Injuries to the Shoulder: When should you worry?
By Raphael Rey Roybal, M.D., M.B.A.
Affecting nearly 66 percent of adults during their life time, neck pain is yet another common burden to the human condition. Not surprisingly, pains in the neck have several possible physical causes other than our jobs, our kids, the traffic, etc., etc. However, neck pain associated with a specific pattern of pain in the upper extremity is often caused by compression or pressure on specific nerves of the cervical spine. Already implicated in the degenerative process of the spine, the intervertebral disc of the cervical spine or neck is susceptible to herniation, bulging, and the typical findings of arthritis including bone spurring and ligament hypertrophy. Any or a combination of the above pathological conditions can cause compression or “pinching” of a nerve leaving the cervical spine on its way to the upper extremity causing the symptoms of cervical radiculopathy.
Cervical radiculopathy is defined as arm pain following a specific anatomical path depending on the nerve affected. It is believed that compression of the nerve results in an inflammatory response in the nerve including swelling which leads to nerve pain and sometimes dysfunction. Cervical radi-culopathy may or may not present with neck pain. If the compression is either severe enough or present long enough, cervical radiculopathy may also present with specific arm weakness (again following a specific anatomic path) or specific arm and hand numbness. Extension of the neck often makes arm pain worse as extension exacerbates the compression on the nerve. On the other hand, elevating the affected arm over the head can often relieve symptoms as this reduces tension on the nerve while possibly moving the nerve away from the area of most compression. In order to diagnose cervical radiculopathy, an MRI or CT mylogram is necessary to visualize compression on the nerve.
Cervical radiculopathy generally has a favorable outcome. However, numerous long-term studies have shown that roughly only 45 percent of patients following conservative care have complete resolution of symptoms. Cervical traction has been associated with the long-term relief of symptoms in some patients theoretically by temporarily relieving pressure on the nerve allowing the nerve to recover from the changes of inflammation. Because radicular pain is mediated by inflammation of the nerve, epidural steroid injections are often used again with the purpose of reducing inflammation allowing nerve recovery despite the fact that there is yet to be a definitive study proving long term relief. From the data available, it is reasonable to expect that patients who will conservatively resolve their symptoms will do so within six to eight weeks with or without the above treatments although injections, physical therapy, and traction may reduce symptoms during that time frame.
When conservative measures fail or compression includes compression on the spinal cord which changes the urgency and severity of the pathology, surgery is a very successful and tolerable treatment option. Essential to success of the surgery is a thorough decompression or “un-pinching” of the nerves affected. Anterior cervical discectemy and fusion (ACDF) has become the surgical procedure of choice for patients with symptomatic degenerative cervical radiculopathy, which is resistent to non-operative therapy. This operative technique allows the surgeon to safely eliminate the most common causes of cervical neural compression. It also allows for the development of a solid arthrodesis (the artificial induction of joint bone formation) which provides long-term stability. This halts the degenerative process at the treated segment. Commonly, patients experience substantial relief of their radicular symptoms while in the recovery room immediately after surgery.
In recent times, a newer alternative to fusion after cervical spine decompression has been introduced. In an attempt to preserve full spinal motion theoretically protecting the adjacent spinal segments from increased stresses, motion preserving implants or Total Disc Replacements (TDR) for the cervical spine have been developed. While accomplishing the basic goals of restoring disc space height, stability, and alignment, TDR’s can also restore normal physiological motion in carefully selected patients with cervical radiculopathy. Although ACDF is a surgical treatment with results that are very hard to beat, prospective studies comparing ACDF to TDR have generally shown as good or superior results for TDR. Particularly, patients undergoing TDR return to work and full normal activity quicker, primarily because the operative surgeon allows them to begin post-op rehabilitation sooner, without the concern of achieving stable arthrodesis.
TDR is not for every patient with cervical radiculopathy who fails conservative therapy. The application of this new technology to appropriate patients requires careful scrutiny and analysis of an operative spine specialist with additional training in total disc replacement. Depending upon each patient’s anatomy and pathology, cervical TDR or ACDF are two excellent surgical options for unremitting cervical radiculopathy.
For more information about this article or if you have other orthopedic questions, you can contact Dr. Roybal at Chatham Orthopaedics, 4425 Paulsen Street, Savannah, GA 31405 or call him at (912) 355-6615.