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CERVICAL SPINE

Cervical Spine Anatomy


A Patient's Guide to Cervical Spine Anatomy

Introduction

Knowing the main parts of your neck and how these parts work is important as you learn to care
for your neck problem.

Two common anatomic terms are useful as they relate to the neck. The term anterior refers to the
front of the neck. The term posterior refers to the back of the neck. The part of the spine that
moves through the neck is called the cervical spine. The front of the neck is therefore called the
anterior cervical area. The back of the neck is called the posterior cervical area.

This guide gives a general overview of the anatomy of the neck. It should help you understand

• what parts make up the neck


• how these parts work

Important Structures

The important parts of the cervical spine include

• bones and joints


• nerves
• connective tissues
• muscles
• spinal segments

This section highlights important structures in each category.

Bones and Joints

The human spine is made up of 24 spinal bones, called vertebrae. Vertebrae are stacked on top
of one another to form the spinal column. The spinal column is the body's main upright support.

The first seven vertebrae make up the cervical spine. Doctors often refer to these vertebrae as C1
to C7. The cervical spine starts where the top vertebra (C1) connects to the bottom of the skull.
The cervical spine curves slightly inward and ends where C7 joins the top of the thoracic spine
(the chest area).

The base of the skull sits on top of C1, also called the atlas. Two thickened bony arches form a
large hole through the center of the atlas. The opening is large because the spinal cord is wider
where it first exits the brain and skull. Compared to other vertebrae, the atlas also has much
wider bony projections pointing out to each side.

The atlas sits on top of the C2 vertebra. The C2 is called the axis. The axis has a large bony knob
on top, called the dens. The dens points up and fits through a hole in the atlas. The joints of the
axis give the neck most of its ability to turn to the left and right.

Each vertebra is made of the same parts. The main section of each cervical vertebra, from C2 to
C7, is formed by a round block of bone, called the vertebral body. A bony ring attaches to the
back of the vertebral body. This ring has two parts. Two pedicle bones connect directly to the
back of the vertebral body. Two lamina bones join the pedicles to complete the ring. The lamina
bones form the outer rim of the bony ring. When the vertebrae are stacked on top of each other,
the bony rings form a hollow tube that surrounds the spinal cord. The laminae provide a
protective roof over the spinal cord.

A bony knob projects out at the point where the two lamina bones join together at the back of the
spine. These projections, called spinous processes, can be felt as you rub your fingers up and
down the back of your spine. The largest bump near the top of your spine is the spinous process
of C2. At the base of the neck where the cervical and thoracic spines join together, you'll feel
another large spinous process. That's C7.
Each vertebra in the spine has two bony knobs that point out to the side, one on the left and one
on the right. These bony projections are called transverse processes. The atlas has the widest
transverse processes of all the cervical vertebrae. Unlike the rest of the spine, the neck vertebrae
have a hole that passes down through each transverse process. This hole, called the transverse
foramen, provides a passageway for arteries that run up each side of the neck to supply the back
of the brain with blood.

Between each pair of vertebrae are two joints called facet joints. These joints connect the
vertebrae together in a chain but slide against one another to allow the neck to move in many
directions. Except for the very top and bottom of the spinal column, each vertebra has two facet
joints on each side. The ones on top connect to the vertebra above; the ones below join with the
vertebra below.

The surfaces of the facet joints are covered by articular cartilage. Articular cartilage is a smooth,
rubbery material that covers the ends of most joints. It allows the ends of bones to move against
each other smoothly, without friction.

On the left and right side of each vertebra is a small tunnel called a neural foramen. (Foramina is
the plural term.) The two nerves that leave the spine at each vertebra go through the foramina,
one on the left and one on the right. The intervertebral disc (described later) sits directly in front
of the opening. A bulged or herniated disc can narrow the opening and put pressure on the nerve.
A facet joint sits in back of the foramen. Bone spurs that form on the facet joint can project into
the tunnel, narrowing the hole and pinching the nerve.

Nerves

The hollow tube formed by the bony ring on the back of the spinal column surrounds the spinal
cord as it passes through the spine. The spinal cord is a similar to a long wire made up of
millions of nerve fibers. Just as the skull protects the brain, the bones of the spinal column
protect the spinal cord.

The spinal cord travels down from the brain through the spinal column. Two large nerves branch
off the spinal cord from each vertebra, one on the left and one on the right. The nerves pass
through the neural foramina. These spinal nerves group together to form the main nerves that go
to the limbs and organs. The nerves that come out of the cervical spine go to the arms and hands.
Connective Tissues

Ligaments are strong connective tissues that attach bones to other bones. (Connective tissues are
networks of fiber that hold the cells of the body together.) Several long ligaments connect on the
front and back sections of the vertebrae. The anterior longitudinal ligament runs lengthwise
down the front of the vertebral bodies. Two other ligaments run full length within the spinal
canal. The posterior longitudinal ligament attaches on the back of the vertebral bodies. The
ligamentum flavum is a long elastic band that connects to the front surface of the lamina bones.

A special type of structure in the spine called an intervertebral disc is also made of connective
tissue. The fibers of the disc are formed by special cells, called collagen cells. The fibers may be
lined up like strands of nylon rope or crisscrossed like a net.

An intervertebral disc is made of two parts. The center, called the nucleus, is spongy. It provides
most of the shock absorption in the spine. The nucleus is held in place by the annulus, a series of
strong ligament rings surrounding it.
Muscles

The anterior cervical area is covered with muscles that run from the rib cage and collar bone to
the cervical vertebrae, jaw, and skull. The posterior cervical muscles cover the bones along the
back of the spine and make up the bulk of the tissues on the back of the neck.

Spinal Segment

A good way to understand the anatomy of the cervical spine is by looking at a spinal segment.
Each spinal segment includes two vertebrae separated by an intervertebral disc, the nerves that
leave the spinal cord at each vertebra, and the small facet joints that link each level of the spinal
column.

The intervertebral disc separates the two vertebral bodies of the spinal segment. The disc
normally works like a shock absorber. It protects the spine against the daily pull of gravity. It
also protects the spine during heavy activities that put strong force on the spine, such as jumping,
running, and lifting.

The spinal segment is connected by a facet joint, described earlier. When the facet joints of the
cervical spine move together, they bend and turn the neck.

Summary

Many important parts make up the anatomy of the neck. Understanding the regions and
structures of the neck can help you be more involved in your health care and better able to care
for your neck problem.
Cervical Radiculopathy
A Patient's Guide to Cervical Radiculopathy

Introduction

Neck pain has many causes. Mechanical neck pain comes from injury or inflammation in the soft
tissues of the neck. This is much different and less concerning than symptoms that come from
pressure on the nerve roots as they exit the spinal column. People sometimes refer to this
problem as a pinched nerve. Health care providers call it cervical radiculopathy.

This guide will help you understand

• how the problem develops


• how doctors diagnose the condition
• what treatment options are available

Anatomy

What part of the neck is involved?


The spine is made of a column of bones. Each bone, or vertebra, is formed by a round block of
bone, called a vertebral body. A bony ring attaches to the back of the vertebral body. When the
vertebra bones are stacked on top of each other, the bony rings forms a long bony tube that
surrounds and protects the spinal cord as it passes through the spine.

Traveling from the brain down through the spinal column, the spinal cord sends out nerve
branches through openings on both sides of each vertebra. These openings are called the neural
foramina. (The term used to describe a single opening is foramen.)

The intervertebral disc sits directly in front of the opening. A bulged or herniated disc can
narrow the opening and put pressure on the nerve. A facet joint sits in back of the foramen. Bone
spurs that form on the facet joint can project into the tunnel, narrowing the hole and pinching the
nerve.

An intervertebral disc fits between the vertebral bodies and provides a space between the spine
bones. The disc normally works like a shock absorber. An intervertebral disc is made of two
parts. The center, called the nucleus, is spongy. It provides most of the shock absorption. The
nucleus is held in place by the annulus, a series of strong ligament rings surrounding it.
Ligaments are strong connective tissues that attach bones to other bones.

Causes

Why do I have this problem?

Cervical radiculopathy is caused by any condition that puts pressure on the nerves where they
leave the spinal column. This is much different than mechanical neck pain. Mechanical neck pain
is caused by injury or inflammation in the soft tissues of the neck, such as the discs, facet joints,
ligaments, or muscles.

The main causes of cervical radiculopathy include degeneration, disc herniation, and spinal
instability.

Degeneration

As the spine ages, several changes occur in the bones and soft tissues. The disc loses its water
content and begins to collapse, causing the space between the vertebrae to narrow. The added
pressure may irritate and inflame the facet joints, causing them to become enlarged. When this
happens, the enlarged joints can press against the nerves going to the arm as they try to squeeze
through the neural foramina. Degeneration can also cause bone spurs to develop. Bone spurs may
put pressure on nerves and produce symptoms of cervical radiculopathy.

Herniated Disc

Heavy, repetitive bending, twisting, and lifting can place extra pressure on the shock-absorbing
nucleus of the disc. A blow to the head and neck can also cause extra pressure on the nucleus. If
great enough, this increased pressure can injure the annulus (the tough, outer ring of the disc). If
the annulus ruptures, or tears, the material in the nucleus can squeeze out of the disc. This is
called a herniation.

Although daily activities may cause the nucleus to press against the annulus, the body is
normally able to withstand these pressures. However, as the annulus ages, it tends to crack and
tear. It is repaired with scar tissue. Over time, the annulus becomes weakened, and the disc can
more easily herniate through the damaged annulus. If the herniated disc material presses against
a nerve root it can cause pain, numbness, and weakness in the area the nerve supplies.

Spinal Instability

Spinal instability means there is extra movement among the bones of the spine. Instability in the
cervical spine (the neck) can develop if the supporting ligaments have been stretched or torn
from a severe injury to the head or neck. People with diseases that loosen their connective tissue
may also have spinal instability. Spinal instability also includes conditions in which a vertebral
body slips over the one just below it. When the vertebral body slips too far forward, the
condition is called spondylolisthesis. Whatever the cause, extra movement in the bones of the
spine can irritate or put pressure on the nerves of the neck, causing symptoms of cervical
radiculopathy.

Symptoms

What does the condition feel like?

The symptoms from cervical radiculopathy are from pressure on an irritated nerve. These
symptoms are not the same as those that come from mechanical neck pain. Mechanical neck pain
usually starts in the neck and may spread to include the upper back or shoulder. It rarely extends
below the shoulder. Headaches are also a common complaint of both radiculopathy and
mechanical neck pain.

The pain from cervical radiculopathy usually spreads further down the arm than mechanical neck
pain. And unlike mechanical pain, radiculopathy also usually involves other changes in how the
nerves work such as numbness, tingling, and weakness in the muscles of the shoulder, arm, or
hand. With cervical radiculopathy, the reflexes in the muscles of the upper arm are usually
affected. This is why doctors check reflexes when people have symptoms of cervical
radiculopathy.

Diagnosis

How do doctors diagnose the problem?

Doctors gather the information about your symptoms as a way to determine which nerve is
having problems. Diagnosis begins with a complete history of the problem. Your doctor will ask
questions about your symptoms and how your problem is affecting your daily activities. Your
answers can help your doctor determine which nerve is causing problems.
Next, the doctor examines you to see which neck movements cause pain or other symptoms.
Your skin sensation, muscle strength, and reflexes are tested in order to tell where the nerve
problem is coming from.

X-rays of the cervical spine can show the cause of pressure on the nerve. The images show
whether degeneration has caused the space between the vertebrae to collapse. They may also
show if a bone spur is pressing against a nerve.

If more information is needed, your doctor may order magnetic resonance imaging (MRI). The
MRI machine uses magnetic waves rather than X-rays to show the soft tissues of the body. This
test gives a clear picture of the discs, nerves, and other soft tissues in the neck. The machine
creates pictures that look like slices of the area your doctor is interested in. The test does not
require any special dye or needles and is painless.

Sometimes it isn't clear where the nerve pressure is coming from. Symptoms of numbness or
weakness can also happen when the nerve is being pinched or injured at other points along its
path. (An example of this is pressure on the median nerve in the wrist, known as carpal tunnel
syndrome.) Electrical studies of the nerves going from the neck to the arm may be requested by
your doctor to see whether the nerve problem is in the neck or further down the arm. However,
most doctors take X-rays and try other forms of treatment before ordering electrical tests. These
tests are usually only needed when the diagnosis is not clear.

If your doctor orders electrical studies, several tests are available to see how well the nerves are
functioning, including the electromyography (EMG) test. This test measures how long it takes a
muscle to work once a nerve signals it to move. The time it takes will be slower if nerve pressure
from radiculopathy has affected the strength of the muscle.

Another electrical test that may be used instead of EMG is cervical root stimulation (CRS). This
test involves putting a small needle through the back of the neck into the nerve where it leaves
the spinal column. Readings of muscle action are then taken of the muscles on the front and back
of the upper arm and along the inside of the lower arm. Doctors use the readings to determine
which nerve is having problems.

Treatment

What treatment options are available?

Nonsurgical Treatment

Unless the nerve problem is getting worse rapidly, most doctors will begin with nonsurgical
treatments.

At first, your doctor may prescribe immobilization of the neck. Keeping the neck still for a short
time can calm inflammation and pain. This might include one to two days of bed rest and the use
of a soft neck collar. This collar is a padded ring that wraps around the neck and is held in place
by a Velcro strap. Normally, a patient need only wear a collar for one to two weeks. Wearing it
longer tends to weaken the neck muscles.

Doctors prescribe certain types of medication for patients with cervical radiculopathy. Severe
symptoms may be treated with narcotic drugs, such as codeine or morphine. But these drugs
should only be used for the first few days or weeks after problems with radiculopathy start
because they are addictive when used too much or improperly. Muscle relaxants may be
prescribed to calm neck muscles that are in spasm. You may be prescribed anti-inflammatory
medications such as aspirin or ibuprofen.

Some doctors have their patients work with a physical therapist. At first, treatments are used to
ease pain and inflammation. Electrical stimulation treatments can help calm muscle spasm and
pain. Traction is a way to gently stretch the joints and muscles of the neck. It can be done using a
machine with a special head halter, or the therapist can apply the traction pull by hand.

Some patients are given an epidural steroid injection (ESI). The spinal cord travels in a tube
within the bones of the spinal canal. The cord is covered by a material called dura. The space
between the dura and the spinal column is the epidural space. It is thought that injecting steroid
medication into this space fights inflammation around the nerves, the discs, and the facet joints.
In some cases, the steroid injection is given around one specific nerve. This is called a selective
nerve block. The response to this treatment helps confirm which nerve root is causing the
symptoms.

Doctors usually have their patients try nonoperative treatments for at least three months before
considering surgery. But when patients simply aren't getting better, or if the problem is becoming
more severe, surgery may be suggested.

Surgery

Most people with cervical radiculopathy get better without surgery. In rare cases, people don't
get relief with nonsurgical treatments. They may require surgery. There are several types of
surgery for cervical radiculopathy. These include

• foraminotomy
• discectomy
• fusion

Foraminotomy

A foraminotomy is done to open the neural foramen and relieve pressure on the spinal nerve root.
A foraminotomy may be done because of bone spurs or inflammation.

Related Document: A Patient's Guide to Cervical Foraminotomy

Discectomy

In a discectomy, the surgeon removes the disc where it is pressing against a nerve. Surgeons
usually perform this surgery from the front (anterior)of the neck. This procedure is called
anterior cervical discectomy. In most patients, discectomy is done together with a procedure
called cervical fusion, which is described next.

Fusion

A fusion surgery joins two or more bones into one solid bone. The purpose for treating cervical
radiculopathy with fusion is to increase the space between the vertebrae, taking pressure off the
nerve. The surgery is most often done through the front of the neck. After taking out the disc
(discectomy), the disc space is filled in with a small block of bone graft. The bone is allowed to
heal, fusing the two vertebrae into one solid bone. The space between the vertebrae is propped
and held open by the bone graft, which enlarges the neural foramina, taking pressure off the
nerve roots.

Rehabilitation

Nonsurgical Rehabilitation

What should I expect from treatment?


Even if you don't need surgery, your doctor may recommend that you work with a physical
therapist. Patients are normally seen a few times each week for one to two months. In severe
cases, patients may need a few additional weeks of care.

Your therapist creates a program to help you regain neck and arm function. Treatments for
cervical radiculopathy often include neck traction, described earlier. Though neck traction is
often done in the clinic, your therapist may give you a traction device to use at home.

It is very important to improve the strength and coordination in the neck and shoulder blade
muscles. Your therapist can also evaluate your workstation or the way you use your body when
you do your activities and suggest changes to avoid further problems.

After Surgery

Rehabilitation after surgery for cervical radiculopathy can be a slow process. You will probably
need to attend physical therapy sessions for six to eight weeks, and you should expect full
recovery to take up to four months.

During physical therapy after surgery, your therapist may use treatments such as heat or ice,
electrical stimulation, massage, and ultrasound to help calm pain and muscle spasm. Then you
begin learning how to move safely with the least strain on the healing neck.

As the rehabilitation program evolves, you will do more challenging exercises. The goal is to
safely advance your strength and function. As your therapy sessions come to an end, your
therapist will help you with decisions about getting you back to work. Your therapist can do a
work assessment to make sure you'll be able to do your job safely. Your therapist may suggest
changes that could help you work safely, with less chance of reinjuring your neck.
When your treatment is well under way, regular visits to the therapist's office will end. The
therapist will continue to be a resource for you. But you will be in charge of doing your exercises
as part of an ongoing home program.
A Patient's Guide to Cervical Foraminotomy

Introduction

Foraminotomy is a surgical procedure for widening the area where the spinal nerve roots exit the
spinal column. A foramen is the opening around the nerve root, and otomy refers to the medical
procedure for enlarging the opening. In this procedure, surgeons widen the passageway to relieve
pressure where the spinal nerve is being squeezed in the foramen.

This guide will help you understand

• why the procedure becomes necessary


• what surgeons hope to achieve
• what to expect as you recover

Anatomy

What parts of the neck are affected?

The spine is made of a column of bones. Each bone, or vertebra, is formed by a round block of
bone, called a vertebral body. The spinal canal is a hollow tube formed by the bony rings of all
the vertebrae. The spinal canal surrounds and protects the spinal cord within the spine. There are
seven vertebrae in the neck that form the area known as the cervical spine. The vertebrae are
separated by intervertebral discs.

Traveling from the brain down through the spinal column, the spinal cord sends out nerve
branches through openings on both sides of each vertebra. These openings are called the neural
foramina. (The term used to describe a single opening is foramen.)
The intervertebral disc sits directly in front of the opening. A bulged or herniated disc can
narrow the opening and put pressure on the nerve. A facet joint sits in back of the foramen. Bone
spurs that form on the facet joint can project into the tunnel, narrowing the hole and pinching the
nerve.

Rationale

What do surgeons hope to achieve?

Foraminotomy alleviates the symptoms of foraminal stenosis. In foraminal stenosis, a nerve root
is compressed inside the neural foramen. This compression is usually the result of degenerative
(or wear and tear) changes in the spine.

Wear and tear from repeated stresses and strains on the neck can cause a spinal disc to begin to
collapse. As the space between the vertebral bodies shrinks, the opening around the nerve root
narrows. This squeezes the nerve. The nerve root is further squeezed in the foramen when the
facet joint lining the outer edge of the foramen becomes inflamed and enlarged as a result of the
same degenerative changes.

The degenerative process can also cause bone spurs to develop and point into the foramen,
causing further irritation. In a foraminotomy, the surgeon removes the tissues around the edges
of the foramen, essentially widening the opening in order to take pressure off the nerve root.

Preparations

How will I prepare for surgery?

The decision to proceed with surgery must be made jointly by you and your surgeon. You should
understand as much about the procedure as possible. If you have concerns or questions, you
should talk to your surgeon.

Once you decide on surgery, you need to take several steps. Your surgeon may suggest a
complete physical examination by your regular doctor. This exam helps ensure that you are in
the best possible condition to undergo the operation.

On the day of your surgery, you will probably be admitted to the hospital early in the morning.
You shouldn't eat or drink anything after midnight the night before.

Surgical Procedure

What happens during the operation?

Patients are given a general anesthesia to put them to sleep during most spine surgeries. For
shorter procedures such as foraminotomy, patients are usually given a gas form of anesthesia
through a mask. As you sleep, your breathing may be assisted with a ventilator. A ventilator is a
device that controls and monitors the flow of air to the lungs.
This surgery is usually done with the patient lying face down on the operating table. The surgeon
makes an incision down the middle of the back of the neck. The skin and soft tissues are
separated on the side where the spinal nerves are compressed. Some surgeons use a surgical
microscope during the procedure to magnify the area they'll be working on.

The surgeon may use a small, rotary cutting tool (a burr) to shave the inside edge of the facet
joint. This opens up the outer rim of the neural foramen. The burr is sometimes used to shave a
small section of the bony ring on the back of the vertebra above and below the affected nerve
root.

Small cutting instruments are used to carefully remove soft tissues within the neural foramen.
The surgeon takes out any small disc fragments that are present and scrapes off nearby bone
spurs. In this way, tension and pressure are taken off the nerve root.

The muscles and soft tissues are put back in place, and the skin is stitched together. Patients are
sometimes placed in a soft collar after surgery to keep the neck positioned comfortably.

Complications

What might go wrong?

As with all major surgical procedures, complications can occur. Some of the most common
complications following foraminotomy include

• problems with anesthesia


• thrombophlebitis
• infection
• nerve damage
• ongoing pain

This is not intended to be a complete list of the possible complications, but these are the most
common.

Problems with Anesthesia

Problems can arise when the anesthesia given during surgery causes a reaction with other drugs
the patient is taking. In rare cases, a patient may have problems with the anesthesia itself. In
addition, anesthesia can affect lung function because the lungs don't expand as well while a
person is under anesthesia. Be sure to discuss the risks and your concerns with your
anesthesiologist.

Thrombophlebitis (Blood Clots)

Thrombophlebitis, sometimes called deep venous thrombosis (DVT), can occur after any
operation. It occurs when the blood in the large veins of the leg forms blood clots. This may
cause the leg to swell and become warm to the touch and painful. If the blood clots in the veins
break apart, they can travel to the lung, where they lodge in the capillaries and cut off the blood
supply to a portion of the lung. This is called a pulmonary embolism. (Pulmonary means lung,
and embolism refers to a fragment of something traveling through the vascular system.) Most
surgeons take preventing DVT very seriously. There are many ways to reduce the risk of DVT,
but probably the most effective is getting you moving as soon as possible. Two other commonly
used preventative measures include

• pressure stockings to keep the blood in the legs moving


• medications that thin the blood and prevent blood clots from forming

Infection

Infection following spine surgery is rare but can be a very serious complication. Some infections
may show up early, even before you leave the hospital. Infections on the skin's surface usually
go away with antibiotics. Deeper infections that spread into the bones and soft tissues of the
spine are harder to treat and may require additional surgery to treat the infected portion of the
spine.

Nerve Damage

Any surgery that is done near the spinal canal can potentially cause injury to the spinal cord or
spinal nerves. Injury can occur from bumping or cutting the nerve tissue with a surgical
instrument, from swelling around the nerve, or from the formation of scar tissue. An injury to
these structures can cause muscle weakness and a loss of sensation to the areas supplied by the
nerve.

Ongoing Pain

Many patients get nearly complete pain relief from the foraminotomy procedure. As with any
surgery, however, you should expect some pain afterward. If the pain continues or becomes
unbearable, talk to your surgeon about treatments that can help control your pain.

After Surgery

What happens after surgery?

Patients are usually able to get out of bed within an hour or two after surgery. Your surgeon may
have you wear a soft neck collar. If not, you will be instructed to move your neck only carefully
and comfortably.

Most patients leave the hospital the day after surgery and are safe to drive within a week or two.
People generally get back to light work by four weeks and can do heavier work and sports within
two to three months.

Outpatient physical therapy is usually prescribed when patients have extra pain or show
significant muscle weakness and deconditioning.
Rehabilitation

What should I expect during my recovery?

Rehabilitation after foraminotomy surgery is generally needed for only a short period of time. If
you require outpatient physical therapy, you will probably need to attend therapy sessions for
two to four weeks. You should expect full recovery to take up to two or three months.

Many surgeons prescribe outpatient physical therapy within four weeks after surgery. At first,
treatments are used to help control pain and inflammation. Ice and electrical stimulation
treatments are commonly used to help with these goals. Your therapist may also use massage and
other hands-on treatments to ease muscle spasm and pain.

Active treatments are added slowly. These include exercises for improving heart and lung
function. Walking, stationary cycling, and arm cycling are ideal cardiovascular exercises.
Therapists also teach specific exercises to help tone and control the muscles that stabilize the
neck and upper back.

Your therapist works with you on how to move and do activities. This form of treatment, called
body mechanics, is used to help you develop new movement habits. This training helps you keep
your neck in safe positions as you go about your work and daily activities. At first, this may be
as simple as helping you learn how to move safely and easily in and out of bed, how to get
dressed and undressed, and how to do some of your routine activities. Then you'll learn how to
keep your neck safe while you lift and carry items and as you begin to do heavier activities.
As your condition improves, your therapist will begin tailoring your program to help prepare you
to go back to work. Some patients are not able to go back to a previous job that requires heavy
and strenuous tasks. Therapists may suggest changes in job tasks that enable you to go back to
your previous job. They may also provide ideas for alternate forms of work. You'll learn to do
your tasks in ways that keep your neck safe and free of extra strain.

Before your therapy sessions end, your therapist will teach you a number of ways to avoid future
problems.
Cervical Discectomy
A Patient's Guide to Cervical Discectomy
Introduction

Cervical discectomy is surgery to remove one or more discs from the neck. The disc is the pad
that separates the neck vertebrae; ectomy means to take out. Usually a discectomy is combined
with a fusion of the two vertebrae that are separated by the disc. In some cases, this procedure is
done without a fusion. A cervical discectomy without a fusion may be suggested for younger
patients between 20 and 45 years old who have symptoms due to a herniated disc.

This guide will help you understand

• why the procedure becomes necessary


• what surgeons hope to achieve
• what to expect during your recovery

Anatomy

What parts of the neck are involved?


Surgeons usually perform this procedure through the front of the neck. This is called the anterior
neck region. Key structures include ligaments, bones, intervertebral discs, spinal cord, spinal
nerves and the neural foramina.

Surgery is occasionally done through the back, or posterior region, of the neck. Important
structures in this area include the ligaments and bones, especially the lamina bones.

Rationale

What do surgeons hope to achieve?

Discectomy is used to alleviate symptoms of a herniated disc. A disc herniation happens when
the nucleus inside the center of the disc pushes through the annulus, the ligaments surrounding
the nucleus. The herniated disc material may push outward, causing pain. Numbness or weakness
in the arm occurs when the nucleus pushes on the spinal nerve root. Of greater concern is a
condition in which the nucleus herniates straight backward into the spinal cord, called a central
herniation. Discectomy relieves pressure on the ligaments, nerves, or spinal cord.

Discectomy is also commonly used when the surgeon plans to fuse the bones of two neck
vertebrae into one solid bone. Most surgeons will take the disc out and replace the empty space
with a block of bone graft, a procedure called cervical fusion.

Discectomy alone is usually only used for younger patients (20 to 45 years old) whose symptoms
are from herniation of the disc. But some surgeons think discectomy should always be combined
with fusion of the bones above and below. They are concerned that the empty space where the
disc was removed may eventually collapse and fill in with bone. Inserting a bone block during
fusion surgery helps keep pressure off the spinal nerves because the graft widens the neural
foramina. The neural foramina are openings on each side of the vertebrae where nerves exit the
spinal canal. Most research on discectomy by itself shows good short-term benefits compared to
discectomy with fusion. But more information is needed about whether the long-term results are
equally as good.

Preparations

How will I prepare for surgery?

The decision to proceed with surgery must be made jointly by you and your surgeon. You should
understand as much about the procedure as possible. If you have concerns or questions, you
should talk to your surgeon.

Once you decide on surgery, your surgeon may suggest a complete physical examination by your
regular doctor. This exam helps ensure that you are in the best possible condition to undergo the
operation.

On the day of your surgery, you will probably be admitted to the hospital early in the morning.
You shouldn't eat or drink anything after midnight the night before.
Surgical Procedure

What happens during the operation?

Cervical discectomy is commonly done through the anterior (front) of the neck. This is called
anterior cervical discectomy. However, when many pieces of the herniated disc have squeezed
into the posterior (back) of the spine, surgeons may need to operate through the back of the neck
using a procedure called posterior cervical discectomy.

Patients are given a general anesthesia to put them to sleep during most spine surgeries. As you
sleep, your breathing may be assisted with a ventilator. A ventilator is a device that controls and
monitors the flow of air to the lungs.

Anterior Discectomy

The patient's neck is positioned facing the ceiling with the head bent back and turned slightly to
the right. A two-inch incision is made two to three fingers' width above the collar bone across the
left-hand side of the neck. The left side is chosen to avoid injuring the nerve going to the voice
box. Retractors are used to gently separate and hold the neck muscles and soft tissues apart so the
surgeon can work on the front of the spine.

A needle is inserted into the herniated disc, and an X-ray is taken to identify and confirm it is the
correct disc. A long strip of muscle and the anterior longitudinal ligament that cover the front of
the vertebral bodies are carefully pulled to the side. Forceps are used to take out the front half of
the disc. Next a small rotary cutting tool (a burr) is used to carefully remove the back half of the
disc. A surgical microscope is used to help the surgeon see and remove pieces of disc material
and any bone spurs that are near the spinal cord.

The muscles and soft tissues are put back in place, and the skin is stitched together.

Posterior Discectomy

This method is used when the herniated disc has fragmented into small pieces near the spinal
nerve.

The operation is usually done with the patient lying face down with the neck bent forward and
held in a headrest. The surgeon makes a short incision down the center of the back of the neck.
The skin and soft tissues are separated to expose the bones along the back of the spine.

Then the surgeon may use an X-ray to identify the injured disc. A burr is used to shave the edge
off the lamina bones, the back part of the ring over the spinal cord. When the disc has jutted
straight backward into the spinal cord (central herniation), surgeons may need to completely
remove both lamina bones in order to see better and to be able to clear all the pieces of the disc
near the spinal cord.
After shaving the lamina bone, the surgeon cuts a small opening in the ligamentum flavum, a
ligament within the spinal canal and in front of the lamina bone. By removing part of this
ligament, the surgeon exposes the spot where the disc fragments are pressed against the spinal
nerve. Next, the spinal nerve is gently moved upward. Using a surgical microscope, the surgeon
magnifies the area in order to carefully remove the disc fragments and any bone spurs.

The muscles and soft tissues are put back in place, and the skin is stitched together.

Complications

What might go wrong?

As with all major surgical procedures, complications can occur. Some of the most common
complications following discectomy include

• problems with anesthesia


• thrombophlebitis
• infection
• nerve damage
• ongoing pain

This is not intended to be a complete list of the possible complications, but these are the most
common.

Problems with Anesthesia

Problems can arise when the anesthesia given during surgery causes a reaction with other drugs
the patient is taking. In rare cases, a patient may have problems with the anesthesia itself. In
addition, anesthesia can affect lung function because the lungs don't expand as well while a
person is under anesthesia. Be sure to discuss the risks and your concerns with your
anesthesiologist.

Thrombophlebitis (Blood Clots)

Thrombophlebitis, sometimes called deep venous thrombosis (DVT), can occur after any
operation. It occurs when the blood in the large veins of the leg forms blood clots. This may
cause the leg to swell and become warm to the touch and painful. If the blood clots in the veins
break apart, they can travel to the lung, where they lodge in the capillaries and cut off the blood
supply to a portion of the lung. This is called a pulmonary embolism. (Pulmonary means lung,
and embolism refers to a fragment of something traveling through the vascular system.) Most
surgeons take preventing DVT very seriously. There are many ways to reduce the risk of DVT,
but probably the most effective is getting you moving as soon as possible. Two other commonly
used preventative measures include

• pressure stockings to keep the blood in the legs moving


• medications that thin the blood and prevent blood clots from forming
Infection

Infection following spine surgery is rare but can be a very serious complication. Some infections
may show up early, even before you leave the hospital. Infections on the skin's surface usually
go away with antibiotics. Deeper infections that spread into the bones and soft tissues of the
spine are harder to treat and may require additional surgery to treat the infected portion of the
spine.

Nerve Damage

Any surgery that is done near the spinal canal can potentially cause injury to the spinal cord or
spinal nerves. Injury can occur from bumping or cutting the nerve tissue with a surgical
instrument, from swelling around the nerve, or from the formation of scar tissue. An injury to
these structures can cause muscle weakness and a loss of sensation to the areas supplied by the
nerve.

The nerve to the voice box is sometimes injured during surgery on the front of the neck. When
doing anterior neck surgery, surgeons prefer to go through the left side of the neck where the
path of the nerve to the voice box is more predictable than on the right side. During surgery, the
nerve may get stretched too far when retractors are used to hold the muscles and soft tissues
apart. When this happens, patients may be hoarse for a few days or weeks after surgery. In rare
cases where the nerve is actually cut, patients may end up with ongoing minor problems of
hoarseness, voice fatigue, or difficulty making high tones.

Ongoing Pain

Many patients get nearly complete relief of symptoms from the discectomy procedure. As with
any surgery, however, you should expect some pain afterward. If the pain continues or becomes
unbearable, talk to your surgeon about treatments that can help control your pain.

After Surgery

What happens after surgery?

Patients are usually able to get out of bed within an hour or two after surgery. Your surgeon may
have you wear a hard or soft neck collar. If not, you will be instructed to move your neck only
carefully and comfortably.

Most patients leave the hospital the day after surgery and are safe to drive within a week or two.
People generally get back to light work by four weeks and can do heavier work and sports within
two to three months.

Outpatient physical therapy is usually prescribed only for patients who have extra pain or show
significant muscle weakness and deconditioning.

Rehabilitation
What should I expect as I recover?

Patients usually don't require formal rehabilitation after routine cervical discectomy surgery.
Surgeons may prescribe a short period of physical therapy when patients have lost muscle tone in
the shoulder or arm, when they have problems controlling pain, or when they need guidance
about returning to heavier types of work.

If you require outpatient physical therapy, you will probably only need to attend therapy sessions
for two to four weeks. You should expect full recovery to take up to three months.

At first, therapy treatments are used to help control pain and inflammation. Ice and electrical
stimulation treatments are commonly used to help with these goals. Your therapist may also use
massage and other hands-on treatments to ease muscle spasm and pain.

Active treatments are added slowly. These include exercises for improving heart and lung
function. Walking, stationary cycling, and arm cycling are ideal cardiovascular exercises.
Therapists also teach specific exercises to help tone and control the muscles that stabilize the
neck and upper back.

Your therapist works with you on how to move and do activities. This form of treatment, called
body mechanics, is used to help you develop new movement habits. This training helps you keep
your neck in safe positions as you go about your work and daily activities. You'll learn how to
keep your neck safe while you lift and carry items and as you begin to do other heavier activities.

As your condition improves, your therapist will begin tailoring your program to help prepare you
to go back to work. Some patients are not able to go back to a previous job that requires heavy
and strenuous tasks. Your therapist may suggest changes in job tasks that enable you to go back
to your previous job. Your therapist can also provide ideas for alternate forms of work. You'll
learn to do your tasks in ways that keep your neck safe and free of extra strain.

Before your therapy sessions end, your therapist will teach you a number of ways to avoid future
problems.
Anterior Cervical Discectomy and Fusion
A Patient's Guide to Anterior Cervical Discectomy and
Fusion

Introduction

Anterior cervical discectomy and fusion (ACDF) is a procedure used to treat neck problems such
as cervical radiculopathy, disc herniations, fractures, and spinal instability. In this procedure, the
surgeon enters the neck from the front (the anterior region) and removes a spinal disc
(discectomy). The vertebrae above and below the disc are then held in place with bone graft and
sometimes metal hardware. The goal is to help the bones to grow together into one solid bone.
This is known as fusion. The medical term for fusion is arthrodesis.

Operating on the back of the neck is more commonly used for neck fractures. That procedure is
called posterior cervical fusion.

This guide will help you understand

• why the procedure becomes necessary


• what surgeons hope to achieve
• what to expect during your recovery

Anatomy

What parts of the neck are involved?


Surgeons perform this surgery through the front part of the neck. Key structures include the
ligaments and bones, intervertebral discs, the spinal cord and spinal nerves, and the neural
foramina.

Rationale

What do surgeons hope to achieve?

In most cases, ACDF is used to stop symptoms from cervical disc disease. Discs start to
degenerate as a natural part of aging and also from stress and strain in the structures of the neck.
Over time, the disc begins to collapse, and the space decreases between the vertebrae.

When this happens, the openings around the spinal nerves (the neural foramina) narrow and may
begin to put pressure on the nerves. The long ligaments in the spine slacken. They may even
buckle and put pressure on the spinal cord. The outer rings of the disc, the annulus, weaken and
develop small cracks. The nucleus in the center of the disc may press on the weakened annulus
and actually squeeze out of the annulus. This is called a herniated disc. The herniated disc may
press on ligaments, nerves, or even the spinal cord. Fragments of the disc that press against the
outer annulus, spinal nerves, or spinal cord can be a source of pain, numbness, and weakness.
Pressure on the spinal cord, called myelopathy, can also produce problems with the bowels and
bladder, changes in the way you walk, and trouble with fine motor skills in the hands.

Discectomy is the removal of the disc (and any fragments) between the vertebrae that are to be
fused. When symptoms are coming from the disc, it is hoped that this stops the symptoms.

Related Document: A Patient's Guide to Cervical Discectomy

Once the disc is removed, surgeons spread the bones of the spine apart slightly (distraction) to
make room for the bone graft. This is bone material that can be taken from the top of the pelvis
bone (autograft) or from a natural substitute (allograft). The bone graft separates and holds the
vertebrae apart. Enlarging the space between the vertebrae widens the opening of the neural
foramina, taking pressure off the spinal nerves that pass through them. Also, the ligaments inside
the spinal canal are pulled taut so they don't buckle into the spinal canal.

No movement occurs between the bones that are fused together. By holding the sore part of the
neck steady, the fusion helps relieve pain. And it prevents additional wear and tear on the
structures inside the section that was fused. This keeps bone spurs from forming, and it has been
shown that fusion causes existing bone spurs to shrink. By fusing the bones together, surgeons
hope that patients won't have future pain and problems from cervical disc disease.

Preparations

How will I prepare for surgery?


The decision to proceed with surgery must be made jointly by you and your surgeon. You should
understand as much about the procedure as possible. If you have concerns or questions, you
should talk to your surgeon.

Once you decide on surgery, your surgeon may suggest a complete physical examination by your
regular doctor. This exam helps ensure that you are in the best possible condition to undergo the
operation.

On the day of your surgery, you will probably be admitted to the hospital early in the morning.
You shouldn't eat or drink anything after midnight the night before.

Surgical Procedure

What happens during the operation?

Patients are given a general anesthesia to put them to sleep during most spine surgeries. As you
sleep, your breathing may be assisted with a ventilator. A ventilator is a device that controls and
monitors the flow of air to the lungs.

The patient's neck is positioned facing the ceiling with the head bent back and slightly to the
right. A two-inch incision is made two to three fingers' width above the collar bone across the
left-hand side of the neck. Surgeons often choose the left side to avoid injuring the nerve going
to the voice box. Retractors are used to gently separate and hold the neck muscles and soft
tissues apart so the surgeon can work on the front of the spine.

A needle is inserted into the disc, and an X-ray is taken to identify the correct disc. A long strip
of muscle and part of the long ligament that covers the front of the vertebral bodies are carefully
pulled to the side. Forceps are used to take out the front half of the disc. Next, a tool is attached
to the vertebrae to spread them apart. This makes it easier for the surgeon to see between the two
vertebrae. A small rotary cutting tool (a burr) is used to carefully remove the back half of the
disc. A special microscope is used to help the surgeon see and remove pieces of disc material and
bone spurs near the spinal cord.

A layer of bone is shaved off the flat surfaces of the two vertebrae. This causes the surfaces to
bleed. This is necessary to help the bone graft heal and join the bones together.

The surgeon measures the depth and height between the two vertebrae. A section of bone is
grafted from the top part of the pelvis. It is measured to fit snugly in the space where the disc
was taken out. The surgeon increases the traction pull to separate the two vertebrae, and the graft
is tamped into place.
The traction pull is released. Then the surgeon tests the graft by bending and turning the neck to
make sure it is in the right spot and is locked in place. Another X-ray may be taken to double
check the location of the graft.

A drainage tube may be placed in the wound. The muscles and soft tissues are put back in place,
and the skin is stitched together. The surgeon may place your neck in a rigid collar.

Complications

What might go wrong?

As with all major surgical procedures, complications can occur. Some of the most common
complications following ACDF include

• anesthesia
• thrombophlebitis
• infection
• nerve damage
• problems with the graft
• nonunion
• ongoing pain

This is not intended to be a complete list of the possible complications, but these are the most
common.

Problems with Anesthesia


Problems can arise when the anesthesia given during surgery causes a reaction with other drugs
the patient is taking. In rare cases, a patient may have problems with the anesthesia itself. In
addition, anesthesia can affect lung function because the lungs don't expand as well while a
person is under anesthesia. Be sure to discuss the risks and your concerns with your
anesthesiologist.

Thrombophlebitis (Blood Clots)

Thrombophlebitis, sometimes called deep venous thrombosis (DVT), can occur after any
operation. It occurs when the blood in the large veins of the leg forms blood clots. This may
cause the leg to swell and become warm to the touch and painful. If the blood clots in the veins
break apart, they can travel to the lung, where they lodge in the capillaries and cut off the blood
supply to a portion of the lung. This is called a pulmonary embolism. (Pulmonary means lung,
and embolism refers to a fragment of something traveling through the vascular system.) Most
surgeons take preventing DVT very seriously. There are many ways to reduce the risk of DVT,
but probably the most effective is getting you moving as soon as possible. Two other commonly
used preventative measures include

• pressure stockings to keep the blood in the legs moving


• medications that thin the blood and prevent blood clots from forming

Infection

Infection following spine surgery is rare but can be a very serious complication. Some infections
may show up early, even before you leave the hospital. Infections on the skin's surface usually
go away with antibiotics. Deeper infections that spread into the bones and soft tissues of the
spine are harder to treat and may require additional surgery to treat the infected portion of the
spine.

Nerve Damage

Any surgery that is done near the spinal canal can potentially cause injury to the spinal cord or
spinal nerves. Injury can occur from bumping or cutting the nerve tissue with a surgical
instrument, from swelling around the nerve, or from the formation of scar tissue. An injury to
these structures can cause muscle weakness and a loss of sensation to the areas supplied by the
nerve.

The nerve to the voice box is sometimes injured during surgery on the front of the neck.
Surgeons usually prefer to do surgery on the left side of the neck where the path of the nerve is
more predictable than on the right side. During surgery, the nerve may be stretched too far when
retractors are used to hold the muscles and soft tissues apart. When this happens, patients may be
hoarse for a few days or weeks after surgery. In rare cases in which the nerve is actually cut,
patients may end up with ongoing minor problems of hoarseness, voice fatigue, or difficulty
making high tones.

Problems with the Graft


Fusion surgery requires bone to be grafted into the spinal column. The graft is commonly taken
from the top rim of the pelvis. There is a risk of having pain, infection, or weakness in the area
where the graft is taken.

After the graft is placed, the surgeon checks the position of the graft before completing the
surgery. However, the graft may shift slightly soon after surgery to the point it is no longer able
to hold the spine stable. When the graft migrates out of position, it can cause injury to the nearby
tissues. A second surgery may be needed to align the graft and to apply metal plates and screws
to hold it firmly in place.

Nonunion

Sometimes the bones do not fuse as planned. This is called a nonunion, or pseudarthrosis. (The
term pseudarthrosis means false joint.) If the joint motion from a nonunion continues to cause
pain, you may need a second operation. In the second procedure, the surgeon usually adds more
bone graft. Metal plates and screws may also be added to rigidly secure the bones so they will
fuse together.

Ongoing Pain

ACDF is a complex surgery. Not all patients get complete pain relief with this procedure. As
with any surgery, you should expect some pain afterward. If the pain continues or becomes
unbearable, talk to your surgeon about treatments that can help control your pain.

After Surgery

What happens after surgery?

After ACDF, patients usually wear a special neck brace for several months. These neck braces
are often bulky and restrictive. However, the bone graft needs time to heal in order for the fusion
to succeed. This requires the neck to be held still.

Recently, surgeons have begun using metal hardware, called instrumentation, to lock the bones
in place. This hardware includes metal plates and screws that are fastened to the neck bones.
They hold the neck bones still so the graft can heal, replacing the need for a rigid neck brace.

Patients may stay in the hospital for one to two days after surgery. When the surgery is done on
an outpatient basis, patients may even go home the same day of surgery. Patients can get out of
bed as soon as they feel up to it. They are watched carefully when they begin eating to make sure
they don't have problems swallowing. They usually drink liquids at first, and if they are not
having problems, they can start eating solid food.

Patients are able to return home when their medical condition is stable. However, they are
usually required to keep their activities to a minimum in order to give the graft time to heal.

Rehabilitation
What should I expect as I recover?

Rehabilitation after ACDF can be a slow process. You will probably need to attend therapy
sessions for two to three months, and you should expect full recovery to take up to eight months.

Many surgeons prescribe outpatient physical therapy beginning a minimum of four weeks after
surgery. At first, treatments are used to help control pain and inflammation. Ice and electrical
stimulation treatments are commonly used to help with these goals. Your therapist may also use
massage and other hands-on treatments to ease muscle spasm and pain.

Active treatments are slowly added. These include exercises for improving heart and lung
function. Walking and stationary cycling are ideal cardiovascular exercises. Therapists also teach
specific exercises to help tone and control the muscles that stabilize the neck and upper back.

Your therapist also works with you on how to move and do activities. This form of treatment,
called body mechanics, is used to help you develop new movement habits. This training helps
you keep your neck in safe positions as you go about your work and daily activities. At first, this
may be as simple as helping you learn how to move safely and easily in and out of bed, how to
get dressed and undressed, and how to do some of your routine activities. Then you'll learn how
to keep your neck safe while you lift and carry items and as you begin to do other heavier
activities.

As your condition improves, your therapist will begin tailoring your program to help prepare you
to go back to work. Some patients are not able to go back to a previous job that requires heavy
and strenuous tasks. Your therapist may suggest changes in job tasks that enable you to go back
to your previous job or to do alternate forms of work. You'll learn to do these tasks in ways that
keep your neck safe and free of extra strain.

Before your therapy sessions end, your therapist will teach you ways to avoid future problems.
A Patient's Guide to Cervical Radiculopathy
Introduction

Degeneration of the cervical spine can result in several different conditions that cause problems.
These are usually divided between problems that come from mechanical problems in the neck
and problems which come from nerves being irritated or pinched. A cervical radiculopathy is a
problem that results when a nerve in the neck is irritated as it leaves the spinal canal. This
condition usually occurs when a nerve root is being pinched by a herniated disc or a bone spur.

The purpose of this information is to help you understand:

• The anatomy of the cervical radiculopathy


• The signs and symptoms of cervical radiculopathy
• How the condition is diagnosed
• The treatments available for treatment of the condition

Anatomy

In order to understand your symptoms and treatment choices, you should start with some
understanding of the general anatomy of your neck. This includes becoming familiar with the
various parts that make up the neck and how these parts work together.

Causes

Cervical Radiculopathy ("Pinched Nerve")

When a nerve root leaves the spinal cord and the cervical spine it travels down into the arm.
Along the way each nerve supplies sensation (feeling) to a part of the skin of the shoulder and
arm. It also supplies electrical signals to certain muscles to move part of the arm or hand. When a
nerve is irritated or pinched -- by either a bone spur or a part of the intervertebral disc -- it causes
problems in the nerve and the nerve does not work quite right. This shows up as weakness in the
muscles the nerve goes to, numbness in the skin that the nerve goes to and pain where the nerve
travels. In the neck, this condition is called cervical radiculopathy. Let's look at the different
causes of cervical radiculopathy.

Pinched nerve from a herniated disc

Bending the neck forward and backward, and twisting left and right, places many kinds of
pressure on the vertebrae and disc. The disc responds to the pressure from the vertebrae by acting
as a shock absorber. Bending the neck forward compresses the disc between the vertebrae. This
increased pressure on the disc may cause the disc to bulge toward the spinal canal and the nerve
roots.
Injury to the disc may occur when neck motion puts too much pressure on the disc. One of the
most painful injuries that can occur is a herniated disc. In this injury, the tear in the annulus
portion of the intervertebral disc is so bad that part of the nucleus pulposus squeezes out of the
center of the disc. The annulus can tear or rupture anywhere around the disc. If it tears on the
side next to the spinal canal, when the nucleus pulposus squeezes out, it can press against the
spinal nerves. Pressure against the nerve root from a herniated disc can cause pain, numbness,
and weakness along the nerve. There is also evidence that the chemicals released from the
ruptured disc may irritate the nerve root, leading to some of the symptoms of a herniated disc --
especially pain.

Herniated discs are more common in early middle-aged adults. This condition may occur when
too much force is exerted on an otherwise healthy intervertebral disc. An example would be a car
accident where your head hit the windshield. The force on the neck is simply too much for even
a healthy disc to absorb and injury is the result. A herniated disc may also occur in a disc that has
been weakened by the degenerative process. Once weakened, less force is needed to cause the
disc to tear or rupture. However, not everyone with a ruptured disc has degenerative disc disease.
Likewise, not everyone with degenerative disc disease will suffer a ruptured disc.

Pinched nerve from degeneration and bone spurs

In middle aged and older people, the degenerative disc disease can cause bone spurs to form
around the nerve roots. This usually occurs inside the foramen -- the opening in the cervical
spine where the nerve root leaves the spine to travel into the arm. If these bone spurs get big
enough they may begin to rub on the nerve root and irritate the nerve root. This causes the same
symptoms as a herniated disc. The irritation causes pain to run down the arm, numbness to occur
in the areas the nerve provides sensation to and weakness in the muscles that the nerve supplies.

Symptoms

A cervical radiculopathy causes symptoms that radiate out away from the neck.
What this means is that although the problem is in the spine, the symptoms may
be felt in the shoulder, the arm, or the hand. The symptoms will be felt in the
area where the nerve that is irritated travels. By looking at where the symptoms
are, the spine specialist can usually tell which nerve is involved. The symptoms
include pain, numbness and weakness. The reflexes in the upper arm can be
affected.

When you are suffering from a cervical radiculopathy, there is usually also neck
pain and headaches in the back of your head. These are sometimes referred to as
occipital headaches because the area just about the back of the neck is called the
"occiput."

Diagnosis

Finding the cause of neck pain begins with a complete history and physical
examination. After the history and physical examination, your doctor will have a
good idea of the cause of your pain. To make sure of the exact cause of your neck pain, your
doctor can use several diagnostic tests. These tests are used to find the cause of your pain -- not
make your pain better. Regular X-rays, taken in the doctor's office, are usually a first step in
looking into any neck problem and will help determine if more tests will be needed.

Complete History

A "complete history" is usually two parts. One part is written; a form that you fill out while you
wait to see the doctor. While you fill out the form, take time to think about everything you can
remember that relates to your neck pain and write it down. The more you can tell him, the faster
he can diagnose the cause and help relieve your pain. The second part of your history will be
answering questions. Your doctor will ask you to describe when your neck pain began and the
type of pain you are having.

For example, he may ask:

• when did the pain first begin?


• have you increased your activity level?
• have you had an injury, or surgery, to your neck at any time?
• does the pain go down into your arms or legs?
• what causes your neck to hurt more or less?
• have you had any problems with your bowels or bladder?

Physical Examination

Once most of the information is gathered, your doctor will give you a thorough physical exam.
During the exam your doctor will look at your neck to find out how well your neck is
functioning. This includes:

• how well you can bend your neck and roll your head in all directions
• how well you can twist your neck
• if there is tenderness around the neck
• if there are muscle spasms around the neck and shoulders

Tests that examine the nerves that leave the spine is also important. This includes:

• testing for numbness in the arms and hands


• testing the reflexes
• testing the strength of the muscles in the arms, hands, and legs
• testing for signs of nerve irritation

X-rays

X-rays show the bones of the cervical spine. Most of the soft tissue structures of the spine, such
as the nerves, discs, and muscles, do not show up on X-ray. X-rays can show problems that
affect the bones, such as infection, fractures, or tumors of the bones. X-rays may also give some
idea of how much degeneration has occurred in the spine. X-rays alone will not show a herniated
disc. The X-rays will be useful in showing how much degeneration and arthritis are affecting the
neck. Narrowing of the disc space between each vertebra and bone spurs do show up on X-rays.

Magnetic Resonance Imaging (MRI)

The MRI is the most commonly used test to evaluate the spine because it can show abnormal
areas of the soft tissues around the spine. The MRI is better than X-ray because in addition to the
bones, it can also show pictures of the nerves and discs. The MRI is done to find tumors,
herniated discs, or other soft-tissue disorders. The MRI is painless and lasts about 90 minutes.
During the MRI, very detailed computer images of sections of the spine are taken. Unlike most
other tests, which use X-rays, the MRI uses magnetic fields and radio waves to see the structures
of the neck. Pictures can also be taken in a cross section view. The MRI allows the doctor to
clearly see the nerves and discs without using special dyes or needles. In many cases, the MRI
scan is the only special test that needs to be done to find what is causing your neck pain.

Before the MRI, you will be asked to remove any metal objects, such as jewelry. You will also
be asked if you have metal implants such as a pacemaker or joint replacement. Because of the
strong magnetic field, people with certain types of metal implants cannot undergo MRI.

The MRI scanner is a very large machine with a tunnel-like area in the center. While you lay on
a table, the table slides into the tunnel of the scanner. Once in position, you will be asked to
remain very still for the rest of the test. During the test you will hear the clicking and thumping
noises as the scanner moves. While the scanner is taking pictures, the technician can see the
pictures on a monitor and record them.

Treatment

Treatment for any spine condition should include two main goals:

• relieve pain
• reduce the risk of re-injury

The treatment of neck pain can range from the reassurance that nothing is wrong to very delicate
surgery. Treatment is always based on the individual and his symptoms. In general, treatment for
neck pain falls into two broad categories: conservative treatment, meaning things you can do
short of surgery, and surgical treatment.

Conservative Treatment

Medication

Medications are commonly used to control pain, inflammation, muscle spasm, and sleep
disturbance.

Some general tips about treatment with medicines:


• medicine should be used wisely! Take all medications exactly as prescribed by your doctor and
report any side effects to him.
• some pain medicines are highly addictive!
• no pain medicine will control chronic pain if used over a long period of time.
• no medicine will cure neck pain of degenerative origin.

Mild pain medications can reduce inflammation and pain when taken properly. Medications will
not stop degeneration, but they will help with pain control.

For a more detailed description of the use of pain medications in back and neck pain, please refer
to the document entitled:

• Medications for Back Pain

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 normal alignment. Cervical collars can be soft (made of foam) or
hard (made of metal or plastic). Because these collars can restrict the movement of your head,
you may need help eating and with 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 your pain at night and allow you to sleep better. These cervical
pillows are specially designed to place the right amount of curvature in the neck while you sleep
and decrease the amount of irritation on the nerve roots. The pillows can be purchased from drug
stores and from your therapist.

Epidural Steroid Injection (Nerve Block)

If other treatments do not relieve your back pain, you may be given an epidural steroid injection,
or a cervical nerve block. An epidural steroid injection places a small amount of cortisone into
the bony spinal canal. Cortisone is a very strong anti-inflammatory medicine that may control the
inflammation surrounding the nerves and may ease the pain caused by irritated nerve roots. The
epidural steroid injection is not always successful. This injection is often used when other
conservative measures do not work, or in an effort to postpone surgery.

Surgery

In some cases, the cervical radiculopathy will not improve with non surgical care. In these cases
your surgeon may recommend surgery to treat your cervical radiculopathy. Your surgeon may
also recommend surgery if you begin to show signs of:

• unbearable pain
• increasing weakness
• increasing numbness
• muscle wasting
• the problem begins to affect the legs also

One of the most common operations used to treat a cervical radiculopathy caused by pressure
from bone spurs and a herniated disc is the Anterior Cervical Fusion.

For a complete description of the procedure to remove the disc and perform a fusion for neck
pain, you may wish to review the document entitled:

• Anterior Cervical Fusion

After surgery you will probably be placed in some type of brace while healing occurs. Following
an anterior cervical fusion it is not unusual to wear a brace for 6 to 12 weeks while the fusion
occurs. For a complete understanding of different types of spine braces and to understand what
types of braces are used, you may wish to review the document, entiltled:

• Back and Neck Braces

Rehabilitation

Physical Therapy

Whether you have surgery or not, your doctor may have a physical therapist work on an exercise
program developed just for you. The physical therapist will teach you ways to prevent further
injury to your neck. Many problems in the cervical spine can be improved greatly with a good
exercise program and good education on neck mechanics.

For a complete description of the rehabilitation of neck pain, you may wish to review the
document entitled:

• Neck Rehabilitation
A Patient's Guide to Rehabilitation of the Cervical Spine
Introduction

Your doctor may have you see a physical therapist who will design a neck-care program just for
you. Your physical therapist will evaluate your condition to determine the best way to help ease
your pain and help your neck move better. You will also be given ways to take care of your neck
so you can avoid pain and prevent further injury to your neck.

Your First visit to Physical Therapy

On your first visit, your physical therapist will want to gather some more information about the
history of your neck problem. You may be given a questionnaire that helps you tell about the day
to day problems you are having with your neck. The information you give will help measure the
success of your treatment. You may also be asked to rate your pain on a scale of one to ten. This
will help your physical therapist gauge how much pain you have now and how your pain changes
once you've had treatment. Your physical therapist will probably ask some more questions about
your neck problem to begin zeroing in on the source of your pain and to know what will be
needed to help relieve it. Here are some questions your therapist may ask you:

• How long have you had neck pain?


• Where do you feel the pain?
• What makes the pain better or worse?
• How does your pain affect your daily activities?
• Do you have headaches?
• Do you have pain in your shoulder, arm, or hand?
• Do you have any numbness or tingling?

Physical Therapy Evaluation

Once all this information has been gathered, your neck condition will be evaluated.

Posture/observation: Your physical therapist will begin by checking your posture to see if your
soreness is coming from changes in posture. Imbalances in the position of your spine can put
pressure on sore joints, nerves, and muscles. Postures used for a long time at school, with
hobbies, or when working can change the balance of muscle strength and flexibility. Muscles
that have been stretched over time tend to be weaker, while muscles that are put in shortened
positions can begin to overpower the weaker ones. This can put added strain on areas around the
neck that can cause a problem or make a sore area worse. Helping you improve your posture can
oftentimes make a big difference in easing pain.

Range of motion (ROM): Next, your physical therapist will check the ROM in your neck. This
is a measurement of how far you can move your neck in different directions. Neck movements
include bending the neck forward and backward (flexion and extension), bending to either side
(side bending), and turning the neck to one side and the other (rotation). Measurements may also
be taken of upper back and/or shoulder movements. Your ROM is written down to compare how
much improvement you are making with the treatments.

Neurological screen: Your physical therapist may need to do some tests to check the nerves of
your neck. This part of the evaluation looks at your reflexes, sensation, and strength in your
neck, shoulders, and arms. The results of these tests can help your physical therapist know which
area of the neck may be causing problems for you and can guide the type of treatment to help
your condition.

Manual examination: You may be given a manual examination of the muscles and joints of the
neck. Your physical therapist will carefully move your neck in different positions to make sure
that the joints are moving smoothly at each level of the neck. This will help guide treatment to
the joint that is tight (called a hypomobility) or where a joint may have been injured and is
moving too much (called a hypermobility). Some of the movements you'll feel are where your
physical therapist is looking at the flexibility of the muscles around your neck. This type of
examination can help guide your therapist to know where your soreness is coming from and
which type of treatment will help you the most.

Special tests: Other special tests may be done if your physical therapist thinks your neck pain is
coming from other areas or causes. Other areas that may need to be looked at include:

• Thoracic outlet: This is where a group of nerves and vessels make their way out of the chest
cavity and travel down the arm. Problems in this area can cause numbness, pain, or even
coldness in the arm and hands.

• Temporomadibular joint (jaw): Problems here can cause headaches, pain in your upper neck,
and even spasm in muscles of the neck.

• Thoracic spine: Problems beginning in the upper back can include joints and muscles of the
thorax or even in the alignment of one or more ribs, which can cause pain to radiate toward the
neck and shoulder.

• Nerve tension: Nerves of the mid and lower neck travel down the arm to service the arm and
hand. Irritation or scarring around the covering of these nerves can cause pain that radiates
from the neck to the upper back or even into the arm. By locating scarred or irritated areas
along the nerve, a treatment called "neural mobilization" can be used to free up movement in
the nerve and to ease the soreness you feel.

• Ergonomics: Ergonomics is a way to look at where and how you do your work or hobby
activities. Your physical therapist may want to understand your ergonomics to figure out if the
way you do your activities is making your condition worse. Sometimes even simple corrections
of your hobby or work station can make a big difference in easing neck sypmtoms.

Palpation: The evaluation usually ends with palpation. Palpation is when your physical therapist
feels the soft tissues around the neck. This is done to check the skin for changes in temperature
or texture, which could tell if you have inflammation or nerve irritation. Palpation is also done to
find whether there are tender points or spasm in the muscles around the neck and upper back.
This too can give your therapist a good idea about which treatments will help you the most.

Treatment plan: Once the examination is done, your therapist will put together a treatment plan.
The treatment plan lists the types of treatments that will be used for your condition. It gives an
indication of how many visits you will need and how long you may need therapy. It also includes
the goals that you and your therapist think will be the most helpful for getting your activities
done safely and with the least amount of soreness. Finally, it will include a prognosis, which is
how your therapist feels the treatment will help you improve.

Physical Therapy Treatment

Controlling your pain and symptoms

Easing pain: Your therapist may choose from one or more of the following tools, or modalities,
to help control the symptoms you are having:

Rest: Resting the painful joints and muscles helps calm soreness, giving your neck time to heal.
If you are having pain with an activity or movement, it should be a signal that there is still
irritation going on. You should try to avoid all movements and activities that increase your pain.
In the early stages of your problem, your doctor or therapist may want you to use a soft or hard
neck collar to limit neck movement nearly completely.

Specific Rest: Specific rest encourages safe movement of the joints and muscles on either side
of a painful area, while protecting the sore spot during the initial healing phase. Select exercises
can be given to encourage safe movement of the shoulders and upper back. If you've been
prescribed a collar, you will likely be instructed to take it off a few times a day so you can do
some gentle and controlled exercises.

Positioning: The results of the evaluation will give your therapist a clear picture of ways you can
position your neck for the greatest comfort. A special pillow, called a contour pillow, may be
suggested to help get your neck in the most comfortable position while sleeping or resting. A
commercial neck roll, or even a rolled towel, can be slid inside your pillow case so that when
you lie back, the roll fills in and supports the curve in your neck. Other special ways to rest your
head and neck may be given by your therapist to help take away arm pain that is coming from
your neck.

Ice: Ice makes the blood vessels in the sore area become more narrow, called vasoconstriction.
This helps control inflammation that is causing pain. Some ways to put ice on include cold
packs, ice bags, or ice massage. Cold packs or ice bags are generally put on the sore area for 10
to 15 minutes. Ice massage is done by rubbing an ice cube or ice cup on a sore spot or tender
point. It's as easy as freezing a small paper cup full of water. Once the water freezes, simply tear
off the top inch of the cup and rub the exposed ice on the sore spot for three to five minutes, or
until it feels numb.
Heat: Heat makes blood vessels get larger, called vasodilation. This action helps to flush away
chemicals that are making your neck hurt. It also helps to bring in nutrients and oxygen which
help the area heal. True heat in the form of a moist hot pack, a heating pad, or warm shower or
bath is more beneficial than creams that merely give the feeling of heat. Hot packs are usually
placed on the sore area for 15 to 20 minutes. Special care must be taken to make sure your skin
doesn't overheat and burn. It's also not a good idea to sleep with an electric hot pad at night.

Ultrasound: An ultrasound machine produces high frequency sound waves that are directed
toward the sore area. Passing through the body's tissues, these waves vibrate molecules. This
causes friction and warmth as the sound passes through the tissue. The rest of the sound changes
to heat in the deeper tissues of the body. This heating effect helps flush the sore area and brings
in a new supply of nutrient and oxygen-rich blood. Ultrasound treatments are a way for your
therapist to reach tissues that are over two inches below the surface of your skin.

Phoresis: This means to "carry or transmit." There are two methods that therapists can use to
transmit substances across the skin. Phonophoresis uses the high frequency sound waves of
ultrasound to "push" a steroid medication (cortisone) through the skin. Iontophoresis uses a small
machine that produces a mild electrical charge, which is used to carry medicine, usually a
steriod, through the skin. The steroid is a very strong antiinflammatory medication that actually
stops the pain-causing chemical reaction within the cells of the sore tissue in your body. Either
type of phoresis may be used in place of a cortisone injection.

Electrical Stimulation: This treatmemt stimulates nerves by sending an electrical current gently
through your skin. Some people say it feels like sort of like a massage on their skin. Electrical
stimulation can ease pain by sending impulses that are felt instead of pain. Two respected
scientists discovered a theory, called the Gait Theory. This theory says that when you feel a
sensation other than pain, like rubbing, massage, or even a mild electrical impulse, your spinal
column will actually "close the gate" and not let pain impulses pass to the brain. In the case of
electrical stimulation, the electrical impulses speed their way across the skin and on to the central
nervous system much faster than pain. By getting there first, the electrical information "closes
the gate" to pain, blocking its passage to the brain. Once the pain eases, muscles that are in
spasm begin to relax, letting you move and exercise with less discomfort. Other settings on the
machine can be used to help your body release endorphins. These are natural chemicals formed
within your body that behave like a strong drug in reducing the perception of pain for up to eight
hours at a time.

Soft tissue mobilization/massage: Physical therapists are trained in many different forms of
massage and mobilization when treating the neck. Massage has been shown to calm pain and
spasm by helping muscles relax, by bringing in a fresh supply of oxygen and nutrient-rich blood,
and by flushing the area of chemical irritants that come from inflammation. Soft tissue
treatments can help tight muscles relax, getting them back to a normal length. This will help you
begin to move with less pain and greater ease. Physical therapists have special training in a
variety of different ways to mobilize or massage. These can include gentle strokes, called
effleurage. Myofascial release techniques help restore better movement by getting the thick layer
of fascia below the skin and around muscles to "give". Strain-counter-strain is a type of therapy
that is especially helpful when tender points are causing muscles to restrict movement. The
treatment is usually done in a way that the muscle is put in a special position, usually where the
muscle is shortest. The position is held long enough to "reset" the nerve input to the muscle.
Another way to help soft tissues "move" is by the use of muscle energy technique. Your therapist
will place your muscle in a certain position and then direct you to use your muscles against the
therapist's force. As you relax, your therapist will gradually "take up the slack", giving a stretch
on the muscle.

Joint mobilization: These are graded pressures and movements that are done by skilled physical
therapists. Gentle graded pressures help lubricate joint surfaces, easing stiffness and helping you
begin moving with less pain. Pain that is left unchecked can quickly escalate to an uncomfortable
"cycle of pain and muscle guarding." In other words, the pain can make your muscles go into
spasm, in which your muscles try to guard the sore joints, keeping you from wanting to move
your neck at all. When movement stops, your brain gets an uninterupted flow of pain sensation.
Ouch! This leads to a cycle of even more muscle spasm and pain because your muscles try to
"protect" you from painful movement. By applying gentle pressures, or mobilizations, your
therapist will begin to halt the flow of pain information, which helps muscles relax. Once your
muscles begin to relax, you will begin to feel other sensations than pain. As your pain eases,
more vigorous grades of mobilization may be used to lengthen tissues around the joint helping
restore better movement in your neck.

Traction: Sore joints and muscles in the neck often feel better when a traction "pull" is used.
Your therapist will test at first to see if you can get relief with this type of treatment. Traction can
be done in a variety of ways. There are traction machines that allow you to relax comfortably
with either a halter or cusion behind your neck. The machine is set to pull on this halter or
cushion for a certain amount of time and pressure. Manual traction is another way for your
therapist to put a graded pull on your neck. There are also traction devices that can be issued for
you to use at home. The amount of pull that is used will depend on your condition. A gentle
on/off pressure may be better early on to help control pain or if there is pain from arthritis. More
vigorous traction can help take away pain if a joint is mildly sore or tight.

Exercises

Strengthening your neck

Exercise is important during all stages of recovery from neck pain. Different types of exercises
will be used by your physical therapist as you get better. In the early stages, when your neck is
still quite painful, specific exercises may be suggested to help reduce your pain. Supporting your
neck in certain positions as suggested by your therapist can take pressure off sore or injured
areas. These positions are sometimes easier to get into by using a pillow, rolled towel, or
commercial neck roll. You may need to relax back on a recliner or matress for best results. In
cases of significant pain, you may be given a set of breathing exercises. Deep, diaphragmatic
breathing, helps air to reach even the lower lobes of your lungs. Combining deep breathing to a
slow relaxing count can help muscles relax, while bringing much needed oxygen to sore tissues.
Neck pain can be physically and emotionally draining. Relaxation exercises may not correct your
problem, but they can help control pain and its accompanying stress.
Movement is also important, even when your neck is still painful. Careful movements suggested
by your therapist can safely ease pain by providing nutrition and lubrication to injured and sore
areas. Movement of joints and muscles also signals the nervous system to block incoming pain.
Common movement exercises include active range of motion, in which you are encouraged to
move your neck toward directions that don't hurt. Your therapist will evaluate which movements
will be safest and best for you. In some cases, pain will ease with the addition of pressure into
one or another direction. Again, your therapist will need to determine which movements are best
for your condition. Avoid movements that hurt or seem to irritate the soreness in your neck.

As your neck becomes less painful, the exercises will be changed to focus on improving the
overall health of your neck. These changes will focus on exercises for:

• Flexibility
• Strength
• Coordination
• Aerobic conditioning

Exercises that increase flexibility help to reduce pain and make it easier to keep your neck and
spine in a healthy position. Tight muscles cause imbalances in spinal movements. This can make
injury of these structures more likely. Flexibility exercises for the neck, chest, and upper
shoulders can be helpful in establishing safe movement. A slow progression of stretching
exercises can increase flexibility in these areas, ease pain, and reduce the chance of reinjury.

The next stage of exercise focuses on the strength of the muscles that support the neck. These
muscles help bring the spine into a safe position--and keep it there! Trained muscles can keep
your neck healthy by getting it into better posture. A series of strengthening exercises, called
stabilization training, is a way to get better balance in the muscles around your neck, chest, and
upper back. These stabilization exercises are helpful in supporting your neck in safe positions
while you are working or when you are doing other daily activities. Strengthening and
stabilization exercises are simple to do at home and don't have to require any expensive
equipment. By practicing these exercises often, you will become comfortable keeping your neck
in healthy positions and postures with all your activities.

Strong muscles need to be coordinated. As the strength of the spinal muscles increases, it
becomes important to train those muscles to work together. Learning any physical activity takes
practice. Muscles must be trained so that the physical activity is under control. Muscles that are
trained to control safe movement of the spine help reduce the chance of injury. You will be
taught exercises to help train your neck, chest, and upper back muscles to work together in
protecting your spine.

Finally, attention will be directed to increasing your overall fitness. The word aerobic means
"with oxygen". By using oxygen as they work, muscles are better able to move continuously,
rather than in spurts. Fitness training allows the muscles to become more efficient at obtaining
nutrients and oxygen from the blood. As the muscles use up the nutrients and oxygen, chemical
waste products are created that can cause pain. Training also increases the ability of muscles to
get rid of these waste products.
Exercise has other benefits as well. Vigorous exercise can cause chemicals called endorphins to
be released into the blood. These chemical hormones act as natural pain relievers in reducing
your pain. It will be important that you pick an aerobic activity you can enjoy and stick with it!

Once your pain is controlled, your range of motion is improved, and your strength is returning,
you will be progressed to a final home program. Your therapist will give you some ideas to help
take care of any more soreness at home. You'll be given some ways to keep working on the range
of motion and strength too. Before you are done with physical therapy, more measurements will
be taken to see how well you're doing now compared to when you first started in therapy.

Prevention and long term self care for the neck

Is this is your first experience with a neck problem? Maybe you've had ongoing problems for
many years. In either case, your best bet for avoiding neck problems in the future is to get a
handle on ways you can prevent further neck pain and/or injury. It is also helpful to know how to
take care of your neck if pain strikes again.

Posture: Using healthy posture is like holding a defense shield against future neck problems.
Pain and injury CAN be prevented. When your joints are positioned in their safe--or neutral
posture--the body works like an elegant machine. It works safely and even more productively.
When unbalanced postures are used, problems are more likely to happen. Prevention of neck
pain and injury has a lot to do with keeping a balanced position of the spine and extremities.
When standing, this balance follows a plumb line from ear to ankle. In a seated position, this line
descends from the ear to the hip. A rule of thumb for the extremities is to keep them in thier
relaxed positions.

There are three natural curves in the spine. From a side view, the neck (cervical spine) curves
slightly inward. The midback (thoracic spine) curves slightly outward. The low back (lumbar
spine) curves slightly inward. Keeping this relationship while standing, sitting, or moving is the
basis for healthy posture. When moving, bend at the hips to avoid rounding or straightening the
spine. This keeps the spine safe during activities like lifting and walking.

For better sitting posture, sit with a good upright alignment of the spine by using a comfortable
chair designed to support correct posture. Avoid slouching by keeping your low back against the
back of the chair. Bending the head forward strains the neck and affects the nerves and arteries
leading to the arms. Your shoulders should be relaxed, and the elbows, hips, and knees should be
bent at right angles (ninety degrees). Avoid pressure to the back of the knees. Your feet should
be kept flat on the floor or supported by a foot rest.

Akward posture places stress on the body that can lead to neck pain. Slouching with the spine or
leaning the head forward puts the body out of alignment, causing the limbs to be stretched and
bent. Too much bending (flexion) or straightening (extension) in the spine increases the risk of
injury. Symptoms of pain, tingling, or numbness in the arm or hand may also come from poor
neck posture. The slight inward curve of the neck balances the head on the spine. Avoid extreme
postures, like gazing up at the stars, or bending your head down for long periods when reading a
book. Keeping balanced posture is a measure you can use to prevent further injury and pain in
your neck.

Ergonomics: Ergonomics is a look at the way people do work. What does ergonomics have to
do with the ache in your neck? It could have alot to do with it. It's possible that even minor
changes in the way you do your work or hobby activities could ease the pain you feel now while
preventing further neck injury or pain.

In some cases, it is best to have someone trained in ergonomics, like a physical or occupational
therapist, check your work station and the way you do your work. The first step will be for them
to ask you some questions about your work, which makes good sense. Since you're the one doing
the job, you will have an expert opinion about what seems to be working, what could be done
differently, and what tasks seem to be causing the most problems for you. Once these questions
are covered, the evaluator will want to watch you do the work tasks. Areas that will be noted
include the postures you use, repetitions to complete the task, rest time between tasks, and the
amounts of weight you are dealing with. For office workers, the examiner will look at alignment
of the computer monitors, chairs, desk heights, etc. Other areas that may be evaluated include
work heights, tools of the trade, lighting, and temperature. It's also helpful to look at your work
postures and work tasks to see if what you are doing can be done with less stress and strain on
your body.

When the work site evaluation is over, you or your supervisor will probably be given some
recommendations--some of these may even be ones you came up with! Ergonomics doesn't
always have to involve expensive changes. Even minor adjustments can make a huge difference
in easing your pain and preventing further problems.

Work Place Strategies: These strategies are ideas of how to work with greater safety and even
better productivity. Have you ever felt stress or tension at work? Chances are good that you
wouldn't have a pain or worry if you didn't. The reality is that people are often called on to do
even more with less resources. They are faced with more responsibility and more deadlines to get
their tasks done. The health of your neck may be at risk with these mounting pressures. But
scientists have helped us learn that there is a defence in the face of these mounting pressures.
They have shown the importance of using the "Three R's" to help ease tension and reduce neck
pain at work. Here are the three Rs:

Rest: This includes taking frequent breaks during the work hour. It also means choosing
alternate activities to get your mind ready for a new job task. Activities include deep breathing,
walking, napping, or exercising.

Relaxation: Take a load off. Lie back. Turn down the lights, and listen to your favorite tape or
CD. Attempt to breath slowly and deeply, allowing your abdomen to rise and fall rythmically.
Using visual imagery can also aid in relaxation. Try to visualize each muscle relaxing one after
another.
Recovery: Our bodies need a chance to heal. Repeated and prolonged activities can take their
toll if the body doesn't get a chance to recover. Recovery helps repair these sore and achy tissues
along the way, keeping them healthy.

Whether at work or at home you can use these ideas to help prevent neck pain and injury. Here
are some additional tips to use at work to avoid tension and keep your neck healthy:

Be Relaxed. Try to work with your muscles relaxed. To stay relaxed, look relaxed.

Pace Yourself.Keep an even keel. Avoid sudden changes in your workload. Try to avoid last
minute "panics" to meet deadlines.

Take a Break.Take a thirty second "microbreak" every twenty to thirty minutes to do some deep
breathing and a few exercises. Take a few minutes each hour to do some exercises, get a drink,
or go bug a coworker. Use your lunch break to take a nap or a walk.

Change Positions. Avoid holding your neck, trunk, or limbs still for a long time. Plan ways to
get the job done using different positions. Sit for a bit--then stand for a bit. Or simply readjust
your approach to the task.

Rotate Duties. Rotating or sharing your tasks can be fun by offering a new worksetting, while
giving your body a chance to recover.

Avoid Caffeine and Tobacco. These can heighten stress, reduce blood flow, and elevate the
awareness of neck pain.

Taking Care of Your Neck

If you've had neck pain once, there's a fair chance you'll have it in one form or another in the
future. When pain comes back again and again, it is called recurrent pain. Even though you may
have been treated for neck pain or problems in the past, it's not a guarantee you won't have pain
again. The question, then, is whether you can take care of your neck if soreness does return.

Your therapist will probably give you a thorough home program when you get done with your
treatments. Some of the exercises will be helpful to keep up with as a way to keep your neck
healthy over time. You may also be given ways to help control pain or symptoms if they don't go
completely away, or if they return in the future. Although there are many good "home remedies",
you will want to visit your family doctor if these symptoms appear:

• Pain with no apparent injury that doesn't go away within a week to 10 days
• Pain that doesn't ease or change with movement
• Pain that actually wakes you up at night
• Pain that shoots from your neck down into your arm when you cough or sneeze
• "Visceral" symptoms of nausea, diarrhea, dizziness, blurred vision, ringing in the ears, etc.
• Numbness, tingling, or weakness in your arms or legs
If you feel achiness or pain that is not associated with the red flags listed above, here are some
home treatment ideas you may be given to ease your symptoms:

Rest: When neck pain strikes, don't do activities that make your pain worse. Remember the
benefits of rest (see above).

Ice: For the first two to three days, you may get help by appling a home-made cold pack. Simply
place two parts crushed ice in a plastic bag with one part rubbing alcohol. This lets you reuse the
bag without having it freeze solid between uses. When you're ready to use the cold pack, wrap it
in a wet washcloth. Then place it on the sore area for up to fifteen minutes a few times a day.

Contrast: On day three, you may find more relief by using a "contrast" of ice and heat. This is
where you begin by placing a cold pack on the sore area for 10 minutes. Then place a heating
pad on for another 10 minutes. You can repeat the process a couple times, finishing with the
heat.

Heat: Once the acute symptoms are controlled (two to three days), you may get good relief using
a heating pad. Remember to turn off the pad before going to sleep. Check your skin regularly to
make sure you are not getting too much heat.

Traction: In some cases, your therapist may have found out that you get good relief with neck
traction. That can be good news. There are a number of traction units that can be used at home.
Some of these work by giving a traction pull as water is added to a bag. Others work by pumping
air pressure into a neck cushion. A simple way to do traction at home is to place two tennis balls
in a sock. Lay down with the sock sideways just below the back of your head. The two tennis
balls will give a gentle traction, and the pressure of the balls can help relieve headaches, neck
pain, and upper back discomfort.

TENS: This stands for transcutaneous electrical nerve stimulation. If you've been treated in the
clinic with electrical stimulation, your therapist will have a good idea if this kind of treatment
helps you. If so, there are small, pocket-sized electrical stimulation units that can be used up to
24 hours a day if needed to keep pain at bay. Your therapist may choose to issue one of these, but
only if you can't get good pain relief in other ways. Also, a prescription from your doctor is
required for you to use one on your own.

Exercise: Some exercises are designed to help take pain away. After you have completed your
physical therapy visits, your therapist will have gotten a good idea what types of exercise help
you control your pain. Your therapist will go over the exercises that will give you the best relief
if you get sore again. Remember to only do the exercises in the way your therapist has instructed.
Overdoing them could make your pain worsen.

Long-term strategies: The best way to treat neck pain is to avoid it all together. A good exercise
regimen can help. Also, remember the benefits of good posture, ergonomics, and work habits--
and use them. If you are trying to take care of your neck but you're not getting adequate relief,
you may need to revisit your physical therapist for additional help.
Home program: Once your pain is controlled, your range of motion is improved, and your
strength is returning, you will be progressed to a final home program. Your therapist will review
some of the ideas listed above to help take care of any more soreness at home. You'll be given
some ways to keep working on the range of motion and strength too. Before you are done with
therapy, more measurements will be taken to see how well you're doing now compared to when
you first started in therapy.
A Patient's Guide to Back and Neck Braces
Introduction

If you are diagnosed with a spinal disorder, deformity, or


potential problem that can by helped through the use of
external structural support, your physician may recommend the
use of a back or neck brace. Braces offer a safe, non-invasive
way to prevent future problems or to help you heal from a
current condition.

The use of braces is widely accepted. They are effective tools


in the treatment of spine disorders. In fact, more than 99% of
orthopedic physicians advocate using them.

Braces are really nothing new. They have actually been around
for centuries. Lumbosacral corsets (for the lower back) were
used as far back as 2000 B.C.! Bandage and splint braces were
used in 500 A.D. in an effort to correct scoliosis (a spine with a
sideways curve). Recently, braces have become a popular way
to actually help prevent primary and secondary lower back
pain from ever occurring.

There are more than 30 types of back supports available for spine disorders. This website will
discuss several common types and why they are used.

This website will cover:

• Neck Braces
• Trochanteric Belts
• Sacroiliac and Lumbosacral Belts
• Corsets
• Rigid Braces
• Hyperextension Braces
• Molded Jackets
• Lifting Belts
• Clinical Uses
• Goals of Spinal Bracing
• Possible Drawbacks
Neck Braces

Neck braces are used to provide stability of the cervical spine after neck surgery, a trauma to the
neck, or as an alternative to surgery. They are probably the type of spinal brace you most
commonly see people wearing. There are several types available, including:

Soft Collar - This flexible brace is placed around the neck. It is typically used after a more rigid
collar has been worn for the major healing. It is used as a transition to wearing no collar.

Philadelphia Collar - This is a more rigid/stiff collar that has a front and back piece that
attaches with Velcro on the sides. It is usually worn 24 hours a day until your physician instructs
you to remove it. This collar is used for conditions such as: a relatively stable cervical (upper
spine) fracture, cervical fusion surgery, or a cervical strain. Another similar type is the Miami
cervical brace.

Sterno-Occipital Mandibular Immobilization Device (SOMI) - A SOMI is a brace that holds


your neck in a straight line that matches up with your spine. It offers rigid support to a damaged
neck and prevents the head from moving around. With this brace, you are unable to bend or twist
your neck. The restriction of motion helps the muscles and bones to heal from injury or surgery.

If you look at what the name means, you will better understand what a SOMI does: "sterno"
means your upper and middle chest, "occipital" is the base of your skull, "mandibular" refers to
your jaw and chin, and "immobilization" describes the support and movement restriction the
brace offers. The SOMI is worn on the parts of the body for which it is named. First, there is a
chin piece that the lower jaw rests on. Second, the chin piece connects by straps to a headband
that is worn across the forehead. Third, the chin piece connects to a chest piece by a front metal
extension. Finally, the chest piece then rests on the upper and middle chest - sort of like a vest.
This connects to the occipital piece, which supports the base of the head.

This brace is obviously a bit more complicated and cumbersome than some of the others, but it
provides excellent support for an injured neck.
Halo - The main purpose of the halo is to immobilize the head and neck. This is the most rigid of
the cervical braces. It is only used after complex cervical spine surgery or if there is an unstable
cervical fracture. The halo looks a lot like the word sounds. It has a titanium ring (halo) that goes
around your head, secured to the skull by four metal pins. The ring then attaches by four bars to a
vest that is worn on the chest. The vest offers the weight to hold the ring and neck steadily in
place. The Halo is worn 24 hours a day until the spine injury heals.

Trochanteric Belts

The trochanteric belt is usually prescribed for sacroiliac joint pain or pelvic fractures. The belt
fits around the pelvis, between the trochanter (a bony portion below the neck of your thigh bone)
and the iliac (pelvis) ridges/crests. It is about five to eight centimeters wide and it buckles in
front, just like a regular belt.

Sacroiliac and Lumbosacral Belts

The lumbosacral belt helps to stabilize the lower back. These belts are usually made of heavy
cotton reinforced by lightweight stays. The pressure can be adjusted through laces on the side or
back of the belt. These belts range in widths between 10 to 15 centimeters, and 20 to 30
centimeters. The sacroiliac belt is used to prevent motion by putting a compressive force on the
joints between the hipbone and sacrum (base of the spine).

Corsets

Corsets provide rigidity and support for the back. Corsets can vary in length. A shorter or longer
corset will be prescribed, depending upon your condition. A short corset is typically used for low
back pain, while a longer one is used for problems in the mid to lower thoracic spine. When
people think of corsets, they usually conjure up images of women from earlier centuries who
used them to make their waists look smaller. Today, in the treatment of back problems, corsets
refer to a type of back brace that extends over the buttocks and is often held up by shoulder
straps. Like the corsets of old, these lace up from the back, side, or front. There are metal stays
that provide the appropriate rigidity and support for the back.

Rigid Braces

These braces are typically prescribed for low back pain and instability. If greater rigidity is
needed to support the spine than can be found in standard back supports, rigid frame spinal
bracing is often prescribed. These are stiff braces. They usually consist of rear uprights that
contour to the lumbar (lower) spine and pelvis, along with thoracic bands. There are also fabric
straps on the braces that provide pressure in the front. Common types of rigid models are:

Williams Brace - This type of brace has no vertical uprights in the middle so that
flexion/bending is allowed.

Chair-back Brace - This type immobilizes the lumbar spine in the neutral position. The chair-
back is designed to reduce sideways and revolving movement of the lower spine.

Raney Flexion Jacket - This type reduces lumbar lordosis by holding the patient in a neutral tilt.

Hyperextension Braces

This brace is designed to prevent excessive bending, and it is often prescribed to treat frontal
compression fractures that have occurred around the junction of the thoracic and lumbar spine.
The brace can also be used for post surgery healing from a spinal fusion.

These braces offer support that allows anterior (front) pressure unloading of the thoracic
vertebrae by restricting flexion (bending) of the thoracic and lumbar spine.

Hyperextension braces have a front rectangular metal frame that puts pressure over the upper
sternum and the pubis/pubic bone. This encourages spinal extension. There is opposing pressure
applied over the T-10 level (the tenth vertebra in your thoracic spine). The braces offer what is
called "three-point stabilization" to the spine through a front abdominal pad, a chest pad, and a
rear pad at the level of the fracture.

By applying pressure in three-points - sternal, pubis and rear Lumbosacral - the spine is
extended/stretched. The sternum is the narrow, flat bone in the front middle of thorax. The thorax
is the portion of body between the base of the neck and the lower diaphragm.

The most common types of Hyperextension Braces are Knight Taylor and Jewett.

Molded Jackets

These jackets are designed to distribute pressure widely over a large area. By immobilizing the
patient from the neck to the hips, pressure is distributed evenly, taking excess pressure off
overloaded or unstable areas. These jackets were originally made of plaster of Paris, but now are
typically made out of molded plastic.

Lifting Belts

These belts are designed to reduce low back strain and muscle fatigue that can occur when you
are lifting heavy objects. The belt circles around the waist, covering the lumbar region of the
spine, and closes in front. These belts are usually made of cloth or canvas and do not have stays.
Some models also have lordosis pads.

Clinical Uses

The braces/supports are most frequently used to treat: low back pain, trauma, infections,
muscular weakness, neck conditions, and osteoporosis. Braces, belts, and jackets are designed to
immobilize and support the spine when there is a condition that needs to be treated. Depending
on the model that is used, they can put the spine in a: neutral, upright, hyper-extended, flexed, or
lateral-flexed position.

Goals of Spinal Bracing

Spinal bracing is used for a variety of reasons such as to: control pain, lessen the chance of
further injury, allow healing to take place, compensate for muscle weakness, or prevent or
correct a deformity. More specifically, lumbar corsets and braces compress the abdomen, which
increases the intra-abdominal pressure. This act allows pressure on the vertebral column to
unload, providing some relief.

There are other reasons bracing is used. One is the theory that they insulate the skin, producing
increased warmth that decreases the sensation of pain - much like a heating pad. Another reason
is that the increase in abdominal pressure produces hydraulic support for the back. Finally,
certain types of movement may cause stress to the pain generators in the back. The decrease in
range of movement by using bracing may relieve this type of pain.

Possible Drawbacks
Though the effects of bracing are primarily positive, they can lead to a loss of muscle function,
due to inactivity. Bracing can sometimes lead to psychological addiction, so that even when the
patient is healed and ready to be taken off the back brace, he or she feels dependent upon it for
physical support.
A Patient's Guide to Anterior Cervical Fusion
Introduction

Most neck pain is due to degenerative changes that occur in


the intervertebral discs of the cervical spine and the joints
between each vertebra. The vast majority of patients who have
neck pain will not require any type of operation. However, if
the non-operative treatments fail to control your pain, your
surgeon may suggest an anterior cervical fusion to try to
reduce your neck pain.

The purpose of this information is to help you understand:

• The anatomy of the cervical spine


• The rationale for performing an anterior cervical fusion
• What you can expect from this procedure, including possible complications

Anatomy

In order to understand your symptoms and treatment options, you should start with some
understanding of the general anatomy of your neck. This includes becoming familiar with the
various parts that make up the neck and how these parts work together.

Please review the document, entitled:

• Cervical Spine Anatomy

Rationale

Surgery is not necessary in every case. No one type of surgery works for every neck pain
problem. Numerous surgical procedures have been designed to treat each type of neck pain. An
anterior cervical fusion is done for two reasons:

• To remove pressure from the nerve roots caused by bone spurs or herniated disc material
• To stop the motion between two vertebrae - a spinal segment

The Operation

Discectomy

One of the most common surgical procedures for problems in the cervical spine is an anterior
cervical discectomy. The term "discectomy" means "remove the disc". A discectomy relieves the
pressure on a nerve root by removing the herniated disc causing the pressure on the nerve root.
In the cervical spine, the disc is usually removed from the front. An incision is made in the front
of your neck right beside your trachea (windpipe). The muscles are moved to the side. The
arteries and nerves in the neck are protected as well.

Once the spine is reached from the front, each disc and vertebra are identified using an X-ray to
make sure that the right disc is being removed. Once this is determined, the disc is removed all
the way back to the spinal cord. Any bone spurs that are found sticking off the back of the
vertebra are removed as well. Great care is taken to not damage the spinal cord and nerve roots.

In the cervical spine, a discectomy is usually combined with a spine fusion where the two
vertebrae on either side of the disc that has been removed, are allowed to heal together, or fuse.
The cervical fusion is described in detail below.

Anterior Cervical Fusion

Once the disc has been removed between the vertebrae, a cervical fusion is performed. This
procedure allows the surgeon to fill the space left by removing the disc with a block of bone
taken from the pelvis. Placing a bone graft between two or more vertebrae causes the vertebrae
to grow together, or fuse.

The bone graft is usually taken from the pelvis at the time of surgery, but some surgeons prefer
to use bone graft obtained from a bone bank. Bone graft from a bone bank 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. This is in order to
reduce the risk of passing on diseases, such as AIDS or hepatitis, to the recipient.

There are two basic types of spinal fusion:

Anterior Interbody Fusion

This type of fusion is much more common in the neck. This type of fusion is described above. In
the interbody fusion, a bone graft is placed between two vertebrae and replaces the removed disc.
During the healing process, the vertebrae grow together, creating a solid piece of bone out of the
two vertebrae.

Posterior Fusion

You may hear the term posterior fusion as well. In the posterior fusion, the bone graft is placed
on the back side of the vertebrae. During the healing process, the vertebrae grow together,
creating a solid piece of bone out of the two vertebrae. This type of fusion is only rarely used in
the cervical spine, generally only for fractures of the spine. If surgery is necessary, the anterior
interbody cervical fusion is used to treat most problems in the neck caused by degenerative disc
disease. These include unrelieved neck pain and pressure on the nerve roots caused by bone
spurs or a herniated disc.
The goal of spinal fusion is to stop the motion caused by segmental instability. This reduces the
mechanical neck pain caused from excess motion in the spinal segment. 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. Increasing the distance between the vertebrae also makes the foramen larger in
the back part of the spinal column. This may reduce the pinching and irritation of the nerve roots
by bone spurs around the foramen.

Instrumented Cervical Fusion

When doing a cervical fusion, the bone graft may simply be wedged in between the vertebra. It is
held there simply because it is wedged in tight. In recent years, there has been an increase in the
use of metal plates, screws, and rods to try to increase the success of helping the spine to fuse.
Many different types of metal implants are used; all try to hold the vertebrae in position while
the fusion heals. Bone heals best when it is held still, without motion between the pieces trying
to heal together. The healing of a fusion is no different than healing a fractured bone, such as a
broken arm. However, the neck is a difficult part of the body to hold still.

In the past, casts and braces were used in an attempt to reduce the motion in the neck and to
increase the success rates of a spinal fusion. In most cases, these braces and casts were simply
too cumbersome to wear for three months, and did a poor job of actually holding the neck still
enough to allow the fusion to heal.

In the cervical spine, the most common form of internal fixation is using a metal plate and
screws. The plate sits on the front of the vertebrae and the screws go backwards into the vertebral
body to help hold the plate in place and to help keep the bone graft from slipping out of place.

By using metal plates and screws, the vertebra can be held rigidly in place while the fusion heals.
Braces and casts are not needed.

Rehabilitation

Complications

With any surgery, there is a risk of complications. When surgery is done near the spine and
spinal cord these complications (if they occur) can be very serious. Complications could involve
subsequent pain and impairment and the need for additional surgery. You should discuss the
complications associated with surgery with your doctor before surgery. The list of complications
provided here is not intended to be a complete list of complications and is not a substitute for
discussing the risks of surgery with your doctor. Only your doctor can evaluate your condition
and inform you of the risks of any medical treatment he or she may recommend.

To understand more about the potential complications of spinal surgery, please review the
documen,t entitled:
A Patient's Guide to Complications of Spine Surgery
Introduction

With any surgery, there is the risk of complications. When surgery is done near the spine and
spinal cord, these complications (if they occur) can be very serious. Complications could involve
subsequent pain and impairment and the need for additional surgery. You should discuss the
complications associated with surgery with your doctor before surgery. The list of complications
provided here is not intended to be a complete list of complications and is not a substitute for
discussing the risks of surgery with your doctor. Only your doctor can evaluate your condition
and inform you of the risks of any medical treatment he or she may recommend.

Anesthesia Complications

The vast majority of surgical procedures require that some type of anesthesia be done before the
surgery. This is so that you will not feel, or be aware of the procedure. The simplest form of
anesthesia is local anesthesia. Local anesthesia is done by injecting a medication (usually
Novocain) around the area of the surgical procedure that "numbs" the skin and surrounding
tissue. The most complex form of anesthesia is general anesthesia. General anesthesia is where
you go completely to sleep during the surgical procedure. Medications are given by intravenous
lines (IVs) to put you to sleep. Special machines breathe for you, monitor your vital signs, and
alert the anesthesiologist to any problems while you are asleep. You are kept asleep during the
operation by a combination of medications given through the IV line and "anesthetic gases" that
you inhale through special machines controlling your breathing. Most spinal operations require
general anesthesia. A very small number of patients may have problems with general anesthesia.
These can be problems due to reactions to the drugs used, problems arising from your other
medical problems, and problems due to the anesthesia. Be sure to discuss these complications
with your anesthesiologist.

Thrombophlebitis

When blood clots form inside the veins of the legs, it is referred to as Deep Venous Thrombosis
(DVT). This is a common problem following many types of surgical procedures. It is true that
these blood clots can also form in certain individuals who have not undergone any recent
surgery. These blood clots form in the large veins of the calf and may continue to grow and
extend up into the veins of the thigh, and in some cases into the veins of the pelvis.

The risk of developing DVT is much higher following surgery involving the pelvis, and surgery
involving the lower extremities. There are many reasons that the risk of DVT is higher after
surgery. First, the body is trying to stop the bleeding associated with surgery, and the body's
clotting mechanism is very hyperactive during this period. In addition, injury to blood vessels
around the surgical site, from normal tugging and pulling during surgery, can set off the clotting
process. Finally, blood that does not move well sits in the veins and becomes stagnant. Blood
that sits too long in one spot usually begins to clot.
Why do we worry about blood clots? Blood clots that fill the deep veins of the legs stop the
normal flow of venous blood from the legs back to the heart. This causes swelling and pain in the
affected leg. If the blood clot inside the vein does not dissolve, the swelling may become chronic
and can cause discomfort and swelling permanently. While this may seem bad enough, the real
danger that a blood clot poses is much more serious. If a portion of the forming blood clot breaks
free inside the veins of the leg, it may travel through the veins to the lung, where it can lodge
itself in the tiny vessels of the lung. This cuts off the blood supply to the portion of the lung that
is blocked. The portion of the lung that is blocked cannot survive and may collapse. This is
called a pulmonary embolism. If a pulmonary embolism is large enough, and the portion of the
lung that collapses is large enough - it may cause death. With this in mind, it is easy to see why
prevention of DVT is a serious matter.

Reducing the risk of developing DVT is a high priority following any type of surgery. Things
that can be done to reduce the risk of developing DVT fall into two categories:

• Mechanical - getting the blood moving better


• Medical - using drugs to slow the clotting process

Mechanical

Blood that is moving is less likely to clot. Getting YOU moving so that your blood is circulating
is perhaps the most effective treatment against developing DVT. While you are in bed, other
things can be done to increase the circulation of blood from the legs back to the heart. Simply
pumping your feet up and down (like pushing on the gas pedal) contracts the muscles of the calf,
squeezes the veins in the calf, and pushes the blood back to the heart. You cannot do this too
much!

Pulsatile stockings do the same thing. A pump inflates these special stockings that wrap around
the calf and thigh every few minutes, squeezing the veins in the calf and thigh pushing the blood
back to the heart. Support hose, sometimes called TED hose, are still commonly used following
surgery. These hose work by squeezing the veins of the leg shut. This reduces the amount of
stagnant blood that is pooling in the veins of the leg - and reduces the risk of that blood clotting
in the veins. Finally, getting you out of bed walking will result in muscle contraction of the legs
and keep the blood in the veins of the leg moving.

Medical

Drugs, which slow down the body's clotting mechanism, are widely used following surgery of
the hip and knee to reduce the risk of DVT. These drugs include simple aspirin in very low risk
situations, and heparin shots twice a day in moderately risky situations. In conditions that have a
high risk for developing DVT, several very potent drugs are available that can slow the clotting
mechanism very effectively. Heparin can be given by intravenous injection, a new drug called
Lovenox can be given in shots administered twice a day, and Coumadin can be given by mouth.
Coumadin is the drug of choice when the clotting mechanism must be slowed for more than a
few days because it can be taken orally.
In most cases of spinal surgery, both mechanical and medical measures are used simultaneously.
It has become normal practice to: use pulsatile stockings immediately after surgery, have you
begin exercises immediately after surgery, get you out of bed as soon as possible, and place you
on some type of medication to slow the blood clotting mechanism.

Lung Problems

The success of your surgery includes taking care of your lungs afterwards. It is important that
your lungs are working at their best following surgery to ensure that you get plenty of oxygen to
the tissues of the body that are trying to heal. Lungs that are not exercised properly after surgery
can lead to poor blood oxygen levels and even develop pneumonia (an infection in the lungs).

There are several reasons that your lungs may not work normally after surgery. If you were put
to sleep with a general anesthetic for your surgery, the medications used for the anesthesia may
temporarily cause the lungs not to function as well as normal. This is one reason that a spinal
type anesthetic is recommended whenever possible. Lying in bed prevents completely normal
function of the lungs and the medications you take for pain may cause you not to breathe as
deeply as you normally would.

You can think of the lung like a large sponge. All the small air pockets where the blood receives
oxygen are like the small holes in a sponge. If the small holes collapse, or squeeze together, no
air can get into the holes to supply oxygen to the blood. When we breathe deeply, the lungs
expand and all the individual holes of the sponge fill with air. Coughing does the same thing
because we increase the pressure of the air coming into the holes of the sponge. Lungs that have
collapsed areas not only do not move oxygen into the blood, they cannot remove the fluids and
mucous normally produced by the lungs. This can create an area that is ripe for developing
bacteria that can grow and produce a lung infection, or pneumonia.

After surgery, you will need to do several things to keep your lungs working at their best. Your
nurse will encourage you to take frequent deep breaths and cough often. He or she will be there
to coach you. Getting out of bed, even upright in a chair, allows the lungs to work much better.
Therefore, as soon as possible, you will be allowed to get into a chair. The respiratory therapist
has several tools to help maintain optimal lung function. The incentive spirometer is a small
device that measures how hard you are breathing and gives you a tool to help improve your deep
breathing. If you have any other lung disease, such as asthma, the respiratory therapist may also
use medications that are given through breathing treatments to help open the air pockets in the
lungs.

Infection

Any time surgery is performed, there is a risk of infection. However, infections occur in less than
1% of spinal surgeries. An infection can be in the skin incision only, or it can spread deeper to
involve the areas around the spinal cord and the vertebrae. A wound infection that involves only
the skin incision is considered a "superficial" infection. It is less serious and easier to treat than
the deeper infection. Surgeons take every precaution to prevent infections. You will probably be
given antibiotics right before surgery - especially if bone graft, metal screws, or plates will be
used for your surgery. This is to help reduce the risk of infection.

If the surgical wound becomes red, hot, and swollen and does not heal, it may be infected.
Infections will usually cause increasing pain. You may run a fever and have shaking chills. The
wound may ooze clear liquid or yellow pus. The wound drainage may smell bad.

Contact your doctor immediately so the wound can be treated and antibiotic medication can be
prescribed if necessary. The superficial wound infection can usually be treated with antibiotics,
and perhaps removing the skin stitches. The deeper wound infections can be very serious and
will probably require additional operations to drain the infection. In the worst cases, any bone
graft, metal screws, and plates that were used may need to be removed.

Hardware Fracture

In many different types of spinal operations, metal screws, plates, and rods are used as part of the
procedure to hold the vertebrae in alignment while the surgery heals. These metal devices are
called "hardware". Once the bone heals, the hardware is usually not doing much of anything.
Sometimes before the surgery is completely healed the hardware can either break - or move from
the correct position. This is called a "hardware fracture". If this occurs it may require a second
operation to either remove the hardware or replace the hardware.

Implant Migration

Implant migration is a term used to describe the fact that the implant has moved from where the
surgeon placed it initially. This usually occurs fairly soon after surgery - before the healing
process has progressed to the point where the implant is firmly attached by scar tissue or bone
growth. If the implant moves too far, it may not be doing its job of stabilizing the two vertebrae.
If it moves in a direction towards the spine or large vessels - it may damage those structures. If
you have a problem with implant migration, your surgeon may have to perform a second
operation to replace the implant that has moved. Your doctor will check the status of the
hardware with X-rays taken during your follow-up office visits.

Spinal Cord Injury

Any time you operate on the spine, there is some risk of injuring the spinal cord. This can lead to
serious injuries to the nerves or the covering of the spinal cord - the dura. The spinal cord is a
column of nerves that connects your brain with the rest of your body, allowing you to control
your movements. The nerve fibers in your spinal cord branch off to form pairs of nerve roots that
travel through the small openings (foramina) between your vertebrae. The nerves in each area of
the spinal cord connect to specific parts of your body. Damage to the spinal cord can cause
paralysis in certain areas and not others, depending on which spinal nerves are affected.

Persistent Pain
Some spinal operations are simply unsuccessful. One of the most common complications of
spinal surgery is that it does not get rid of all of your pain. In some cases, it may be possible to
actually increase your pain. Be aware of this risk before surgery and discuss it at length with
your surgeon. He or she will be able to give you some idea of the chance that you will not get the
relief that you expect.

Some pain after surgery is expected, but if you experience chronic pain well after the operation,
you should let your doctor know.

Sexual Dysfunction

The spinal cord and spinal nerves carry the nerve signals that allow the rest of your body to
function, feel sensation - and even have sex. Damage to the spinal cord and the nerves around the
spinal cord can cause many problems. If a nerve is damaged that connects to the pelvic region, it
could cause sexual dysfunction.

Transitional Syndrome

One of the interesting things about how the spine works is that it behaves like a chain of
repeating segments. When the entire spine is healthy, each segment works together to share the
load throughout the spinal column. Each segment works with its neighboring segment to share
the stresses imposed by movements and forces acting on the spine. However, when one or two
segments are not working properly, the neighboring segments have to take on more of the load. It
is the segment closest to the non-working segment that gets most of the extra stress. This means
that if one or more levels are fused anywhere in the spine, the spinal segment next to where the
surgery was performed begins to take on more stress. Over time, this can lead to increased wear
and tear to this segment, eventually causing pain from the damaged segment. This is called a
transitional syndrome because it occurs where the transition from a normal area of the spine to
the abnormal area that has been fused.

Pseudoarthrosis

The term "pseudo" means false and "arthrosis" refers to joint. The term "pseudoarthrosis" then
means false joint. A surgeon uses this term to describe either a fractured bone that has not healed
or an attempted fusion that has not been successful. A pseudoarthrosis usually means that there is
motion between the two bones that should be healed, or fused, together. When the vertebrae
involved in a surgical fusion do not heal and fuse together, there is usually continued pain. The
pain may actually increase over time. The spinal motion can also stress the metal hardware used
to hold the fusion. The screws and rods may break, leading to an increase in pain. A
pseudoarthrosis may require more surgery to try to get the bones to heal. Your surgeon may add
more bone graft, replace the metal hardware, or add an electrical stimulator to try to get the
fusion to heal.
A Patient's Guide to Pain Medications for Back Pain
Mild pain medications can reduce inflammation and pain when taken properly. Medications will
not stop degeneration, but they will help with pain control.

Aspirin

Aspirin compounds are over-the-counter pain relievers that can help relieve minor pain and back
ache. The main potential side effect of aspirin is the development of stomach problems,
particularly ulcers with or without bleeding. You should not take aspirin if you are pregnant. In
fact, you should not take any medication unless you have discussed the medication with your
obstetrician.

NSAIDs (Non-Steroidal Anti-Inflammatory Drugs)

NSAIDs include over-the-counter pain relievers such as ibuprofen or naproxen. These


medications once were only available by prescription. NSAIDs are very effective in relieving the
pain associated with muscle strain and inflammation. They block the inflammatory response in
joints. However, be aware that NSAIDs can decrease renal function if you are an older patient.
Excessive use can lead to kidney problems. Again, do not take them if you are pregnant.

Non-narcotic Prescription Pain Medication

Non-narcotic analgesics (the term analgesics means "pain relievers") address pain at the point of
injury. Analgesics are ideal in the treatment of mild to moderate chronic pain. Tylenol and
aspirin are the most widely used over-the-counter analgesics. Medications that are analgesics and
require a prescription from the doctor include NSAIDs such as: carprofen, fenoprofen,
ketoprofen, and sulindac. To reduce any side effects: do not lie down for 15 to 30 minutes after
taking medication, avoid direct sunlight, wear protective clothing, and sun block. Avoid using
these medications if you are pregnant, have recurrent ulcers, or liver problems.

Narcotic Pain Medications

If you experience severe pain, your health provider might prescribe a narcotic pain medication
such as codeine and morphine. Narcotics relieve pain by acting as a numbing anesthetic to the
central nervous system. The strength and length of pain relief differs for each drug. Narcotics can
cause related side effects such as nausea, vomiting, constipation, and sedation or drowsiness.
These side effects are predictable and can often be prevented. Common preventative measures
include: not taking sleeping aids or antidepressants in conjunction with narcotics, avoiding
alcohol, increasing fluid intake, eating a high fiber diet, and using a fiber laxative or stool
softener to treat constipation. Remember that narcotics can be addictive if used excessively or
improperly.

Muscle Relaxants
If you are having muscle spasms, muscle relaxants can help relieve pain, but they are only shown
to be marginally effective. They also have a significant risk of drowsiness and depression. Long-
term use is not suggested; only three to four days is typically recommended.

Antidepressants

Back pain is actually a common symptom of depression and could be an indicator of its
presence. Antidepressants can relieve emotional stress that leads to symptoms of back pain. An
important fact to note - it seems that the same chemical reactions in the nerve cells that trigger
depression also control the pain pathways in the brain. Some antidepressant medications seem to
reduce pain, probably because they affect this chemical reaction in the nerve cells. Some types of
antidepressants also make rather good sleeping medications. If you are having trouble sleeping
due to your back pain, your doctor may prescribe an antidepressant to help you get back to a
normal sleep routine. Antidepressants can have several side effects such as: drowsiness, loss of
appetite, constipation, dry mouth, and fatigue.