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Cervical Spine Stenosis

 That Awful Neck Pain That Won’t Let Up!….
 What Could It Be?

Have You Ever Heard Of Cervical Spine Stenosis?

That’s a lot of words…what does it mean?  Cervical Spine Stenosis (CSS) is a degenerative disease that most often happens over time, with years of wear and tear.  This is more commonly referred to as arthritis of the spine.  The spinal canal and neural foramen narrow and compress the spinal cord and nerve roots.  Stenosis occurs when pressure increases inflaming the facet joints.  Studies show that we can start the degenerative process, depending on how well we take care of our bodies, as early as our 30’s.  Genetics and congenital factors can predispose a person for stenosis.  Usually, the very severe symptoms don’t show until age 60 and older.   Other causes of CSS include cervical spondylosis and diffuse idiopathic skeletal hyperostosis (DISH), or calcification of the posterior longitudinal ligament.  These will be discussed later.

What is the Cervical Spine?  Where does it begin and where does it end?

The Cervical Spine is made up of the first seven vertebrae in the spine.  The first two vertebral bodies in the cervical spine are called the Atlas and the Axis.   The Cervical Spine is much more mobile than the Thoracic (mid-back) or the Lumbar (lower-back).
*FUN FACT:  The Atlas is named after the mythical Greek god who supported the weight of the world on his shoulders…and this vertebral body supports the weight of our head.

What are the symptoms of Cervical Spine Stenosis (CSS)?  Because of constriction and inflammation it may cause symptoms of shooting pain, that may feel a little like an electric shock.  This can be especially so if you flex your neck and tip your chin to your chest.  Other sensations may include: numbness, tingling, weakness, burning and pins and needles in the involved extremity.
Your physician will have to do testing because these type symptoms can also be due to other problems such as disc herniation.
Stenosis is a chronic, progressive process that can have episodes of worsening. 

So, how does your physician test for Cervical Spine Stenosis (CSS)?  Most often the best diagnostic tool is the MRI (Magnetic Resonance Imaging).  With this method you don’t have the concern of radiation exposure like with X-Rays.  X-Rays are still used in some cases.  Another good point to make concerning the MRI;  it can determine whether or not the spinal cord is narrowing and where the narrowing is occurring, the degree of the compression, and any nerve roots that may be involved.  After the diagnosis is made then, a plan of treatment can be implemented.

What are the treatment options?  That depends on the severity of the diagnosis and the particular individual patient.  If the diagnosis is a mild problem, the physician may implement physiotherapy (which may include water therapy) and/or the use of a cervical collar.  The treatment plan could also include anti-infammatory and analgesic medications to help control and lessen inflammation and pain.   The exact physical therapy regimen would have to be decided by your physician along with your physical therapist and/or chiropractor.  If the diagnosis is a severe form causing a lot of other physical problems then, most probably you’ll be looking at surgical options.

So, what are my surgical options?  This too, depends on the severity and the individual patient.  The physician looks at other health concerns and age in each patient since there are risks in all surgical procedures.  Some of your options include the following:
*  Laminectomy:  This procedure is usually performed under general anethesia.  The patient is placed face-down on the operating table. The exact procedure depends on the location of the problem, if it is in the neck, the head is clamped to prevent movement. The skin is marked for incision. The surgeon first cuts through the skin. The muscle is then cut, peeled back from the vertebrae and held in place with special instruments called retractors. The lamina, which is between the bony projection of the vertebrae (the ‘points’ that can be felt with fingers) and the transverse process or ‘wing’, is removed. What happens next depends on the problem. For example, the surgeon may then trim the protruding bits of a herniated disc. Once the surgery is completed, the muscle and skin are sutured (sewn) closed.
 
This procedure may be chosen if the patient has a herniated disc that is causing symptoms of pain, numbness and weakness in the arm.
Post-Op:  Routine post-operative observations will be taken and charted, including temperature and blood pressure. The patient’s wound is checked for redness, swelling and signs of infection. Muscle spasms are quite common following laminectomy. Pain relief is ordered and given regularly. Note is made of ability to pass urine, as sometimes this may be affected immediately following surgery. The patient may have intravenous fluids for a few days, which may include an antibiotic. Initially, two people have to help the patient to roll over in bed. The patient is taught the proper method of rolling the body in order to maintain proper body alignment. This is most important for the first 48 hours or so. The patient is assisted out of bed after a few days. A physiotherapist gives specific instructions on how to get out of bed properly in order to avoid stress and strain on the wound site. The patient is encouraged to walk, stand and sit for short periods. The patient is taught how to prevent twisting, flexing or hyperextending the back while moving around.

A regular exercise program following surgery is most important to increase your spinal muscle strength and flexibility, and to protect against future injury. Occasionally, the operation doesn’t work and the original symptoms remain. At other times, the operation isn’t expected to relieve symptoms, but is performed to prevent the area from deteriorating further. In this case, original symptoms will probably remain, but might not get any worse. Some patients may develop chronic back pain after laminectomy surgery, a medical condition known as “postlaminectomy syndrome.” Some surgeons believe that the laminectomy procedure, by removing excessive amounts of bone and ligament from the spine, disturbs the biomechanical stability of the spinal column, resulting in pain.

Anterior Cervical Disectomy:  An operation where the cervical spine is reached through a small incision in the front of your neck.  After the soft tissues of your neck are separated, the intervertebral disc and bone spurs are removed.

Anterior Cervical Disectomy with Fusion:  An operation performed on the upper spine to relieve pressure on one or more nerve roots and/or the spinal cord.  The term is derived from the words Anterior (front), cervical (neck) and fusion (joining the vertebrae with a bone graft).

Foraminotomy:  Surgical opening or enlargement of the bony opening traversed by a nerve root as it leaves the spinal canal. A procedure carried out alone or in conjunction with disc surgery.

Corpectomy:  Excision of vertebral body usually combined with interpostion of prosthesis or bone graft.

Laminoplasty:  The lamina are hinged laterally and opened like a door, and secured in their new position with suture or bone to enlarge the spinal canal.

Cervical Fusion:    It involves the stabilization of two or more vertebrae by locking them together (fusing them). The fusion stops the vertebral motion and as a result, the pain is also stopped.  Trauma and degenerative disc disease (DDD) can cause a need for this type surgery.  This procedure can take 2 to 6 hours to perform, depending on the number of vertebrae involved.  Again, one of the risks involved in this procedure is that the bone graft may not take.  This also leaves the patient with less mobility of the neck.   This is one reason why physicians are now looking at Cervical Disc Replacement or Artificial Disc Replacement.

What is Artificial Disc Replacement?  Replacing the old and worn out disc with an artificial disc that is made of a material that is meant to last awhile.  This procedure has been used in clinical trials in Europe for about 15 years.  Surgeons have used this procedure in the United Kingdom for several years now, with exceptional results.  The success rate for artificial disc replacement surgery is not as straight forward as listing a series of spine surgery statistics. Success is judged on many subjective and objective measures. The artificial disc operation is usually judged successful if the patient’s pain is dramatically reduced, mobility is restored and there is no lingering complication. Please note here that we did not say that the pain was completely eliminated, only that was dramatically reduced. If a patient has experienced back pain for many years from degenerative disc disease, changes due to compression of the ligaments of the spine, the spinal processes and nerves may still cause pain after the artificial disc is inserted. Nerve changes may cause phantom pain, which is pain that is no longer caused by the initial mechanical force on the nerve. So while the doctor from an objective point of view considers the artificial disc operation a success, the patient may not, because pain is still present. This is why we hear success rates varing between 70% and 96%.

These success rates for the artificial disc are significantly higher than fusion operations, which are usually rated between 50 and 55 percent. What is not often included in fusion spine surgery statistics is the 25% of fusion patients that have significant pain from the bone harvesting of the verterbral plug in the hip. 

Good preop testing and diagnosis are the most important part in developing a patient’s treament plan and enhances the chance for success. Also, a determination to manage postop pain by the patient, if present, is important to the long term success of the artificial disc procedure, as phantom pain can be mitigated or stopped. One should remember that spine surgery statistic only tell part of the story where artificial disc replacement surgery is concerned.

 Here are a few examples of the artificial discs that are in use or are being tested in clinical trials:

The Prestige LP Cervical Disc is made from a new titanium ceramic that has enhanced wear characteristics.  It is a ball and trough configuration which helps to replicate true motion.  This disc replacement is available in Europe.  According to “The Spine Journal”,  experimentally and clinically, the Prestige has proven to be successful in preserving motion.  The device has also proven to be durable.
 
The Bryan® (Medtronic Sofamor Danek, Memphis, TN, USA) has been used successfully since 2002. 
Over 500 patients have received artificial disc replacements (ADR) in the last 2 years in Europe.  To date, none have been removed.
There are several more artificial disc replacement devices being studied in clinical trials and not all data is in.  Talk to your physician/ surgeon to see which replacement device would be best suited to your needs.

As with any surgical procedure, there are risks involved.  This doesn’t mean these things will happen, it’s just good to stay informed as to what the risks are.  This is a list associated with artificial disc replacement as well as for cervical fusion.

Risks include, but not limited to, pain, infection, blood clots, blood loss, allergic reactions and death
Other risks and discomforts

    difficulty swallowing
    hoarseness
    breakage, degradation or displacement of the implant or plate
    failure to achieve fusion
    impaired muscle function
    spinal instability
    a change in the curvature of the spine
    vessel damage/bleeding
    nerve injuries, including upper or lower extremity peripheral nerve injury, numbness, clumsiness, foot drop
    reflex sympathetic dystrophy (RSD) and weakness
    tears or hardening of the tissues surrounding the disc
    deterioration of the facet joints, which are next to the vertebrae
    spinal stenosis, or narrowing of the spinal canal
    osteolysis related to wear debris

When undergoing surgery using the Cervical Replacement procedure, surgery time is usually 1-2 hours.  Most patients leave the hospital the following day.  Soft collar is optional.  There are few activity restrictions for the first 6 weeks.
Recovery is always quicker if you abide by the treatment plan set out by all your medical staff.
   

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