Chronic neck pain is one of the more frequent problems we see in our new patients because of its complexity and difficulty in finding the true cause of pain.
Patients may present themselves with numbness or pain radiating from the neck into the arm due to nerve compression. They may be diagnosed with cervical radiculopathy which is caused by herniated disc, or spondyliotic foraminal stenosis. When many doctors think there is a radiculopathy, a surgery will be recommended.
Chronic neck pain usually centers around the nerves.
Chronic neck pain usually centers around the nerves. A disc in the neck can become herniated or “bulge” because of the wear and tear of the tendons, ligaments, and muscles. One possible diagnosis out of many may be spondylolisthesis – where one vertebra slides forward over the bone below it. Another reason neck pain is so prevalent is that the weight of the head is not proportionate to the strength and size of the neck, you do not have a good ability to hold your head up.
Sometimes in an attempt to stabilize the weakened area of the neck, bone spurs will form (osteoarthritis) to “hold things in place.” It is at this point “conservative treatments” for alleviating the pain of the neck area are used. This can begin with a steady diet of anti-inflammatory medications to ease the nerve pain. Cortisone may be injected to reduce inflammation and swelling.
Chiropractics is often tried to push the vertebrae back into place and usually it does, but the vertebrae will slip back because of loose ligaments that chiropractors can cause, and the pain cycle starts again. As pain increases, the surgical consultation is considered. To prevent pain, either bone is chipped away from the nerves (laminectomy) or a cervical fusion to prevent the vertebrae from slipping out of place is recommended. Fusion surgery is of course a complicated surgery, metal and/or bone is attached to the vertebrae and “fused” together to prevent the vertebrae from moving and cause distress on the nerves. Fusion surgery has its draw backs. First, even if successful, the fusion will limit the patient’s mobility in the neck region.
Second, the fusion can cause a “different pain,” because new stress is placed on the non-fused area above and below the fusion. Third, new pain can be caused by the damage of the surgery to connective and supportive tissue, i.e., ligaments and tendons already in a weakened state.
Neck MRI findings.
Everyday we get many emails. In many of these emails the person asking a question sends me their cervical neck MRI findings. That is all they send: A cut and paste of their MRI report. They never say what their pain is like, how this neck pain is affecting their day to day quality of life, or any other glimpses into how this chronic neck pain is hurting them. The email that they send me is all about their neck MRI. Our own clinical findings and that of researchers is that maybe your neck pain should not be all about your MRI. It should be about you.
As many of you are already aware, MRI interpretations can be a long, hard to understand, somewhat frustrating thing for a patient to see and read. The MRI may also seemingly describes a lot of problems with a lot of terminology that can be considered frightening. This may, for many, cause unneeded anxiety and fear. I have been doing regenerative medicine for more than 25 years. Over the years we have been blessed to have helped many people with their neck pain. I have seen patients with varying degrees of degenerative cervical spine disease trying to avoid surgery, I have also seen patients after a cervical neck surgery with more challenges than before the surgery who, unfortunately, may have had a surgery that they did not need. The one thing many of these people had in common was a cervical neck MRI that suggested a lot more problems than the patient was actually having.
Is the neck MRI really showing what my problem is?
Interpreting MRIs can be challenging. In a recent study from March 2019, (1) researchers found the most prevalent MRI findings were:
- Cervical foraminal stenosis (77%)
- The foramen is the gap or passages between the vertebrae that the nerves pass through. If this passageway is made narrower by bony overgrowth there is obviously less space for the nerves to pass through. Over time this passageway can close up enough that the nerves are “pinched.” Why does the bone overgrow? Bone overgrowth can be caused by spinal instability. When the cervical spine is unstable, loose, or wobbly, neck moves in an unnatural motion. Cervical neck instability is generally caused by stressed, weakened and damaged spinal ligaments.
As bad as it may look on an MRI, cervical foraminal stenosis, may not be causing the patient any problems: We have seen this clinically and researchers have seen it and reported it in their published studies:
A January 2023 paper (2) had patients create a drawing showing where their neck hurt. Then this drawing was matched to an MRI of their spine. The radiculopathy level determined from the pain drawings showed poor overall agreement with MRI. “This study revealed a lack of agreement between the segmental level affected determined from the patient’s pain drawing and the affected level as identified on MRI. The large overlap of pain and non-dermatomal distribution of pain reported by patients likely contributed to this result.”
For some people there was a rush to surgery because of what their MRI said. Doctors at Yale University suggested (3) to doctors that they should not solely rely on MRI readings when evaluating patients for neck pain treatment because the MRI may suggest a surgery that is not really needed. The researchers of this study wrote: “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).”
The surgeons suggested that the patient was treated based on what the MRI said, not what they patient said was wrong with them.
In the Clinics in orthopedic surgery,(4) surgeons wrote: “Cervical foraminal stenosis is one of the degenerative changes of the cervical spine; however, correlations between the severity of stenosis and that of symptoms are not consistent in the literature. Studies to date on the prevalence of stenosis are based on images obtained from the departments treating cervical lesions, and thus patient selection bias may have occurred.”
The surgeons suggested that the patient was treated based on what the MRI said, not what they patient said was wrong with them. Perhaps this is why when people send me an email, some never suggest what their symptoms are, only what their MRI said. In this study, the surgeons also suggest that patients may have been sent to surgery that was suggested based on the bias of the MRI interpretation. A surgery the patient may have not needed at all.
Returning to our initial overview of most prominent MRI readings, next came
- uncovertebral arthrosis (74%)
- This is wear and tear damage occurring at the uncovertebral joint or Luschka’s joint, located on each side of the four cervical vertebrae at C3 to C7 in the cervical spine. This is where bone spurs most commonly develop.
- and disc degeneration (67%)
- This is of course are the problems herniated or pinched nerves.
Do these problems indicate surgery? Research: “It is difficult to rule out the possibility of bias; radiological findings may influence surgeon’s decision making.”
Let’s look again at the study in the Clinics in orthopedic surgery.
- “Cervical neuromuscular disease is manifested by symptoms in specific neuromuscular regions of the upper limbs, and radiating pain is mostly caused by cervical nerve root compression due to stenosis of the cervical vertebrae. In the presence of progressive neurological deterioration, intractable pain, signs of myelopathy, fracture, instability, or ligamentous injury, and bone anomalies or destruction are associated with surgical indications.
- “However, (this can all be) asymptomatic. To determine the affected level that requires cervical spine surgery, the patients undergo neurological and physical examinations and then both CT and magnetic resonance imaging (MRI); if the results do not match, additional neurophysiological testing is required to determine the affected level. However, if neurological examinations are performed after radiological examinations, it is difficult to rule out the possibility of bias; radiological findings may influence surgeon’s decision making.”
Sometimes surgery is recommended. But should it be for you?
This is a good question and one that certainly needs to be answered inside an examination room. However, returning to our initial overview of the most prominent MRI readings, let’s look at the least prevalent finding:
- nerve root compromise or compression (2%)
Now if you are in that 2% there is a strong chance that you are suffering from cervical radiculopathy or pain from the nerves. In theses cases surgical options may have to be considered, but, a second opinion looking for non-surgical options may also be warranted.
In my article on this website: How fast does degenerative disc disease progress in the neck? I write that 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 show that 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.
Is “Unstable” Spondylolisthesis Really Unstable?
For many patients with “unstable” cervical degenerative spondylolisthesis, observation may be a better choice than surgery, according to the researchers who conducted a study described below. (5)
Degenerative spondylolisthesis refers to a slipped vertebrae caused by vertebral fracture or attenuation of the pars inarticularis, a part of the vertebra. Because spondylolisthesis is commonly thought to result in instability of the cervical spine, spinal fusion surgery (arthrodesis) is sometimes considered the appropriate treatment. The authors of this study wrote: “Our results suggest that the majority of these patients may be stable and do not develop progression of disease or catastrophic neurologic deficits.”
The researchers analyzed the natural history of cervical degenerative spondylolisthesis in 27 patients. The 16 men and 11 women in the study underwent cervical spine radiographs (x-rays) on two occasions at least two years apart. The patients’ average age at the time of the initial radiograph was 59 years; average time to the follow-up radiographs was 39 months. Measurements on the paired radiographs were carefully compared to determine whether and how much the cervical slippage increased over time. Initial x-rays showed instability (at least two millimeters of displacement between vertebrae) in several patients. However, during follow-up, none of the patients showed further progression, defined as additional displacement of two millimeters or more. The average progression was only about one-half millimeter. Twenty-one patients had backward displacement (retrolisthesis) of the cervical vertebrae, while six had forward displacement (anterolisthesis). The patients with retrolisthesis had somewhat greater slippage during follow-up; however, none had a dislocation or suffered neurological damage.
No Progression of Slippage or Symptoms
Of 16 patients who had symptoms such as neck pain or sensory abnormalities at the initial visit, most were successfully managed without surgery. Of the 11 patients who were initially symptom-free, none developed symptoms during follow-up. The study is one of the few to look at the natural history of the results and suggests that at medium-term follow-up, the conditions appear to be “relatively stable” in most patients. Dr. Park (the lead author of this study) and colleagues write: “This begs the question, if an ‘unstable’ spine does fine without treatment, is it really unstable?
Our results suggest that the majority of these patients may be stable and do not develop progression of disease or catastrophic neurologic deficits.”
The researchers acknowledge some important limitations of their study—particularly the small number of patients and relatively short follow-up period. However, the results suggest that for
many patients, cervical spondylolisthesis is a nonprogressive condition that does not necessarily require surgical treatment. The authors conclude, “In the absence of neurologic symptoms, we recommend observation of patients with degenerative spondylolistheses of the cervical spine.”
A 2018 paper cited Dr. Park’s 2013 research by saying “In 2013, Park and his colleagues, studied the natural history of 27 patients with degenerative cervical spondylolisthesis and reported that they seemed to remain stable from 2 to nearly 8 years of follow-up. Reports concerning cervical spondylolisthesis have increased, but the research is still insufficient to clarify the pathology and proper treatment choice for this disease.” (6) The traditional and most used treatment is the “watch and wait” means of assessment if the patient is stable or getting worse.M
Follow up research on progression of cervical spine degenerative disc disease
Dr. Park and his fellow researchers issued a follow up study in 2019. (7) What the research team continued to define is what is the 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.
Examining a group of 218 cervical spine patients, who did not have the cervical spine surgery, the doctors assessed the progression of disc slippage at least five years later, though the average follow up of this patient base was six and one-half years.
- A finding was 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.
Neck pain is one of the problems we commonly see in my office. There are a number of ways to incur a neck injury, which damages the tendons and ligaments around the joints of the neck. Alternative symptoms associated with this type of damage can include headaches, jaw pain, ear pain, vertigo, loss of voice or hoarseness, and even irritable bowel syndrome. Some of the symptoms can often be alleviated with Stem Cell Therapy, PRP, or Prolotherapy. One study noted successful Prolotherapy injections in traumatic cervical instability, and suggested that this type of treatment should be explored as a viable option to cervical fusion surgery.(6)
Neck specific exercises and physiotherapy
A January 2023 study (3) found that both neck specific exercises and Physiotherapy could significantly help patients with headaches and dizziness as a result of cervical radiculopathy. The exercises started with isolated low-load sensorimotor exercises and progressed to endurance exercises. “The individual physical activity consisted of a recommendation of an aerobic and/or muscular physical activity or training, and the general prescription consisted of at least 30 minutes of physical activity at moderate intensity three times per week.” Discuss with your health care provider which exercises would benefit you the most.
Treating cervical ligaments to restore neck stability
In our office, treating chronic neck pain begins with the repair and strengthening of cervical ligaments. Ligaments are the connective tissue that hold your cervical spine vertebrae in place and your neck in its correct anatomical alignment. When your ligaments are weak, they can no longer hold the neck in proper alignment. When the neck is not in alignment the vertebrae can pinch nerves, constrict arteries, put pressure on your esophagus among other problems that may cause the myriad of symptoms people relay to us in their emails.
C1-C2 instability and a reverse curve
Of the many emails that I get are ones which discuss C1-C2 cervical spine instability. Many emails will talk about chronic upper cervical subluxation at C1-C2 and a reverse curve. The normal curve of the spine is shaped like a backwards “C.” If you have a problem with your neck, Lordosis is probably a word you are very familiar with. When your curve went from a natural “C” shape to a reverse curve you were probably told you had a reversed lordosis or your neck had become Kyphotic. Your neck is now curving in the opposite direction. This may be causing a lot of pain. Some of the pain maybe from muscle spasms. As the muscles are trying to stabilize the spine, the extra workload causes spasms.
When the spine is moving towards a reversed curve, adjacent segments may show cervical disc degeneration at lower levels such as C2-C3, C3-C4. These are the problems which will lead many people to a cervical spine fusion.
Too much fusion surgery? Should adjacent asymptomatic levels be included in fusion surgery if they demonstrate severe radiographic degeneration?
An August 2021 study (11) questioned whether 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 this study the researchers evaluated whether asymptomatic preoperative magnetic resonance imaging (MRI) abnormalities at adjacent levels were predictive of reoperation 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.
Whiplash
Hyperextension neck injuries, more commonly referred to as whiplash, are a complex problem for patients. In one study, doctors found that individuals with whiplash-associated disorders reported more additional causes of pain, more painful locations, and higher pain intensity than individuals with chronic neck pain from other causes.(6)
Patients with whiplash-related disorders also have a greater fear of movement, and doctors are calling for revising standardized tests to determine the extent of the patients’ problems.(7)
Further, doctors are seeking reasons why some people recover within months and others report symptoms for extended periods.
They find a strong and plausible association, as does the study above, between severe disability, clinical levels of pain, catastrophizing, and low mental health.(8)
Injection treatments
An October 2021 paper (12) suggests that “Evidence is growing to support the use of regenerative injection treatments, including prolotherapy, platelet-rich plasma (PRP), platelet lysate (PL), and mesenchymal stromal cells. . . PRP is a safe injectate that shows promise for effective treatment of axial neck pain when utilized in a thoughtful manner targeting ligamentous laxity, intraarticular facet arthritis, and nerve root irritation. Though this early data is encouraging, more comprehensive, randomized controlled trials including a larger number of patients are needed to further validate these findings. Given the significant impact of neck pain on quality of life for an aging population, an overreliance on opioid medications for the management of chronic musculoskeletal pain by providers, and the significant societal costs, both directly and indirectly, a more comprehensive treatment approach from a biomechanical perspective that offers the possibility of disease modification rather than symptom management is needed.”
Comparing regenerative injections, decompression and pain-killer and anti-inflammatory approaches to cervical radiculopathy.
A December 2020 study (13) analyzed the equivocal evidence in support of the effectiveness of each of the three co-existing approaches to conservative treatment of cervical radiculopathy: biological (regenerative), mechanical (decompression) and physical (analgesic and anti-inflammatory). These treatments were compared by dividing 90 patients into six treatment groups.
- Biological treatment: 4 ultra-sound-guided periradicular injections of ACS (Autologous conditioned serum) or PRP (1 per week);
- Mechanical treatment: manual therapy or traction therapy – 8 sessions (two per week);
- Physical treatment: laser therapy or collagen magnetophoresis (the use of a magnetic field in collagen application) – 8 sessions (two per week).
Comparison findings:
- Biological treatments were more effective than mechanical and physical therapies in reducing pain, improving the disability index and proprioception of the hand both immediately on completion of therapy and after a follow-up period, which may suggest their regenerative properties.
- Physical and mechanical therapies produced improvement in the above-mentioned indicators on completion of the therapy, but subsequently exerted a very slight effect during the follow-up period without evident regenerative effects; moreover, a regression of the results was actually recorded for traction therapy. Caution should be paid when using traction therapy in the acute period of root edema, due to possible signs of intolerance of the procedure and exacerbation of the discomfort.
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References
1 Jensen RK, Jensen TS, Grøn S, Frafjord E, Bundgaard U, Damsgaard AL, Mathiasen JM, Kjaer P. Prevalence of MRI findings in the cervical spine in patients with persistent neck pain based on quantification of narrative MRI reports. Chiropractic & manual therapies. 2019 Dec;27(1):13.
2 Marco B, Evans D, Symonds N, Peolsson A, Coppieters MW, Jull G, Löfgren H, Zsigmond P, Falla D. Determining the level of cervical radiculopathy: Agreement between visual inspection of pain drawings and magnetic resonance imaging. Pain Practice. 2023 Jan;23(1):32-40.
3 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.
4 Ko S, Choi W, Lee J. The Prevalence of Cervical Foraminal Stenosis on Computed Tomography of a Selected Community-Based Korean Population. Clin Orthop Surg. 2018 Dec;10(4):433-438. doi: 10.4055/cios.2018.10.4.433. Epub 2018 Nov 21. —2549
5 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.
6 Aoyama R, Shiraishi T, Kato M, Yamane J, Ninomiya K, Kitamura K, Nori S, Iga T. Characteristic findings on imaging of cervical spondylolisthesis: analysis of computed tomography and X-ray photography in 101 spondylolisthesis patients. Spine surgery and related research. 2018 Jan 20;2(1):30-6.
11 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).
12. Williams C, Jerome M, Fausel C, Dodson E, Stemper I, Centeno C. Regenerative Injection Treatments Utilizing Platelet Products and Prolotherapy for Cervical Spine Pain: A Functional Spinal Unit Approach. Cureus. 2021 Oct 8;13(10).
13 Godek P, Murawski P, Ruciński W, Guzek M. Biological, Mechanical or Physical? Conservative Treatment of Cervical Radiculopathy. Ortopedia, Traumatologia, Rehabilitacja. 2020 Dec 1;22(6):409-19.