It's a Pain in the Neck
Your neck carries the weight of the world. Not really, but it does carry the weight of a bowling ball. Hunching your shoulders or slumping at your desk makes its job more difficult. When your mother told you to stand or sit up straight, she was right. Good posture can make a huge difference over the years and reduce the stresses to your neck. If mom's advice is not heeded, you pay the price over the years as its vulnerability shows up as it is subjected to aging and injury.
Your neck is comprised of bones, discs, joints, tendons, muscles, ligaments and nerves, any which can be a source of pain. If nerves are involved, you can also experience numbness, tingling or weakness in your arms and even your legs. Pain also can be experienced as a result of adjacent parts like your jaw, head and shoulders. So how do your sort out the pain and get the care you need to live with "pain in the neck"?
Arthritis in the neck, called cervical spondylosis, is a natural consequence of aging in the older adult. As we age, the intervertebral discs in the neck begin to lose water content, resulting in disc bulging into the spinal canal. Additionally, arthritis causes bony and ligamentous enlargement , which can also push into the spinal canal. Neck pain can typically be divided into the categories of:
- Neck pain
- Radiculopathy (shoulder/arm pain)
- Myelopathy (spinal cord compression)
- Combinations of above
Neck pain by itself typically results from muscular or ligamentous factors which can be related to stress, poor posture, arthritis, previous trauma, or degeneration of cervical (neck) discs. Identifying the specific cause of pain can be difficult. As with low back pain, most neck pain is self-limiting and resolves with conservative care. Conservative care includes physical therapy, anti-inflammatory medication, activity modification and traction. Chiropractic cervical manipulation is controversial—clinical trials have shown that rehabilitative neck exercises are superior to manipulation alone. There are also risks involved with neck manipulation that are significantly more serious than those seen with the lower back.
Surgical intervention for neck pain by itself should be reserved for those with segmental instability, tumors, infections, or development of nerve compression. Performing fusions for osteoarthritis has been shown not to be significantly superior to placebo; therefore, it should be avoided except in special circumstances.
Radiculopathy (Shoulder/Arm Pain)
Pain radiating to your shoulder, through your shoulder blades or down your arm as well as numbness or tingling in your fingers can result from a problem in your neck. Radiculopathy refers to symptoms resulting from compression of specific nerve root(s). Patients describe sharp pain, tingling, numbness, burning sensation, and possibly aching in the anatomic area(s) supplied by the compressed nerve(s). That's because the nerves that extend out from between the cervical vertebrae provide sensation and trigger movement in these areas. Neck pain often accompanies this and can be just as debilitating. Nerve root compression may be a result of disc herniation, spinal stenosis (abnormal constriction of the spinal canal secondary to arthritis), tumor or infection.
A study of more than 700 patients, who presented with neck radiculopathy secondary to a herniated disc, showed that <>>99% had arm pain, 85% had sensory abnormalities, 80% had neck pain and 68% had muscle weakness. Interesting to note, 10% of patients had headaches as a result of the disc herniation; 18% had chest pain.
Although x-rays do not show soft tissue well, an MRI can be very helpful in identifying the specific level(s) of nerve compression. Electromyography/nerve conduction studies (EMG/NCS) may be indicated to determine the severity of the neurologic problem, identify the nerve roots involved, and define neck causes of pain vs. more peripheral nerve compression, such as carpal tunnel syndrome.
Nonsurgical treatment for radiculopathy is usually the first step. Many patients with radiculopathy, especially those with a herniated disc, improve substantially without any treatment at all. Those whose symptoms persist often benefit from physical therapy, epidural injections, cervical traction, a soft collar, anti-inflammatory medication, and short-term narcotics along with muscle relaxants.
Reasons to consider surgery include disabling or persistent weakness from the radiculopathy or progressive neurologic deficit. Surgery for radiculopathy includes decompressing the affected nerve(s). Depending on your specific diagnosis, surgery is performed either from the front or the back of the neck (anterior cervical discectomy and fusion) or from the back of the neck (laminectomy).
While radiculopathy refers to symptoms from the nerve roots which exit the spine, Myelopathy refers to injury to the spinal cord and its function. This results from narrowing of the spinal canal to such an extent that the spinal cord itself becomes compressed. Typically this results from cervical spinal stenosis (narrowing of the spinal canal from enlarged arthritic bones and soft tissues). Symptoms of myelopathy include neck and arm pain along with dysfunction. This may include arm weakness or clumsiness. Patients often report difficulty with handwriting, buttoning a shirt or opening doors. Lower extremity symptoms include weakness, frequent falls and difficulty walking. Progression of the disease is variable. Some patients experience rapid progression, whereas others stabilize or decline very slowly. Your surgeon will need various tests, in addition to the physical examination including an MRI and a nerve conduction study, to determine the severity of the myelopathy. Patients who are in the stable category may not need surgery. Physical and occupational therapy along with anti-inflammatory medications may be all that is needed for pain control and improved function.
Once myelopathy becomes progressive, surgery is indicated. It is unclear how much reversal of the myelopathic symptoms can be obtained from surgery, but we do know that the progression can be halted. Depending on the severity of the disease process, location of compression, bone quality, and overall medical health, the surgery may entail an approach from the front, back, or a combination. Your surgeon will consider all of these variables prior to planning the approach.
Surgery of the neck is performed either from the front, back, or a combination of the two. Standard surgery for a herniated disc involves removing the disc from the front and inserting allograft (cadaver) bone in the remaining space in order to fuse together the disc above and below the herniated disc. We no longer require bone from the patient's pelvis in order to achieve high fusion rates resulting in significantly less post-operative pain and >90% patient satisfaction. A hospital stay for a one or two-level herniated disc surgery is 24-48 hours. Thanks to modern instrumentation, there is no need for post-operative bracing.
More complicated procedures, such as multiple level decompressions or tumor removal, may involve surgery from the back of the neck or a combination of front/back surgery. Obviously, these procedures are technically demanding and should only be performed by spine surgeons. Risks of spine surgery include infection, bleeding, nerve/spinal cord injury, difficulty swallowing, hoarseness, residual pain, and potential need for further surgery in the future.
Pain Relief Possible
Now that you know more about various types of neck problems, don't let a "pain in the neck" get the best of you! There are multiple treatment options available for pain relief, most of which do not involve surgery. Should surgery become necessary, we at the Sonoran Spine Center will develop a treatment plan dedicated to your specific condition to help maximize recovery and get you back to enjoying life!