CERVICAL SPINE DISEASE

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"

What to try "First"

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

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

Cervical Traction

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

Epidural Steroid Injections (ESI)

Cervical Spondylosis (Degenerative Arthritis/Osteoarthritis)

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

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.

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This page last edited on 2/19