I regularly see patients who have been told by another doctor that they need surgery for neck instability, or who have already had a failed cervical spine surgery. Why do so many patients undergo neck surgery? One reason is their fear that symptoms may progress. Another is that they are sometimes told they may be risking paralysis without it. Most commonly, though, it is because the doctor does not know how to heal neck pain due to ligament injury.
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. (1)
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.” (2) The traditional and most used treatment is the “watch and wait” means of assessment if the patient is stable or getting worse.
Doctors suggest in the medical journal Spine: “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)
Compounding this is the ever-present rush to surgery spurred on by MRI: “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.”(4)
Follow up research on progression of cervical spine degenerative disc disease
Dr. Park and his fellow researchers issued a follow up study in 2019. (5) 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)
“Physicians should be aware of inconsistencies inherent in the interpretation of cervical MRI findings.”
For some people there was a rush to surgery because of what their MRI said. Doctors at Yale University suggested 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).” (10)
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.
References
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 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.
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 Park MS, Moon SH, Oh JK, Lee HW, Riew KD. Natural history of cervical degenerative spondylolisthesis. Spine. 2019 Jan 1;44(1):E7-12.
6. Centeno CJ, Elliott J, Elkins WL, Freeman M. Fluoroscopically guided cervical Prolotherapy for instability with blinded pre and post radiographic reading. Pain Physician. 2005;8:67-72
7. Myrtveit SM, Skogen JC, Sivertsen B, et al. Pain and pain tolerance in whiplash-associated disorders: a population-based study. Eur J Pain. 2015 Nov 16.doi: 10.1002/ejp.819. [Epub ahead of print.]
8. Vernon H, Guerriero R, Kavanaugh S, Puhl A. Is “fear of passive movement” a distinctive component of the Fear-Avoidance Model in whiplash? J Can Chiropr Assoc. 2015 Sep;59(3):288-93.
9. Casey PP, Feyer AM, Cameron ID. Course of recovery for whiplash associated disorders in a compensation setting. Injury. 2015 Nov;46(11):2118-29. doi:10.1016/j.injury.2015.08.038. Epub 2015 Sep 3.
10 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.
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.