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| Patient Education -- Cervical
Pain |
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Cervical
Pain
Pain or discomfort in the neck is a common reason for
patients to seek medical care. Most cases are not serious.
A muscle spasm, brought on by poor posture, sleeping position
or stress, is the most frequent causes of neck pain. But
an aching neck can be a symptom of a more serious problem.
Disc degeneration, narrowing of the spinal canal, arthritis
and even cancer can cause neck pain. For serious neck
problems a primary care physician and often a specialist,
such as a neurosurgeon, should be consulted.
When to See a Physician
A doctor should be consulted if neck pain occurs after
an injury or blow to the head. Also see a doctor if a
fever or headache accompanies the neck pain, if a stiff
neck prevents you from touching your chin to your chest,
if pain shoots down one arm, if there is a tingling in
your hands or if pain does not decrease after a week.
You can take a number of steps on your own to alleviate
neck pain caused by strain or spasm of the neck muscles.
Improve your posture and change the way you sleep. Take
rest breaks at work instead of sitting or standing in
the same position. Do exercises to stretch the neck and
shoulder muscles. Use hot showers, hot compresses or a
heating pad to relax tense muscles. Take aspirin or ibuprofen.
Understanding the Neck
The neck is part of a long flexible column of bones and
other tissue, often referred to as the spinal column or
backbone, that extends through most of the body. The neck
region of the spinal column is called the cervical spine,
which consists of seven bones or vertebrae that are shaped
like building blocks.
Intervertebral discs separate the vertebrae from one another.
These discs allow the spine to move freely and act as
shock absorbers when a person moves.
The back of each vertebra forms a tube-like canal of bone
that runs down the back. This space is called the spinal
canal, through which the spinal cord and nerves travel.
The spinal cord is surrounded by cerebrospinal fluid and
three protective membranes called the dura, the pia and
the arachnoid.
A pair of spinal nerves exit each vertebra through small
openings called foramina (one to the left and one to the
right). These nerves connect to the muscles, skin and
tissues of the body, providing sensation and movement
to all parts of the body. The delicate spinal cord and
nerves are further supported by strong muscles and ligaments
that are attached to the vertebrae. The cervical spine
needs to be strong because it also holds up the head,
which can weigh 10 pounds or more.
Common Disorders of the Cervical Spine
Cervical Disc Disorders
The discs in the neck can wear out in the course of aging
or can be damaged by sudden movement (whiplash), poor
posture or diseases such as arthritis. Neck pain occurs
when the herniated disc pinches the nerve or when arthritis
progresses to the point where it involves the joints of
the spine. Arthritis can lead to degeneration of the disc
as well as abnormal bone growths (spurs) next to the joints.
These spurs are the result of repetitive movement and
can irritate the adjacent nerve and cause pain.
Cervical disc disorders are typically marked by intermittent
neck pain, followed by severe neck and sometimes arm pain.
The pain is sufficient to awaken a person from sleep.
Irritated nerves also can lead to numbness or weakness
in the arm or forearm, tingling in the fingers and coordination
problems. Severe nerve impairment or even paralysis can
develop if the disorder is left untreated.
Pressure on the spinal cord from a herniated disc or bone
spur in the neck can also be a very serious problem. Virtually
all of the nerves of the body have to pass through the
neck to reach their final destination (arms, chest, abdomen,
legs).
Cervical Stenosis
Cervical stenosis is a narrowing of the spinal canal that
can pinch the spinal cord. The normal aging process is
usually the cause. The discs dehydrate over time, causing
them to lose their ability to act as shock absorbers.
At the same time, degenerative changes in the vertebrae
can lead to the growth of bone spurs that compress the
nerve roots. The bones and ligaments that make up the
spine gradually thicken and become less pliable. These
changes cause the spinal canal to narrow.
Symptoms of cervical stenosis are neck pain, numbness
and weakness in the hands, inability to walk at a quick
pace, deterioration of fine motor skills and muscle spasms
in the legs.
Osteoarthritis
The joints in the neck deteriorate as people age, sometimes
leading to osteoarthritis. The symptoms of osteoarthritis
are pain radiating to the shoulder or between the shoulder
blades and pain that is worse at the start of the day,
improves during the day and gets worse again at the close
of the day. This pain usually diminishes with rest. Patients
with a previous history of a whiplash injury are six times
more likely to develop this condition.
Injury
Whiplash is one of the most common injuries to the neck
and commonly occurs after a rear-end automobile crash.
Whiplash symptoms include neck stiffness, shoulder or
arm pain, headache, facial pain and vertigo. Pain from
a whiplash injury can be caused by tears and bleeding
in the muscles that support the neck, ligament rupture,
or a disc tearing away from a vertebra.
Diagnosing Neck Problems
A physician investigates a neck problem through a medical
history, physical exam and diagnostic tests. The physical
examination includes an assessment of sensation, strength
and reflexes in various parts of the body to help pinpoint
which nerves or parts of the spinal cord are affected.
The doctor may then order various diagnostic studies to
determine more precisely the nature and extent of the
disorder. These studies may include:
X-rays: An x-ray shows the bones of the neck and
determines if there is significant wear and tear or disease
of the bone. It also shows whether the bones are aligned
(lined-up) properly.
Computed Tomography (CT): A CT (also known as a
CAT scan) produces an image of the neck based on x-rays
but displayed in slices. It helps clarify the relationship
of the disc or bone spurs to the spinal cord and nerves.
The CT may be done in conjunction with a myelogram of
the neck to provide additional information.
Magnetic Resonance Imaging (MRI): The MRI uses
a powerful magnetic field rather than x-rays to produce
a detailed anatomical picture of the neck and the structures
within it. An MRI is probably the best test to see herniated
discs since they are soft tissues that are invisible to
x-rays.
Myelogram: The myelogram is an x-ray with a special
dye that highlights the spinal cord and nerves. The dye
is usually injected into the fluid space around the spinal
cord with a needle and then the x-rays are obtained. Myelograms
have largely been replaced by CT and MRI scans.
Electromyogram and Nerve Conduction Studies (EMG/NCS):
Unlike the other tests, which help a doctor determine
anatomy and structure, these tests primarily study how
the nerve and muscles are actually working together. They
test for the impulse coming from the brain and/or spinal
cord. If the impulse is blocked, it may be delayed or
diminished enroute to its final destination (i.e., muscle,
skin, toe, finger-tips). This information can assist in
determining which nerves or muscles are functioning abnormally.
Discography: This is a special x-ray test that
may help identify which discs are damaged and if they
are a source of pain. It uses a contrast dye injected
into the disc space to image the disc.
Treatment
Patients with neck pain are usually treated conservatively
at first. Non-surgical treatments often can provide sufficient
relief. Most cervical disc herniations, for example, heal
with time and conservative treatment and do not require
surgery.
Conservative treatment includes bed rest, reduction of
physical activity, physical therapy and wearing a cervical
collar, which provides support for the spine, reduces
mobility and lessens pain and irritation. An injection
of corticosteroids may be used to temporarily relieve
pain. A cervical traction device may be used to further
relieve the pressure on the nerves in the neck. This device
attaches to the head and pulls up on the head using a
pulley system and weights. It is usually applied a few
times a day and can be used while sitting or lying in
bed.
Mild cervical stenosis can be treated conservatively for
extended periods of time as long as the symptoms are restricted
to neck pain. Severe stenosis requires referral to a neurosurgeon.
Treatment of whiplash injuries consists of analgesics,
non-steroidal anti-inflammatory drugs, muscle relaxants
and aggressive physical therapy. Home cervical traction
and manipulation are sometimes helpful. Approximately
65 percent of whiplash patients make a full recovery,
25 percent have minor residual symptoms and 5 to 10 percent
develop chronic pain syndromes.
Conservative treatment options may continue for up to
eight weeks. If there is severe muscle weakness or progressive
symptoms, a more aggressive timetable may be warranted
to avoid an irreversible wasting away of the muscles.
When Surgery is Necessary
Surgery may be needed when conservative treatments for
cervical disc problems do not provide relief. The choice
of treatment and the decision as to when to perform the
operation should be determined by a neurosurgeon, the
medical specialist trained in the surgical treatment of
disorders of the spine.
Surgery may be advisable if:
• You miss work because of pain.
• You are unable to join in family activities because
of pain or muscle weakness.
• Your pain forces you to spend more time alone,
away from friends and family.
• You feel frustrated or depressed because of your
pain.
• You are otherwise in good health.
Factors in determining the type of surgical treatment
include what type of disease (herniated disc or bone spurs),
whether there is pressure on the spinal cord or spinal
nerves and if the spine is dislocated in addition to pressure
on the cord or nerves. Other factors include age, duration
of disorder, other medical conditions and previous medical
history.
Surgery has its limitations. It can''t reverse all the
effects of overuse or aging, and it carries risks. Yet
it may be the only way to relieve pain, numbness and weakness.
Surgical Procedures
Anterior Cervical Discectomy
The most common surgical procedure on the neck relieves
pressure on one or more nerve roots or on the spinal cord.
The operation enlarges the nerve opening and removes the
disc, as well as removing any attached bone spurs that
could be compressing the spinal sac and nerve roots.
The surgeon makes an incision in the front (anterior)
of the neck. The soft tissues within the neck are separated
to allow the surgeon to reach the front of the spine,
after which the disc and any bone spurs are removed. Sometimes
the space between the vertebrae is refilled with a small
piece of bone in a procedure called fusion. The bone may
be the patient''s, taken from the hipbone, or it may be
taken from a donor bone bank. In addition to the bone,
a metal plate at the fusion site may be attached to further
strengthen the fusion. Over time, the vertebrae and bone
fuse together, creating a more stable structure.
Anterior cervical discectomy typically involves few risks.
These include infection, bleeding, stroke, injury to the
recurrent laryngeal nerve (causing temporary or permanent
hoarseness), and injury to the involved nerve root(s)
or the spinal cord, both of which can cause paralysis.
Overall, the risk is low and is much less than 5 percent
for most healthy people.
Cervical Corpectomy
A more extensive version of the discectomy procedure,
a cervical corpectomy involves removing vertebrae as well
as discs. It is a more difficult surgery than a discectomy
and the risks are slightly higher. These include nerve
root and spinal cord damage, bleeding, infection, damage
to the trachea or esophagus, graft dislodgement and continued
pain. The most serious risk is complete or partial quadriplegia
if the spinal cord is damaged.
Posterior Hemi-laminectomy
This operation is performed through a vertical incision
in the back (posterior) of the neck, generally in the
middle. The bone around the spinal cord or the bone around
the nerve opening is removed, as are the attached ligaments
exerting pressure on the spinal sac and nerve roots. Once
the nerve is located, it is gently moved aside and an
incision is made on the outside covering of the disc,
through which the disc material is then removed.
Recovery After Surgery
A cervical collar or brace may be fitted around a patient''s
neck after surgery. Occasionally, a drainage tube may
be used and is typically removed after a day or two. Intravenous
(IV) fluids will be ordered during the early recovery
period.
A patient who has had an anterior cervical discectomy
or corpectomy may have a sore throat. If a piece of bone
was taken from a hip for a graft, the area of incision
is usually sore.
The length of the hospital stay is determined by the progress
of recovery and by a patient''s home situation. A patient
is provided with instructions regarding his brace, incision
care and physical activity when he leaves the hospital.
After Leaving the Hospital
Patients generally wear a brace for a few weeks and normally
are not allowed to drive, lift heavy objects or engage
in contact sports or vigorous physical activity for a
while. Pain in the neck or arms may continue but will
slowly lessen as the nerve heals. Medication may be necessary.
Numbness or tingling sensations are often the last symptoms
to fade away.
Patients need to adopt habits that reduce the risk of
neck pain such as good posture and proper body mechanics
when lifting and even during routine daily tasks.
Role of Neurosurgeons
Neurosurgeons are medical specialists trained to help
patients suffering from neck pain. Neurosurgeons provide
the operative and non-operative (prevention, diagnosis,
evaluation, treatment, critical care and rehabilitation)
care of neurological disorders. Neurosurgeons undergo
six to eight years of specialized training following medical
school, one of the longest training periods of any medical
specialties. A major focus of neurosurgical training is
management of disorders of the spine.
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