I regularly see patients who have been told by another doctor that they need a neck surgery to prevent the further degeneration of their cervical spine. Some of these patients are very frightened by what their doctor told them. Some were told that if their symptoms progress they could risk permanent damage to their ability to function maybe to the point of paralysis.
“I am worried if I do not get surgery my neck will get worse”
Research has strongly suggested that many patients decide on cervical fusion surgery because they fear a progression of their problem that will lead to permanent disability. However, follow-up data on patients with degenerative disease of the upper (cervical) spinal vertebrae show little or no evidence of worsening degeneration over time. In 2013, doctors published findings that suggested that the majority of these patients may be stable and do not develop progression of disease or catastrophic neurologic deficits.
The researchers identified 27 patients with cervical degenerative spondylolisthesis (a slipped disc causing nerve pressure) for inclusion in their study.(1)
Here is what they found. For many of you, this terminology may sound familiar and you may recognize that your MRI included many of these terms.
- Eleven patients had cervical spondylolisthesis at C4-C5,
- Nine at C3-C4,
- Six at C5-C6,
- and one at C2-C3.
- Initially, 6 had anterolisthesis (disc forward displacement) and 21 had retrolisthesis (disc backward displacement)
- At baseline, 3 of 6 patients with anterolisthesis and 7 of 21 patients with retrolisthesis had translation of more than 2 mm on dynamic views.
- At baseline, 11 had no cervical symptoms, (This is a scenario I talk about often, MRI shows disc displacement, but the person shows no sign of pain or loss of motion. Should this person be scared into an unnecessary surgery?)
- 8 had cervicalgia (sharp neck pain that is felt in back and shoulders)
- 7 had radiculopathy (radiating pain into the elbows and hands)
- and 1 had myelopathy. Myelopathy needs a surgical consultation as paralysis and incontinence are at risk.
Same patients, on average, seen more than three years later show limited or no progression of cervical spine disease
- At the final visit, none of the anterolistheses or retrolistheses had progressed.
- At the final visit, 7 of 10 patients with initial translation of more than 2 mm on dynamic views had no change.
- Of 17 patients with less than 2 mm of initial dynamic motion, 3 patients progressed to have more than 2 mm of dynamic translation. All 3 of these had retrolisthesis initially. None had clinical worsening of symptoms at the final visit.
The natural history of cervical degenerative anterolisthesis and retrolisthesis seems to be stable during 2 years to nearly 8 years. Although those with retrolisthesis seem to have a higher propensity to increase their subluxation, none experienced dislocation or neurological injury.
In 2019, the same researchers followed up six years later
In their 2019 follow up paper published in the prestigious medical journal Spine (2) the researchers continued looking for progression for cervical spine slippage. They noted that in their previous study described above that 2- to 7-year follow-up showed that degenerative spondylolisthesis of the cervical spine did not progress. The purpose then of this study was to see if longer-term follow-up would reveal that these patients neck slippage actually do progress over time.
- 218 patients with greater than 5-year follow-up without surgery were examined.
- They were categorized as either having or not having cervical spondylolisthesis.
- The average follow-up duration was six and one-half years. Progression of translation (slippage) was found in 20 patients (9.2%), including 4 patients in the spondylolisthesis group and 16 patients in the control group. Progression of translation was not related to the presence of spondylolisthesis or the severity of translation at the initial evaluation, but was more common in the elderly and in the patients with anterior translation than those with posterior translation at the initial evaluation. In addition, progression of spondylolisthesis was not correlated with any change of symptoms.
- Conclusion: Progression of cervical spondylolisthesis is not related to the presence of spondylolisthesis at baseline.
Observation, rush to surgery NOT endorsed by researchers
Doctors at the Rothman Institute, Thomas Jefferson University and Hospitals found: “With many surgeons expanding their indications for cervical spine surgery, the number of patients being treated operatively has increased. Unfortunately, the number of patients requiring revision procedures is also increasing, but very little literature exists reviewing changes in the indications or operative planning for revision reconstruction.” (3)
What these researchers are saying in their study is that doctors have broadened the criteria for neck surgery so more can be justified. However, the literature is not keeping up with ways to help the increasing new group of failed neck surgery patients.
A majority of patients with clearly defined MRI abnormalities who were not at all bothered by neck pain
Compounding this is the always present rush to surgery spurred on by MRI. Doctors at Yale University suggested to doctors not to solely rely on MRI readings when evaluating patients for neck pain treatment: “Physicians should be aware of inconsistencies inherent in the interpretation of cervical MRI findings and should be aware that some findings demonstrate lower agreement than others (in recommending surgery).” (4) This agrees with the first study showing a majority of patients with clearly defined MRI abnormalities who were not at all bothered by neck pain.
Revision cervical fusion surgery – Should adjacent asymptomatic levels be included in revision fusion surgery if they show severe radiographic degeneration? Researchers say NO even if MRI shows abnormalities at adjacent levels
An August 2021 study (5) added to the question as to should surgeons fuse adjacent segments that remain asymptomatic. The researchers suggested that Anterior cervical discectomy and fusions (ACDFs) are generally limited to the levels causing neurological symptoms, but whether adjacent asymptomatic levels should be included if they demonstrate severe radiographic degeneration is a matter of controversy. In evaluating whether asymptomatic preoperative magnetic resonance imaging (MRI) abnormalities at adjacent levels were predictive of reoperation (if they were not dealt with in the first surgery would they cause the need for a second further fusion) for symptomatic adjacent-segment degeneration (ASD) after the initial Anterior cervical discectomy and fusion. Their findings do not support including asymptomatic levels in an anterior fusion construct, even if severe MRI abnormalities are present preoperatively.
The failure of Cervical Total Disc Replacement
A March 2021 study (9) presented the experiences of doctors at the Department of Neurosurgery, at International St. Mary’s Hospital with failures in Cervical-Total Disc Replacement and revision surgery outcomes.
The doctors “retrospectively examined patients who underwent revision surgery due to the failure of Cervical-Total Disc Replacement between May 2005 to March 2019. Thirteen patients (8 males and 5 females) were included in this study. The mean age was 46.1 years (range: 22-61 years), and the average follow-up period was 19.5 months (range: 12-64 months).
Results: The main complaints of patients were posterior neck pain (77%), radiculopathy (62%), and/or myelopathy (62%). The causes of failure of C-TDR were improper indications for the procedure, osteolysis and mobile implant use, inappropriate techniques, and postoperative infection. The most common surgical level was C5-6, followed by C4-5.
Do patients rush to neck surgery because they are tired of pain medications?
The use of opioids or painkillers among people who have been suffering with long-term neck pain sufferers is significant. We see patients all the time who come into the office with a gallon size baggie of current and past medications. What is worse is that many of these prescriptions are not helpful. This is when many patients decide on the surgery. Not because of fear of worsening condition, but rather, fear of opioid addiction and the side effects.
Use of painkillers after surgery is worse
Many people get a good benefit from a cervical spine surgical procedure. Some do not. For those who did not get benefit from the surgery and their physical conditioned worsened, the need and abuse of painkillers became that much worse. Doctors publishing in the medical journal Anesthesia & Analgesia (6) warn against theses abuses of prolonged pain-killer usage after surgery. They reported “Preoperative factors, including legitimate prescribed opioid use, self-perceived risk of addiction, and depressive symptoms each independently predicted more prolonged opioid use after surgery. Each of these factors was a better predictor of prolonged opioid use than postoperative pain duration or severity.”
The investigators of the study suggested that the patients felt or knew that they would be in great pain during the surgical recovery period and that other factors including depression added to this fear. Opioid addiction came easily. The prolonged opioid use after surgery made healing at the least, difficult.
Especially among the older patients
Published in the Archives of Internal Medicine (7) researchers suggested that prescribing opioids to older patients shortly after surgery resulted in long-term analgesic use. The researchers suggested while opioids can be beneficial, they are associated with significant adverse effects such as sedation, constipation and respiratory depression, and their long-term use can lead to physiologic tolerance and addiction.
Chronic neck and back leads to problems of pain management including over-medication. If you have suffered from long-standing pain, chronic prolonged pain surgery and you want to explore ways of finding alternatives to opioid use, let’s explore the possibilities of regenerative medicine.
See more in related articles:
1 Park MS, Moon SH, Lee HM, Kim SW, Kim TH, Suh BK, Riew KD. The natural history of degenerative spondylolisthesis of the cervical spine with 2-to 7-year follow-up. Spine. 2013 Feb 15;38(4):E205-10.
2 Park MS, Moon SH, Oh JK, Lee HW, Riew KD. Natural history of cervical degenerative spondylolisthesis. Spine. 2019 Jan 1;44(1):E7-12.
3 Helgeson MD, Albert TJ. Surgery for Failed Cervical Spine Reconstruction. Spine (Phila Pa 1976). 2011 Nov 8. [Epub ahead of print]
4 Fu MC, Webb ML, Buerba RA, et al. Comparison of agreement of cervical spine degenerative pathology findings in magnetic resonance imaging studies. Spine J. 2016 Jan 1;16(1):42-8. doi: 10.1016/j.spinee.2015.08.026. Epub 2015 Aug 17.
5 Kundu B, Eli I, Dailey A, Shah LM, Mazur MD. Preoperative Magnetic Resonance Imaging Abnormalities Predict Symptomatic Adjacent Segment Degeneration After Anterior Cervical Discectomy and Fusion. Cureus. 2021 Aug 18;13(8).
6 Carroll I, Barelka P, Wang CK, et al. A Pilot Cohort Study of the Determinants of Longitudinal Opioid Use After Surgery. Anesth Analg. 2012 Jun 22.
7 Wolf MS et al (2012). Risk of unintentional overdose with non-prescription acetaminophen products. Journal of General Internal Medicine; DOI: 10.1007/s11606-012-2096-3
8 Mauskop A, Rothaus KO. Stem Cells in the Treatment of Refractory Chronic Migraines. Case Rep Neurol. 2017 Jun 14;9(2):149-155. doi: 10.1159/000477393. PubMed PMID: 28690531; PubMed Central PMCID: PMC5498934.
9 Kim KR, Chin DK, Kim KS, Cho YE, Shin DA, Kim KN, Kuh SU. Revision Surgery for a Failed Artificial Disc. Yonsei Medical Journal. 2021 Mar 1;62(3):240.