CHAPTER 38 Nonoperative Management of Cervical Disc and Degenerative Disorders
Degenerative, or spondylotic, cervical conditions comprise a spectrum of disorders including degenerative disc disease with axial neck pain, cervical radiculopathy from root compression, and cervical myelopathy from compression of the spinal cord. In most cases, the underlying pathoanatomy begins with degeneration of the cervical disc. Subsequently, the disc can herniate or bulge, causing spinal cord or nerve root compression. Significant loss of disc height may lead to segmental kyphosis. Abnormal kinematics in the motion segment can lead to instability or to the formation of compensatory osteophytes at the level of the disc space and in the uncovertebral joints, which can also cause neural compression. Facet joints may hypertrophy, causing foraminal stenosis, and the ligamentum flavum can hypertrophy or buckle, leading to spinal canal stenosis.
Patients with cervical disc and degenerative disorders often seek medical attention for relief of neck pain, arm pain, weakness, or numbness. Except for individuals with myelopathy or severe, progressive weakness, most patients are initially treated nonoperatively because many have a self-limited course that resolves without surgery. This chapter examines the role of nonoperative management in the treatment of degenerative cervical disorders.
Population-based cross-sectional surveys have shown that acute and chronic neck pain is widely extant in the general population.1–3 From the Norwegian registry, Bovim and colleagues1 showed an overall prevalence of neck pain of 34.4%, with 13.8% of these individuals reporting chronic neck pain of greater than 6 months’ duration. Similar numbers were reported for chronic neck pain in Finland.3 In 2000, Cote and colleagues2 found that 54% of 1131 subjects had experienced significant neck pain in the previous 6 months, with nearly 5% reporting being highly disabled from neck pain. Many cases of acute neck pain may arise from soft tissue sprains and muscle strains, but ongoing neck pain is more suggestive of a spondylotic source.
The natural histories of most nonmyelopathic spondylotic cervical disorders are statistically favorable. In a study of 205 patients with axial neck pain4 and an average follow-up of 15.5 years, 79% noted improvement with nonoperative care, 43% reported a pain-free state, and 32% continued to complain of moderate to severe persistent pain. The severity of the symptoms at initial presentation and a history of a specific injury were suggestive of long-term persistent symptoms.
In the classic study by Lees and Turner,5 the natural history of cervical radiculopathy was also shown to be generally favorable. Of 51 patients with radiculopathy and long-term follow-up (2 to 19 years), 45% had only a single episode of pain without recurrence, 30% had mild symptoms, and only 25% had persistent or worsening symptoms. No patients with radiculopathy progressed to myelopathy in their series. On the basis of this study and clinical experience and because it is impossible to identify at the onset of symptoms patients who will or will not improve, nonoperative treatment is generally the initial approach for most patients with cervical radiculopathy. Surgery is reserved for patients with neurologic deficits, progressive dysfunction, or failure to improve after an appropriate course of nonoperative treatment. The definition of what constitutes an appropriate course of nonoperative treatment (in terms of duration and actual regimen) has not been standardized, however.
Although nonoperative treatment is the initial “default” pathway for most patients with nonmyelopathic cervical disorders, it is unclear whether commonly used nonoperative regimens improve on natural history. No controlled trials have compared the various nonoperative regimens (e.g., physical therapy, modalities, traction, medications, manipulation, and immobilization) versus the natural history (i.e., no treatment at all). It is also unclear whether nonoperative treatment outcomes can equal outcomes of surgery.
One series of cervical radiculopathy reported that 20 of 26 (77%) patients had good to excellent results with a progressive program of nonoperative treatment consisting of immobilization, ice, rest, nonsteroidal anti-inflammatory drugs [NSAIDs], traction, postural education and strengthening, oral steroid tapers, acupuncture, and transcutaneous electrical nerve stimulation.6 Based on comparisons with previously published surgical series, the authors suggested that their nonoperative outcomes were comparable to surgical outcomes and superior to the natural history of cervical radiculopathy. This interpretation of the study is limited, however, by the absence of true controls in the surgical or natural history categories.
Another study retrospectively compared outcomes of surgical versus nonsurgical treatment and found favorable outcomes with the latter7; however, meaningful comparisons could not be made between the groups in this study because the surgical patients initially presented with more severe disease. In contrast, the real issue is not whether surgery “works” under the appropriate circumstances: Any surgeon who has treated a patient with cervical radiculopathy who has suffered for months despite conservative treatment who wakes up immediately after surgery with complete resolution of symptoms can attest to that fact. The unresolved question remains, however: Given that many patients improve without surgery, when and in whom should surgery be recommended—and is there a way to predict who needs surgery at the outset to avoid delays in delivering the ultimately needed treatment?
Other factors may affect the natural history of cervical spondylosis. Smoking has been well documented as a risk factor for neck pain8–10 and has been shown to advance degeneration of the intervertebral disc and connective tissues. Smoking also may contribute to accelerated deterioration of an individual’s aerobic fitness. Occupations requiring excessive cervical motion and overhead work may accelerate the process of disc degeneration, as can vibration caused by heavy equipment.8,10–12 For these individuals, a change in occupation may be necessary to alleviate symptoms. Active litigations claims (e.g., motor vehicle accidents) may provide the patient with incentive to have continued complaints. Likewise, active workers’ compensation claims have long been recognized to have an adverse effect on the outcomes of injuries sustained on the job.
Cervical myelopathy, by contrast, is generally considered to be a surgical disorder because myelopathy has been shown to be progressive over time.13 Surgery has also been shown to have better functional and neurologic outcomes than nonoperative care in myelopathy.14 It is commonly held that early surgery may improve prognosis in myelopathy by limiting the extent of irreversible spinal cord damage. Nonoperative management of myelopathy is reserved for patients with mild cases, in whom careful follow-up is necessary, or patients with prohibitive surgical risk factors.
Goals of Treatment
The immediate goals of treatment are to control the patient’s pain and to minimize the disruption of the patient’s everyday life. In addition to treatment, education is important in helping the patient to understand the problem and what to expect in the future.
For patients presenting with an acute problem, pain control is generally the first concern. Although medication is commonly the first line of defense, it needs to be viewed as a temporary measure. Because a painful, immobile cervical spine can limit nearly any activity, return of function may be a slow process in cervical degenerative disease. The longer the patient’s activity level is limited, the greater the impact on deconditioning. Activity levels may decline even further as the patient becomes fearful that any motion may cause recurrence or exacerbation of the symptoms. This combination of pain and inactivity may result in a patient with chronic pain if left untreated. Table 38–1 summarizes available nonoperative treatments for cervical degenerative disorders.
|Cervical collars||Immobilization may decrease inflammation and muscle spasm||Muscle atrophy from prolonged use|
|Ice or heat||Ice may relieve acute pain and spasm; heat beneficial when regaining motion||Heat may exacerbate pain in acute period|
|Traction||With neck in flexion may relieve foraminal compression||Avoid in myelopathic patients; if neck extended, may worsen compression of narrowed foramen|
|NSAIDs||Safe, cost-effective method to decrease inflammation||Gastrointestinal side effects, cardiovascular risks with COX-2 inhibitors|
|Narcotics||Rapid pain relief in acute period||Constipation, sedation, depression, and potential for abuse|
|Corticosteroids||May decrease radicular pain acutely||Avascular necrosis, increased blood glucose, unproven long-term benefits|
|Muscle relaxant||Acute relief of muscle spasms||Sedation, fatigue, abuse potential, limits participation in rehabilitation|
|Exercise and physical therapy||Well tolerated, aerobic conditioning||No long-term pain benefits shown, forceful passive range of motion may lead to further injury and increased pain|
|Cervical manipulation||Some anecdotal reports of relief||No objective evidence of improvement in pain; rare potential complications including myelopathy, spinal cord injury, vertebrobasilar artery injury|
|Cervical steroid injections||Anti-inflammatory effect, interruption of nociceptive input/sympathetic blockade, mechanical disruption of adhesions||Rare complications include dural puncture, meningitis, epidural abscess, intraocular hemorrhage, epidural hematoma, adrenocortical suppression, paralysis|
COX-2, cyclooxygenase-2; NSAIDs, nonsteroidal anti-inflammatory drugs.
Bracing, Immobilization, and Rest
A short course of bed rest is used to treat patients with lumbar disorders; cervical collars are analogously used to manage patients with cervical pathology. Immobilization of the neck is thought to diminish inflammation around an irritated nerve root. Immobilization may also diminish muscle spasm. Alternatively, the warmth provided by wearing the collar may be therapeutic.15 The efficacy of collars in limiting the duration or severity of problems such as radiculopathy has not been shown, however.16 In one study of patients with whiplash injury, soft collars did not have an effect on the duration or degree of neck pain.17
Although short-term use of collars may be beneficial, prolonged immobilization should be avoided to prevent atrophy of the cervical musculature. Most authors recommend weaning off of the collar over no more than 2 weeks. Because extension can often be more painful than flexion for many patients with acute neck spasm, patients may be more comfortable wearing a traditional soft collar “backwards.” Wearing the collar this way promotes relative flexion of the neck and enlargement of the neuroforamina. Similarly, use of an inverted-V–shaped pillow during sleep may be beneficial by promoting neck flexion. Nighttime collar wear may be helpful by maintaining proper cervical alignment during the entire night and protecting the discs from abnormal loads associated with poor sleeping posture. After a few days, the collar may be discontinued from wear in the daytime but may be maintained for longer term at night if the patient desires. Hard collars are typically not used because they can be uncomfortable and too rigid.
Ice, Heat, and Passive Modalities
Cold therapy such as ice often provides quick relief of discomfort for patients with acute pain and spasm. Heat may exacerbate the pain during this immediate period. When motion has started to return, heat is more likely to be beneficial. These measures can generally be tried by the patient at home and do not require the attention of a physician unless they are used directly to facilitate an active rehabilitation program. Massage, ultrasound, and iontophoresis all have failed to be of proven long-term efficacy.18 Other passive modalities that require no effort on the part of the patient may also be of limited value because the patient is not an active participant in his or her own recovery.
Anecdotally, intermittent home traction is said to help relieve symptoms temporarily in patients with axial neck pain or radiculopathy. Traction has failed to show long-term benefit, however, for patients with axial neck pain or cervical radiculopathy.19–22 Traction should be avoided in myelopathic patients to prevent stretching of a compromised spinal cord. Some instruction sheets for commonly used home traction units still show the patient with his or her back to the door, leading to an extension traction vector; this may worsen arm pain in patients with radiculopathy if the compromised foramen is narrowed further as a result. Instead, traction with the neck in relative flexion is more likely to lead to symptom relief in the patient with radiculopathy. If there is no response during the first few applications, use of traction should be discontinued.
The most commonly used medications in the treatment of cervical disc disease are anti-inflammatory agents (including corticosteroids), narcotics, muscle relaxants, and antidepressants.23
Nonsteroidal Anti-inflammatory Drugs
NSAIDs are commonly used to treat various musculoskeletal conditions including cervical disc disease. The mechanism of action is related to their anti-inflammatory and analgesic effects. Although these medications are generally very safe, patients who are on long-term NSAID therapy should be monitored for potential liver, kidney, and gastrointestinal problems. Aspirin and ibuprofen are readily available over-the-counter and have good effectiveness at low cost. Selective cyclooxygenase-2 inhibitors are now widely accessible and may diminish the incidence of side effects such as stomach upset, but in controlled trials of osteoarthritis, they do not seem to be any more efficacious than nonselective NSAIDs.24–26 Cyclooxygenase-2 inhibitors also work without inhibiting platelet function. Although many of these agents seem to be well tolerated by most patients even with a history of gastrointestinal problems, potential cardiovascular risks have tempered their routine use.27