Neck Pain and Cervical Disc Disease: Basics of Diagnosis and Treatment Aaron J. Bianco, MD March 11, 2016

Disclosures Stryker consultant for surgeon training  No conflicts of interest directly related to this presentation 

Cervical Disc Disease   

Arthritic changes in the neck develop with aging Loss of disc height, bony spurs, and disc herniations occur This can cause: ◦ Neck pain ◦ Arm pain from nerve root irritation (Radiculopathy) ◦ Loss of balance and numbness in hands from compression of spinal cord (Myelopathy)

Anatomy

Tanaka, Fujimoto, An et al, Spine, 2000

Neck Pain Common in US population  Often associated with minor trauma, car accidents, etc.  Can have associated headaches  Usually self-limited but may be treated with medications, exercises, and physical therapy  Most cases are nonsurgical 

Cervical Radiculopathy Pain radiating to arm(s) in a radicular distribution  Loss of reflexes, sensation, or motor deficit can occur  Often confused with shoulder pathology, carpal tunnel syndrome, etc. 

Disc herniation 

Tear in outer layer (annulus) allows inner soft layer (nucleus) to push out

Cervical Myelopathy 

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Compression of spinal cord (not nerve roots) by bone spurs and discs Leads to weakness, loss of balance, and trouble walking. Can be irreversible Generally gets progressively worse over time, with brief periods of plateau

Important Questions You Should Ask Your Patients 

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Location of neck pain ◦ Radiating into trapezius, rhomboid, periscapular area Arm pain Limited motion Occipital headache Relieving positions?

Source of pain Muscle strain/ligaments  Disc 

◦ Discograms do not always predict 

Facet ◦ Mixed results with Facet blocks

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Loss of sagittal balance ◦ Muscle/ Ligament strain

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Direct compression of nerves

Diagnostic Imaging X-ray Disc height  Spur formation  Facet Hypertrophy 

Diagnostic Imaging - MRI Assess disc herniation  Canal stenosis  Foraminal stenosis 

Natural History: Radiculopathy 

Lees and Turner ◦ At long term follow- up (2-19 years) of 51 patients with radiculopathy  45% had only a single episode of pain without recurrence  30% had mild symptoms  25% had persistent or worsening symptoms

Non operative Treatment Neck pain or radiculopathy (arm pain) with less than 4-6 weeks of symptoms  No major weakness (motor deficit)  No cord compression 

Types of Nonoperative Treatment NSAIDs, soft collar  Physical Therapy – isometric stabilizing excercises, traction  Epidural & nerve root injections 

◦ 40-71% success ◦ Risks of nerve injury or stroke (rare) 

Manipulation ◦ Can be useful in muscle strains for short-term use

Indications for Surgical treatment Myelopathy  Infection  Tumor  Progressive neurologic deficit  Pain persists despite non operative treatment course (6-12 weeks) 

Operative treatment 

Anterior Discectomy and Fusion ◦ Removes disc and replaces with bone graft ◦ Most common approach

Posterior Laminectomy (sometimes combined with Fusion)  Laminoplasty  Disc Replacement 

◦ Motion-sparing ◦ Long-term results not as well known

Anterior Discectomy and Fusion

Anterior Cervical Fusion Iliac crest (your own bone) or allograft (from Bone Bank)  Plate and screws often used to allow early motion and avoid bracing  Some surgeons use collar 6-12 weeks  No clear evidence of increased fusion rates with postoperative immobilization 

Placement of bone graft and plate for stability

Posterior Decompression Laminotomy  Foraminotomy  Disc excision 

Cervical Laminectomy

Laminoplasty Provides Decompression  Less risk of junctional stenosis and instability  Only for patients with normal (lordotic) alignment 

Disc Replacement

Conclusions Conservative treatment is first option for cervical radiculopathy and axial neck pain  Earlier surgical treatment usually recommended for myelopathy (spinal cord compression)  Outcomes are generally excellent when diagnosis and treatment started early 

Thank you!