Neck Pain / Cervical Spondylosis
CERVICAL RADICULOPATHY
Degeneration of the cervical spine can result in several different conditions that cause problems. These are usually divided between problems that come from mechanical problems in the neck and problems which come from nerves being irritated or pinched.
A cervical radiculopathy is a problem that results when a nerve in the neck is irritated as it leaves the spinal canal. This condition usually occurs when a nerve root is being pinched by a herniated disc or a bone spur.
Causes
Cervical Radiculopathy (“Pinched Nerve”)
Pinched nerve from a herniated disc
Bending the neck forward and backward, and twisting left and right, places many kinds of pressure on the vertebrae and disc. The disc responds to the pressure from the vertebrae by acting as a shock absorber. Bending the neck forward compresses the disc between the vertebrae. This increased pressure on the disc may cause the disc to bulge toward the spinal canal and the nerve roots.
Injury to the disc may occur when neck motion puts too much pressure on the disc. One of the most painful injuries that can occur is a herniated disc.
In this injury, the tear in the annulus portion of the intervertebral disc is so bad that part of the nucleus pulposus squeezes out of the center of the disc. The annulus can tear or rupture anywhere around the disc. If it tears on the side next to the spinal canal, when the nucleus pulposus squeezes out, it can press against the spinal nerves.
Pressure against the nerve root from a herniated disc can cause pain, numbness, and weakness along the nerve. There is also evidence that the chemicals released from the ruptured disc may irritate the nerve root, leading to some of the symptoms of a herniated disc — especially pain.
Herniated discs are more common in early middle-aged adults. This condition may occur when too much force is exerted on an otherwise healthy intervertebral disc. An example would be a car accident where your head hit the windshield. The force on the neck is simply too much for even a healthy disc to absorb and injury is the result. A herniated disc may also occur in a disc that has been weakened by the degenerative process. Once weakened, less force is needed to cause the disc to tear or rupture. However, not everyone with a ruptured disc has degenerative disc disease. Likewise, not everyone with degenerative disc disease will suffer a ruptured disc.
Pinched nerve from degeneration and bone spurs
In middle aged and older people, the degenerative disc disease can cause bone spurs to form around the nerve roots. This usually occurs inside the foramen — the opening in the cervical spine where the nerve root leaves the spine to travel into the arm. If these bone spurs get big enough they may begin to rub on the nerve root and irritate the nerve root. This causes the same symptoms as a herniated disc. The irritation causes pain to run down the arm, numbness to occur in the areas the nerve provides sensation to and weakness in the muscles that the nerve supplies.
Symptoms
A cervical radiculopathy causes symptoms that radiate out away from the neck. What this means is that although the problem is in the spine, the symptoms may be felt in the shoulder, the arm, or the hand. The symptoms will be felt in the area where the nerve that is irritated travels. By looking at where the symptoms are, the spine specialist can usually tell which nerve is involved. The symptoms include pain, numbness and weakness. The reflexes in the upper arm can be affected.
When you are suffering from a cervical radiculopathy, there is usually also neck pain and headaches in the back of your head. These are sometimes referred to as occipital headaches because the area just about the back of the neck is called the “occiput.”
Diagnosis
Finding the cause of neck pain begins with a complete history and physical examination. After the history and physical examination, your doctor will have a good idea of the cause of your pain. To make sure of the exact cause of your neck pain, your doctor can use several diagnostic tests.
These tests are used to find the cause of your pain — not make your pain better. Regular X-rays, taken in the doctor’s office, are usually a first step in looking into any neck problem and will help determine if more tests will be needed.
Complete History
Your doctor will ask you to describe when your neck pain began and the type of pain you are having.
For example, he may ask:
when did the pain first begin?
have you increased your activity level?
have you had an injury, or surgery, to your neck at any time?
does the pain go down into your arms or legs?
what causes your neck to hurt more or less?
have you had any problems with your bowels or bladder?
Physical Examination
Once most of the information is gathered, your doctor will give you a thorough physical exam. During the exam your doctor will look at your neck to find out how well your neck is functioning. This includes:
how well you can bend your neck and roll your head in all directions
How well you can twist your neck
If there is tenderness around the neck
If there are muscle spasms around the neck and shoulders
Tests that examine the nerves that leave the spine is also important. This includes:
Testing for numbness in the arms and hands
Testing the reflexes
Testing the strength of the muscles in the arms, hands, and legs
Testing for signs of nerve irritation
X-rays
X-rays show the bones of the cervical spine. Most of the soft tissue structures of the spine, such as the nerves, discs, and muscles, do not show up on X-ray. X-rays can show problems that affect the bones, such as infection, fractures, or tumors of the bones. X-rays may also give some idea of how much degeneration has occurred in the spine. X-rays alone will not show a herniated disc. The X-rays will be useful in showing how much degeneration and arthritis are affecting the neck. Narrowing of the disc space between each vertebra and bone spurs do show up on X-rays.
Magnetic Resonance Imaging (MRI)
The MRI is the most commonly used test to evaluate the spine because it can show abnormal areas of the soft tissues around the spine.
The MRI is done to find tumors, herniated discs, or other soft-tissue disorders. During the MRI, very detailed computer images of sections of the spine are taken. Unlike most other tests, which use X-rays, the MRI uses magnetic fields and radio waves to see the structures of the neck.
Pictures can also be taken in a cross section view. The MRI allows the doctor to clearly see the nerves and discs without using special dyes or needles. In many cases, the MRI scan is the only special test that needs to be done to find what is causing your neck pain.
Treatment
Treatment for any spine condition should include two main goals:
Relieve pain
Reduce the risk of re-injury
Conservative Treatment
Medication
Medications are commonly used to control pain, inflammation, muscle spasm, and sleep disturbance.
Cervical Collar
A cervical collar is often used to provide support and limit motion while an injured neck is healing. It also helps keep the normal alignment. Cervical collars can be soft (made of foam) or hard (made of metal or plastic)
Cervical Pillow
A special pillow may help your pain at night and allow you to sleep better. These cervical pillows are specially designed to place the right amount of curvature in the neck while you sleep and decrease the amount of irritation on the nerve roots.
Epidural Steroid Injection (Nerve Block)
If other treatments do not relieve your pain, you may be given an epidural steroid injection, or a cervical nerve block.
An epidural steroid injection places a small amount of cortisone into the bony spinal canal. Cortisone is a very strong anti-inflammatory medicine that may control the inflammation surrounding the nerves and may ease the pain caused by irritated nerve roots. The epidural steroid injection is not always successful. This injection is often used when other conservative measures do not work, or in an effort to postpone surgery.
Surgery
In some cases, the cervical radiculopathy will not improve with non surgical care. In these cases your surgeon may recommend surgery to treat your cervical radiculopathy. Your surgeon may also recommend surgery if you begin to show signs of:
Unbearable pain
increasing weakness
increasing numbness
muscle wasting
the problem begins to affect the legs also
One of the most common operations used to treat a cervical radiculopathy caused by pressure from bone spurs and a herniated disc is the Anterior Cervical Fusion.
After surgery you will probably be placed in some type of brace while healing occurs. Following an anterior cervical fusion it is not unusual to wear a brace for 6 to 12 weeks while the fusion occurs.
Rehabilitation
Physical Therapy
Whether you have surgery or not, your doctor may have a physical therapist work on an exercise program developed just for you. The physical therapist will teach you ways to prevent further injury to your neck. Many problems in the cervical spine can be improved greatly with a good exercise program and good education on neck mechanics.
CERVICAL SPONDYLOTIC MYELOPATHY
Cervical= having to do with the spine in the neck
Spondylotic= having to do with spinal degeneration
Myelopathy= damage to the spinal cord
Cervical spondylotic myelopathy is damage to the spinal cord in the neck.
The spinal cord begins at the base of the brain and runs down through the spinal canal, an enclosed tube made of bones, cartilage and ligament tissue of the spine. The spinal cord transmits electrochemical signals between the brain and the body. The spinal cord is surrounded by a few millimeters of fluid-filled space, which helps to protect it from trauma and allows flexibility without injury to the spinal cord.
Myelopathy, or damage to the spinal cord, can occur for a number of reasons. The most common cause of myelopathy is when the spinal cord is compressed, or squeezed. This compression disrupts normal nerve transmission. Arthritis of the spine, or spondylosis is the most common reason the spinal cord is compressed.
Spondylosis refers to degenerative, or age-related, changes in the spine. These changes include disc degeneration, bone spurs, and thickened ligaments.
Cervical spondylotic myelopathy, therefore, is myelopathy (spinal cord damage) caused by spondylosis (degeneration) in the cervical spine (neck).
It affects the fibers of the spinal cord that transmit impulses to the arms, hands, and legs. As a result, it can cause weakness, numbness, tingling, or rarely, pain in these areas.
Symptoms
The symptoms of cervical spondylotic myelopathy depend on the level(s) of the spinal cord that are involved and the pattern of the involvement.
Symptoms may include:
- numbness of the hands
- clumsiness of the hands
- arm and/or hand weakness
- leg stiffness (“walking like a robot”)
- loss of balance
- urinary urgency
- neck pain–may be present but is not usually a significant complaint
The timing of the appearance of symptoms and progression varies from person to person. The rate of progression of symptoms may also change over time. Symptoms may progress rapidly for a period of time and then enter a period of stability. Alternatively, the symptoms may progress slowly but steadily.
Causes and Risk Factors
Cervical spondylotic myelopathy is caused by spondylosis, or age-related degeneration. Common degenerative changes include bone spurs (osteophytes), disc bulges, and thickened ligaments.
These changes may narrow the spinal canal, encroaching on the fluid-filled space around the spinal cord. Eventually this stenosis, or narrowing, can impinge on the spinal cord itself. The resulting compression (squeezing) damages the delicate fibers of the spinal cord.
Tests and Diagnosis
Post-myelography computed tomography (myelo-CT) – consists of X-rays taken after the injection of radio-opaque contrast material into the spinal fluid via a lumbar puncture. This procedure may provide useful images of the interior of the spinal canal, and can reveal indentations of the spinal fluid sac caused by bulging discs or bone spurs that might be compressing the spinal cord or nerves.
- Magnetic resonance (MR) imaging scan – the best method of imaging the spinal cord, nerve roots, intervertebral discs, and ligaments. MR scans may be used to obtain high-resolution images of the cervical spinal canal and the spinal cord.
Treatments
The primary treatment of cervical spondylotic myelopathy is to decompress the spinal cord (remove the pressure from it). The surgery is performed to prevent the progression of symptoms. In other words, the goal of surgery is simply to prevent symptoms from getting any worse. Damage that has occurred in the spinal cord itself can heal, but it is impossible to predict the degree of healing. The prognosis is different in every case.
The exact procedure chosen is based on the location and type of stenosis, the overall alignment of the cervical spine, and many other factors.
The surgeon may perform surgery from the front of the neck, which is called an anterior approach. These surgical procedures may include the following:
- anterior cervical discectomy and fusion
- anterior cervical corpectomy
In other situations, the surgeon may perform surgery from the back of the neck, which is called a posterior approach. These surgical procedures may include the following:
- cervical laminectomy
- cervical laminectomy and fusion
- cervical laminoplasty
In some cases, the surgeon may perform surgery using both an anterior and a posterior approach.
The surgeon will provide information on the available surgical procedures and will tailor the treatment to each patient and case.
