from group to group. Patients were followed up to six months after treatment with no change in results.

The purpose of this current study was to identify factors that predict poor outcome. The results were compared with what physical therapists (PTs) thought might be the psychosocial predictors of results.

A large number of patients (350) with neck pain were included in this study. Patients were evaluated based on social class, type of work, and type of pain (local versus widespread). General physical and mental health were measured using standard health surveys.

Outcomes were measured by patient report of change in neck pain (improved or not improved). Predictors of poor outcome (no improvement) included low patient expectations and catastrophizing symtpoms.

Patients who catastrophize symptoms describe their pain as terrible. They believe it’s never going to get any better. The data from this study shows that PTs can consistently identify who these patients are and who will have a poor response to treatment.

The authors conclude that patients at risk for poor treatment results may need a different approach to physical therapy. Routine PT for neck pain is not likely to change the symptoms. Future studies may help find an approach that is successful with patients who have factors that predict a poor outcome.

Until recently, cervical spine fusion has been the treatment of choice for degenerative disc disease (DDD) in the neck. Artificial disc replacement (ADR) may be changing the treatment options for this condition.

The advantage of an ADR over spinal fusion is that the implant preserves neck motion. The idea is to maintain cervical spine motion for as long as possible. ADR may improve long-term outcomes for DDD over fusion.

In this study from Germany, patients treated for cervical spine DDD with fusion were compared to an equal number of patients who got an ADR instead. Fusion was done using a procedure called an anterior cervical discectomy and fusion (ACDF).

A special X-ray machine called roentgen stereometric analysis (RSA) was used to measure motion in the neck. RSA readings were taken right after surgery and again at 3, 6, 12, 24, and 52 weeks. Other measures used to compare the results included pain levels and neurologic symptoms.

The results showed that pain was reduced equally well with either treatment. Spine motion was much greater in the ADR group. Over time, cervical spine motion did decrease in the implant group. They still had much more motion than the fusion group.

The authors conclude that cervical disc replacement accomplishes its goals of pain relief while preserving motion. Positive outcomes were still present one year after the surgery. Longer follow-up studies are needed. For now, the first step has been accomplished.

Scientists are moving slowly and cautiously toward using human discs transplanted to other humans. The first report of five patients receiving donated human disc material has been published.

Spine surgeons from Hong Kong and Beijing have conducted a five-year follow-up study on these five patients. They all received cervical (neck) disc materials. The discs were donated by young, healthy adults who died in car accidents.

The transplant surgeon removed the diseased disc. A cube-like shape was made between the two vertebrae. The transplanted disc and the end-plates on either side were inserted into the opening. No other means were used to hold the discs in place. In other words, no metal plates, screws, or wire were used to fasten the transplanted disc in place.

The patients receiving the donor discs did not need drugs to prevent rejection. No immune reaction occurs because there is a natural lack of blood supply to the disc itself. This means rejection is not a problem. Immune suppressing medications are not required.

Patients were followed for five years. One patient had a natural fusion at the two-year check-up. One other patient had neck and arm pain from pressure on the spinal nerve root. But the donated disc did not prolapse or herniate.

At the end of five years, all five patients had some loss of disc height. This is a sign of mild disc degeneration. There were no symptoms or indications of painful degeneration. The next level above and below the transplanted disc was not degenerating either.

The authors of the study say the transplanted discs are easier to revise if needed compared to disc replacements or spinal fusion. Some surgeons still feel it is necessary to wait for further results before attempting similar procedures.

For now, the use of transplanted human disc material remains under study. A slow, cautious, and scientific approach is advised.

When conservative care (meaning nonsurgical treatment) doesn’t help with cervical radicular syndromes, epidural injections may be the next step. Neck and arm pain, numbness, tingling, and weakness that persist for weeks or months may lead to the decision to try an injection.

The injection is called an interlaminar cervical epidural steroid injection (ICESI). A steroid and numbing solution is injected into the epidural space. The epidural space is between the dura (protective lining inside the vertebra) and the inside of the spinal canal.

An interlaminar injection is done by placing the needle directly in from the back of the spine. The tip of the needle goes between the laminae of two adjacent vertebra. The laminae is the part of the vertebra that forms the bony ring around the epidural space and the spinal cord.

ICESI is a safe treatment but complications are reported. In this review article, the minor and major problems that can occur with ICESI are discussed.

Minor complications occur within the first 24 hours. They can be treated easily and often go away on their own. Neck pain, headache, dizziness, and facial flushing are the most common effects. Nausea, vomiting, and fever may occur. Some patients report arm weakness, insomnia, and tenderness at the injection site.

Major complications are rare but can include a hematoma (pocket of blood), infection, and nerve root injury. Puncture of the dura is a complication that leads to another problem: severe headache. More serious problems such as permanent spinal cord injury and/or death can also occur.

The authors suggest that knowing what potential complications can occur should help the injectionist to avoid these problems. Some specific measures to prevent complications are also provided.

For example, patient movement must be kept to a minimum. The site of injection should be chosen carefully based on MRI results. Injections are best done at two sites: C7-T1 and C6-C7.

When problems do occur, quick identification and treatment gives the best results. More studies are needed to standardize injection techniques. This may help prevent or reduce both minor and major complications of ICESI.

Neck pain that travels down the arm is called cervical radiculopathy. The pain is usually caused by pressure on a spinal nerve as it exits the spinal canal. Bone spurs and disc herniation are the most common sources of compression on the nerves.

In this article, orthopedic surgeons from Emory University review the pathology and the anatomy of cervical radiculopathy. They offer a summary of important clinical tests and X-rays to perform in making the diagnosis. Nonsurgical and surgical treatment are discussed.

Nonsurgical treatment includes short-term use of a soft, cervical collar; traction; and medications. Manipulation, physical therapy, and steroid injections are also part of a conservative plan of management.

Surgery is the last treatment option considered. It may be advised only after an extended trial of nonsurgical care. The operation may be done from the front of the neck (anterior) or from the back (posterior approach). The most common procedure is an anterior cervical decompression and fusion (ACDF).

With an ACDF, the disc or bone spur pressing on the nerve is removed. This is done without disturbing the nerve tissue. Pulling on the nerve tissue could cause further trauma. Fusing the two vertebral bones together using bone graft material actually lifts the vertebrae apart. This has an added decompressive effect.

Artificial disc replacement (ADR) may become an option in the future. For now the FDA has only approved clinical trials with cervical ADRs. This means the approach is not available outside of an authorized research facility.

Outcomes for cervical radiculopathy are good after surgical decompression. Patients report pain relief and improved function. Since surgery is permanent, every effort is made first to take care of the problem conservatively. And, in fact, three out of four people get the symptom relief they need from nonoperative care.

The decision to choose surgery is made by the patient and surgeon together. Duration and type of symptoms make a difference. Prior surgery and/or the presence of any scar tissue in the neck can make a difference.

It is not possible to predict in advance who will respond well to treatment. Therefore, the authors suggest that even severe symptoms should be treated conservatively first. Conservative care may not change the final outcome, but it can decrease symptoms and improve quality of life. Surgery is not a perfect solution, but it can help many patients at risk for permanent nerve damage.