Neck Problems

As is the case with low back problems, the symptom driving most surgical decision-making is arm pain due to a pinched nerve. The pain is similar to sciatica in that it is described as shock like or electricity like and usually extends down the arm in a very specific distribution, frequently below the elbow and into the fingers of the hand. If the nerve pinching or compression is severe enough, loss of function in the form of weakness and / or numbness can result. The usual non-surgical treatment consists of medication to control the pain, a non-steroidal anti-inflammatory drug, and physical therapy, which is frequently in the form of cervical traction. The intent of the traction is to reduce pressure on the nerve in the neck and is probably the most useful of the therapy modalities.

In cases of persistent pain or loss of function despite an appropriate regimen of conservative treatment, surgery is considered. The usual preoperative diagnostic test is a MRI scan of the neck. Other tests might include a myelogram (spinal tap X-ray test) and CT scan. Nerve testing in the form of an EMG (electromyogram) and NCV (nerve conduction velocity study) also can be useful. The most common causes of a pinched nerve are either a disc herniation or bone spur.

The discs are the shock absorbing cushions between the vertebrae and are composed of a soft tissue material often characterized as jelly like, but is in truth more like crab meat. It is normally contained between the bones by a ligament, the annulus that can weaken from injury or wear and tear, allowing the disc tissue to extrude and come into contact with the nerve root leaving the spinal cord. Given time, most disc herniations will be resorbed by the body. Surgery is performed to achieve timely relief of severe arm pain or to restore loss of function before it potentially becomes permanent.

Bone spurs or osteophytes are degenerative build ups of calcium that grown slowly and are related to wear and tear. They can similarly pinch a nerve, but the onset of pain is commonly more gradual and loss of function somewhat less common. The two common surgical approaches for a pinched nerve in the neck are posterior (from the back of the neck) and anterior (from the front of the neck). The decision as to which is the preferred approach is usually made on the basis of the MRI findings.

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Anterior Cervical Discectomy and Fusion ^

This surgical technique requires a small incision on the right side of the neck. The front surface of the vertebral column is approached by temporarily moving the trachea (airway) and esophagus (food passageway) off center, allowing access to the front surface of the disc. The disc is removed in its entirety, allowing removal of a herniated disc fragment or a bone spur compressing a nerve or the spinal cord. The disc is then replaced with a wafer or dowel of bone that is gradually incorporated into the vertebrae on either side of the disc space, resulting in a union or fusion between the adjacent vertebrae. Metallic plates and bone screws are commonly used to help secure the vertebrae, reducing motion and increasing the probability of the fusion healing properly. A neck brace is commonly used following surgery during the healing phase.

The hospital stay is normally overnight and at the time of discharge, patients are capable of basic self-care. A return to work to a sedentary or light duty job is normally possible within two weeks. More physical employment requires a longer recovery.

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Posterior Cervical Discectomy or Foramenotomy ^

This surgical technique involves an incision in the back of the neck in the midline. The neck muscles are moved aside to access the back of the spinal column, usually resulting in more short term discomfort than the anterior approach described above. Only a small portion of the disc or bone spur is removed, enough to take the pressure off the nerve root but not enough to require a fusion of the bones. The recovery is similar, although with more muscular discomfort in the first month. Since a fusion is not performed, there is less long-term restriction of neck movement as the basic biomechanics of the neck are only minimally altered.

The technique chosen is usually dependent upon the results of the imaging studies. As a very broad generalization, posterior approaches are performed more commonly for ruptured discs, and anterior approaches more commonly for bone spurs.

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Peripheral Nerve Problems ^

In addition to nerves being pinched in the neck (nerve roots), nerves can be compressed in the extremities. These are referred to as peripheral nerves, meaning outside the spinal column. The two most common conditions are carpal tunnel syndrome and ulnar neuropathy, referred to as peripheral nerve entrapment neuropathies.

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