Anterior Cervical Fusion

Rationale

An anterior cervical fusion is performed through an incision in the front of the neck.An anterior cervical fusion is used
to remove pressure from nerve roots or the spinal cord caused by bone spurs or a herniated disc
to stop the motion between two or more vertebrae

Removing pressure from the nerve roots or spinal cord can ease arm pain. Problems from pressure on the nerves, such as numbness or weakness in the arm or difficulty walking, may also improve. Fusion of the problem vertebrae reduces mechanical pain caused from too much motion in the spinal segment.

Procedure

Discectomy

Anterior cervical discectomy is one of the most common surgical procedures for problems in the cervical spine. The term discectomy means to "remove the disc." This procedure is routinely used to relieve pressure on a spinal nerve or the spinal cord cause by a herniated disc.

Discectomy is also done when the surgeon intends to fuse two or more bones of the neck together. This procedure of disc removal and fusion (described below) is often used to treat degenerative problems (called spondylosis) in the neck.

In the cervical spine, the disc is usually removed from the front. An incision is made in the front of the neck beside the trachea (windpipe). The muscles are moved to the side. The arteries and nerves in the neck are also protected.

Upon reaching the front of the spine, the surgeon uses an X-ray to identify the correct disc. The problem disc is removed all the way back to the spinal cord. If any bone spurs are found sticking off the back of the vertebrae and your surgeon thinks they may also be causing you pain, they may be removed at the time of surgery. Great care is taken to not damage the spinal cord and nerve roots.

Anterior Cervical Fusion

After the disc has been removed between the vertebrae, a cervical fusion is performed. The space where the disc was taken out is filled with a block of bone taken from the top rim of the pelvis. Bone taken from your own body is called autograft. Your surgeon may obtain bone from a source other than your body, called allograft. This bone is kept in a bone bank. Placing a bone graft between two or more vertebrae causes the vertebrae to fuse.

The anterior cervical fusion may also be done in a way that spreads the vertebrae apart a bit, trying to restore the space between them. This is done to recreate the normal height of the disc space and to restore the normal inward curve of the neck (called lordosis). Increasing the distance between the vertebrae also widens the opening (foramina) where the nerves come out of the spine. Restoring the size of the foramina is done to relieve pressure and irritation from bone spurs where the nerves pass through the foramina.

Most neck problems are from a degenerative, or aging, condition of the spine. Degenerative disc disease and cervical stenosis are two diagnoses that can lead to pressure on the spinal cord or nerve roots. Surgery to remove this pressure can be done from the front (anterior) or back (posterior) of the neck. Doctors use the anterior approach more often because the pressure is usually on the front portion of the nerves or spinal cord.

Anterior Interbody Fusion

When an interbody fusion is done, the disc between two vertebrae is removed, and a bone graft is positioned in its place. As the body heals, the graft fuses to the vertebrae above and below it. When more than one disc needs to be removed, a larger bone graft is inserted. Patients usually wear a brace after the surgery. The brace limits movement between the vertebrae, increasing the chances for a successful fusion.

Bone heals best when it is held still-without motion between the pieces trying to heal. The healing of a fusion is no different than healing a fractured bone, such as a broken arm. However, the neck is one part of the body that is difficult to hold still, even with a brace worn around the outside of the neck. Wearing a brace for several months after the surgery can be uncomfortable.

The success of a fusion can also be improved by screwing metal (titanium) plates or rods to the front of the spine. This holds the vertebrae and graft rigidly in place while the fusion heals. These implants are referred to as instrumentation or internal fixation. There are many different types of spinal implants used with the intent of stabilizing the neck and maximizing healing of the fusion. When doctors use this type of instrumentation, a brace may be needed for a shorter period of time, or not at all.

Anatomy of the Cervical Spine

Neck

The cervical spine is made up of the first seven vertebrae in the spine. It starts just below the skull and ends just above the thoracic spine. The cervical spine has a lordotic curve, a backward "C"-shape-just like the lumbar spine. The cervical spine is much more mobile than both of the other spinal regions. Think about all the directions and angles you can turn your neck.

Unlike the rest of the spine, there are openings on each side of the vertebra in the cervical spine for arteries (blood vessels that carry blood away from the heart). The arteries that run through these openings carry blood to the brain.

The upper two vertebrae in the cervical spine, the atlas and the axis, differ from the other vertebrae because they are designed specifically for rotation. These two vertebrae are the reason your neck can move in so many directions.

The atlas is the first cervical vertebra-the one that sits between the skull and the rest of the spine. The atlas does not have a vertebral body, but it does have a thick forward (anterior) arch and a thin back (posterior) arch with two prominent sideways masses.

The atlas sits on top of the second cervical vertebra, the axis. The axis has a bony peg called the odontoid process, which sticks up through the hole in the atlas. It is this special arrangement that allows the head to turn from side to side as far as it can. Special ligaments between the atlas and the axis allow for a great deal of rotation.

The cervical spine is very flexible, but it is also at risk for injury from strong, sudden movements, such as whiplash-type injuries. There is limited muscle support in the cervical area. The head weighs about 12 to 15 pounds and is balanced on top of the atlas bone at the top of the spine. Sudden, strong head movements can cause damage to the bones, ligaments, or even the arteries that carry blood to the brain.

Other Major Segments

Thoracic Spine (Mid Back)
Lumbar Spine (Low Back)

Important Structures of the Spine

Vertebrae
Intervertebral Discs
Facet Joints
Neural Foraminae
Spinal Cord
Nerve Roots
Paraspinal Muscles
Spinal Segments

Cervical Corpectomy and Strut Graft

Introduction

Many cervical problems are due to degenerative changes that occur in the discs and joints of the neck. These changes commonly take place as a natural part of aging and from the affects of daily wear and tear on the parts of the spine. Degenerative changes in the neck sometimes lead to a serious condition where pressure is put on the spinal cord. One surgical option to relieve the pressure is to remove the degenerative vertebrae and replace them with bone graft. This procedure is called a corpectomy and strut graft.

Learn about cervical corpectomy and strut graft including

how the cervical spine is affected
why the procedure is performed
what you can expect from this procedure including possible complications

Anatomy

In order to understand your symptoms and treatment choices, it is helpful to start with a basic understanding of the anatomy of the neck. This includes becoming familiar with the various parts that make up the cervical spine and how they work together.

Rationale

An effective procedure for removing the pressure on the spinal cord due to
spinal stenosis is to remove one or several vertebral bodies to take pressure off the spinal cord. The procedure is called a corpectomy. Corpus means "body" and ectomy means "remove." The discs between the vertebrae are also removed.

After removal of the vertebral body (or bodies), a cervical fusion is performed. When the bodies of one or more vertebrae are taken out, a bone graft is inserted to fill the space. As the bone graft heals, it fuses to the intact vertebrae above and below it. The bone graft provides structural support to the cervical spine.

Procedure

In the cervical corpectomy procedure, the vertebrae are removed from the front. An incision is made in the front of the neck beside the trachea (windpipe). The muscles are moved to the side. The arteries and nerves in the neck are also protected.

Upon reaching the front of the spine, the surgeon uses an X-ray to identify the correct vertebrae and discs. The vertebral bodies and discs causing problems are removed all the way back to the spinal cord. Bone spurs that extend from the back of the vertebrae toward the spinal canal are removed as well. Special care is taken to reduce the risk of damaging the spinal cord and nerve roots.

Once the vertebrae and discs have been removed, the space between the vertebrae above and below must be filled. Doctors typically implant a graft of bone into the space. The section of bone graft works like a "strut" to support the spine. The strut may be formed by taking bone from your hip (pelvis) or from the fibula bone in your leg. Bone taken from your own body is called autograft. Your surgeon may also use allograft, which is bone taken from a source other than your body and stored in a bone bank.

Learn more about the use of bone graft.

Some method of internal fixation to hold the bones and bone graft in place is normally used. The most common method is to use metal (titanium) plates and screws. The plate sits on the front of the remaining vertebrae, covering the strut graft. Screws are placed into the vertebral bodies above and below the graft to hold the plate in place and keep the bone graft from slipping.

Complications

Like all surgical procedures, operations on the neck may have complications. Because the surgeon is operating around the spinal cord, neck operations are always considered extremely delicate and potentially dangerous. Take time to review the risks associated with cervical spine surgery with your doctor. Make sure you are comfortable with both the risks and the benefits of the procedure planned for your treatment.

Rehabilitation

This is a serious and complex operation. Patients usually wear a neck brace after surgery. Some patients may need the extra support of a halo brace. Most patients do not require rehabilitation after this surgery. However, a short period may be needed for patients who are having pain or difficulty doing routine activities. A physical therapist may work with you to design a specific exercise program.

Once the fusion is healed, you may progress toward a more vigorous rehabilitation program.

Cervical Fusion

Introduction

Many neck problems are due to degenerative changes that occur in the intervertebral discs of the cervical spine and the joints between each vertebra. Other problems are the result of injury to parts of the spine or complications of earlier surgeries. The vast majority of patients who have neck problems will not require any type of surgery. But if conservative treatments fail to control the pain, your surgeon may suggest a cervical fusion.

Learn about cervical fusion including

how the cervical spine is affected
what types of problems can benefit from cervical fusion
what differentiates an anterior cervical fusion from a posterior cervical fusion
what you can expect from this procedure including possible complications
how rehabilitation can improve your results
Related Document: Anterior Cervical Fusion
Related Document: Posterior Cervical Fusion

Anatomy

Learn more about the anatomy of the cervical spine.

Rationale

If it becomes apparent that surgery will be needed, there are a number of surgical procedures designed to treat various neck problems. A cervical fusion is used

to stop the motion between two or more vertebrae
to stabilize unstable fractures of the cervical spine
to straighten or realign the cervical spine

The goal of a spinal fusion is to allow two or more vertebrae to grow together or fuse into one solid bone. If you are suffering from pain in the moving parts of the spine (mechanical pain), the fusion can stop the excess motion between the vertebrae and reduce your pain.

If your neck is unstable due to a fracture or dislocation of the vertebrae, the fusion stabilizes the spine. This is particularly important when the spinal cord hasn't been injured. By surgically stabilizing the problem area in the neck, the spinal cord is protected as the neck heals. Even when the spinal cord has been damaged and the patient is paralyzed, a spinal fusion can enable the patient to get out of bed and into a wheelchair sooner. By stabilizing the spine, fusion allows the patient to begin rehabilitation earlier.

A cervical fusion may also be suggested to straighten the spine or to control a deformity of the cervical spine such as a cervical kyphosis. This is a condition where the natural inward curve of the neck reverses. This deformity occurs when the cervical spine is unstable and begins to bend forward.

Learn more about cervical kyphosis.

Procedure

There are two types of cervical fusion procedures, anterior cervical fusion, and posterior cervical fusion.

Related Document: Anterior Cervical Fusion
Related Document: Posterior Cervical Fusion

In the anterior cervical fusion, the operation is done from the front of the neck. In the posterior cervical fusion, the operation is done through an incision in the back of the neck. A bone graft is used to connect the problem vertebrae. During the healing process, the vertebrae grow together, creating a solid piece of bone. This halts motion between the problem vertebrae, creating stability in the neck. Cervical fusion is used to treat cervical fractures, dislocations, and other pathologies. It is also used to correct deformities in the neck.

The bone graft used for cervical fusion is usually taken from the pelvis (hip) at the time of surgery. However, some surgeons prefer to use bone graft from a bone bank. This is bone that is taken from organ donors and stored under sterile conditions until needed for operations such as spinal fusion. The bone goes through a rigorous testing procedure, similar to a blood transfusion, before being used for fusion surgery.

Learn more about the use of bone graft

Complications

A minimum of three months is needed for the bones to fuse together and become solid. Yet the bone graft will continue to mature for one to two years. Your doctor may have you wear a rigid neck brace or halo vest for up to three months after surgery to keep your spine still and make sure the bones fuse. You may not require a rigid brace after a simple fusion using instrumentation.

Most patients are able to return home when their medical condition is stabilized, usually within one week after fusion surgery. Limit your activities to avoid doing too much too soon. Avoid activities that put strain on the healing fusion, such as forceful bending or twisting movements of the neck. Delay activities that require heavy or forceful use of your arms, such as lifting, until your doctor determines these activities are safe.

Learn more about possible complications of spine surgery.

Rehabilitation

Learn more about surgical after care.

Physical Therapy

Your doctor may have you attend physical therapy beginning a minimum of five weeks after surgery. A well-rounded rehabilitation program assists in calming pain and inflammation, improving your mobility and strength, and helping you do your daily activities with greater ease and ability. Therapy sessions may be scheduled up to three times each week for six to eight weeks.

The goals of physical therapy are to help you

learn ways to manage your condition and control symptoms
improve flexibility and strength
learn correct posture and body movements to protect the fusion
return to work safely

Learn more about spinal rehabilitation after surgery.

Cervical Kyphosis

Introduction

When viewed from the side, the normal cervical spine curves slightly inward. This inward curve is called lordosis. Kyphosis is a term used to describe a type of abnormal curve in the spine. A kyphotic curve looks like the letter "C" with the opening of the C pointing towards the front. This type of curve is the opposite of a normal lordotic curve, which has the opening facing towards the back. The larger the abnormal curve, the more serious the problem. Several different conditions can lead to an excessive kyphosis.

Learn about cervical kyphosis including

-what causes cervical kyphosis
-what problems may be caused by cervical kyphosis
-how surgery is used to treat the condition

Anatomy

In order to understand your symptoms and treatment choices, it is helpful to start with a basic understanding of the anatomy of the spine. This includes becoming familiar with the various parts that make up the neck and how they work together.

As described earlier, the cervical spine normally has a lordosis, or inward curvature. Kyphosis is an abnormal condition in the neck in which the normal inward curve reverses. This causes an abnormal forward curve in the cervical spine.

The stability of the cervical spine and its ability to stay in the lordotic position depends on other parts of the spine. The vertebral bodies need to be strong enough to support the head and keep the normal shape of the spine. The facet joints, ligaments, and soft tissues in the back of the neck and back must be strong. And the muscles in the back must be able to resist the effect of gravity pulling the head forward. If there is damage to any of these three areas, a kyphotic deformity can develop, and the weight of the head can cause reversal of the normal curvature of the spine.

Causes

This condition has several possible causes and can develop in both children and adults.

Iatrogenic Causes

Kyphosis can occur for iatrogenic reasons. "Iatrogenic" means that the problem happened from the effects of a medical treatment, such as surgery. Kyphosis can happen after laminectomy surgery. This procedure is done to relieve pressure on the spinal cord or spinal nerves. During the procedure, the lamina bone that covers the spinal canal is removed. Sometimes part or all of the facet joints are also removed during the procedure. This can cause looseness between the problem verterbrae. When this happens, the spine may begin to tilt forward.

Kyphosis may also happen after cervical fusion surgery. In this case, the spine will begin to "bend" over the topmost part of the fusion. The forward tilt causes an imbalance that can lead to kyphosis. Similar problems can also arise if the fusion fails to heal properly (pseudarthrosis). Even when a fusion heals normally, kyphosis can occur if the vertebrae heal with improper alignment.

Degenerative Disc Disease

Degeneration of the intervertebral disc can lead to kyphosis in the neck. In older adults, the wear and tear of aging can cause the discs to collapse. This may cause the head to tilt forward, making the neck bend forward too. This process may steadily get worse over many years. The weight of the head causes the unbalanced forces to push the neck further and further forward. This slowly leads to a loss of the normal curve and may end with a cervical kyphosis. Learn more about degenerative disc disease.

Congenital Defect

Cervical kyphosis can be congenital, which means that you are born with it. A person born with some sort of defect, such as incomplete formation of part of the spine, may end up with an increasing kyphosis in the neck. Congenital kyphosis usually leads to a growth disturbance of the vertebrae. Instead of growing normally, the vertebrae grow into a triangular-shape with the thin end pointing forward. Because the vertebrae are stacked on top of each other, the triangle shape causes the spine to have a forward curvature. When a child has congenital kyphosis, there are generally additional birth defects in other areas of the body, most commonly of the kidneys and urinary system.

Trauma

Cervical kyphosis can occur as the result of an injury to the neck. Vertebral compression fractures cause the vertebral body to collapse into the shape of a wedge. This causes the section of spine to tip forward, and the resulting imbalance leads to a loss of the normal curvature of the neck. Other injuries that damage the ligaments along the back of the cervical spine can also cause kyphosis. If the kyphosis gets bad enough, it can narrow the spinal canal and put pressure on the spinal cord (spinal stenosis).

Other Causes

Other less common causes of cervical kyphosis include infections or tumors in the spine, systemic (whole body) diseases that affect the spine such as ankylosing spondylitis and radiation therapy for cancer in the neck. Children especially who have had radiation therapy to the neck may have altered growth in the cervical vertebrae, leading to future problems with kyphosis.

Symptoms

The symptoms and severity of kyphosis vary. Symptoms range from minor changes in the shape of your spine, to severe deformity, neurologic deficits, and chronic pain. Neck movement may become limited, making it difficult to turn the neck fully or to look up for very long. The abnormal forward curvature can eventually appear unattractive. Neck pain may be present, especially if the kyphosis is caused by degenerative changes.

If the kyphosis is severe, pressure can occur on the spinal nerve roots or spinal cord. This can cause weakness in the arms or legs, loss of grip strength, or difficulty walking due to spasticity in the legs. Bowel or bladder control may be lost. In extremely severe cases that are left untreated, paralysis from the neck down may even result.

With a kyphotic deformity, the spinal cord may be stretched where the spine bends forward. The spinal cord is the body's connection to the brain. When it is damaged or compressed, the body loses some of its ability to function properly. If pressure builds up on the spinal cord, it can cause myelopathy. Myelopathy may impair normal walking, hand and finger use, and bowel and bladder function. Doctors take these symptoms very seriously because severe myelopathy that is not treated may lead to permanent nerve damage. Pressure on the spinal cord can eventually lead to quadriplegia, paralysis of all four limbs.

Diagnosis

Finding the cause of your neck problem begins with a complete history and physical exam. Various diagnostic tests may be ordered to help your doctor determine exactly what is causing your symptoms. The most common tests used to diagnose cervical kyphosis are X-ray and MRI.

Treatment Options

The typical treatment for congenital kyphosis is surgery. Early surgical intervention usually produces the best results and can prevent progression of the curve. The type of surgical procedure will depend on the nature of the abnormality. Conservative treatments do not have much success at correcting this type of kyphosis. When surgery is not done, it is critical that the condition is observed and that close medical follow-up is done, including X-rays and MRI scans. This is to make sure the kyphosis isn't worsening to the point it causes more serious problems.

Conservative Treatment

Treatment for cervical kyphosis depends largely on whether there is pressure on the spinal cord. If there is, surgery may be suggested. If the cervical kyphosis is primarily causing pain and concern about your appearance, then the doctor may consider trying to control the pain and deformity with a neck brace for a short period of time, pain medications, and a physical therapy program.

Physical Therapy

Your doctor may have you work with a physical therapist. A well-rounded rehabilitation program assists in calming pain and inflammation, improving your mobility and strength, and helping you do your daily activities with greater ease and ability.

Exercise has not proven helpful for changing the kyphotic curve in the neck. However, it can be helpful in providing pain relief. Therapy sessions may be scheduled two to three times each week for up to six weeks.

The goals of physical therapy are to help you

learn correct posture and body movements to counteract the effects of kyphosis
maintain appropriate activity levels
maximize your neck range of motion and strength
learn ways to manage your condition

Surgical Treatment

If the kyphosis is flexible, the decision to go ahead with surgery will be based on the progression of the curve and the amount of pain it causes. If the curve and pain are minor, surgery may not be recommended-even if the deformity looks unattractive. If the deformity is severe and the pain is chronic, surgery may be a good option.

Surgery is usually not recommended when the deformity is fixed (inflexible but not worsening) and if there are no problems with the nerves or spinal cord. If a fixed deformity is accompanied by neurological problems from pressure on the spinal cord, the need for surgery is greater. Surgical correction is the most difficult type of treatment for cervical kyphosis.

Surgery to treat cervical kyphosis usually involves spinal fusion combined with segmental instrumentation. This means that some type of metal (titanium) plate or rod is used to hold the spine in the proper alignment to straighten it. Surgery may require two procedures done during the same operation. First, surgery to the front of the spine is done to relieve the pressure on the spinal cord. The second procedure is done through the back to fuse the spine and prevent the kyphosis from returning.

If the kyphosis is due to ankylosing spondylitis (AS), the connection between the cervical and thoracic spine is the problem area. This type of cervical kyphosis is usually a fixed deformity. In AS the discs between each vertebra of the entire spine calcify and fuse the bones of the spine together. If there is a cervical kyphosis after AS fuses the spine, the surgeon may need to do an osteotomy of the fused spine. "Osteo" means bone, and "otomy" means cut. This procedure involves cutting the front of the spinal column so the surgeon can straighten the spine. The spinal cord is not cut-only the bones of the vertebrae in the front of the spinal column.

Cervical Laminectomy

Introduction

The spinal cord needs adequate space inside the spinal canal. The spinal canal is a protective ring of bone that surrounds the spinal cord. Conditions such as fractures, dislocations, tumors, or degenerative changes in the discs and joints of the neck can put pressure on the spinal cord. This is because the protective ring of bone around the spinal cord does not expand to accommodate more space. Extra pressure within the confined space of the spinal canal can place the entire spinal cord in danger. Surgery to open the back of the spinal cord is one way to relieve pressure that is on the spinal cord. This procedure is called laminectomy.

Learn about cervical laminectomy including

how the cervical spine is affected
why a laminectomy is performed
what you can expect from this procedure including possible complications
how rehabilitation can improve your results

Rationale

Bone spurs or a herniated disc can take up space inside the spinal canal and put pressure on the spinal cord. This condition is called spinal stenosis. If spinal stenosis is the main cause of your symptoms, the spinal canal may need to be enlarged. Bone spurs that are pressing on the nerves may need to be removed. This can be achieved with a complete laminectomy. Laminectomy means "remove the lamina".

Removing the lamina gives more room for the spinal cord and spinal nerves and relieves the pressure. Surgeons may also remove bone spurs that may be causing irritation and inflammation around the spinal nerves.

Procedure

The surgeon begins by making an incision down the center of the back of the neck. The neck muscles are then moved to the side.

Upon reaching the back surface of the spine, the surgeon uses an X-ray to identify the problem vertebra. The lamina is removed, taking the pressure off the back part of the spinal cord and nerves.

Removing the entire lamina in the cervical spine may cause problems with the stability of cervical spine. If the facet joints are damaged during the laminectomy, the spine may become unstable and cause problems later. One way that spine surgeons try to prevent this problem is not to actually remove the lamina. Instead they simply cut one side of the lamina and fold it back slightly. The other side of the lamina opens like a hinge. This makes the spinal canal larger, giving the spinal cord more room. The cut area of the lamina eventually heals to keep the spine from tilting forward.

Complications

Rehabilitation

You'll be able to get up and begin moving within a few hours after surgery. Your doctor may have placed you in a neck collar after surgery. Limit your activities to avoid doing too much too soon. Most patients are able to return home when their medical condition is stabilized, usually within a few days after surgery.

Physical Therapy

Your doctor may have you attend physical therapy beginning four to six weeks after surgery. A well-rounded rehabilitation program assists in calming pain and inflammation, improving your mobility and strength, and helping you do your daily activities with greater ease and ability. Therapy sessions may be scheduled two to three times each week for up to six weeks.

The goals of physical therapy are to help you

learn how to manage your condition and control symptoms
improve flexibility and strength
learn correct posture and body movements to reduce neck strain
return to work safely

Cervical Radiculopathy

Introduction

Cervical radiculopathy occurs when a nerve in the neck is irritated as it leaves the spinal canal. Commonly thought of as a "pinched nerve," cervical radiculopathy is generally from a herniated disc or a bone spur that is pressing against an inflamed nerve root. Most often these are a result of degenerative changes in the neck.

Learn about cervical radiculopathy including

how the cervical spine is affected
what symptoms accompany the condition
how the condition is diagnosed
what treatment options are available

Anatomy

Causes

Cervical Radiculopathy ("Pinched Nerve")

Nerve roots that go from the spinal cord in the cervical spine travel into the arm. Along the way, these nerves supply sensation (feeling) to areas of the skin from the shoulder to the fingers. They also carry electrical signals to muscles that move the arm, hand, or fingers. Problems occur when one of these nerves becomes inflamed and is pinched by a herniated disc or bone spur. This may show up as weakness, numbness, and pain where the nerve travels. The pain may feel deep, dull, and achy. Or you may have sharp, shooting pain along the path of the nerve. Muscles controlled by the affected nerve root may also weaken. In the neck, this condition is called cervical radiculopathy.

Disc Herniation

The neck is subject to tension and pressure when the neck moves. The disc between each vertebra responds by acting as a shock absorber. Bending the neck forward compresses the discs between the vertebrae and tends to bulge the discs backward toward the spinal canal and nerve roots.

Problems may occur when the center part of the disc, the nucleus pulposus, squeezes out of the disc and puts pressure on nerves in the neck. This condition, called disc herniation, can happen when a tear in the outer ring of the disc (the annulus) allows the nucleus to squeeze through. The annulus can tear or rupture anywhere around the disc. If it tears next to the spinal canal, the nucleus can squeeze out and put pressure on the spinal cord or spinal nerves. Pressure against the nerve root from a herniated disc can cause numbness and weakness along the nerve. When the nerve root is inflamed, the added pressure from the disc may also cause vague, deep pain in the neck, shoulder, and upper arm. It can also cause sharp, shooting pain to radiate along the pathway of the nerve.

This condition may occur when too much force is exerted on an otherwise healthy intervertebral disc. Heavy forces on the neck may simply be too much for even a healthy disc to absorb.

Herniated discs are more common in middle-aged adults. This is because the natural process of aging causes the discs to become weakened from degeneration. Less force is needed to cause the degenerated disc to herniate. Not everyone with a herniated disc has degenerative problems. Likewise, not everyone with degeneration will suffer a herniated disc.

Bone Spurs

In older people, degenerative disc disease can cause bone spurs to form near the nerve roots. If these bone spurs get big enough, they may begin to rub on the nerve root and irritate it. This usually occurs inside the foraminae, which are small openings on each side of the spinal column where the nerve roots leave the spine. An irritated nerve root that is squeezed by a bone spur can cause the same symptoms as a herniated disc in the neck-pain, numbness, and weakness in the arm.

Symptoms

Cervical radiculopathy causes symptoms that radiate away from the neck. Although, the problem is in the neck, the symptoms will be felt wherever the nerve travels-shoulder, arm, or hand. By locating the symptoms, your doctor can usually tell which nerve in the neck is having problems. Symptoms generally include pain, numbness, and weakness. The reflexes in the upper arm can also be affected.

Neck pain and headaches near the back of the head are common with cervical radiculopathy. The back of the head is called the occiput, which is why headaches in this area are called occipital headaches.

Diagnosis

Finding the cause of your neck problem begins with a complete history and physical exam. After the history and physical exam, the doctor may have a good idea of the cause of your pain or other symptoms. To make sure of the exact cause of your neck pain, several diagnostic tests can be used. These tests are used to find the cause of the pain, not make it better. Standard X-rays, are usually a first step in looking into any neck problem. These include an oblique (angled) view, along with X-rays taken as you bend forward (flexion) and backward (extension). Your doctor will also determine whether other tests, such as an MRI, are needed.

Treatment Options

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 proper alignment. Cervical collars can be soft (made of foam) or hard (plastic). Because these collars can restrict head movement, you may need help with eating or other activities. The skin under the collar needs to be checked every day to prevent blisters or sores.

Cervical Pillow

A special pillow may help ease your pain at night and allow you to sleep better. Cervical pillows are specially designed to place the right amount of curvature in the neck while you sleep and to decrease the amount of irritation on the nerve roots. These pillows can be purchased from drug stores or from a physical therapist.

Physical Therapy

Therapists use cervical traction to gently stretch the neck and to relieve pressure on the irritated nerve root. Electrical stimulation eases muscle spasm and pain. Exercises focus on improving strength and coordination of the neck, shoulders, and upper back. Therapy sessions may be scheduled two to three times each week for up to six weeks.

The goals of physical therapy are to help you

learn correct posture and body movements to reduce neck strain
maintain appropriate activity levels
maximize your neck range of motion and strength
learn ways to manage your condition

ESI

If other treatments do not relieve your neck pain, you may be given an epidural steroid injection(ESI), also called a nerve block. An ESI places a small amount of cortisone into the bony spinal canal. Cortisone is a strong anti-inflammatory medicine that may control the inflammation surrounding the nerves and may ease the pain caused by irritated nerve roots. This injection is often used when other conservative measures do not work, or in an effort to postpone surgery. This treatment is not always successful but may provide short-term help. Learn more about spinal injections.

Surgical Treatment

Cervical radiculopathy doesn't always improve with conservative care. Surgery may be recommended when the following conditions are present:

unbearable pain that doesn't respond to medical management
unacceptable weakness
weakness that is progressing
evidence of spinal cord compression
bowel or bladder concerns

One of the most common operations used to treat a cervical radiculopathy caused by pressure from bone spurs and a herniated disc is an anterior cervical fusion.

After surgery, you may be placed in some type of neck brace for up to 12 weeks while healing. Learn more about braces used to treat neck problems.

Cervical Spinal Stenosis

Introduction

Most cervical problems are due to degenerative changes that occur in the discs and joints of the neck. Degenerative changes that affect the structures of the spine can cause the spinal canal to become too narrow, a condition called spinal stenosis. This may lead to pressure on the spinal cord. Bone spurs that stick into the spinal canal take up space, making the spinal canal smaller. They can press against the spinal cord or nerve roots.

Pressure on the spinal cord from spinal stenosis can cause symptoms of myelopathy. Myelopathy may impair normal walking, hand and finger use, and bowel and bladder function. Doctors take these symptoms very seriously because severe myelopathy that is not treated may lead to permanent nerve or spinal cord damage. Pressure on nearby nerve roots can cause radiculopathy and may produce pain, weakness, or sensory changes in the area supplied by nerves that go from the cervical spine to the shoulder, arm, or hand.

Learn about cervical spinal stenosis including

what causes the condition
what symptoms are present with spinal stenosis
how the condition is diagnosed
what treatment options are available

Anatomy

Causes

To best understand cervical spinal stenosis it is helpful to know how wear and tear affects the parts of the spine. This process is called degeneration.

As we age, the disc loses some of its water content and, as a result, some of its shock absorbing ability. The first changes that occur in the disc are tears in the outer ring of the disc, called the annulus. Tears in the annulus may occur without symptoms. You may not notice when they occur or what caused them. These tears heal by forming scar tissue.

Scar tissue is weaker than normal tissue. Repeated injuries and tears cause more wear and tear to the disc. As the disc wears, it gets less and less "spongy", eventually becoming unable to act as a shock absorber.

As the disc continues to wear, it begins to collapse. The space between each vertebra becomes smaller. This collapse affects how the facet joints in the back of the spine "line up." Like any other joint in the body, the change in the way the spine bones fit together causes abnormal pressure on the articular cartilage covering the facet joints. Articular cartilage is a smooth, shiny material that covers the end of the bones in most joints in the body. Over time, this abnormal pressure causes wear and tear arthritis (osteoarthritis) of the facet joints.

Bone spurs may form around the vertebrae and facet joints. Eventually, bone spurs may begin to form. These spurs may begin to press against the spinal cord, leading to the symptoms of myelopathy discussed earlier. Or the spurs can put pressure on the nerves where they leave the spinal canal. This can lead to symptoms of radiculopathy (described below).

The combined effects of the bone spurs, bulging discs, and thickened ligaments place the spinal cord at risk of being squeezed inside the spinal canal.

Symptoms

The symptoms from spinal stenosis depend on whether pressure is affecting the spinal nerve roots or the spinal cord. A (>radiculopathy) usually only causes symptoms in the neck and arms. Pressure on the spinal cord (myelopathy) can affect the arms and legs.

Radiculopathy is a condition that can happen from pressure on a spinal nerve root. Commonly thought of as a "pinched nerve," this type of pressure feels different than pressure on the spinal cord. Pressure on an irritated or inflamed nerve root may produce feelings of pins and needles in the area supplied by the nerve root. The pain may feel deep, dull, and achy. Or you may have sharp, shooting pain along the path of the nerve. Muscles controlled by the affected nerve root may also weaken. Muscles controlled by the affected nerve root may also weaken.

Pressure on the spinal cord (myelopathy) is a greater concern, because it can lead to permanent spinal cord damage. Symptoms from myelopathy vary. Feelings of numbness or weakness can affect both arms and both legs. A loss of muscle control in the legs, called spasticity, may cause difficulty walking. "Position sense" may be lost in the arms or legs. This affects the ability to know where your arms or legs are when your eyes are closed. When this occurs it becomes difficult to use the arm and hands and to know where you are placing your feet as you walk. Myelopathy may disturb the normal function of the bowels and bladder.

Diagnosis

Finding the cause of your neck problem begins with a complete history and physical exam. After the history and physical exam, your doctor will have a good idea of the cause of your pain and symptoms. To make sure of the exact cause of your neck pain, several diagnostic tests can be used. Standard X-rays, taken in the doctor's office, are usually a first step in looking into any neck problem and will give your doctor an idea of whether cervical spinal stenosis exists. These include an oblique (angled) view, along with X-rays taken as you bend forward (flexion) and backward (extension). Your doctor will also determine whether other tests, such as an MRI, are needed.

X-rays of cervical disc degeneration

MRI scan showing cervical stenosis.

Treatment Options

Conservative Treatment

Epidural Steroid Injection (Nerve Block)

If other treatments do not relieve your neck pain, you may be given an epidural steroid injection (ESI), also called a nerve block. An ESI places a small amount of cortisone into the bony spinal canal. Cortisone is a strong anti-inflammatory medicine that may control the inflammation surrounding the nerves and may ease the pain caused by irritated nerve roots. This injection is often used when other conservative measures do not work, or in an effort to postpone surgery. This treatment is not always successful but may provide short-term help. Learn more about spinal injections.

Related Document: epidural steroid injection

Physical Therapy

If your condition is causing only mild symptoms and does not appear to be getting worse, your doctor may have you work with a physical therapist. A well-rounded rehabilitation program assists in calming pain and inflammation, improving your mobility and strength, and helping you do your daily activities with greater ease and ability.

In mild cases, nonsurgical treatments offer ways to control symptoms and enable you to improve without surgery. You may be issued a neck brace to hold your neck steady, reducing extra strain. You will need to limit your activities, especially heavy and repeated movements of the arms and neck. Therapists use electrical stimulation to ease muscle spasm and pain. Treatments may also include cervical traction to gently stretch the joints and muscles in the neck. Therapy sessions may be scheduled two to three times each week for up to six weeks.

The goals of physical therapy are to help you

learn correct posture and body movements to minimize the effects of stenosis
maintain appropriate activity levels
identify symptoms of stenosis that require medical attention
learn ways to manage your condition

Surgical Treatment

Cervical myelopathy can be a serious problem. The pressure on the spinal cord usually will not go away without surgery, and the symptoms may continue to get worse. If you do not improve with non-operative care, your doctor may suggest surgery.

There are several surgical procedures used to treat cervical spinal stenosis that is causing cervical myelopathy; all have the same goal-to relieve the pressure on the spinal cord by making the spinal canal larger.

Your surgeon may suggest an operation called a laminectomy, in which the backside of the vertebrae is opened to allow more room for the spinal cord. Discectomy, the removal of one or more discs, may be suggested if stenosis is coming from problems of disc herniation. This surgery may be done from the front or back of the spine. Or your surgeon may suggest an operation that is done from the front of the neck-a corpectomy and strut graft. This operation involves removing the discs and vertebral bodies in the area where problems are occurring. Bone spurs that are pushing into the spinal cord are also removed. The vertebrae are then replaced with a solid piece of bone graft (called a strut graft). The strut graft heals over time to create a solid fusion of the spine where the vertebral bodies have been removed.

Posterior Cervical Fusion

Rationale

The posterior cervical fusion is performed through an incision in the back of the neck. A posterior cervical fusion is used

to stop the motion between two or more vertebrae
to recreate the normal curve of the cervical spine and keep a spinal deformity from getting worse
to stabilize the spine after a fracture or dislocation of the cervical spine

Procedure

This surgery is done through the back of the neck. A bone graft is placed on the back surface of the problem vertebrae. During the healing process, the vertebrae grow together, creating a solid piece of bone. This type of fusion is used in the cervical spine for fractures and dislocations. It is also used to correct deformities in the neck.

The goal of spinal fusion is to stop the motion caused by segmental instability. This reduces the mechanical neck pain caused from too much motion in the spinal segment.

You may also hear the term anterior fusion. This procedure is commonly used to treat neck problems. The surgeon works from the front (anterior) of the neck. A bone graft is placed between two vertebral bodies (interbody area) to replace the disc that normally sits between them. During the healing process, the vertebrae grow together, creating a solid piece of bone. Learn more about the use of bone graft.

Anterior Cervical Fusion
Bone Grafts

Instrumented Posterior Cervical Fusion

A graft that is held tightly in place has a better chance of fusing the vertebrae together. To improve fusion, doctors commonly use metal plates, screws, and rods. These implants are referred to as instrumentation. Many different types of metal implants are used with the intent of maximizing healing of the fusion.

When instrumentation is used to improve the success of a posterior fusion, metal rods or plates are attached to the bone structures in the back of the spine. Stainless steel or titanium cables can also be used. When doctors use this type of instrumentation, a brace may only be needed for a short period of time, or not at all.

Anterior Cervical Fusion

Rationale

Procedure

Anterior Cervical Fusion

Anterior Interbody Fusion

Anatomy of the Cervical Spine

Neck

Other Major Segments

Important Structures of the Spine

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Cervical Corpectomy and Strut Graft

Introduction

Anatomy

Rationale

Procedure

Complications

Rehabilitation

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Cervical Fusion

Introduction

Anatomy

Rationale

Procedure

Complications

Rehabilitation

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Cervical Kyphosis

Introduction

Anatomy

Causes

Symptoms

Diagnosis

Treatment Options

Cervical Laminectomy

Introduction

Rationale

Procedure

Complications

Rehabilitation

Physical Therapy

Cervical Radiculopathy

Introduction

Anatomy

Causes

Symptoms

Diagnosis

Treatment Options

Cervical Spinal Stenosis

Introduction

Anatomy

Causes

Symptoms

Diagnosis

Treatment Options

Posterior Cervical Fusion

Rationale

Procedure

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