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Women and Neck Pain

Neck pain is reported by the National Institute of Health to be the second most common type of chronic pain next to back pain. Women report suffering from neck pain more frequently than men. Various causes of neck pain include arthritis, muscle strain, degenerative disc disease, disc herniation, stress, poor posture, smoking, tumor, and trauma. One of the most common causes of neck pain in women ages 20-40 is muscle tension and stress. This is good news since this type of neck pain is very easily and successfully treated with proper exercise and stretching.

It is important that anyone suffering from neck pain that lasts more than a couple of weeks follow up with their physician for proper diagnosis and treatment of their pain. Typically x-ray evaluation and a thorough exam can aide in the diagnosis. Occasionally, your physician may need to order other tests like MRI or EMG in order to further evaluate your pain.

Common treatments for neck pain include various medications, physical therapy, and massage therapy. For patients suffering from nerve pain in one or both of the arms radiating from the neck, steroid injections may be helpful as well. The only treatment proven to slow down arthritic processes in the neck is proper exercise including specific strengthening and stretching for the neck, shoulders and upper back. A physical therapist can develop a home program for patients to continue to follow on their own. It is also important for the patient to learn proper posture, to quit smoking, and have an ergonomic station for her computer. Exercise has also been proven to lower stress, but developing other healthy outlets for stress reduction is also helpful in reducing neck pain.

Overall, it is important for the patient to understand the cause of neck pain lasting more than a couple of weeks. Proper diagnosis leads to proper treatment. This empowers the patient to take control of the pain

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Artificial Disc Replacement

The Emergence of Artificial Disc Replacement

artificial_diskMore than 80% of Americans will experience significant back pain at least once in their lives. The personal and monetary impact can be staggering. A major cause of back pain is the degeneration of the shock absorbers, discs that are positioned in between the bony vertebral bodies of the spine. disc degeneration can be painful and often difficult to treat long term. A promising surgical option recently approved by the FDA is the use of artificial discs.

The Spinal Disc

Spinal discs lie between the vertebrae in our spines, serve as shock absorbers, and allow range of motion. However, as early as in our 30's, these discs begin to lose their water content and then degenerate. This results in disc flattening, tearing or fraying which can irritate nerve endings resulting in back pain. We are not sure why some people experience these changes earlier than others although there is evidence that genetic influences, environmental stresses and accumulations of major and minor trauma can contribute to a painful disc.

Conservative Treatment Options

Initial treatment for a painful disc is always conservative care. Acetaminophen (Tylenol) or non-steroidal anti-inflammatory medications such as aspirin or ibuprofen can be helpful at reducing the back pain. Sometimes it is necessary to take a prescribed anti-inflammatory medication. It can be helpful to undergo trunk strengthening exercise programs in physical therapy since this approach can also reduce pain and help slow the degenerative process. Exercise programs must be continued on a regular basis to make a long term difference. As the trunk muscles become stronger, some of the load across the spine is alleviated and patients feel less back pain. For most patients, their pain and function are improved with nonoperative care to the point that they can lead a reasonably normal life. Unfortunately, a conservative treatment is not always successful at relieving pain and restoring function, which leads to the next step of surgical intervention. Up until this point, the surgical solution meant spinal fusion surgery. Recently, there is also artificial disc replacement surgery for select patients.

Minimally Invasive Procedures

For the small percentage of patients who fail conservative treatments, the minimally invasive options are limited. There is no FDA approved method of effectively reinflating the worn-out disc. Hopefully, this will be an option in the future. Recent interventions include Intra-discal Electrothermal Therapy (IDET) (1997). IDET involves inserting a probe into the affected disc and heating up the outer core of the disc space to 90 degrees (Celsius) for 15-20 minutes in an effort to cauterize tiny nerve endings in the disc, making them less sensitive to pain. Results have been limited, with the latest studies showing only 33-50% patient satisfaction at one year follow up.

Surgical Options

Surgical options for patients with degenerative disc disease who are deemed surgical candidates (not everyone with degenerative discs is a surgical candidate) involve removing the affected disc(s) and either: 1) Fusing the affected segment(s) or 2) Inserting an artificial disc.

Spinal Fusion

The mainstay of surgical treatment for patients with degenerative disc disease who have failed 6-12 months conservative care is to fuse the painful level(s). Spinal fusion entails stopping the motion at a painful motion segment (the joint formed by two vertebral bodies). Fusion takes place by placing bone in between the vertebral bodies. As the bone grows, it fuses the vertebrae together, thus, eliminating the motion at a specific level. Success rates with fusions performed for degenerative disc disease range in the literature between 65 and 93%. It has become the standard of care for discogenic pain and is often very effective in relieving pain.

Bone grafting is required for spinal fusion. The standard in spine surgery is harvesting bone from the patient's pelvis at the time of surgery. However, to improve healing and reduce risk of chronic pain at the bone graft site, other alternatives are now being used. Bone morphogenic protein (BMP) is now frequently used to enhance healing of the fusion. It not only improves the fusion rate but increases its success and often eliminates the need for harvesting bone graft.

Spinal fusion does have its drawbacks. First, the bone does not always heal or "fuse" correctly. A spinal fusion at one or more levels causes stiffness and decreased motion of the spine. Spinal fusion at one or more levels can increase the stress to the rest of the spine. Because of these problems, alternative treatment options such as the artificial disc have been pursued.

Artificial Disc Replacement

Based on the success of other joints in the body successfully treated with joint replacement, efforts began in Europe back in the 1980's to develop an artificial disc replacement. The potential benefit of the artificial disc is to preserve motion of the operated segment allowing the patient more flexibility to bend forward, backward, and rotate or twist. It is also hoped that adjacent levels of the spine will be less likely to become arthritic.

One of these, the SB Charite (Germany) artificial disc, recently completed Food and Drug Administration (FDA) clinical trials and received final approval in the Fall of 2004. Results from the FDA 2 year follow-up were as successful as an anterior fusion. A patient satisfaction survey showed a significant superiority of the Charite group over the fusion group. At 24 months, 88% of patients implanted with the Charite Artificial disc expressed satisfaction with the procedure, compared with 81% of fusion patients. On average, patients implanted with the Charite Artificial disc were discharged from the hospital a half-day sooner than fusion patients.

The materials, cobalt chromium (endplates) and ultra-high molecular weight polyethylene (sliding core) used in the Charite are similar to those used in hip and knee replacements. Patient selection is key to successful artificial disc replacement. Patients must have failed at least six months of conservative treatment such as pain medication or physical therapy. The typical patient is between 18 and 60 years old and has degenerative disc disease between L4-5 and/or L5-S1 with less than 3mm of vertebrae slippage. Candidates suffer from low back pain as the major complaint (rather than leg pain).

The disc is designed to restore disc space height, restore disc flexibility, prevent disc degeneration at adjacent segments and reduce or eliminate pain from motion and improve a patient's functional activities.

The surgical time it takes to implant an artificial disc is similar to that of a fusion, but the procedure is done from the front, as opposed to most fusions which are performed from the back. Typical hospital stay is between 2-4 days, and patients typically have minor motion and lifting restrictions for 6 weeks. These restrictions are less than with a spinal fusion.

Unlike spinal fusion, artificial disc replacement does not yet enjoy long-term follow up results. Considering the young age of most recipients, there is some concern over the long term success rate of these implants. The good news is that if the implant fails to eliminate pain or if the patient develops debilitating pain in the facet (adjacent small joints in the spine) joints, the patient can still undergo a fusion to alleviate the pain.

Artificial disc replacement is an exciting new development. It is a new tool available to certain patients and their spine surgeons to address chronic low back pain due to degenerative disc disease. Research has shown that it can be a benefit to those candidates who have failed conservative management and fit the criteria for patient selection. For more information, you should be evaluated to discuss your options.

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Posture Matters: Back and Neck Pain

By Bert Bednar, DPT

Remember when your mom would tell you to sit up straight or walk with your head up and shoulders back? Once again, your mother was right. Posture does matter. In fact, we all know it's better to use good posture. So why do we still slouch? Research has proven that poor posture contributes to back and neck pain. Sitting in a poor posture can contribute to other aspects of your health including eye strain, headaches, shoulder pain, and carpal tunnel syndrome.

Posture Affects Pain

Painful, and potentially disabling, conditions can insidiously develop as a direct result of poor sitting or standing posture, improper lifting mechanics and working habits, or begin with unrelated injuries that are then made worse by poor ergonomics.

When you deviate from normal anatomic posture, unnecessary stress and strain are placed on the normal curves of your spine causing these curves to slowly change. Over time these minor alternations make your spine more vulnerable to injury. For this reason, utilizing the principles of your best posture is critical to keeping stress and strain as low as possible. This will decrease injury to your spinal discs, decrease unnecessary muscle strain, prevent muscular imbalances, as well as protect small joints within your spine (facets) and supporting structures. Common outcomes of poor posture results in rounded shoulders, flat back, forward head positioning, improper muscular tension, and upper and lower back pain.

Proper posture is achieved by understanding the principles of appropriate seated and standing positioning along with proper flexibility, muscle strength and self-discipline. Let's discuss the best posture for standing, sitting, lying down and the importance of positional changes.

Standing Posture

Did you know that a bending forward posture can contribute to increased degenerative disc wear? To protect from disc wear and tear, it's best to utilize proper standing posture as much as your own body stance will allow. Although pathology can prevent you from achieving ideal alignment, adhering to the principles of proper posture can still help you attain your best and prevent the worsening of many conditions.

Picture an imaginary line from your ear to your shoulder to your hip to your ankle. With perfect posture, this imaginary line would align perfectly with these joints. Proper standing posture also includes holding your head up, looking forward with your shoulders held back and your chest out. Maintaining this posture provides for equal and well-distributed weight-bearing on the spinal discs, which allows the back muscles to be in a balanced position and decrease undue stress on the small facet joints and ligaments of the spine. Reducing these stresses will decrease pain and help to prevent injury.

To maintain your best posture, it's important to check yourself periodically as to how you are standing. Initially it will seem awkward; however, it becomes easier as your muscles get used to your new posture.

Sitting Posture

Slumping in a chair will overstretch and fatigue muscles. This posture can lead to injury resulting in severe neck and back pain.

When seated, sit back in your chair as far as possible. Your buttocks should be at the end of the chair to maintain a straight back with a normal low back (lumbar) curve. While seated, good posture is achieved by looking forward, keeping your shoulders pulled back and your spine up against the back of your chair. Select your chair height so your feet can be placed flat on the floor. If your chair is too high for your feet to reach the ground, use a small foot stool.

Keep your work close to you. Whenever possible, position your work so your arms do not extend past your chest. Adjust your chair's arm rests so that your elbows can be supported. Get in the habit of working while your elbows are on your arm rests. If you are able to implement these principles correctly your body position should promote a right angle at your elbows, hips, and knees.

It is important to take frequent breaks from sitting. Even maintaining proper seated posture can eventually be hard on spinal structures. Getting up and stretching periodically will help to keep tension from mounting to an unsafe level in your spinal muscles. Proper upper back and core strength will make achieving proper posture feel more natural.

Lying Posture

Proper lying posture varies far more than seated and standing postures. Generally accepted guidelines include a mattress which supports bony prominences and keeps you in proper alignment whether you are lying on your back, side or abdomen. If you rest on your side, a pillow placed between your knees will decrease strain on your lower back. Supporting the natural spinal curve of your neck is also important. A good rule of thumb is to find a position that is comfortable. If you are lying in a position resulting in unnecessary strain on your muscles and joints you will have difficulty sleeping and typically awaken stiff or sore. Remember good alignment is hardly ever achieved when reading in bed. Comfort should be your guide when you select an appropriate mattress or pillow. Getting restful sleep can depend on using appropriate principles for lying on your back, side or abdomen.

Changing Positions

Change your position frequently during prolonged activities. If you have been sitting for awhile, stand and stretch your back into a straight or neutral position. If you are standing and working overhead, bend your back forward periodically to give your back a break.

Most of us can relate to having a work day that involves lifting, reaching, typing, or driving. Most of us maintain a forward rounded position while performing many of these tasks. After keeping this posture for hours per day, over the span of weeks, months and years, our body tends to adapt to this sustained position. This results in a flexed forward or rounded shoulder position. Incorporating proper postural and core strengthening as well as neck, trunk, arm and leg stretches into your daily schedule can help to prevent you from developing a rounded posture and resulting pain.

Posture is Only One Aspect of Maintaining Functionality as We Age

Everyone performs "work" or tasks daily and many believe the work or task is sufficient to sustain musculoskeletal health. Unfortunately as we grow older, this is less often the case. To insure continued strength, flexibility and endurance, it is best to incorporate activities that accomplish three important exercise types: 1) Stretch muscle groups to reduce risk of injury and maintain flexibility, 2) Perform strengthening exercises for shoulders, upper back, low back, abdomen and legs to help decrease stress and protect your joints 3) Engage in endurance activities to maintain a healthy heart muscle and pulmonary function. Regularly-scheduled exercises that address these important aspects of body maintenance become more critical as we age. Since our body eventually will break down when not supported and maintained properly, use exercise, posture and ergonomic principles to maintain and enjoy body health for life.

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Cervical Disc Herniation (Neck)

"A Pinched Nerve in the Neck"

What is it?

jeep_053In between the vertebrae of the neck are cervical discs. The cervical disc serves to cushion the weight of the head while allowing the vertebrae to move. When a piece of the disc escapes through a tear in its thick containment ligaments called the annulus, this is called a cervical disc herniation. Herniations occur into the spinal canal and can compress the spinal nerves or even the spinal cord.

Causes

Most often, patients do not remember a specific event or injury that caused their disc herniation. It most often seems to start without any apparent reason. Occasionally, an automobile accident, work injury, or sports injury is the cause. The thick containment structure for the disc, the annulus, becomes thin starting around age 30 - 40. This leads to disc bulging and herniation. The annulus can also be torn from an injury. When the annulus tears, the disc material is no longer contained and can extrude or herniate through the tear in the annulus and enter the spinal canal.

Signs and Symptoms

The most common symptom of a disc herniation is pain that radiates across the shoulder and into the arm, through the forearm and often into the hand. The area of arm pain depends on which disc in the neck is herniated. A herniated disc may also cause pain across to the shoulder only and not down the arm. It may cause pain only into certain fingers. Numbness over parts of the arm or hand is common. Weakness in muscle groups associated with the nerve is also not uncommon. An injured cervical disc can also cause referred pain around the shoulder blade or scapula. Headaches and neck pain are also common. If the disc herniation is large enough to compress the spinal cord, numbness, tingling or weakness in the legs might develop.

Nonoperative Treatment Options

Most cervical disc herniations that cause radiating arm pain will improve over the first six to eight weeks after symptoms occur. The majority of patients who have arm pain will notice that the pain slowly improves over this two month time frame and numbness and weakness may also improve. The initial treatment approach should include anti-inflammatory medications such as aspirin, Advil or Aleve. Physical therapy including general traction can also play a roll and provide some relief. In some cases, epidural steroid injections may be appropriate. It is very important that patients with a cervical disc herniation not have passive manipulation of the cervical spine such as chiropractic treatments. Such forceful movement on the cervical spine can cause more of the disc to herniate, increasing the arm pain, numbness, weakness, with potentially catastrophic results. Such manipulation of the neck should be avoided completely.

Surgery

If radiating arm pain, numbness, tingling or weakness persists beyond six to eight weeks, surgery may be indicated. Surgery is also indicated if profound weakness exists, if there is progressive numbness or weakness, or if symptoms in the legs develop. If none of these are present, the decision to proceed with surgery is made on the basis of the patients desire to obtain relief from the radiating arm pain. Surgery for a cervical disc herniation is not recommended for patients who only have neck pain.

Surgical Procedure

The procedure to remove the disc from the neck is very commonly performed in the United States with excellent results. A 1 1/2 inch incision is made in the left front of the neck. The trachea and esophagus are retracted toward the patient's right while the pulse and neck vessels are retracted leftward. The cervical spine is very close and accessible in the front part of the neck. The cervical disc is then removed and in its place, a piece of bone graft from the bone bank is positioned to maintain the height of the vertebrae and prevent neck pain from developing after the surgery. Often, a titanium plate is placed across the disc to make it more stable. Surgery takes 1 to 1 1/2 hours and the patient awakens with a cervical collar in place. The collar is worn for six weeks while the bone heals. Following this, the collar is removed and the patient can resume most activities.

Surgical Results

The results from cervical diskectomy have shown approximately a 95% chance at good or excellent relief from the radiating arm pain. Numbness generally improves. Weakness in the effected arm may require some physical therapy to fully recover. Improvement and strength in the arm is expected over time. After three to four months from surgery, the patient can resume full-unrestricted activities. About 7% of neck motion is lost when a disc is removed. Most people do not notice a difference in their neck motion after surgery.

Surgical Complications

The complications from this surgery are very rare. The most common of these is the failure of the bone fusion. This happens in 5 to 8% of patients. When it occurs, half of the patients have no symptoms from it and nothing further is required. For the patients who do develop neck pain as a result of the failure of fusion, additional surgery may be required to obtain a solid fusion of the disc and alleviate the neck pain. The risk of paralysis with this surgery is one in several thousand. Infection rate is less than one in a hundred. Other complications are even more rare.

Long Term

The long-term outlook for patients who have undergone cervical disc herniation is excellent. Patients are able to resume full activity, in some cases even including full contact sports. For patients who have several herniated discs removed, collision sports such as football should be avoided. Even for those patients involved with heavy labor jobs such as construction, the expectation is that these patients will be returned to work without restriction.

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Answers for Neck Pain

By Terrence Crowder, M.D.

artificial_disk3A natural consequence of aging is degeneration. When this degeneration occurs in the spine, it is called spondylosis (or degenerative arthritis of the spinal vertebra) . Although degeneration can affect any part of the spine and is common in adults, development of pain and disability from spondylosis is far less common. More than 60% of all adults will experience neck pain in their lifetime but only 5% will be disabled by it. Seventy percent of those seeking medical treatment for their neck pain will experience complete or significant relief of their symptoms.

Your neck carries the weight of a bowling ball so as you can imagine, hunching your shoulders or slumping at your desk makes its job more difficult. Good posture can make a huge difference over the years and reduce the work of your neck. Contrary, poor posture can make your neck vulnerable to aging and injury.

Spinal Anatomy and Disease Process

The neck, or cervical spine, is comprised of bones, discs, joints, tendons, muscles, ligaments and nerves, any of which can be a source of pain. If nerves are involved, symptoms of numbness, tingling or weakness in an arm or legs can occur. Sometimes pain is due to adjacent parts such as the head and shoulders or jaw. It can be confusing but neck problems can be accurately diagnosed so treatment options can be instituted.

In the cervical spine, there are seven stacked bones called vertebrae. These vertebrae serve to support the head, allow motion, and connect the head to the rest of the body.

In between each vertebral level of the cervical spine, a spinal disc and two facet joints located behind each disc take on the weight and strain of the neck supported by ligaments and muscles. As we grow older, the discs between the vertebrae lose their water content, resulting in disc height loss and bulging into the spinal canal. Spondylosis (arthritis) causes the development of bone spurs and ligamentous involvement which can push into the spinal canal as well.

Causes of Neck Pain

Disorders of the cervical spine can be broken down into three categories: 1) cervicalgia, or neck pain, 2) radiculopathy, or pain that radiates into a shoulder or arm, and 3) myelopathy, compression of spinal cord or, a combination.

Most causes of neck pain are not serious and can be resolved by simple means. Pain caused by improper ergonomics, posture, stress or chronic muscle fatigue usually is easily solved. However, sometimes neck pain can signify something more serious. If postural and ergonomic changes don't solve the problem, it deserves an investigation to determine the cause (diagnosis) and appropriate treatments. Some symptoms of various neck disorders include dull aching, pain increased by movement of the neck, numbness, tingling, tenderness, sharp shooting pain, or dizziness. Experiencing weakness in an arm or leg, or a shuffling gait is reason to seek prompt medical evaluation.

Diagnosing Neck Pain

A thorough review of symptoms includes location, intensity, duration and pattern of radiating pain and noting any injury. Positions that aggravate or relieve the pain should be noted too. A neck examination should be done at rest and in motion. During the exam, the nervous system is evaluated to determine nerve involvement.

Diagnostic imaging testing begins with plain x-rays which help identify degenerative and rheumatoid arthritis, cancer, trauma, and infection. Magnetic resonance imaging (MRI) has become the test of choice when evaluating the patient with neck pain. Computer tomography (CT) is also helpful in assessing the cervical spine. CT scans give a more detailed view of the joints, bones, and alignment of the vertebrae. If dye is added to the spinal canal to better delineate soft tissue before a CT is performed, it is called a CT myelogram. Other tests that can be helpful include electromyography (EMG) and nerve conduction studies (NCS). Because multiple clinical studies have shown that a significant number of people with no symptoms exhibit degenerative changes on imaging films, the physical exam and history, along with any imaging studies, must be used to delineate and correlate the true reason for one's pain.

Treatment for Neck Pathology

An accurate diagnosis is the first step to instituting treatments, which can include physical therapy to strengthen muscles around the neck, anti-inflammatory medication, heat/ice applications, soft collar, traction and activity modification. Other options considered are spinal injections, topical anesthetic creams, topical pain patches, muscle relaxants, analgesics or surgical intervention. Chiropractic cervical manipulation is controversial. Studies show that rehabilitative neck exercises are superior to manipulation. There are risks associated with neck manipulation that are significantly more serious than those seen with lower back.

Radiculopathy (Arm or Shoulder Pain)

Radiculopathy refers to symptoms resulting from nerve compression of specific nerve root(s). One who experiences possible nerve compression in the neck can complain of sharp or aching pain, tingling, numbness, and/or a burning sensation in the upper extremity. Weakness of the muscles supplied by that nerve may also occur. Neck pain can accompany these complaints. Possible reasons for radicular pain include disc herniation, spinal stenosis (narrowing of the spinal canal due to degeneration), tumor or infection.

Conservative treatment is always tried first. The majority of patients with radiculopathy particularly those diagnosed with a disc herniation improve without any treatment. Persistent symptoms can benefit from the same conservative treatment as neck pain without radicular symptoms.

Myelopathy

The origin of myelopathy differs from radiculopathy. While radiculopathy refers to nerve roots which exit the spine, myelopathy refers to injury to the spinal cord itself. Cervical spinal stenosis (narrowing of the spinal canal from enlarged arthritic bones and soft tissues) can cause compression of the spinal cord. Patients complain about difficulty with handwriting, small finger tasks or even opening a door. Lower extremity symptoms include weakness, loss of balance, difficulty walking and decreased bowel or bladder control. Severity of myelopathy varies from mild to rapid progression. Those patients who are stable can go as is while those whose symptoms and compression progress, surgery is recommended to stop or stabilize the progression.

Non-Operative Treatment

A number of non surgical treatment options exist for the treatment of cervicalgia, radiculopathy, or myelopathy. Classic conservative treatment involves using nonsteroidal medications to reduce inflammation and physical therapy to strengthen the supporting muscles around the cervical spine which resolve complaints in a significant percentage of patients. Rest, patient education, and acupuncture have shown some benefit in a few studies. Occasional immobilization in a cervical collar can be beneficial when neck pain is severe. Manual or automated traction have also been shown to provide relief. Epidural and selective nerve steroid injections have shown good short term benefit but do not decrease the rate of eventual surgery. One can also consider spinal injections of the arthritic facet joints or by burning away the nerves supplying the joint with some success.

Considering Surgery

If nonoperative treatment fails and symptoms persist or progress, surgical intervention may become necessary. Multiple factors are considered when deciding the approach to surgical intervention. Surgery of the neck is either performed from the front, back, or a combination of the two. Surgery can be as simple as a one-level discectomy through a minimally invasive approach to more complicated procedures for multiple decompressions or tumor removal. For selected cases that have disc pathology, artificial disc replacement, which preserves motion, is now an option. Since cervical procedures can be technically demanding, they should be performed by spine surgeons.

Fortunately, there are a range of options when deciding the approach and type of surgery that is best for the problem. Most importantly, the surgery should be selected to produce the best outcome for the patient in the long term, not because it is new or is popular in marketing circles.

A Final Word

A thorough medical history and examination are essential along with appropriate imaging studies so symptoms and findings can be correlated. While nonoperative treatments will benefit the majority of patients, if these methods fail, surgical interventions offer excellent resolution of certain cervical spine disorders. Although no one ever wants to resort to having surgery, it can be a viable solution to return you to improved comfort and a more active lifestyle.

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