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Neck Pain and Cervical Spondylosis

Introduction
The cervical spine consists of the top 7 vertebrae of the spine. Doctors often refer to these vertebrae as C1 - C7, with the "C" indicating cervical, and the numbers 1-7 indicating the level of the vertebrae. C1 is closest to the skull, while C7 is closest to the thoracic (chest/rib cage) region of the spine.

The cervical spine is particularly susceptible to degenerative problems because of:
• its large range of motion
• Somewhat complex anatomy.

Symptoms
Symptoms include, neck pain, pain around the back of the shoulder blades, arm complaints (pain, numbness or weakness), and rarely, difficulty with hand dexterity or walking. Symptoms are commonly described as a soreness or stiffness of the neck, which may or may not be associated with a minor injury. Patients often attribute this to a "cold wind" or "sleeping wrong" that may or may not be a factor. Muscle strains tend to improve within a week or so. However, if the pain persists longer, call your doctor, as it may be another condition that needs medical treatment.

Cervical disk herniations are more characteristic in the young (less than forty-years old), while cervical spondylosis(degeneration) and stenosis are typically found in older patients. The degenerative process may begin in any of the joints in the cervical spine, and over time it may also cause secondary changes in the other joints

Symptoms may include:
• Neck soreness on one or both sides
• Burning pain
• Tingling sensations
• Stiffness
• Pain around the shoulder blades
• Arm complaints (pain, numbness or weakness)
• Pain that moves around your body (for instance, down an arm)
• Trouble walking or writing
• Trouble swallowing or talking
• Headache
• Dizziness
• Nausea
• Blurred vision
• Fever
• Night sweats
• Tiredness
• Unintentional weight loss
It is important to treat your neck pain properly. Seek medical attention if your neck pain persists - and seek immediate attention if you have any of the emergency signs listed in the red box below.

Warning Signs
Neck pain is one of the symptoms of meningitis, a relatively rare but very serious contagious infection. You need urgent medical care if you have neck pain with:
• High fever
• Sensitivity to light
• Irritability
• Severe tenderness with neck movement

Neck pain can also be due to injury. A severe neck injury could be life-threatening. You may need emergency medical treatment if you have neck pain with:
• Numbness
• Weakness
• Tingling symptoms

The image above is a general illustration of the spine and is not an exact replica of the cervical spine.

Common causes of neck pain
Cervical Stenosis
When disc degenerates, the normal relationships of the bones are lost and there is a condition of instability- one vertebra moving in an abnormal manner in relation to the next vertebra. In an attempt to stabilize, new bone grows outward - osteophytes. Osteophytes can be found near the disc spaces and around the facet joints. If they grow in areas where nerves or the spinal cord are nearby, they can impinge or compress these structures. This can cause pain, numbness, tingling, or weakness to varying degrees. If significant enough to cause nerve dysfunction, it is known as cervical stenosis.

Cervical Disc Herniation
is more or so like the disc prolapse/herniation in the lower back. In the process of sustaining increased mechanical loads, the outer aspect of the disc, known as the annulus becomes stressed and with time, small tears can form in it. The gel center, known as the nucleus, can be ejected from the disc through an annular tear. This is called a disc herniation. If the disc herniates in the direction of the spinal cord or nerve root, it can cause neurologic compromise. Disc herniations in the cervical spine can be serious. If significant enough, they can cause paralysis of both the upper and lower extremities, though this is extremely rare.

In most cases, a patient complains of neck pain associated with radiating pain to one arm. This is caused by compression of a nerve root. With time some herniated discs resolves or shrinks. Sometimes, disc herniations can persist, causing prolonged symptoms and neurologic problems, which may lead to surgical considerations

Cervical Spondylosis
It is really nothing more than a description of what happens to the vast majority of our cervical spines as we get older. It is known that a high percentage of patients without any neck pain or other symptoms have spondylosis of the spine. In some people, however, spondylosis may be associated with neck pain. Spondylosis is likely the end result of disc degeneration that has been present for a very long time.

Diagnosing the Problem
A neurologic examination will be done to rule out a neurologic deficit. A shoulder examination will also probably be done to ensure that the symptoms are indeed originating from the neck.

Various diagnostic tools may be used, including:

X-rays
X-rays are useful for identifying such problems as:
• narrowing of the intervertebral disc space
• anterior osteophytes (i.e. bony spurs)
• Spondylosis (i.e. arthritis) of the facet joints
• osteophytes from the uncovertebral joints (see figures below)


                                         X-ray views of cervical vertebrae

Computed Tomography
Computed tomography (CT) can highlight the bony changes associated with degenerative spondylosis (arthritis). Osteophytes can be observed and evaluated as well. However, CT does not provide for optimal evaluation of discs (although it may sometimes show disc herniations).

Magnetic Resonance Imaging
Magnetic resonance imaging (MRI) is a powerful tool in the assessment of patients with cervical spondylosis. Images from MRI's can help doctors to identify disc herniations, osteophytes and joint arthrosis. MRI is best suited for soft disc herniations, but often times more information is needed.



                                        MRI assessment of cervical vertebrae

Myelogram/CT
It is often utilized in complex cases involving multi-level disease, or suboptimal MRI images. It is very useful in delineating bone spurs from safe disc herniations.

Discography
As in the lumbar and thoracic spine, cervical discography (see figure) remains controversial. Although the discogram may add to the clinician's knowledge, it should not be used by itself to predicate treatment.




Treatment Options
After the doctor has conducted the necessary tests to identify the problem in the cervical spine, a treatment plan will then be developed. Various treatment options are available, and can be subdivided into two categories:
Non operative treatment
Operative treatment.

Nonoperative Treatment
Nonoperative treatment of cervical degenerative disease provides good to excellent results in over 75% of patients. A multidisciplinary approach includes:
Immobilization - can be achieved using a collar or braces; most beneficial during acute exacerbations of pain by reducing motion at the symptomatic levels.

Physical therapy and manipulation (chiropractic) - can be useful in decreasing muscle spasms that can contribute to symptoms; this is where heat, electrical stimulation, tractions and exercise have their maximum benefit.

Medications - including painkillers, nonsteroidal anti-inflammatory, and muscle relaxants. In many cases, nonoperative treatment can provide good long-term results.

Pain management Modalities

Operative Treatment
A surgeon is likely to consider a surgical treatment of a cervical degenerative problem if one or more of the following criteria are met:
• Non operative treatments have been tried and failed
• The disorder is causing spinal cord dysfunction
• The disorder is causing prolonged arm pain or weakness

The surgical procedure proposed for these patients is removing the bone spur and possible fusion of two or more cervical vertebrae. In most instances, the preferred approach is an anterior (i.e. from the front) Interbody fusion. Using the anterior approach, a surgeon can perform a complete discectomy (i.e. removal of the disc between two vertebrae), and then seek to restore the normal disc space height and normal lordosis (i.e. the concave curve in the cervical spine) by implanting a carefully sculpted graft. A titanium plate may be utilized to improve the rate of fusion and avoid a neck brace.

A posterior approach (from the back of the spine) is often considered when a cervical disc has herniated laterally (i.e. sideways).

What is new?
The new concept is the motion preservation surgery - Cervical Disc Replacement .

Conclusion
Cervical spine degenerative disorders can be diagnosed more accurately and treated more effectively today than even five or ten years ago. Under the guidance and treatment of an expert spine specialist, most patients can now hope to see a very significant improvement in their condition.


 * " This information is for educational purposes only and should not be relied upon as medical advice. It has not been designed to replace a physician's independent judgment about the appropriateness or risks of a procedure for a given patient."

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