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Spine Conditions and Treatments

Neck Pain

Photo of skeleton showing neck painOur goal is to provide you with optimal care for your neck problem. We believe that excellent education is critical to enhance patient outcomes. The following information was written to help you understand the cause of your neck pain and your treatment options. Medical problems and medical terminology are not always easy to understand, so if any part of this does not make sense to you, please ask your doctor to explain it. Good communication between you and your doctor will help make sure you get better as quickly as possible. Remember, this information is very general, and it may not all apply to you.

 

What can I do to make myself feel better?

 

The basics are a little bit of rest, heat and ice, and medicines to reduce inflammation. In addition to these temporary band-aids, maintaining your ideal weight, getting regular aerobic exercise, and not smoking have been proven to decrease recurrence of back and neck pain flare-ups. The good news is that mechanical pain from muscle strains, as well as arm or leg pain from a “pinched nerve” typically respond very well to non-operative care.

Ultimately, treatment of ongoing neck or back problems must be directed at the cause. This may mean losing weight, getting your muscles in better shape, or improving your posture when you are sitting, standing and sleeping.

  • Rest
    Studies show that exercise is more effective at treating cases of simple neck or back pain than bed rest and drugs, but a day or two of rest may help you feel better. Keep bed rest to a minimum! Studies have shown that limiting bed rest is important to a quick recovery.

    A good position for relief when your back hurts is to lie on your back on the floor with pillows under your knees, with your hips and knees bent and your feet on a chair, or just with your hips and knees bent. This takes the pressure and weight off your back.

    Neck or back pain can cause discomfort with any activity. Lying down may seem like the most logical solution, but more than two days of bed rest can make you weaker, which might ultimately make activity more painful and recovery slower. Even if it hurts, walk around for a few minutes every hour. After one or two days of rest, get up and start moving around. Begin slowly and progress to your previous level of activity.
  • Heat and Ice
    Use ice in the first couple of days of acute pain. Ice reduces inflammation by constricting the blood vessels and reducing blood flow and swelling. Ice should not be applied for more than five minutes at a time, because it could cause frostbite.

    After 48 hours of acute pain, heat may be applied to the affected area. Heating pads or a hot bath can help relax painful muscle spasms. As with ice, great care must be taken not to leave the heating pad in place for long periods of time risking burns to the skin, so don’t leave heat in one place for more than 20 to 30 minutes at a time.
  • NSAIDs
    NSAIDs stands for “non-steroidal anti-inflammatory drugs.” They have advantages over narcotic painkillers because they are not addictive and they help control the swelling that can cause pain. At the first sign of back or neck pain, start taking NSAIDs as instructed on the bottle. You should do this regularly for a few days to break the cycle of pain and inflammation. If taken regularly, these medications can provide a stable level of the drug in your body. Avoid letting the medications wear off before taking another dose the next day, which allows the cycle of pain to restart.

    Follow the instructions on the bottle. Take your medication with food to help prevent stomach irritation. Do not take more than one NSAID at a time. For example, if you’re taking ibuprofen, don’t take naproxen, too.

    Acetaminophen (Tylenol) is technically not an NSAID, but it may also help your pain. As long as you do not have liver problems, you can take Tylenol in between doses of NSAID.

    Motrin, Nuprin and Advil are common brand names for ibuprofen, one of the common NSAIDs that should be taken three times a day (every 8 hours) for maximum effectiveness.

    Aleve and Naprosyn are common brand names for naproxen, another common NSAID that only needs to be taken twice a day (every 12 hours).
  • Quit Smoking
    If you smoke, quit. Smoking is a risk factor for arthrosclerosis (hardening of the arteries), which can cause low back pain and degenerative disc disorders.
  • Lose Weight
    Maintain a healthy weight. Extra weight, especially around the midsection, can put strain on your lower back.
  • Stay Active
    Regular exercises to restore the strength of your back and a gradual return to everyday activities are important for your full recovery. During early recovery it is recommend that you exercise 10 to 30 minutes a day, 1 to 3 times a day.

    Perform crunches and other abdominal-muscle strengthening exercises to provide muscular spine stability. Swimming, stationary bicycling and brisk walking are good aerobic exercises that generally do not put extra stress on your back and help you stay fit overall.

    Some specific exercises can help your back. One is to gently stretch your back muscles. Lie on your back with your knees bent and slowly raise your left knee to your chest. Press your lower back against the floor. Hold for five seconds. Relax and repeat the exercise with your right knee. Do 10 of these exercises for each leg, switching legs.

    Another important aspect of your home exercise program should be to stretch and improve your overall flexibility. These simple exercises can be done throughout the day.

    You can obtain a prescription from your Primary Care Provider to a Physical Therapist who specializes in physical therapy of the spine to supervise your exercise program. The most important part of your physical therapy is for you to get in the habit of doing some daily exercises at home. Keeping your neck and back strong, flexible and healthy will make you more resistant to future pain.
  • Be Careful
    Good posture and good body mechanics (the way you do things) can help your neck and back feel better longer.

    Sit in chairs with straight backs or low back support. Keep your knees a little higher than your hips. Adjust the seat or use a low stool to prop your feet on. Turn by moving your whole body rather than by twisting at your waist.

    When driving, sit straight and move the seat forward. This helps you not lean forward to reach the controls. You may want to put a small pillow or rolled towel behind your lower back if you must drive or sit for a long time.

    If you must stand for long periods, rest a foot on a low stool to relieve pressure on your lower back. Every five to 15 minutes, switch the foot you are resting on the stool. Maintain good posture: keep your ears, shoulders, and hips in a straight line, with your head up and your stomach pulled in.

    If you sleep on your back, put pillows under your knees and a small pillow under your lower back. If you sleep on your side, put a pillow under your head to support your neck and a pillow between your knees. Do not sleep on your stomach unless you put a pillow under your hips. Use a firm mattress. If your mattress is too soft, put a board of half-inch plywood under the mattress to add support.

    Use correct lifting and moving techniques, such as squatting to lift a heavy object. Don't bend at the waist and lift. Get help if an object is too heavy or awkward. Using proper lifting form is vital to preventing injury to the spine. Lifting tasks should be performed with good body mechanics and/or with the assistance of another if the object is too cumbersome to lift alone.
  • Be Kind to Yourself
    Avoid stressful situations if possible, as this can cause muscle tension.

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When should I see my primary care physician?

 

The good news is that most people with neck pain will eventually feel better without surgery. If you have tried rest, ice/heat, anti-inflammatories and gentle exercise but your pain continues for more than a couple of weeks, you should probably see your doctor.

In general, you should get medical care right away if:

  • Your leg, foot, groin or rectal area feels numb.
  • The pain was caused by an injury such as a fall or car crash.
  • You have trouble sleeping because of the pain.
  • Your pain is so intense that you cannot move around.
  • You lose weight without trying or have a fever, chills, or a history of cancer.
  • You have trouble urinating or controlling your bowels.
  • Your pain does not seem to be getting any better after two or three weeks.

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What can my doctor do for me?
  • Focused Physical Therapy
    A prescription is required for physical therapy, and physical therapists can treat any area of the spine. Physical therapy entails instruction of proper exercise and technique, spine education, and hands-on therapy such as heat, ice, ultrasound, massage (myofascial release), and perhaps trials of traction. The most important part of a physical therapy routine is for you to learn to do some of the exercises on your own every day.
  • Prescription Medications
    Most spinal disorders respond to anti-inflammatory medications, muscle relaxants and pain medications such as narcotics. Low-dose steroids may be prescribed over a short course to also decrease pain and inflammation.
  • Discuss Other Treatment Options
    Massage, chiropractic care or manipulations to the neck can feel good in many cases. You should discuss these with your doctor, since certain conditions should not be manipulated. You should maintain a treatment strategy that is consistent with your physician’s experience.
  • Diagnostic Imaging
    There are several different types of imaging and studies that might help your doctor decide how to help you. The first step would be to take X-rays of your neck or back. Depending on your condition, your doctor might also decide to order MRIs, CT scans or nerve conduction studies. See the section on “How do we figure out what’s wrong?” for more information on each of these.

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Are there non-surgical procedures (physiatry) to help with my neck pain?

 

If initial measures fail to secure significant relief from pain and/or significant progress toward the patient’s functional goals, more aggressive, spine interventions should be considered. Given the health risks associated with long-term use of any medication, particularly NSAIDS or narcotics, these procedures are worthy of consideration.

At the New England Musculoskeletal Institute and the Comprehensive Spine Center, the following injection therapies are used together with electro diagnostic studies both as diagnostic tools and to directly administer medications to the source of pain.

  • Selective nerve root blocks provide relief for leg and arm pain due to pinched or irritable nerve root caused by disc protrusion or canal narrowing.
  • Facet joint injections relieve low back pain.
  • Sacroiliac injections address low back pain caused by dysfunction of these joints.
  • Transforaminal steroid injections alleviate neck and low back pain arising from degenerative discs.
  • Lumber discogram to determine the level of disc pain.

These minimally invasive procedures are performed under X-ray guidance using today’s best imaging tools and intravenous contrast materials to precisely identify the source of pain and administer medications to the exact site.

Several multi-center studies, including the Spine Patients Outcome Research Trial (SPORT), have shown that these procedures provide significant relief from pain. The studies have also established evidence-based practice guidelines.

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When should I see a spine specialist?

 

If you have any of the following symptoms, you should discuss with your primary care doctor and arrange to see a spine specialist as soon as possible. At our facility, we have both spine surgeons and physiatrists who specialize in the care of patients with neck pain. In general, the physiatrist will develop non-operative treatment plans to manage neck pain. These regimens will include medicines, physical therapy and/or injections to help alleviate your neck or arm pain. If these regimens do not work, you may need a referral to a spine surgeon for evaluation for possible surgery.

  • Pain persisting more than six weeks
  • Pain spreading down arm(s) or leg(s)
  • Weakness
  • Worsening symptoms
  • Trouble walking or maintaining your balance
  • Trouble controlling your bowel or bladder

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What can a spine surgeon do for my neck or arm pain?

 

If non-operative management of your neck or arm pain is unsuccessful, then you may be a candidate for cervical spine surgery. Cervical spine surgery is generally performed on an elective basis to treat either nerve/spinal cord impingement (decompression surgery) or spinal instability (fusion surgery). The two procedures are often combined, because a decompression may de-stabilize the spine and create the need for a fusion to add stability. Spinal instrumentation (such as a small plate and screws) can also be used to help add stability to the spinal construct. Surgery for herniated cervical discs is considered in patients with continued symptoms who have failed appropriate conservative measures. Neurologic symptoms, such as weakness or gait difficulty, may require surgery on an earlier basis.

The cervical spine can either be approached from the front (anterior approach) or from the back (posterior approach). In general, when possible, most surgeons favor an anterior approach for most conditions. An anterior approach results in less disruption of the normal musculature and is also easier to maintain the normal alignment of the spine.
Many degenerative conditions of the spine cause a loss of the normal lordosis (gentle curvature of the spine), and by opening up the front of the spine this lordosis can be reestablished. However, there are some conditions that do require a posterior approach or a combined anterior/posterior approach.

Deciding to Use Bone Graft or Other Substitutes
Many spine procedures require the use of extra material (your own bone, human donor grafts or synthetic materials) to improve the results of surgery. Some studies have shown that using your own bone (usually taken from your hip) leads to a higher fusion rate, but there is the added risk of a problem related to the iliac crest donor site. Allograft (donor bone) avoids the problems associated with taking a bone graft from the pelvis, but the trade-off is a somewhat lower fusion rate. There are pluses and minuses to almost every decision in life, and success and complication rates often vary from the “average” for individual surgeons. You should talk to your surgeon about his or her experience and recommendations, and then decide together what the best surgical plan will be for you.

Some typical spinal surgeries include:

  • Anterior Cervical Discectomy and Fusion (ACDF): The most common surgery for symptomatic herniated cervical discs, ACDF exposes your cervical spine through a surgical cut in the front of your neck so that your surgeon can remove the disc(s) or bone spurs that are causing your symptoms. The intervertebral disc is removed and replaced with a small plug of bone or other graft substitute, that – in time – will fuse the vertebrae. ACDF can be done for single or multiple level disc herniations as indicated.
  • Cervical Corpectomy: A procedure that removes a portion of the vertebra and adjacent intervertebral discs to allow for decompression of the cervical spinal cord and spinal nerves. A bone graft, and in some cases a metal plate and screws, is used to stabilize the spine.
  • Foraminotomy: A procedure that removes the foramina (the area where the nerve roots exit the spinal canal) to increase the size of the nerve pathway.
  • Laminoplasty: A procedure that reaches the cervical spine (neck) from the back of the neck, which is then reconstructed to make more room for the spinal canal.
  • Laminotomy: A procedure that removes only a small portion of the lamina (a part of the vertebra) to relieve pressure on the nerve roots.

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How do we figure out what is wrong?

 

The most common and basic diagnostic test is an X-ray. In many cases, regular X-rays are the only diagnostic test that your physician will require. However, if more detailed structural information is needed to devise a treatment plan, then your doctor may go on to order other studies such as Magnetic Resonance Imaging (MRI) or Computed Axial Tomography (CT or CAT) scans.

Other common diagnostic tests include those tests that provide information as to the function of the spinal cord and nerves. These include Electromyography/Nerve Conduction Velocities (EMG/NCVs) and Somatosenory Evoked Potentials (SSEPs). Their use is typically required on a case-by-case basis, and they are not needed as often as the structural diagnostic tests.

  • X-rays
    Plain X-rays are not painful. They are a quick, non-invasive study that can provide good information regarding the structure, or building blocks, of the spine – the bony anatomy of the spine and the overall alignment. The X-rays are performed at a variety of angles around the neck to gain as much diagnostic information as possible. X-rays can help evaluate the alignment of your spine, diagnose fractures, bone spurs (arthritis) and some problems with the spinal discs. In many cases, regular X-rays are the only diagnostic test that your physician will require.

    In a few cases, your doctor may need more information than we see on the X-rays. For most patients, an MRI is the preferred advanced imaging study.
  • MRI
    MRIs are not painful. They do not involve radiation. MRI images show both bony detail and soft tissue detail such as spinal cord, nerve roots, and ligamentous structures. The actual discs, nerves, spinal cord, and bones can be visualized. MRIs are not recommended for people who have pacemakers or metal within their body (for example, machinists with metal filings in their eyes) that could potentially be attracted by the large magnet that runs the MRI. Patients with artificial joint replacements and devices to fix fractures of other bones in the body generally can undergo MRIs. In patients who cannot undergo MRIs, or in some cases where additional information may be needed, CTs with or without dye may be necessary.
  • CT
    CTs show excellent bony detail. They are not painful and are based on X-ray.
    CT may be combined with the injection of dye to create a “myelogram.”
  • CT Myelogram
    Myelography is an invasive technique in which a needle is introduced into the spinal canal and contrast material is injected into the spinal fluid. This allows for details within the spinal canal, and when combined with CT, shows the relationship of the bone to the contents of the spinal canal.
  • Discography
    Discography is an invasive technique which requires a needle to be entered through the skin and into the disc. A contrast material is then injected. The pressures might be measured and, in conjunction with CTs, may reveal internal disruption of the disc or if the disc is herniated.
  • EMG/Nerve Conduction Velocity
    Electrodiagnostic testing is a minimally invasive procedure in which very tiny needles are placed along the spine and along certain muscles. The electrical response between the nerves and the muscles can determine which nerves are not functioning properly.

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