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CERVICAL DISC DISEASE AND CERVICAL DEGENERATIVE (OSTEO) ARTHRITIS - PART 1

(A Patient Information Service)

The cervical (neck) area is the most mobile of any portion of the spinal column. There are seven (7) separate cervical vertebrae (Figures 1 and 2) which are connected to each other through a series of joints, ligaments, discs and muscles. Pathological conditions can affect any of these structures. However, as a normal process of everyday life, there is a certain amount of "wear and tear" that involves any of the moving parts and the structures that connect them. This naturally occurring process is referred to as a "degenerative" change. It is present, to some extent, in everyone who is over 20 years of age. This does not mean that we are all going to experience serious problems with the discs or bones in our necks. Nevertheless, neck pain that results from these problems is very common. In order to understand why these difficulties occur and how to deal with them, it is important to understand something about the way the neck structures work.

The disc acts, in part, like a shock absorber between each vertebral body. The center of the disc (the Nucleus Pulposus) is a soft, gel-like substance that is held in place by a strong, dense multi-layered, multi- ringed capsule, the Annulus Fibrosus (Figure 3). The disc is attached to each adjacent vertebra and is surrounded by a series of very tough ligaments that also connect each vertebra in the Spinal Column. During the natural daily activities of movement and weight bearing, there is a very slow progressive "wear and tear" process in which the soft disc center (Nucleus Pulposus) becomes less rubbery and more brittle. It slowly becomes more like crab meat in its consistency during our 30th through 50th years of life. Beyond these years, the discs wear down; the center shrivels and dries rendering it less efficient as a shock absorber. This process is, to some degree, similar to what happens to "original equipment shock absorbers" on the family car. Unfortunately there are no "real replacement" discs available at this time although experimental products are being developed. The first artificial mechanical joint became available in mid-July 2007 in the manner of the "Prestige"® Cervical Arthroplasty Device (manufactured by Medtronic Sofamor-Danek). This is a stainless steel "ball and trough" design that is approved for implantation at one cervical level (from C3 to C7). There are over a dozen other synthetic bio-plastic/metal Arthroplasty devices designed by other companies currently under clinical investigation. Additional information is available in Cervical Spine Information-Part 2 and/or our website.

During the time that the discs are undergoing these degenerative changes, the Facet Joints (located posteriorly [in the back] and on either side of each vertebra) which assist in connecting one vertebra to the next, are also subjected to increased stresses. These joints are critical for normal neck movement. Each Facet Joint has, as "original equipment", a glistening smooth lining (Synovium) and a small amount of "joint fluid" (Synovial Fluid) that helps to facilitate motion of these joints. The neck motion of everyday activities inevitably results in a certain amount of "wear and tear" on these joints. As the disc becomes less efficient as a shock absorber, more stress is placed on the Facet Joints. The entire process involving the "wear and tear" on the joints, and their response to this "trauma", is called Degenerative Osteoarthritis (osteo=bone; arthritis=inflammatory change in the joints). As part of this process, the glistening, smooth joint surfaces slowly wear down and the joint's lubricating fluid is slowly "used up." The joints, and the bone near them, make every attempt to protect themselves against this wearing down. This response takes the form of laying down new, dense bone in and around the joint. This new hard bone is the body's way to try to prevent the bones from wearing away. In some cases, this new bone forms "spurs" which can compress the neural elements in the Foramen and/or Spinal Canal.

Some people seem to have a tendency towards developing more degenerative disc disease, along with its associated osteoarthritis, faster than other people. In some cases, it appears to be related to adolescent and adulthood sports activities, repetitive heavy lifting or previous neck injuries such as "whiplash" (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). Frequently, no causative agent or experience can be identified. It is important to recognize that many people can have far-advanced degenerative disc disease, osteoarthritis with large bone spurs and have absolutely no history of injuries of any sort. In addition, these same individuals may never have experienced any significant neck discomfort despite the fact that the degenerative process is so 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. 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.

Pain is the most frequent symptom that brings the patient with a neck problem to their physician. The pain may originate from any of the structures that we have reviewed so far, or from some other anatomical areas such as the Nerve Roots (or their coverings) which leave the Spinal Cord at each cervical level. (See figures 4, 5, and 6.) The experience of a painful stiff neck is familiar to most of us. The "stiffness" is usually the result of muscle spasm or tightness in the powerful paravertebral muscles that lie on either side in the back of the neck. This is the body's way to attempt to immobilize the joints that are injured. When the paravertebral muscles contract, 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.

Many patients also experience pain in the back of the skull (suboccipital region), which can be quite severe. It occurs with more severe contraction of these paravertebral muscles and is due to the muscle pulling on its insertion at the base of the skull which is covered by a thin layer (called "Periosteum") that is rich in pain fibres.

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 from 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 from further injury relating to a more important underlying difficulty. It then becomes increasingly important to more precisely identify the underlying pathology. Any persistent or recurring, severe neck pain deserves a more thorough evaluation by your physician.

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 more Facet 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.

Cervical Collars

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 that encircle the neck offer many patients all the relief that is necessary even though they are the least likely to immobilize the neck well. 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. For some people, this may mean several months wearing collars; others many only need this for a few days. An injury to a Facet 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

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 then continue to pursue the activities that are producing damage to the anatomical structures (joints, etc.), you are probably doing yourself (and these body parts) a serious disservice. Muscle relaxants and anti-inflammatory medications are also part of the treatment prescribed by physicians. Self-diagnosis and self-treatment for a recurring problem or a severe neck pain is very unwise. For most patients, prompt proper medically supervised treatment will reduce the likelihood for more extensive chronic neurological deficit and pain. Some patients may require more potent analgesics (narcotics) and more powerful anti-inflammatory agents such as "Steroids". (Please refer to our discussion of "Steroids" later in this monograph.)

One of the more serious disorders of the cervical spine is a Herniated Disc. The "herniated disc" is, in medical terminology, a "Herniated Nucleus Pulposus (HNP)." It is commonly called a "slipped or bulging disc," "ruptured disc," "misplaced” or "displaced" disc — to name a few. In this situation the shock-absorbing, softer center of the disc (Nucleus Pulposus) has pushed against, stretched or torn its way through the confining multiple layers of the capsule (Annulus Fibrosis). The Posterior Longitudinal Ligament, which assists the Annulus Fibrosus to hold the disc in place, is also stretched and damaged but remains intact.

The Spinal Cord is well protected as it lies inside the bony central Spinal Canal formed by each vertebra lying one on top of the other in the spinal column. At 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 pushes backwards it 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 damaged as it is pinched or pressed against the bone of the Spinal Canal. The nerve frequently responds to this pressure by developing Nerve Root swelling which results in more Nerve Root compression in the Neural Foramen. This increased pressure reduces the blood supply to the Nerve Root producing more damage to the Nerve Root and more swelling. A vicious cycle is established which could result in serious (possibly irreparable) injury to the Nerve Root.

A herniated disc is very uncommon in young people. It is more frequent in the third and fourth decades. Oftentimes some form of trauma can be identified as the cause the problem. Neck injuries from automobile accidents or lifting injuries are familiar to most physicians who treat these ailments. Another frequent experience is the herniation of a disc in the morning upon awakening. Each disc takes in some water (from body fluids) at night when lying down rendering the disc larger and under more pressure. In the morning, probably when turning suddenly in bed, there may be considerably more pressure exerted upon the disc. The pain is usually described as deep in the neck and made worse by certain neck movements. Many patients experience pain between the shoulder blades as well as in a shoulder and/or arm. Even in milder forms of disc herniation, the pain can be relentless with periods of relative worsening. Medical treatment will probably become necessary for most patients with a herniated disc. It is necessary to caution that not all neck pains are related to a herniated disc or joint problems. An accurate diagnosis by a skilled physician will help to focus on the precise problem for which specific treatment is appropriate.

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.

Spinal Manipulation

In various regions of this country, patients with herniated discs frequently undergo some form of "spinal manipulation" as part of chiropractic therapy or osteopathic, orthopedic, and (even more rarely) neurosurgical treatment. 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 can occur from overly vigorous Cervical Spine manipulation. At risk are the vitally important Vertebral Arteries which are protected in part of the cervical vertebrae as they course upwards to enter the skull where they supply blood to the Spinal Cord, Brain Stem, Cranial Nerves, Cerebellum and the Brain. Sudden and/or vigorous cervical spine manipulation can damage these vessels resulting in stroke/paralysis/death. 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 may improve many patients with cervical disc disease and/or degenerative arthritis. The traction apparatus lifts the skull and pulls the 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 is needed in order to relieve the pressure on a compressed nerve creating an environment that favors the improved blood flow to the Nerve Root that results in decreased swelling. 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.

Even if the herniated disc "slips" back into place and the pain, tingling, numbness and weakness are completely relieved, there remains an injured, weakened disc capsule and 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 and stress the already 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 may be too 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 make the appropriate choices to 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 occur at some later date. Sometimes the initial injury to the disc capsule and ligament are sufficiently severe that they can never satisfactorily recover, and the patient will eventually experience a recurrence of the "herniation". 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.

Traction can be applied to the cervical spine while the patient is sitting or lying down. One often prescribed system can fit on a doorjamb at home or even at work at your desk. There are expensive pneumatic or cable-driven devices that are not necessarily better than the less expensive, passive varieties. The best traction device is one which allows the patient to lie down and is adjustable for height. When you are lying down (particularly when asleep), you are more likely to be relaxed which means that the strong neck muscles are not counteracting the pull of the traction and the traction does not have to overcome the same gravitational force of the skull as when you are sitting. When recumbent, seven to eight pounds of traction is all that is required. More weight is not better and will cause Temporo-mandibular Joint (TMJ or jaw joint) pain. A "halter" device fits under the chin and attaches to the traction apparatus. 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.

There is one firm rule about using traction. IF IT HURTS, DON'T DO IT. Traction should not make the pain or the symptoms (such as tingling) worse. If it does, stop using it and talk with your physician.

The amount of time spent in traction depends on your condition and the stage of your treatment and recovery. In the acute (early) stages of treatment for a herniated disc, it is best to use the traction for as many hours of the day and night as you can tolerate it. In those patients with advanced weakness in the arm or hand and/or those with unrelieved excruciating pain, your physician may recommend hospitalization for several days where more powerful sedatives, muscle relaxants and pain relievers can be used. As a general rule, we are able to improve most patients with a herniated cervical disc within five days. If the pain or neurological problems are not improved within this time, the problem deserves further evaluation. In the event that there is improvement, further traction at home for seven to 14 days may be necessary. After this, depending on the patient's condition and work requirements, traction can be used intermittently for another few weeks or months.

We have mainly been discussing the medical management for herniated cervical disc; however, the treatments are also appropriate for cervical degenerative arthritis. There are some fundamental differences, in the long-term aspects, between patients with a herniated disc and those with degenerative arthritis (bone spurs). In patients with Nerve Root injuries from a bone spur, the bone spur has been present for years. The acute injury to the nerve is usually the result of some relatively sudden movement or a trivial injury in the face of long standing and relentless pressure on the nerve as it lies against the bone spur in the Neural Foramen (the bone window on the side of the spinal column through which the Nerve Root exits from the Spinal Cord). The compression injury produces Nerve Root swelling inside the Neural Foramen which is already made smaller by the hard bone spurs. Cervical traction can allow the cervical vertebrae to be "stretched apart" for a very short distance. Frequently this is sufficient to allow the Nerve Root enough room so that the swelling can be reduced. Once again, the length of time in the traction apparatus and the degree of vigor with which traction and medical treatment (muscle relaxants, pain relievers and oral steroids) is pursued depends on the severity of the neurological injury and the degree of pain. Cervical Spine manipulation is absolutely inappropriate in the case of nerve injury by a bone spur. The bone spur is not going to be changed by any form of manipulation or medicine. Manipulation of the spine can result in significant injury to the Cervical Nerve Roots or the Spinal Cord in these patients. For those patients who have a serious nerve injury, hospitalization may become appropriate for a trial of cervical traction. If the neurological condition improves then this treatment can be continued; nevertheless, the bone spur(s), as part of a progressive "degenerative" process, will not go away. This does not mean that surgical removal is necessary in the majority of these patients or that surgical treatment is inevitable. It does mean that some reasonable care, caution, and good common sense will be necessary in order to try to avoid repetitive nerve injury.

"Extruded Disc" - A Unique & Important Condition

There is another category of patients who suffer nerve injuries that also deserves special explanation. The condition of an "Extruded Disc" is one in which a portion of the Nucleus Pulposus ("crab meat"/shock absorber portion of the disc) has migrated through a tear in the multi-concentric rings of the Annulus Fibrosus and the Posterior Longitudinal Ligament to occupy a place in the Epidural Space within the Spinal Canal and/or Foramen. These disc fragments can be single or multiple and vary in size from quite small to large. They come to produce pressure upon the Nerve Root and/or the Spinal Cord. In some ways this condition is akin to squeezing toothpaste out of a tube. There is little likelihood that an Extruded Disc will regain its former position (within the disc space) meaning that the pressure that it exerts on the Nerve root and/or Spinal Cord will continue until it is surgically corrected.

An Extruded Disc can and frequently does occur in the presence of significant bone spur formation, although one is in no way dependent upon the other. However, when the two co-exist there is an added dimension of neural element compression. The bone spur has already been present for some time. It may or may not have produced symptoms in the previous years. The additional insult to the nerve by a herniated disc into a previously narrowed Neural Foramen (narrowed by the bone spur) or Spinal Canal may result in a more severe injury to the Nerve Root and/or Spinal Cord. While early preliminary medical treatment is important in an attempt to limit the extent of the Neurological injury, surgical correction is usually required to effectively repair this condition.

Steroids – A Useful Adjunct to Treatment

Steroids are the most powerful "anti-inflammatory" medications and are frequently used to reduce "swelling" of the nervous system tissue. For patients with Nerve Root compression, a SHORT COURSE OF ORAL STEROIDS with or without some of the other treatments (immobilization, traction) may be useful. There are some physicians who recommend the injection of steroids into the space around the Nerve Root (Epidural Space) in order to concentrate the maximum dose in the involved area and to avoid the possible (rare) side effects of oral medication. 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 is important to understand that this EPIDURAL STEROID INJECTION WILL NOT IMPROVE THE HERNIATED DISC OR THE BONE SPUR. THE ONLY REASON FOR USING STEROIDS IS TO ATTEMPT TO REDUCE THE SWELLING OF THE NERVE ROOT THAT HAS RECENTLY BEEN COMPRESSED AND INJURED. 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) and/or a Stenotic (narrowed) Spinal Canal. In any patient this treatment carries with it a risk to further (possibly irreparable) injury to the Spinal Cord and/or 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 insist upon a course of oral steroids first. If this fails then an MRI Scan should be done to determine the cause. Only if there is no evidence of significant Nerve Root/Spinal Cord compression might one then consider the injection. However, we would encourage you to learn about the practitioner's skills and also the risks to neurological injury and to life that are inherent in this treatment. In our considerable experience a course of oral steroids is usually quite effective in reducing the Nerve Root swelling resulting in improvement in the pain within 6-18 hours. This avoids the risk of Nerve Root injury associated with the Epidural Steroid injection method.

Other "Injection" Methods

"Facet Injections" may be appropriate for some patients. This is a temporizing technique that is popular in some regions. The theory is to infiltrate the area immediately surrounding the outside of a damaged facet with a long acting local anesthetic agent. It has no effect on the Facet itself or upon the degenerative process that involves that structure, nor does this affect or improve the cervical Nerve Root.

"Facet Rhizotomy" is another "needle" procedure. In this instance an electrical current is placed through a special needle in an attempt to permanently destroy the small sensory nerve that may supply a degenerative joint. This technique, like any Facet "injection", will have no effect on the underlying degenerative process that affects the joint.

"Chemonucleolysis", a technique that had become popular in the past, involves the injection of an enzyme into the disc to attempt to "digest" the disc. It is absolutely illegal (in the USA) to use this treatment in the cervical spine. If the medication (enzyme) leaks into the area of the Spinal Cord or Nerve Root, there could be a disaster since the enzyme can also "digest" the Spinal Cord or Nerve Root.

Diagnostic Neuroimaging

Let us turn our attention to some of the methods that are used to investigate patients with herniated cervical discs and cervical degenerative arthritis as well as Cervical Spinal Cord and/or Nerve Root injuries. It is worth repeating, for emphasis, the fact that NOT ALL NECK AND ARM PAIN IS DUE TO A HERNIATED DISC, CERVICAL OSTEOARTHRITIS OR NERVE ROOT COMPRESSION. Therefore, the first step is a review of the medical history of the patient together with a comprehensive focused neurological examination. This information forms the basis for the ensuing investigation.

In many cases, the physician will recommend a Cervical Spine X-ray examination. Several viewing angles are a routine part of the evaluation. We prefer front, side (lateral) as well as left and right oblique views in order to properly determine the extent of bone involvement for each of the cervical vertebrae. All the cervical vertebrae are seen on each of these four (4) views. (A fifth view may be taken to better evaluate the first cervical vertebra.) Although the disc (or its herniation) CANNOT BE SEEN by these x-rays, some inference can be made. In the case of degenerative disc disease, the involved disc space(s) will be narrower in height when compared to the normal discs. Even though a narrowed disc space implies degenerative disc disease, it certainly does not mean that this, necessarily, is either the source of the pain or the site of the ruptured disc in any particular patient. The involvement of the various joints of the cervical spine at each level with degenerative arthritis and the degree of bone spur formation can be evaluated by these "plain" x-rays if they are of good quality.

The "Uncovertebral Joints" are important anatomical structures of the cervical Spine that lie bilaterally (both sides) on the antero-lateral (far front) side of each vertebral body immediately adjacent to the Neural Foramen. Degenerative arthritic changes in these joints results in bone spur formation that can cause severe Nerve Root compression at the opening to and throughout the Neural Foramen. Uncovertebral Joint "hypertrophy" (bone spur formation) is one of the most common causes of Foramenal stenosis and Nerve Root injury. Plain x-rays can give some information about this unique anatomy; however, CT scan is the most accurate method to evaluate these structures.

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 x-ray or other neuroimaging (MRI and/or CT scans) studies. If your pattern of neurological involvement suggests a particular Nerve Root and the x-ray shows a significant change at that same level, then it is more likely that this level is the source of the problem. Many patients have bone spurs at more than one level. The fact that they are there does not mean that they are now (or will ever be) the source of any difficulty.

MRI (Magnetic Resonance Imaging) is another technologically advanced examination that can be used for spine problems. For the majority of these patients MRI is the best initial screening neuroimaging technique. It is well suited for "imaging" the Spinal Cord and frequently gives useful information about the other structures such as the discs, spinal canal diameter and the Cerebrospinal Fluid (CSF) space around the Spinal Cord. It provides less information about the bone structure.

CT Scan (Computed Tomography also known as "CAT" - Computerized Axial Tomogram) is another x-ray examination that can be of considerable help in defining the anatomy of a cervical problem. This test is the most effective method for "imaging" the bone and joint anatomy or any other structures that have developed a bony or calcified component (such as the pathologically calcified Posterior Longitudinal Ligament or some Spinal Cord tumors.) It is not reliable in evaluating the disc or Spinal Cord.

The amount of useful information that is gained depends upon a number of factors including the kind of machine that is used. The costs for using newer MRI and CT technology are not much more than those for the older machines. The quality of the information can be very different. Even the most modern MRI or CT devices can fail to give the appropriate information unless they are well supervised. The optimal situation for the best results is to have the test done with modern technology and supervised by an experienced neuroradiologist who should also have the responsibility to interpret the test results.

Both CT and MRI scans have permitted major advances in our diagnostic accuracy and have almost no significant risk to the patient. Neither of these tests would be part of a routine evaluation for a patient with relatively minor neck pain. Most neck pain patients will have an accurate diagnosis made by their physician and will respond to treatment. In the event that your physician suspects a more serious problem such as a nerve injury which doesn't improve, Spinal Cord compression or a congenital abnormality (a condition that you are born with which may not manifest itself until later in life), then these tests may become necessary.

A Myelogram is another specialized x-ray test. When combined with a CT scan, it is usually considered to be the "Gold Standard" as the most accurate neuroimaging study for evaluating the conditions of herniated cervical discs and degenerative arthritis of the cervical spine for which surgery will be appropriate. This test, although very accurate and reliable (if done under optimum circumstances), is more uncomfortable than the others mentioned and carries with it some small risk. We do not recommend this examination unless the patient is clearly a candidate for an operation and the other non-invasive neuroimaging studies have failed to fully elucidate the extent of the structural anatomical condition. In the event that a myelogram becomes appropriate, it is usually carried out in anticipation that surgery is to be done. It is designed to more precisely pinpoint the anatomical extent of the structural problem as well as to evaluate the circumstances of the other Cervical Vertebrae together with the anatomy of the inside of the Spinal Canal. Patients with significant multi-level degenerative arthritis, particularly those with Spinal Canal and/or Foramenal stenosis and/or calcified Posterior Longitudinal Ligament, are among those who may benefit as a result of the critical information derived from this examination.

The Neuroradiologist who will conduct the myelogram will discuss the details of this test with the patient and will review the technique, the small risk and any other additional details that involve that particular patient. The Neuroradiologist will be happy to answer any questions pertaining to any of these investigations.

Each step of the Myelogram is conducted under x-ray (fluoroscopic) control. After the skin insertion site and underlying tissues are infiltrated with a local anaesthetic, a special needle is inserted into the Spinal Canal, through the Dura Mater (the thick tissue layer overlying the Spinal Cord) and into the subarachnoid space where the Cerebrospinal Fluid (CSF) circulates around the Spinal Cord. Once accurate placement of the needle has been confirmed, a special dye substance is injected into the subarachnoid space. Multiple x-rays are taken, including special views from various angles. Immediately thereafter the patient is transported to the CT scan for additional images. It is these images that provide the extraordinary bone detail of the spine that can be critically important in the thorough pre-operative technical surgical planning process required for satisfactory and permanent treatment of the unique anatomical circumstances for any particular patient.

Discogram & Disco CAT Scan

These two neuroimaging studies are mentioned here for the sake of completeness; however, we strongly disagree with the concept of and disapprove of the execution of this "investigation". This involves injecting a dye substance into one or more discs. The "theory" behind it is the presumed reproduction of the patient's pain pattern by increasing the pressure within the "abnormal" disc space. Additionally, the pattern of spread of the injected dye is often interpreted as being "abnormal". In our opinion, this is the most abused and least reliable of any of the investigation methods available to evaluate neck and arm pain patients. For the doctors who order this test, the primary reason for its use is in patients who complain of neck pain in the absence of neurological involvement and have no significant structural spine problems other than some degenerative changes in the disc(s).

Electromyography and Nerve Conduction Velocity (EMG NCV)

There is one other examination that is occasionally used in patients with suspected Nerve Root or Nerve problems. Electromyography (EMG) is an examination of nerves and muscles which can give important information about the electrical function of these nerves and muscles. Neurologists and Physical Medicine Rehabilitation specialists, who have taken additional training in these techniques, can provide very useful information not only about the present state of the nerves (for possible comparison at a later date) but also help to decide about the precise location and the diagnosis of the problem. Some clinical problems may appear to be the result of a Nerve Root injury but may not prove to be so. The EMG is another test that may help to arrive at an accurate diagnosis.

It is important to recognize that not all of these tests are either necessary or appropriate for every patient who has these problems. Your physician will help to guide you towards the ones that best suit your medical condition.

In the event that these non-operative ("Conservative") treatments fail, then surgical alternatives may become appropriate. In most cases surgical intervention is not appropriate until conservative, nonsurgical treatments have failed (unless there is Spinal Cord injury and/or very severe Spinal Canal narrowing due to large bone spurs or significant Spinal Cord compression due to a large herniated disc). In our view, cervical spine operations are rarely appropriate for patients with neck and/or arm pain in the absence of significant neurological deficits or major Spinal Canal narrowing. (Please see Cervical Spine Information-Part 2 for further details of the "Indications for Cervical Spine Surgery".)



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This page last edited on 2/20

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