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CERVICAL SPINE DISEASE

Pain is the most frequent symptom that brings the patient with a neck problem to their physician. The pain may originate from any or all of the anatomical structures in this area such as the bone of the Vertebral Bodies, Nerve Roots (which leave the Spinal Cord at each Cervical Spinal level), Spinal Cord and/or the Cervical Facet Joints.


Figure 1: Anatomical Diagrams of the Cervical Spine. Each vertebra is connected to each other at "three" joints. The Disc space (located anteriorly) is the largest joint. The Two (2) Facet Joints are located on either Postero-lateral aspect of each Vertebra. Note the oblique alignment on the Lateral view (Arrow in Bottom Left Diagram).


Figure 2: Cervical Vertebra with Spinal Cord & Nerve Roots

The experience of a painful stiff neck is familiar to most of us. The "stiffness" is usually the result of muscle spasm or tightness. The spasm is the body's way to attempt to immobilize the joints that are injured. When the muscles contract (tighten), they reduce the amount of movement that the joints would ordinarily have. However, the muscle spasm frequently is quite painful in and of itself. Some patients notice that their muscles feel like "knots." This is the result of increased contraction of some of the muscle fibers. A local application of heat (heating pad, moist or dry heat) or ice (with careful attention not to injure the skin with these temperatures) frequently offers significant relief from the muscle spasm. Massage (with or without liniment, balms, salves, or oils) also may offer welcome relief to the problem of muscle spasm. In many cases the problem is only with the muscle (such as a muscle strain), and these measures provide satisfactory relief. However, it is prudent to remember that the muscle spasm may be an attempt by the body to protect us against further injury from a more important underlying difficulty. It then becomes increasingly important to identify more precisely the underlying pathology. Any persistent or recurring, severe neck pain deserves a more thorough evaluation by your physician.

Neck "Crick"

A neck "crick" is another common complaint. This symptom complex is most frequently experienced upon awakening in the morning. You usually know immediately that you "slept the wrong way." Stiffness and soreness are the hallmarks of this problem. It is the result of excessive stress on one or several joints on one side of the neck most likely related to lying in a peculiar position for some time. For some people, this is a frequent and repetitive annoyance. It may or may not be the result of more serious or advanced "degenerative arthritis." Common sense usually tells these patients to experiment with different sizes and shapes of pillows as well as body sleeping positions (or even mattresses) in order to avoid this recurring discomfort.

What to try "First"

For most people who have these problems, the pain is short lived. In the event that it becomes repetitive or severe and unrelenting, further measures are necessary. The most reliable method for relieving neck pain is to immobilize the neck and therefore reduce the amount of motion in the "damaged" joints. A cervical collar can be very helpful for this. It is not possible to stop all motion in the neck in an awake and ambulatory person except with some extreme measures which are not warranted for these neck problems. Soft, cervical collars are usually made of foam and encircle the neck. They are the least likely to immobilize the neck well; however, they offer many patients all the relief that is necessary. Some patients use this collar at night when lying down and use a more rigid (firm) collar during the time they are out of bed. Obviously the degree to which immobilization is pursued depends upon the extent of the problem. This may mean several months wearing collars for some people, while for others, only a few days. An injury to a joint can take a long time to heal. Unless the patient allows this time for proper healing, they may be inviting more frequent and severe recurrences as well as an acceleration of the "degenerative process."

Medications are frequently used for these conditions. Mild pain relievers are often necessary. However, some caution is needed. Pain is one of the ways that the body has to alert you that something is wrong. If you take medicine to relieve the pain and continue to pursue the activities that are producing damage to the anatomical structures (Facet Joints, etc.), then you are probably doing yourself (and these body parts) a serious disservice. Muscle relaxants and anti-inflammatory medications are also part of the treatment that many patients will be advised to use by their physicians. Self-diagnosis and self-treatment for a recurring problem or a severe neck pain is very unwise. For most patients proper treatment under medical supervision will alleviate the problem early and reduce the likelihood for and the extent of a chronic and more severe disorder.

Herniated Cervical Disc


Figure 3A (Left): A Herniated (Extruded) Cervical Disc (Curved Arrow) is Compressing a Nerve Root.

Figure 3B (Right): A Cervical Myelogram demonstrates the "under-filling" of the Right "Nerve Root Sleeve" (Arrow) caused by the pressure exerted on the Nerve Root by the Extruded Disc in Figure 3A.

One of the more serious disorders of the Cervical Spine is a "Herniated Disc" (in medical terminology, a "Herniated Nucleus Pulposus" or "HNP"). It is also commonly called a "slipped disc," "ruptured disc," "misplaced disc" or "displaced disc" — to name a few. A Herniated Cervical Disc (See Figures 3A & 3B) means that the shock-absorbing, softer center of the disc (Nucleus Pulposus) has pushed its way through the confining multiple layers of the capsule (Annulus Fibrosis) which encircles and holds it in place. The ligaments (Posterior Longitudinal Ligament) which help to hold the disc in place are also stretched and damaged as a result of this injury. The Herniated Disc pushes backwards and may compress the Nerve Root and/or Spinal Cord that lie directly behind it within the bone ring of the Spinal Canal. The Nerve Root can be pinched or pressed against the bone of the Spinal Canal which can cause injury to the Nerve Root itself.

The Spinal Cord is protected inside the bony Spinal Canal which is the Central Canal formed by each vertebra lying one on top of the other in the Spinal Column. For each vertebral level, one pair of Nerve Roots leaves the Spinal Cord through narrow bone openings (the Neural Foramen) on either side of the bony Spinal Canal. When the Herniated Disc presses the Nerve Root against the ring of bone, the Nerve Root can be injured. The Nerve frequently responds to this pressure by developing Nerve Root "swelling" (also called "edema"). Unfortunately, this swelling makes for more Nerve Root compression within the Neural Foramen. This increased pressure can result in less blood supply to the Nerve Root. Decreased blood supply usually produces more damage to the Nerve Root. More damage results in more swelling. A vicious cycle is established which could result in serious damage to the Nerve Root.

Things You Should Know

MOST PEOPLE WHO SUFFER A HERNIATED DISC RECOVER WITHOUT ANY SURGICAL TREATMENT. The object of any treatment is to have the "Herniated" portion of the disc return to its proper place and thus relieve the pressure on the Nerve Root. The blood supply to the Nerve Root will improve once the swelling diminishes. It is equally important to try to allow the damaged disc capsule and ligaments to heal. In various regions of this country, patients with Herniated Discs frequently undergo some form of "spinal manipulation" in the form of chiropractic therapy or osteopathic, orthopedic, and (even more rarely) neurosurgical manipulation. The practitioners of these disciplines are enthusiastic about their results. Undoubtedly, some patients with small herniations do experience relief after spine manipulation. It is also true that very serious injuries to the Spinal Cord, Spinal Nerve Roots and the blood supply to the Brain (the Vertebral Arteries are major vessels supplying blood to the Brain are also carried in part of the neck vertebrae towards the Skull) can occur from overly vigorous Cervical Spine manipulation. As a rule, we recommend against any spine manipulation if there are symptoms of tingling, numbness, electric shock sensation or weakness. If the pain is severe between the shoulder blades or in the arm, one should be very cautious about using spine manipulation. If pain continues or worsens after an effort at spine manipulation, we advise against pursuing the treatment.

Cervical Traction

For those patients who fail to improve with medications and immobilizing collars (or even "manipulation"), there are other forms of treatment that are worthwhile. Cervical traction is a method of applying a steady force to the Cervical Spinal Column that is beneficial to many patients with Cervical Disc Disease and/or Degenerative Arthritis. The traction apparatus lifts the Skull and pulls the Facet Joints of the Cervical Vertebrae apart for a very short distance (1/2 to 1 millimeter). This distance may not seem like much; however, it is frequently all the extra room that a compressed nerve needs in order to relieve the pressure on it and allow the Nerve Root swelling to diminish resulting in an improvement in the blood flow to the Nerve Root. The pain and neurological symptoms should improve if the Nerve Root pressure is satisfactorily relieved early enough. In the case of a Herniated Disc, the traction may also diminish the pressure within the disc space and allow the small piece of ruptured disc to reposition itself in the disc space (a concept currently popularized by the term "Disc Decompression".) Nevertheless, the disc capsule and ligaments have obviously been stretched and damaged. It is very important to recognize that the proper healing of the disc capsule and ligaments is a key element in the LONG-TERM recovery and maintenance of "Cervical Spine health."

Even if the Herniated Disc manages to "slip" back into place and the pain, tingling, numbness and weakness are completely relieved, there remains an injured, weakened Disc Capsule (Annulus Fibrosus) and ligament (the Posterior Longitudinal Ligament). These damaged structures take MONTHS TO HEAL (if ever). There are NO MEDICATIONS and NO EXERCISES which will improve these structures. Exercise can only stretch the already stretched and damaged ligaments. The only treatment that we would recommend is neck immobilization. This usually means wearing a soft collar at night and a firm collar in the daytime. It is uncomfortable to wear the firm collar when lying down. Many patients cannot accept the requirement to wear an immobilizing collar once they feel better. Hopefully with a better understanding of the anatomy and function of these structures, they will permit their tissues time to heal. If the disc capsule and ligament fail to heal well, then one can understand how much more easily a recurrence of the problem can be experienced.

Sometimes the initial injury to the disc capsule and ligament are sufficiently severe that they can never satisfactorily recover, and the patient will experience a recurrence. Only the passage of time (which may turn out to be many years later) will tell. There are no reliable x-rays or other tests to assess the state of these ligaments.

There are several questions that are frequently asked about cervical traction such as: "How much weight? How long do I use it? What position is best? Who should supervise it?"

We strongly urge that cervical traction only be used under the supervision of your physician. Although it is relatively safe, it could cause some damage if improperly applied.

There are many ways to apply cervical traction. Some devices are quite expensive. They are not necessarily better than the less expensive, passive varieties. Traction can be applied to the Cervical Spine while the patient is sitting or lying down. There are devices that can fit on a doorjamb at home or even at work at your desk. Other much more expensive devices incorporate pneumatic or cable-driven systems and usually provide "pulsed" or intermittent traction. The best traction device is one which allows the patient to lie down and is adjustable for height.

When you are lying down, you are more likely to be relaxed which means that the strong neck muscles are not counteracting the pull of the traction. The muscles are most likely to be relaxed when you are asleep. When you are lying down, the traction does not have to overcome the same gravitational force of the skull as when you are sitting. In the lying down position, seven to eight pounds of traction is all that is required. More weight is not better and will cause jaw joint pain. A "halter" collar fits under the chin and attaches to the traction device. In the sitting position, you will need a little more weight, sometimes up to 14 pounds. The angle at which the traction pulls upon the neck should be as close to a "neutral" (straight relative to the spine) position as possible. The traction device should be adjustable to allow for changes in the angle of pulling.

Steroids

There are other treatment methods that deserve some mention. Steroids are among the most potent anti-inflammatory medications which can sometimes reduce "swelling" of the Nervous System. For patients with Nerve Root compression, a short course of oral steroids in addition to some of the other treatments (immobilization, traction) may be useful.

Epidural Steroid Injections (ESI)

There are physicians who routinely recommend the injection of steroids into the space around the Nerve Root (Epidural Space) in order to concentrate the maximum dose possible in precisely the area that is involved and to avoid the possible serious side effects that oral or intramuscularly injected steroids can produce. Although the placement of a needle and narrow catheter near the Nerve Root is technically possible, it requires considerable skill and an element of luck. It will not improve the Herniated Disc or the Bone Spur which are the underlying pathological causes of the Nerve Root (or Spinal Cord) compression and injury. The needle or catheter is being placed into an already narrowed Neural Foramen (either in the case of a patient harboring a Bone Spur and/or a Herniated Disc). In any patient this treatment carries with it a risk to further (possibly irreparable) injury to the Nerve Root. The practitioners of this procedure usually inject a local anesthetic along with the steroid. This should relieve the pain (which in some cases is very severe). However, the pain relief will only last as long as the anesthetic does. (Patients who have had local anesthetic injected for dental work will have an idea of how long this medicine works.) It should not be surprising to learn that these same practitioners will usually recommend a "course" of repetitive injections. This is not a therapeutic alternative that we can recommend. We would caution anyone considering it to learn about the practitioner's skills and also the risks to neurological injury and to life that are inherent in this treatment. A SHORT COURSE OF ORAL STEROID MEDICATION CAN USUALLY ACCOMPLISH THE SAME GOAL WITH CONSIDERABLY LESS COST AND SIGNIFICANTLY LESS RISK.

Cervical Spondylosis (Degenerative Arthritis/Osteoarthritis)

The "disc" acts as a "shock absorber" between each vertebra. As such, they are subject to stress and strain ("wear & tear" which is referred to as "Degenerative Disc Disease) somewhat similar to the "shock absorbers" of a car or truck. During the time that the discs are undergoing these "degenerative changes", the Facet Joints which also connect one vertebra to the next are also subjected to increased stresses. Each joint has, as original equipment, a glistening smooth surface and a small amount of lubrication fluid (Synovial Fluid) to allow for very easy movement of one surface on the other. The everyday activities of life are associated with a considerable amount of neck movement. There is, as a result, a certain amount of "wear and tear" on these joints. As the main shock absorbing system (the disc) becomes less efficient as a shock absorber, more and more stress is taken up by the other joints of these and other Vertebrae. The lubricating fluid of these joints is slowly "used up." The glistening, smooth joint surfaces slowly wear down. These Facet Joints and the bone near them make every attempt to protect themselves against this "wearing down" process. This response takes the form of laying down new, dense bone around the joint. This new hard bone is the body's way to try to prevent the bones from wearing away. The technical term for the new bone is an Osteophyte (which is more commonly called a "bone spur"). This entire process involving the "wear and tear" on the joints and their response to this traumatic process is called Degenerative Osteoarthritis ("osteo" means "bone" and "arthritis" refers to the "inflammatory change in the joints").

Some people seem to have a tendency to develop Degenerative Disc Disease and its associated Osteoarthritis faster than other people. In some cases, it appears to be related to previous neck injuries such as whiplash injuries (as occur in rear-end motor vehicle accidents) or repetitive blows to the top of the head (as occurs in football players and the cliff divers in Acapulco, Mexico). It is important to recognize that many people can have a far-advanced degree of Degenerative Disc Disease, Osteoarthritis, large bone spurs and have absolutely no history of injuries of any sort.

Bone Spur and Calcified Posterior Longitudinal Ligament


Figure 5A (Left): Post-myelographic CT scan (Sagittal View) demonstrating bone spur (Curved Arrows), collapsed interspaces (Small Left Arrows) and high grade stenosis producing Spinal Cord compression (Right-sided Arrows). The Spinal Cord is represented by the "dark" vertically oriented structure (Right-sided Arrows). The Cerebrospinal Fluid (CSF) surrounds the Spinal Cord. It is represented by the "White" space (Broad Uppermost Arrow).

Figure 5B (Right): Post-myelographic CT scan (Axial View). The Spinal Cord is severely compressed to 7.24 millimeters by large bone spurs (Vertical Arrows).

In addition, these same individuals may never have experienced any significant neck discomfort despite the fact that the degenerative process is so far advanced. It is frequently a shock to these patients when they are made aware, for the first time, of the advanced state of their arthritis after an x-ray has been taken. The x-ray may have been taken when the patient complains of severe and relentless neck pain after a fairly trivial neck injury. These patients frequently express their disbelief upon hearing that their disease has actually been present for many years. It is inconceivable to them that they could not have had some pain prior to this. The opposite extreme to this scenario occurs in younger patients (20's and 30's) who experience frequent (and occasionally severe) neck pain from these joints, and in whom x-ray studies are entirely normal.

THE IMPORTANCE OF AN ACCURATE NEUROLOGICAL EXAMINATION

The importance of an accurate neurological examination cannot be overstated since as often as not, we have found that we cannot correlate the degree of arthritis at any particular level with the pain. The only clinical way to correlate the problems, at this stage, is to COMPARE THE NEUROLOGICAL FINDINGS from the physical examination by your doctor with the findings on ACCURATE, HIGH QUALITY NEUROIMAGING (MRI and or CT scans) STUDIES. IF YOUR PATTERN OF NEUROLOGICAL DEFICIT SUGGESTS THE INVOLVEMENT OF PARTICULAR NERVE ROOT(S) AND THE NEUROIMAGING STUDIES show a significant change at that same level, THEN IT IS MORE LIKELY THAT THIS LEVEL IS ALSO THE SOURCE OF THE PAIN.

MANY PATIENTS HAVE BONE SPURS AT MORE THAN ONE LEVEL. THE FACT THAT THEY ARE THERE DOES NOT MEAN THAT THEY NOW (OR EVER WILL BE) THE SOURCE OF ANY DIFFICULTY.

FOR A CLEAR AND CONCISE STATEMENT OF THE INDICATIONS FOR SURGICAL TREATMENT, PLEASE CONSULT OUR CERVICAL SPINE SURGERY SECTION.


Additional Information on this website

Cervical Spine operations constitute a significant part of our practice. A comprehensive Series of Monographs relating to Cervical Spine Disease and the treatment options is available to you in our Downloads & Information Library Section under Patient Education Library.

DISCLAIMER: Every effort has been made by the author (s) to provide accurate and up-to-date information. However, the medical knowledge base is dynamic and errors can occur. By using the information contained herein, the viewer willingly assumes all risks in connection with such use. Neither the author nor Neurosurgical Consultants, p.a. shall be held responsible for errors, omissions in information herein nor liable for any special, consequential, or exemplary damages resulting, in whole or in part, from any viewer(s)' use of or reliance upon, this material.

CLINICAL DISCLAIMER: Clinical information is provided for educational purposes and not as a medical or professional service. Person(s) who are not medical professionals should have clinical information reviewed and interpreted or applied only by the appropriate health professional(s).


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This page last edited on 2/19

All content ©2016 by Neurosurgical Consultants, P.A.
Author, Martin L. Lazar, MD, FACS
All Rights Reserved. See Usage Notices.