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Disk Herniation

As our bodies age, many of our organs go through a very slow degenerative process. This process is not truly abnormal but could be thought of as a natural process we all go through. This process is as common as whitening of our hair or wrinkles on our skin. However, some patients suffer from these changes in different ways. The main reason for this process is the loss of water content from out tissues. Normally the discs which are present between each spine segment has a high content of water. As we age, the water content slowly decreases. This change leads to decrease height of the disc and renders the spinal segments less stable. The disc itself may suffer some damage as well. The outer envelope that covers the disc (annulus) may sustain fissures and tears. This will in turn allows the nucleus of the disc to protrude and push on a nerve that is exiting from the spinal cord.

At the same time another process is going on. As the stability of spine is decreased our body attempts to stabilize this slight instability by making more bone. This bone forming, stabilizing process, makes more bones around the joints (facet joints) in the spine. However, these joints are very close to tunnels that transmit the nerves and the newly produced bone may push on the exiting nerves. This too may cause nerve pain (Radiculopathy). A very important point must be mentioned that not all patients with degenerative changes in their neck will have symptoms. There are many patients with severe degenerative changes on their X-rays and MRI’s who are very comfortable without any symptoms. These changes are only significant if they apply pressure to neural structures or develop into arthritis that is causing pain.

The result from this process is seen in relatively young patients in their 30′s or 40′s. Patients may present complaining of neck pain, headaches, shoulder pain, arm pain, shoulder blade pain, or their combination. Patients commonly describe increased pain when trying to sleep. As the patient lies on their back, the disc has a tendency to follow gravity and push backwards on the nerve. For this reason, some patients may find relief by sleeping in a semi-reclined position. The symptoms may also worsen with any straining which may include coughing, sneezing, passing stool, or lifting objects. Common to all these activities is straining which increases disc pressures and places the nerve under more tension. Bending the neck backward and to the side (Sparling Sign) will decrease the space for the nerve and may reproduce the symptoms. Numbness or weakness may also be present and their distribution (location) will guide us toward the exact location of problem. Your spine surgeon knows the road map (anatomy) of all the nerves in the area and sometimes can predict the exact location of the problem based on the symptoms. Patients are usually active individuals and are frustrated from their condition. Lifestyle changes are seen which is another consequence. Patients that are active with recreational (or even professional) sports are hindered by this dysfunction. Another reason for this problem may be an accident that damages the disc and causes a herniation that pushes on an exiting nerve. This may be a fall or a car accident. In either case, excessive pressure is placed on the disc causing it to rupture and finally herniate backwards on the neural elements. By the time the patient gets to our office, most have been seen by the primary care physician and have been placed on some medications or attempted to correct the problem with physical therapy. Still, many patients may have to be diagnosed in our office. The most common diagnosis confusing this issue is shoulder problems which resembles cervical (neck) radiculopathy. In almost every case shoulder disorders need to ruled out in order to avoid misdiagnosis. Other problems confusing the diagnosis of a pinched nerve is compression along the nerve in other areas such as the arm or forearm. Thoracic Outlet Syndrome is compression of nerves by the first rib and its diagnosis is very difficult and often missed. Diagnostic test and examination usually give us clear diagnosis but this process needs experience and knowledge.

The diagnostic process begins with patient history and physical examination. Almost 90% of patients could be diagnosed just with this modality. If symptoms and history allow an accurate diagnosis, the patient is usually began on a regime of medications. These medications may include Non-Steroidal Anti-inflammatory Drugs or in more severe cases Steroidal medication. If the diagnosis is questionable X-rays and MRI may be requested as the first line of attack. This test is painless and has no radiation. However it is expensive and should be used only if necessary. The MRI exam has its own flaws. Research studies have performed MRI’s on patients with no neck problems and found that 30% of patients will have MRI’s that show some abnormality. But these patients had no problems with their necks! This information leads us to believe that not all abnormalities on the MRI may cause dysfunction or pain in our patients. This is when the knowledge and experience of your spine surgeon is valuable. Anyone can read a report provided by the radiologist, but only your spine surgeon can judge whether the reported abnormalities are significant or not. We commonly see professional football players with sever abnormalities on their MRI. This may be the result of all the insults placed on the neck by this activity. However since this group of patients have very well developed neck musculature, their symptoms do not reflect what we see on their MRI scans. If the MRI has not provided us with a clear diagnosis, we may resort to other diagnostic studies which are not used frequently.

Patients with cervical radiculopathy (nerve pain of the neck) may find relief by raising their arm above their head. This decreases the tension on the nerve and may reduce the pain. Some patients suffering from this condition describe themselves driving with the affected arm resting on their head. However, just the opposite is true with patients suffering from shoulder pain and that could distinguish between the two diagnoses. Secondly, the shoulder joint may be injected with a numbing medication. If the pain disappears after this injection we assume that the pain is generated in the shoulder and we direct our attention to that joint. Changes in sensation, and development of weakness are signs that direct our attention to the neck. Reflex changes are another indication that the problem is originating from the neck.

Many other factors are involved but their discussion may expand into a book rather than a web site. Once the diagnosis is established, most patients will begin a conservative treatment plan with medications, physical therapy and bracing. Each modality is very involved, but their summaries will be included here. Medications may help many patients and is the first modality we use. As the nerve is irritated by the imposed pressure, inflammation is produces which is the primary cause of pain. Pain is produced as a result of inflammation and weakness is produces as a result of pressure. However, usually these two symptoms are seen together. With inflammation, the nerve will undergo swelling which will decrease the available space and this will cause mechanical pressure. This pressure will interfere with the function of the nerve and will lead to motor weakness, numbness, or changes in sensation like burning. Non-Steroidal Anti-inflammatory medications (e.g. Vaux, Celebrex, Motrin, Naprosyn, Feldene, Voltaren, etc.) will decrease inflammation and reduce symptoms. The drawback of these medications is their effect on the stomach which may ultimately lead to bleeding ulcers. Your physician can prescribe the right medications for your specific needs based on your medical history. In more severe cases, Steroidal medication (like Medrol Dose Pack) can be prescribed. These medications have powerful anti-inflammatory properties and may improve symptoms within a few days. However, they may have severe side effects like stomach irritation and cause bleeding ulcers. If the neck symptoms are sever enough, these medications will not have the desired effect. Another scenario may include rapid improvement of symptoms but recurrence within a few days. Physical therapy may be very helpful for some patients. Specifically, traction is very helpful with cervical (neck) radiculopathy (nerve pain). As traction is placed on the neck (many different methods of traction is available) the tunnels that the nerves go through enlarge and pressure over the nerve is released. Patients may experience rapid relief of symptoms with traction. The drawback of traction is that as soon as its taken away, symptoms may come back. And obviously we cannot walk around with traction over our head. Some therapist will have special beds that place traction in their office, or your physician may provide you with an apparatus that can be place at home to provide the necessary traction.

Many theories exist regarding the use of braces. We know that short periods of immobilization/stabilization can help reduce inflammation over the nerve and help in recovery. We commonly provide only a soft collar. and will not recommend a hard or rigid collar since this will de-condition neck musculature and may lead to further problems. The soft collar is provided not for support, but to remind the patient of the neck condition and the need to avoid sudden movement. This will also keep the neck in good posture, further expediting the healing processes. A note of caution — if the brace is not placed properly, this may extend the neck backward and worsen the symptoms. Make sure you ask you therapist regarding the correct placement of your brace. A neck pillow can also help in maintaining good posture while sitting or sleeping.

Other less commonly recommended modalities are spinal injections. Since the results of injections in the neck are not as reliable and there is increased danger if injury in this small area we try to avoid this modality. However, some clinics offer these injections and even report good results. These injections are much more successful in the lower (lumbar) spine and we utilize them much more in that area. The advantage of this technique is the delivery of steroidal medications in high concentration directly to the area of inflammation.

From the above writing we can see that there are many non-operative options in treating this condition. However, still some patients fail to improve with these modalities. If the symptoms are sever enough, and dysfunction is not acceptable, and operative procedure may be offered to the patient. Once the decision to proceed with an operative procedure, your spine surgeon may suggest other diagnostic studies to plan the surgical strategy. Several operative options are available, each with their own risks and benefits. The pathology could be approached from the front of the neck or from the back. Procedures that approach the spine from the front take care of the problem directly by removing the disc and placing bone in the remaining space. This procedure is referred to as Anterior Cervical Discectomy & Fusion. Since most of the time the problem is the disc, removing it results in prompt relief of dysfunction and pain. Often, patients report prompt relief and are usually very happy to have undergone the procedure. Since we fuse a motion segment of neck, many patients are concerned regarding the decreased range of motion. In practice the lost motion is compensated by the other levels and the loss of motion in one level is negligible and not noticeable. Patient may consider to go home on the same day or stay overnight. With front surgery, pain in the neck is usually minimal and is easily manageable. In contrast, procedures that approach the spine from the back go through the muscle layers in the neck. These procedures include Posterior Cervical Laminectomy, Posterior Cervical Foraminotomy, and Micro-Endoscopic Posterior Cervical Foraminotomy. This usually leads to more postoperative pain. However, we do not remove the entire disc and do not fuse a motion segment with this strategy. The bony roof of the spinal canal is removed and the tunnel is opened up to allow more room for the exiting nerve. The procedures approaching the neck from the back are similar with some variations. Laminectomy refers to removal of the bony roof and Foraminotomy refers to the opening of the small canal that the nerve exits through. Micro-Endoscopic foraminotomy is a minimally invasive procedure that uses a very small incision to get to the area of interest. Post-operative pain is much less compared to the other procedures. However, the area of pathology must be very localized and diagnosis certain. Patients may go home on the same day of surgery and is considered an outpatient procedure. Only few selected surgeons can perform Micro-Endoscopic procedures and this discussion should be done with your surgeon. Our office performs such procedures and utilize minimally invasive surgery when when indicated and clearly benefit the patient.

The patient must remember that there are many newly introduced procedures recommended for the benefit of advertising and marketing. We will only recommend procedures that provide superior result and lead to patient satisfaction. We do not perform laser discectomies since many patients report worsening of symptoms and this procedure may lead to disastrous results. Every new procedure introduced into the field of Orthopedic surgery must undergo peer reviewed studies with proven benefits before its approved in our practice. Many procedures are introduced for the benefit of marketing and this issue should be carefully examined by the patient. Such information is readily seen on the internet and patients should be cautioned against them. Our office will provide guidance and further information regarding your specific diagnosis, treatment options, with associated risks and benefits.