COI: Treatments for Neck and Arm Pain
Hi there, my name is John Beiner and I’m an orthopaedic spine surgeon with Connecticut Orthopaedics. First I’ll give a bit of a brief review of what makes up the spine, what parts can hurt and what problems you can get from each part and I’ll talk about sprains and strains, disc herniation, arthritis, and eventually spinal cord problems and myelopathy.
So the anatomy of the spine is shown here in these two figures. In the front of the spine, you have the discs between the vertebra and the discs act like a cushion to protect motion. In the back of the spine, you have facet joints which overlap and in the middle you have the neural elements. So they take a cross-section through this area shown here on the right this is the spinal cord and these are nerve roots coming out of each neural foramen. In the front of the disc, inside the disc is a nucleus and ligament on the outside that’s a strong wall of the disc and contains the pressure. This nucleus is thought to be like jelly in a donut, but it’s actually more rubbery and has some mass to it which makes a difference when it actually is pressing on a nerve.
This is a diagram on the right here, of a herniated disc, which is this one here is pushing backwards towards the spinal cord causing actually some spinal cord compression in this patient.
A simple sprain or strain injury occurs with heavy repetitive lifting, sometimes with overhead work and extension of the neck for a period of time, even simple household chores like raking or vacuuming and of course we all know about whiplash injuries from a car accident or even from a fall. Sometimes however you can sprain your neck just sleeping wrong and you wake up with a stiff neck and it can be largely muscular.
On exam, we note stiffness and tenderness throughout the muscles. These are the trapezius and the latissimus and the rhomboid muscles lower down. These are extensive muscles that control the position of your head and neck and attach onto the back of the skull giving you control over the head. These muscles can go into spasm and can become pretty severe. You don’t usually have extremity weakness or even numbness tingling down the arm for the simple strain injury. The treatment for a sprain or strain is rest for a day or two, but you want to keep moving in general. So, we use anti-inflammatories, although they do have some risks to your GI system. They work pretty well for short periods of time. Sometimes muscle relaxers can help and for some patients, they can give you side effects like fatigue, but a lot of patients find that muscle relaxers will help as well. The mainstay of treatment for a sprain is physical therapy with hands-on treatment as well as range of motion and strengthening exercises to help you keep moving and keep that flexibility. Even aerobic exercise can help.
A disc herniation is a little different problem. This is called a ruptured disc or a slipped disc or an extruded disc and all different terminology from a Radiologist. But really what happens is that annulus, that wall of the disk, has an injury or tear and part of the nucleus ruptures back into the nerve tunnel. This can be central or can be foraminal such as here in this picture where it’s compressing the nerve root like a branch coming off the spinal cord. These can be particularly painful as there’s not a lot of room in here for these nerves. A protrusion is sort of abnormal, a bulge is pretty normal. Once we get above the age of 40 almost everyone has wear and tear including disc bulges and it’s not something we really get too worked up about in general. Sometimes bulging discs can cause pain but mostly they’re a normal phenomenon. If the disc is pressing on a nerve as it’s leaving the nerve tunnel, it can give you severe pain. This is another diagram of what a disc herniation looks like and why it can cause pain. That nerve tunnel is pretty small, especially when you extend your neck and tilt backwards which would be towards the right here on this slide and it can give you a lot of compression of that nerve which causes horrible pain. On an MRI scan we see something like this, a normal disc and seeing between the vertebrae and should really be contained to the back of the vertebral body wall. This disk is extending into where the spinal cord is and it’s a rather large disc herniation that’s no doubt causing nerve compression, but also and most worrisome, causing spinal cord compression.
We call a pinched nerve a radiculopathy. This can be in the cervical or in the lumbar spine. The lumbar spine people think of it as sciatica, but in the neck we frequently don’t know what the source is, but everybody is wired the same so certain nerve roots like C3 and C4, C5, they go to the same spot in all patients. And so where your pain and numbness and tingling travels gives us a clue as to which nerve roots involved, but in addition to a sensory deficit or pain, you can get weakness of certain muscle groups. Because again certain muscle groups are supplied by certain nerves and it’s basically why it’s the same way in everybody. Often the gait is normal and there’s no spinal cord problem with this but you can have abnormal or decreased reflexes or sometimes even normal reflexes.
Natural history of a disc herniation is that most of these get better on their own. They do need some supportive care for most patients and it can take weeks to months to improve with physical therapy and anti-inflammatories but they usually get better. Numbness is usually the slowest part to resolve and can take six to twelve months and sometimes numbness can even be a permanent problem, but we sort of accept that problem rather than going after these surgically unless there’s a lot of pain. So our approach to a disc herniation is that we use anti-inflammatory medication or sometimes even a steroid or a med roll pack. We try to minimize narcotics because of the risk of addiction. Physical Therapy helps quite a bit with these patients and that’s divided into what are called modalities which are hands-on and external techniques, like ultrasound or deep tissue massage, but also exercises and stretching and even traction. Traction increases the space for those nerve roots and for most patients can help quite a bit. If traction works with physical therapy, you can also work at home with a home traction unit which is generally covered by insurance. If this all fails sometimes we use epidural steroid injections in the cervical spine. This however has some risk to it, because you have to put the needle in where the nerve and spinal cord are and that carries some obvious risk of nerve injury or nerve damage and even stroke or paralysis. So we try not to do epidurals in the cervical spine unless absolutely necessary.
A lot of people ask this question, “What is nerve damage? When does it happen?” The answer is we don’t really know when nerve damage happens. We only know when it’s already happened. This can occur when a disc ruptures, it can occur with ongoing compression, or sometimes even with what the patient’s doing. It’s largely an unknown time frame. In other words, some people don’t develop weakness and permanent problems until months after the disc herniation and some people have that develop right away. Some of it depends on which nerve root is involved since some of them seem to be more durable than others.
Weakness is the most worrisome finding for permanent nerve damage, especially in somebody’s dominant arm. To be honest some muscle groups are more important than others. You use your biceps when you’re lifting things up to eat and to manipulate things in space, you don’t use your triceps quite as much, so most people would tolerate a little bit more triceps weakness, but everybody’s different. What we do worry about is when weaknesses worsening or lasting for a long time then we tell patients either have to accept it or fix it with surgery.
In general, when is surgery necessary? It’s not for pain because most time pain will get better although some people have so much pain that they can’t really tolerate it and that can be an indication for surgery as well. We typically operate for progressive or persistent weakness or when the disc is pushing on the spinal cord causing myelopathy or a sickness of the spinal cord. Definitely incapacitating pain or persistent weakness that it fails contributive treatment is what we need to tell your insurance company to get things approved, as well.
What is the surgery? It’s called an ACDF, which stands for, anterior cervical discectomy and fusion. Anterior means we go usually in the front of the neck. We remove the disc, taking away the fragment from where it’s pressing on the nerve or spinal cord and then we fill that disc space with a bone graft, or a cage, which is a spacer or a cylinder of carbon fiber and we can take little shavings of the bone on either side and pack that cage so that we don’t typically have to use cadaver bone which heals really slowly or take bone from your pelvis any longer. Then we stabilized this with a plate and small screws so that this acts like a clamp over the bone and prevents movement, kind of like an internal splint or cast. This surgery works very well and has a success rate of 95 to 100% depending on the patient population. One of the risk factors for not doing well from this type of surgery unfortunately is nicotine use and so we try to encourage patients to avoid smoking or any nicotine use all.
So let’s talk for a moment about arthritis. In the spine this is also called spondylosis for the Greek word for vertebral bodies. Arthritis pain is usually worse in the morning and as you get moving and warm up improves. You get stiff with any prolonged position like driving and you generally can have diffuse neck pain which can radiate to the shoulder blades or scapular region and usually don’t get an abnormal exam in your arms, which are sort of the window to the spine. Sometimes this is a thing that keeps flaring up and sometimes it’s brand new and it’s usually better with rest or laying down or taking the weight of the head off the shoulders. C5 and C6, the disc degeneration and arthritis, is the most common. It causes a straightening of the spine so that you don’t have that normal lordosis and sometimes even instability, meaning when you bend forward and back there’s extra motion or laxity in the vertebra and this can cause increased pain as well. In this slide, I show a picture of what looks like a normal spine versus an arthritic spine where this disc is very degenerative in your body is growing bone spurs around.
Treatment for arthritis is to mobilize. We don’t want you to rest too much because it causes stiffness and that’s a mistake most people make. They put themselves in a collar or they baby it because it hurts which is a normal idea but it actually makes you stiffer overtime and it lets your muscles become even more weak. We do use anti-inflammatories sparingly and mostly we use physical therapy for this. I’ve had patients come in and I tell them that they’ve suffered from cervical arthritis and they have a badly sprained back from being stiff overnight and they think I’m crazy because the pain can be so intense that they feel like something has to be wrong. But the pain becomes really intense because of the stiffness and the muscle guarding and spasm and the way it attached to the back of the skull that makes it easy to get headaches from this as well. We try to mobilize the patient with therapy. We use aerobic exercise to get the blood pumping and get moving. Sometimes even cortisone shots into the joints of the neck which are called, facet joint injections. Cortisone can help quite a bit as well.
Let’s talk a bit about stenosis of the spinal canal. Sometimes narrowing occurs with arthritis and sometimes it occurs with disc herniations. In this picture on the right is a disc herniation that’s rather large and it’s causing an obvious pinching of the spinal cord, which means that that nerve tunnel is very tight. We call the cervical stenosis. Many of you may have experienced this in the lumbar spine as well but there’s actually no spinal cord in the lumbar spine and so although the nerves can be painful, you don’t have the same risk to the spinal cord. When you have stenosis in the cervical spine it’s really only dangerous if what’s known as myelopathy is present and that means that the spinal cord is dysfunctional or sick because it’s getting impressed by either disc or bone spurs. This can also be more of an acute problem from trauma where there is a bone fragment, fracture of the vertebrae or a disc herniation and it can cause something called a central cord injury which is a version of a spinal cord injury and causes more weakness and symptoms in the upper extremities than the lower extremities. The neck pain with stenosis is pretty variable. A lot of people say “I don’t really have any neck pain so how can this be coming from my neck” but the truth is that the nerves that come from the spinal cord give you the most pain and you feel those typically down the arms more so than the neck, so the neck pain is variable but stenosis is usually associated with radiculopathy or sciatica of the arm if you will. So myelopathy or spinal cord trouble usually has no sensory deficit or something that’s called non-focal, which means you can have some numbness and tingling in different parts of your arms. You can have some patchy weakness, meaning not consistent, or sometimes it can be focal to certain muscle groups like your intrinsic muscles of your hand and grip strength can be weakened. One of the earliest signs is that you can’t walk in a straight line without a significant balance trouble. It’s almost as if you’re walking on a ship or a boat and it’s uneven and you can’t quite get your feet under you. A Romberg’s is a test where we have you close your eyes and hold your hands out and see if you can maintain balance, but generally there are signs on exam for hyper reflexes and several pathologic reflexes that indicate to us that your spinal cord is having some trouble.
So imaging is generally CAT scan and MRI scan gives you the most information. Although the plain x-ray is fairly predictive as well so we usually start with plain x-ray. The MRI, which you’ve seen before, is the mainstay of imaging and it shows the spinal cord and fluid on either side of it, but that turns into almost an hourglass where there’s a disc herniation and bones first causing a tightness and in this slide on the right we also see that there is a signal change or a change in color of the spinal cord on imaging, which suggests that there scar tissue being formed there by the body and that scar tissue is replacing basically dead neurons that have been injured or damaged because of the constriction or compression. On CT scan can you see that there’s virtually no disk spaces left.
So what are the surgical options here? Well that’s a different talk almost, but you can go from the front and take out a disc and remove a disc herniation that’s causing depression or sometimes we take out the whole vertebrae and which is called a corpectomy and plate it the same way with a spacer. Sometimes you have to go from the back of the spine using instrumentation and relieving the pressure by opening up the nerve tunnel in the back, that’s called a laminectomy infusion. We typically don’t like to do that as much because it has increased pain and morbidity vs. going in the front of the spine but sometimes it’s necessary if there is problems over multiple levels in their neck. These success stories however have to be remembered when people think about surgery. We don’t do this type of surgery just for pain. We do it to preserve the spinal cord in the nerve roots and these surgeries are generally very successful so at least if it’s something that you need to go through you can expect you’re going to do pretty well afterwards.
That’s it. That’s a good overview of cervical disc herniations and other conditions and what we typically think about when we were considering surgery. Thank you very much.