Anatomy

Rationale

Preparations

Surgical Procedure

Complications

Our Rehabilitation

Anatomy

Rationale

Preparations

Surgical Procedure

Anterior Discectomy

Complications

 

After Surgery

Our Rehabilitation

 

Anatomy

Rationale

Preparations

Surgical Procedure

Complications

After Surgery

Our Rehabilitation

Anatomy

Rationale

Preparation

Surgical Procedure

Complications

After Surgery

Our Rehabilitation

Anatomy

Rationale

Preparations

Surgical Procedure

Complications

After Surgery

Our Rehabilitation

Welcome to First Choice Physical Therapy’s patient resource about Cervical Radiculopathy.

Neck pain has many causes. Mechanical neck pain comes from injury or inflammation in the soft tissues of the neck. This is much different and less concerning than symptoms that come from pressure on the nerve roots as they exit the spinal column. People sometimes refer to this problem as a pinched nerve. Health care providers call it cervical radiculopathy.

This guide will help you understand:

• how the problem develops
• how doctors diagnose the condition
• what treatment options are available

Anatomy

What part of the neck is involved?

The spine is made of a column of bones. Each bone, or vertebra, is formed by a round block of bone, called a vertebral body. A bony ring attaches to the back of the vertebral body. When the vertebra bones are stacked on top of each other, the bony rings forms a long bony tube that surrounds and protects the spinal cord as it passes through the spine.

Spine

Bony Ring Surrounding Spine

Travelling from the brain down through the spinal column, the spinal cord sends out nerve branches through openings on both sides of each vertebra. These openings are called the neural foramina. (The term used to describe a single opening is foramen.)

Foramen

The intervertebral disc sits directly in front of the opening. A bulged or herniated disc can narrow the opening and put pressure on the nerve. A facet joint sits in back of the foramen. Bone spurs that form on the facet joint can project into the tunnel, narrowing the hole and pinching the nerve.

Herniated Disc

An intervertebral disc fits between the vertebral bodies and provides a space between the spine bones. The disc normally works like a shock absorber. An intervertebral disc is made of two parts. The center, called the nucleus, is spongy. It provides most of the shock absorption. The nucleus is held in place by the annulus, a series of strong ligament rings surrounding it. Ligaments are strong connective tissues that attach bones to other bones.

Causes

Why do I have this problem?

Cervical radiculopathy is caused by any condition that puts pressure on the nerves where they leave the spinal column. This is much different than mechanical neck pain. Mechanical neck pain is caused by injury or inflammation in the soft tissues of the neck, such as the discs, facet joints, ligaments, or muscles.

The main causes of cervical radiculopathy include degeneration, disc herniation, and spinal instability.

Degeneration

As the spine ages, several changes occur in the bones and soft tissues. The disc loses its water content and begins to collapse, causing the space between the vertebrae to narrow. The added pressure may irritate and inflame the facet joints, causing them to become enlarged. When this happens, the enlarged joints can press against the nerves going to the arm as they try to squeeze through the neural foramina. Degeneration can also cause bone spurs to develop. Bone spurs may put pressure on nerves and produce symptoms of cervical radiculopathy.

Herniated Disc

Heavy, repetitive bending, twisting, and lifting can place extra pressure on the shock-absorbing nucleus of the disc. A blow to the head and neck can also cause extra pressure on the nucleus. If great enough, this increased pressure can injure the annulus (the tough, outer ring of the disc). If the annulus ruptures, or tears, the material in the nucleus can squeeze out of the disc. This is called a herniation.

Although daily activities may cause the nucleus to press against the annulus, the body is normally able to withstand these pressures. However, as the annulus ages, it tends to crack and tear. It is repaired with scar tissue. Over time, the annulus becomes weakened, and the disc can more easily herniate through the damaged annulus. If the herniated disc material presses against a nerve root it can cause pain, numbness, and weakness in the area the nerve supplies.

Spinal instability

Spinal instability means there is extra movement among the bones of the spine. Instability in the cervical spine (the neck) can develop if the supporting ligaments have been stretched or torn from a severe injury to the head or neck. People with diseases that loosen their connective tissue may also have spinal instability. Spinal instability also includes conditions in which a vertebral body slips over the one just below it. When the vertebral body slips too far forward, the condition is called spondylolisthesis. Whatever the cause, extra movement in the bones of the spine can irritate or put pressure on the nerves of the neck, causing symptoms of cervical radiculopathy.

Symptoms

What does the condition feel like?

The symptoms from cervical radiculopathy are from pressure on an irritated nerve. These symptoms are not the same as those that come from mechanical neck pain. Mechanical neck pain usually starts in the neck and may spread to include the upper back or shoulder. It rarely extends below the shoulder. Headaches are also a common complaint of both radiculopathy and mechanical neck pain.

Pressure on Irritated Nerve

The pain from cervical radiculopathy usually spreads further down the arm than mechanical neck pain. And unlike mechanical pain, radiculopathy also usually involves other changes in how the nerves work such as numbness, tingling, and weakness in the muscles of the shoulder, arm, or hand. With cervical radiculopathy, the reflexes in the muscles of the upper arm are usually affected. This is why doctors check reflexes when people have symptoms of cervical radiculopathy.

Diagnosis

How do health care providers diagnose the problem?

At First Choice Physical Therapy, we gather the information about your symptoms as a way to determine which nerve is having problems. Diagnosis begins with a complete history of the problem. Our Physical Therapists will ask questions about your symptoms and how your problem is affecting your daily activities. Your answers can help us determine which nerve is causing problems.

Next, our Physical Therapist examines you to see which neck movements cause pain or other symptoms. Your skin sensation, muscle strength, and reflexes are tested in order to tell where the nerve problem is coming from.

Some patients may be referred to a doctor for further diagnosis. Once your diagnostic examination is complete, the Physical Therapists at First Choice Physical Therapy have treatment options that will help speed your recovery, so that you can more quickly return to your active lifestyle.

First Choice Physical Therapy provides services for Physical Therapy in Lynn Haven and Panama City Beach.

Our Treatment

Non-surgical Rehabilitation

Unless the nerve problem is getting worse rapidly, therapy usually begins with nonsurgical treatments. At First Choice Physical Therapy, Cervical Radiculopathy patients are normally seen a few times each week for one to two months. In severe cases, patients may need a few additional weeks of care. Our therapist will create a program to help you regain neck and arm function.

At first, treatments are used to ease pain and inflammation and may include immobilization devices and electrical stimulation treatments to help calm muscle spasm and control pain.

When you begin Physical Therapy at First Choice Physical Therapy, we may prescribe immobilization of the neck. Keeping the neck still for a short time can calm inflammation and pain. This might include one to two days of bed rest and the use of a soft neck collar . This collar is a padded ring that wraps around the neck and is held in place by a Velcro strap. Normally, a patient need only wear a collar for one to two weeks. Wearing it longer tends to weaken the neck muscles.

Soft Neck Collar

Treatments for cervical radiculopathy often include neck traction. Traction is a way to gently stretch the joints and muscles of the neck. It can be done using a machine with a special head halter, or the Physical Therapist can apply the traction pull by hand. Though neck traction is often done in our clinic, we may give you a traction device to use at home.

Special Head Halter

It is very important to improve the strength and coordination in the neck and shoulder blade muscles. Our therapist can also evaluate your workstation or the way you use your body when you do your activities and suggest changes to avoid further problems.

At First Choice Physical Therapy, we usually have their patients try nonoperative treatments for at least three months before considering surgery. But when patients simply aren’t getting better, or if the problem is becoming more severe, we may refer you to a surgeon for evaluation.

Post-surgical Rehabilitation

Rehabilitation after surgery for cervical radiculopathy can be a slow process. Although recovery time is different for each individual, you may need to attend Physical Therapy sessions at First Choice Physical Therapy for six to eight weeks, and you should expect full recovery to take up to four months.

During Physical Therapy after surgery, our Physical Therapist may use treatments such as heat or ice, electrical stimulation, massage, and ultrasound to help calm pain and muscle spasm. Then we will begin to teach you how to move safely with the least strain on your healing neck.

As your First Choice Physical Therapy rehabilitation program evolves, you will do more challenging exercises. The goal is to safely advance your strength and function. As your Physical Therapy sessions come to an end, our therapist will help you with decisions about getting you back to work. We can do a work assessment to make sure you’ll be able to do your job safely. Our Physical Therapist may suggest changes that could help you work safely, with less chance of reinjuring your neck.

When your treatment is well under way, your regular visits to First Choice Physical Therapy will end. We will continue to be a resource for you but you will be in charge of doing your exercises as part of an ongoing home program.

First Choice Physical Therapy provides Physical Therapy in Lynn Haven and Panama City Beach.

Portions of this document copyright MMG, LLC.

Physician Review

Your physician may order X-rays of the cervical spine to identify the cause of pressure on the nerve. The images show whether degeneration has caused the space between the vertebrae to collapse. They may also show if a bone spur is pressing against a nerve.

If more information is needed, your doctor may order magnetic resonance imaging (MRI). The MRI machine uses magnetic waves rather than X-rays to show the soft tissues of the body. This test gives a clear picture of the discs, nerves, and other soft tissues in the neck. The machine creates pictures that look like slices of the area your doctor is interested in. The test does not require any special dye or needles and is painless.

Sometimes it isn’t clear where the nerve pressure is coming from. Symptoms of numbness or weakness can also happen when the nerve is being pinched or injured at other points along its path. (An example of this is pressure on the median nerve in the wrist, known as carpal tunnel syndrome.) Electrical studies of the nerves going from the neck to the arm may be requested by your doctor to see whether the nerve problem is in the neck or further down the arm. However, most doctors take X-rays and try other forms of treatment before ordering electrical tests. These tests are usually only needed when the diagnosis is not clear.

If your doctor orders electrical studies, several tests are available to see how well the nerves are functioning, including the electromyography (EMG) test. This test measures how long it takes a muscle to work once a nerve signals it to move. The time it takes will be slower if nerve pressure from radiculopathy has affected the strength of the muscle.

Another electrical test that may be used instead of EMG is cervical root stimulation (CRS). This test involves putting a small needle through the back of the neck into the nerve where it leaves the spinal column. Readings of muscle action are then taken of the muscles on the front and back of the upper arm and along the inside of the lower arm. Doctors use the readings to determine which nerve is having problems.

Doctors prescribe certain types of medication for patients with cervical radiculopathy. Severe symptoms may be treated with narcotic drugs, such as codeine or morphine. But these drugs should only be used for the first few days or weeks after problems with radiculopathy start because they are addictive when used too much or improperly. Muscle relaxants may be prescribed to calm neck muscles that are in spasm. You may be prescribed anti-inflammatory medications such as aspirin or ibuprofen.

Some patients are given an epidural steroid injection (ESI). The spinal cord travels in a tube within the bones of the spinal canal. The cord is covered by a material called dura. The space between the dura and the spinal column is the epidural space. It is thought that injecting steroid medication into this space fights inflammation around the nerves, the discs, and the facet joints. In some cases, the steroid injection is given around one specific nerve. This is called a selective nerve block. The response to this treatment helps confirm which nerve root is causing the symptoms.

Epidural Steroid Injection (ESI)

Surgery

Most people with cervical radiculopathy get better without surgery. In rare cases, people don’t get relief with nonsurgical treatments. They may require surgery. There are several types of surgery for cervical radiculopathy. These include

• foraminotomy
• discectomy
• fusion

Foraminotomy

A foraminotomy is done to open the neural foramen and relieve pressure on the spinal nerve root. A foraminotomy may be done because of bone spurs or inflammation.

Discectomy

In a discectomy, the surgeon removes the disc where it is pressing against a nerve. Surgeons usually perform this surgery from the front (anterior)of the neck. This procedure is called anterior cervical discectomy. In most patients, discectomy is done together with a procedure called cervical fusion, which is described next.

Anterior Cervical Discectomy

Fusion

A fusion surgery joins two or more bones into one solid bone. The purpose for treating cervical radiculopathy with fusion is to increase the space between the vertebrae, taking pressure off the nerve. The surgery is most often done through the front of the neck. After taking out the disc (discectomy), the disc space is filled in with a small block of bone graft. The bone is allowed to heal, fusing the two vertebrae into one solid bone. The space between the vertebrae is propped and held open by the bone graft, which enlarges the neural foramina, taking pressure off the nerve roots.

Welcome to First Choice Physical Therapy’s patient resource about Cervical Spinal Stenosis.

The spinal cord is a column of nerve tissue protected by a bony tube in the spinal column. Conditions that narrow the space in this tube put the spinal cord at risk of getting squeezed. This narrowing in the spinal column of the neck is called cervical spinal stenosis, or cervical stenosis. Pressure against the spinal cord as a result of spinal stenosis causes myelopathy, a condition that demands medical attention. Myelopathy can cause problems with the bowels and bladder, change the way you walk, and affect your ability to use your fingers and hands.

This guide will help you understand:

• what parts make up the spine and neck
• what causes cervical spinal stenosis
• how the condition is diagnosed
• what treatment options are available

Anatomy

What parts make up the spine and neck?

Spine and Neck

The spine is made of a column of bones. Each bone, or vertebra, is formed by a round block of bone, called a vertebral body. A bony ring attaches to the back of the vertebral body, forming a canal.

This bony ring is formed by two sets of bones. One set, the pedicle bones, attaches to the back of each vertebral body. On the other end, each pedicle bone connects with a lamina bone. The lamina bones form a protective roof over the back of the spinal cord. When the vertebra bones are stacked on top of each other, the bony rings forms a long bony tube that surrounds and protects the spinal cord as it passes through the spine.

An intervertebral disc fits between each vertebral body and provides a space between the spine bones. The disc works like a shock absorber. It protects the spine against the daily pull of gravity. It also protects the spine during activities that put strong force on the spine, such as jumping, running, and lifting.

An intervertebral disc is made up of two parts. The center, called the nucleus, is spongy. It provides most of the ability to absorb shock. The nucleus is held in place by the annulus, a series of strong ligament rings surrounding it. Ligaments are strong connective tissues that attach bones to other bones.

Two Parts of Intervertebral Disc

Causes

Why do I have this problem?

The bony spinal canal normally has more than enough room for the spinal cord. Typically, the canal is 17 to 18 millimeters around, slightly less than the size of a penny. Spinal stenosis occurs when the canal narrows to 13 millimeters or less. When the size drops to 10 millimeters, severe symptoms of myelopathy occur. Myelopathy is a term for any condition that affects the spinal cord. The symptoms of myelopathy result from pressure against the spinal cord and reduced blood supply in the spinal cord as a result of the pressure.

Spinal stenosis may develop for any number of reasons. Some of the more common causes of spinal stenosis include

• congenital stenosis
• degeneration
• spinal instability
• disc herniation
• constriction of the blood supply to the spinal cord

Congenital Stenosis

Some people are born with a spinal canal that is narrower than normal. This is called congenital stenosis. They may not feel problems early in life, but having a narrow canal to begin with places them at risk for stenosis. Even a minor neck injury can set them up to have pressure against the spinal cord. People born with a narrow spinal canal often have problems later in life, because the canal tends to become narrower due to the affects of aging. These degenerative changes often involve the formation of bone spurs (small bony projections) that point into the spinal canal and put pressure on the spinal cord.

Degeneration

Degeneration is the most common cause of spinal stenosis. Wear and tear on the spine from aging and from repeated stress and strain can cause many problems in the cervical spine. The intervertebral disc can begin to collapse, shrinking the space between vertebrae. Bone spurs may form that protrude into the spinal canal and reduce the space available to the spinal cord. The ligaments that hold the vertebrae together may become thicker and can also push into the spinal canal. All of these conditions narrow the spinal canal.

Spinal instability

Spinal instability can cause spinal stenosis. Spinal instability means there is extra movement among the bones of the spine. Instability in the cervical spine can happen if the supporting ligaments have been stretched or torn from a severe injury to the head or neck. People with diseases that loosen their connective tissues may also have spinal instability. For example, rheumatoid arthritis can cause the ligaments in the upper bones of the neck to loosen, allowing the topmost neck bones to shift and close off the spinal canal. Whatever the cause, extra movement in the bones of the spine can lead to spinal stenosis and myelopathy.

Disc herniation

Spinal stenosis can occur when a disc in the neck herniates. Normally, the shock-absorbing disc is able to handle the downward pressure of gravity and the strain from daily activities. However, if the pressure on the disc is too strong, such as from a blow to the head or neck, the nucleus inside the disc may rupture through the outer annulus and squeeze out of the disc. This is called a disc herniation. If an intervertebral disc herniates straight backward, it can press against the spinal cord and cause symptoms of spinal stenosis.

Neck Herniates

Constriction of the blood supply to the spinal cord

The changes that happen with degeneration and disc herniation can choke off the blood supply that goes to the spinal cord. The sections of the spinal cord that don’t get blood have less oxygen and don’t function normally, leading to symptoms of myelopathy

Symptoms

What does cervical stenosis feel like?

Cervical stenosis usually develops slowly over a long period of time. This is partly because degeneration in later life is the main cause of spinal stenosis. Symptoms rarely appear all at once when degeneration is causing the problems. A severe injury or a herniated disc may cause symptoms to come on immediately.

The first sign to appear in some patients is a change in the way they walk. They don’t realize this problem is coming from their neck. But pressure on the spinal cord in the neck can affect the nerves and muscles in the legs, leading to changes in the way they walk. Eventually their walking pattern gets jerky and they lose muscle power in the legs. This is called spasticity.

Most patients also have problems in their hands. The main complaint is that their hands start to feel numb. Others feel clumsy when doing fine motor activities like writing or typing. The ability to grip and let go of items becomes difficult because the muscles along the inside edge of the palm and fingers weaken.

Shoulder weakness also develops in many patients. This happens most often when the spinal cord is compressed in the upper part of the neck. Most affected are the shoulder blade muscles and the deltoid muscle, which covers the top and outside of the shoulder. These muscles weaken and begin to show signs of wasting (atrophy) from not getting nerve input.

The area where the spinal cord is compressed in patients with stenosis is very close to the nerves that go to the arm and hand. The problem that compresses the spinal cord in the neck may also affect the nerves where they leave the spinal column. Nerve pressure can cause pain to radiate from the neck to the shoulder, upper back, or even down one or both arms. It can also cause numbness on the skin of the arm or hand and weakness in the muscles supplied by the nerve.

Pressure against the spinal cord also creates problems with the bowels and bladder. Mild spinal cord pressure makes you feel like you have to urinate more often. But it also makes it difficult to get urine to flow (urinary hesitancy). Moderate disturbances cause people to have a weak flow of urine, making them dribble urine. They also have to strain during bowel movements. In severe cases, people aren’t able to voluntarily control their bladder or bowels. This is called incontinence.

Diagnosis

How will my health care provider identify the condition?

Diagnosis begins with a complete history and physical exam. When you first visit First Choice Physical Therapy, our Physical Therapist will ask questions about your symptoms and how your problem is affecting your daily activities. This will include questions about pain, feelings of numbness or weakness, changes in bowel or bladder function, and whether you’ve noticed any changes in the way you walk.

Our Physical Therapist then does a physical examination to see which neck movements cause pain or other symptoms. Your skin sensation, muscle strength, and reflexes are tested. We will also watch you walk to see if there are any subtle changes in your walking pattern.

Some patients may be referred to a doctor for further diagnosis. Once your diagnostic examination is complete, the Physical Therapists at First Choice Physical Therapy have treatment options that will help speed your recovery, so that you can more quickly return to your active lifestyle.

Our Treatment

Non-surgical Rehabilitation

Spinal myelopathy is a serious condition. If your condition is causing significant problems or is rapidly getting worse, we may not begin with nonsurgical treatments and instead recommend you see a doctor to explore surgical options immediately. If the symptoms are mild, your First Choice Physical Therapy Physical Therapist may initially try nonsurgical treatment to see if the symptoms improve.

Although the length of treatment is different for each individual, as a general guideline, First Choice Physical Therapy patients with mild symptoms of cervical myelopathy typically undergo rehabilitation for three to six months.

At first, we may suggest immobilizing the neck. Keeping your neck still for a short time can calm inflammation and pain. We instruct patients to restrict their daily activities by avoiding heavy and repeated motions of the neck, arms, and upper body.

Our therapist may also prescribe a soft neck collar. The collar is a padded ring that wraps around the neck and is held in place by a Velcro strap. Patients wear the collar during waking hours, usually for up to three months. Then they slowly begin to taper the amount of time they wear it each day. After wearing a neck brace for up to three months, most patients slowly resume their routine activities.

Soft Neck Collar

After initial immobilization, our first treatments are used to ease pain and inflammation. Our Physical Therapist may use electrical stimulation treatments to help calm your muscle spasms and pain. We might recommend traction as a way to gently stretch your joints and the muscles of your neck. This can be done using a machine with a special head halter  or our Physical Therapist can apply the traction pull by hand.

Special Head Halter

Post-surgical Rehabilitation

Some patients leave the hospital shortly after surgery. Other surgeries require patients to stay in the hospital for a few days. Physical Therapist routinely see patients for treatment in their hospital room after surgery. Therapy sessions are designed to help patients learn to move and to begin doing routine activities without putting extra strain on the neck.

During recovery from surgery, you may have to be placed in a halo vest or rigid neck brace. These braces are used to restrict motion in the neck to allow the fusion to heal. Patients generally need to be extremely cautious about overdoing activities in the first few weeks and months after surgery.

Most patients spend some time rehabilitating at home. Bone fusion may take several months. When the health care providers are absolutely certain that the bones have fused together, patients are able to discontinue using the neck brace or halo vest.

After being in a rigid neck brace for four to six months, patients are often weak and deconditioned. At First Choice Physical Therapy, our Physical Therapists can work with you on neck movement, strength, and general conditioning.

As our Physical Therapy sessions come to an end, we may help you with decisions about getting back to work. Ideally, patients are able to go back to their previous activities. However, some patients may need to modify their activities to avoid future problems.

At First Choice Physical Therapy, our goal is to help you keep your pain under control, improve your range of motion, and maximize strength and control in your neck. When your recovery is well under way, regular visits to our office will end. We will continue to be a resource, but you will be in charge of doing your exercises as part of an ongoing home program.

First Choice Physical Therapy provides services for Physical Therapy in Lynn Haven and Panama City Beach.

Physician Review

X-rays are used to look for the cause of pressure against the spinal cord. The images can show if degeneration has caused the space between the vertebrae to collapse and may show if a bone spur is pressing against the spinal cord.

Collapsed Vertebrae

If more information is needed, your doctor may order a magnetic resonance imaging (MRI) scan. The MRI machine uses magnetic waves rather than X-rays to show the soft tissues of the body. This test gives a clear picture of the spinal cord and can show where it is being squeezed. This machine creates pictures that look like slices of the area your doctor is interested in. The test does not require any special dye or a needle.

Soft Tissues

A computed tomography (CT) scan may also be ordered. The CT scan is a detailed X-ray that lets doctors see slices of bone tissue. The image can show if bone spurs are protruding into the spinal column and taking up space around the spinal cord.

Your doctor may recommend electrical tests of the nerves that go to your arm and hand. An electromyography (EMG) test is used to check if the motor pathway in a nerve is working correctly. Doctors may also order a somatosensory evoked potential (SSEP) test to locate more precisely where the spinal cord is getting squeezed. The SSEP is used to measure whether a nerve is able to get and send sensory information such as pain, temperature, and touch. The function of a nerve may be recorded with an electrode placed over the skin or with a needle that is inserted into the nerve or sensory center of the brain.

Some patients are given an epidural steroid injection (ESI). The injection is given in a part of the spinal canal called the epidural space. This is the area between the dura (the material that covers the spinal cord) and the spinal column. It is thought that injecting steroid medication into this space fights inflammation around the nerves and discs. This can reduce the swelling and give the spinal cord more room.

Epidural Steroid Injection (ESI)

Surgery

When there are signs that pressure is building on the spinal cord, surgery may be required, sometimes right away. Surgeries used to treat spinal stenosis include

• laminectomy
• anterior cervical discectomy and fusion
• corpectomy and strut graft

Laminectomy

The lamina is the covering layer of the bony ring of the spinal canal. It forms a roof-like structure over the back of the spinal cord. When bone spurs or disc contents have pushed into the spinal canal, a laminectomy is done to take off the lamina bone in order to release pressure on the spinal cord.

Some surgeons completely remove the entire lamina bone, called total laminectomy. Others prefer to keep the lamina in place by forming a hinge on one edge of the bone. This hinge is formed by cutting partially through the lamina on one side. A second cut is made all the way through the lamina on the other side. This edge is then lifted away from the spinal cord, and the other edge acts like a hinge. The hinged side eventually forms a bone union, which holds the opposite side open and keeps pressure off the spinal cord.

Total Laminectomy

Hinge

Anterior Cervical Discectomy and Fusion

A fusion surgery joins two or more bones into one solid bone. Fusion of the neck bones is most often done through the front of the neck. The surgeon takes out the intervertebral disc (discectomy) between two vertebrae. A layer of bone is shaved off the flat surfaces of the two vertebrae to be fused. This causes the surfaces to bleed and stimulates the bone to heal. (This is similar to the way two sides of a fractured bone begin to heal.) A section of bone is grafted from the top part of the pelvis bone and inserted into the space where the disc was taken out. This separates the two vertebra bones, taking pressure off the spinal cord. As the bone graft heals in place, the vertebral bones fuse together into one solid bone.

Corpectomy and Strut Graft

A corpectomy relieves pressure over a large part of the spinal cord. In this procedure, the surgeon takes off the front part of the spinal column and removes several vertebral bodies. The spaces are then filled with bone graft material. Metal plates and screws are generally used to hold the spine in place while it heals. A corpectomy is used in cases of severe spinal stenosis.

Welcome to First Choice Physical Therapy’s patient resource about Dropped Head Syndrome.

Dropped Head Syndrome is characterized by severe weakness of the muscles of the back of the neck. This causes the chin to rest on the chest in standing or sitting. Floppy Head Syndrome and Head Ptosis are other names used to describe the syndrome.

Most of the time, Dropped Head Syndrome is caused by a specific generalized neuromuscular diagnosis. When the cause is not known, it is called isolated neck extensor myopathy, or INEM.

This guide will help you understand:

• what parts make up the cervical spine
• what causes this condition
• how doctors diagnose this condition
• what treatment options are available

Anatomy

What parts make up the cervical spine?

The spine is made up of a column of bones. Each bone, or vertebra, is formed by a round block of bone, called a vertebral body. A bony ring attaches to the back of the vertebral body, forming a canal for the spinal cord. The spinal cord is a made up of nerve cells which grow to look like a rope or cord about one half inch in diameter. The spinal cord attaches to the base of the brain. The base of the brain is called the
brainstem.

The vertebral column is divided into three distinct portions. The cervical, or neck portion attaches to the base of the skull at the upper end. The lower end of the cervical portion connects with the thoracic spine. There are seven cervical vertebrae.

There are many muscles that lie in the neck region. Some attach from the base of the
skull, others to the spine, ribs, collar bone, and shoulder blade. Extension of the neck happens when the top of the head tilts backward. This causes the face and eyes to look up. Flexion of the neck is when the top of the head tilts forward. This causes the eyes to look down. It also lowers the chin to the chest.

The vertebrae stack on top of one another. When looking at the spine from the side, or from the sagittal view, the vertebral column is not straight up and down, but forms an S curve. The cervical spine has an inward curve called a lordosis. The thoracic spine curves outward. This curve is called a kyphosis. The lumbar spine usually has an inward curve or a lordosis. The S curve seen in the sagittal or side view allows for shock-absorption and acts as a spring when the spine is loaded with weight.

Causes

What causes this condition?

Most of the time, Dropped Head Syndrome is caused by a specific generalized neuromuscular diagnosis. These include amyotrophic lateral sclerosis (ALS) also known as Lou Gehrig’s disease, Parkinson’s disease, myasthenia gravis, polymyositis, and genetic myopathies. Other specific causes can include motor neuron disease, hypothyroidism, disorders of the spine, and cancer.

When the cause of Dropped Head Syndrome is not known, it is called isolated neck extensor myopathy, or INEM.

The INEM form of Dropped Head Syndrome usually happens in older persons. The weakness of the muscles in the back of the neck usually occurs gradually over one week to three months.

Symptoms

What does the condition feel like?

The symptoms of dropped head syndrome are usually painless. It most often occurs in the elderly. The weakness is limited to the muscles that extend the neck. Dropped Head Syndrome usually develops over a period of one week to three months. The head is then tilted downward. Because of the weakness of the extensors of the neck, the chin rests on the chest. Lifting or raising the head in sitting or standing is impossible. When lying down however, the neck is able to extend.

Gaze is down at the floor, instead of forward. The face is downward. The neck appears elongated, and the curve at the base of the neck is accentuated. This can cause over stretching or pinching of the spinal cord. When this happens, there may be weakness and numbness of the arms or entire body.

Dropped head syndrome can also cause difficulty swallowing, speaking, and breathing.

Diagnosis

How will my health care provider diagnose this condition?

Diagnosis begins with a complete history and physical exam. When you first visit First Choice Physical Therapy, our Physical Therapist will ask questions about your symptoms and how your problem is affecting your daily activities. We will do a physical examination to test your reflexes, skin sensation, muscle strength.

Some patients may be referred to a doctor for further diagnosis. Most of the time, loss of neck extension occurs as part of a more generalized neurological disorder. Neurological conditions must be considered first because some are treatable. A neurologist will usually be involved to help decide what is causing the chin-on-chest deformity.

Once your diagnostic examination is complete, the Physical Therapists at First Choice Physical Therapy have Physical Therapy options that can help treat your condition.

First Choice Physical Therapy provides services for Physical Therapy in Lynn Haven and Panama City Beach.

Our Treatment

What treatment options are available?

Isolated neck extensor myopathy (INEM) is considered benign because it does not spread or get worse. Symptoms can improve in some cases. It is most often treated conservatively.

At First Choice Physical Therapy, our Physical Therapy treatment of Dropped Head Syndrome is mainly supportive. The weakness remains localized to the neck extensor muscles, and Physical Therapy may help with this.

Our Physical Therapists may recommend neck extension strengthening exercises to provide some improvement. However, many patients find the strengthening both tiring and frustrating. When lying down on your back you can move the neck to maintain range of motion. This helps to avoid unnecessary stiffness and shortening of the muscles in the front of the neck. Our Physical Therapist will recommend that range of motion exercises be done on an ongoing basis to avoid contractures of the neck.

Neck collars are one of the most useful treatments for Dropped Head Syndrome. Wearing a neck collar when you are up will likely improve your activities of daily living.

The collar can partially correct the chin-on-chest deformity. This improves forward gaze and activities of daily living. It also can help prevent contractures of the neck in a fixed flexed posture. However, it can be uncomfortable and cause sores under the chin. In these cases, other options can be suggested to prevent chin discomfort.

First Choice Physical Therapy provides services for Physical Therapy in Lynn Haven and Panama City Beach.

Physician Review

Your doctor will likely order a magnetic resonance imaging (MRI) of your neck. The MRI machine uses magnetic waves rather than X-rays. It shows the anatomy of the neck. It is very good at showing the spinal cord and nerves. The test does not require a dye or a needle.

Electromygraphy (EMG) uses small diameter needles in the muscle belly being tested. It helps determine how well the nerve conducts signals to the muscles.

A muscle biopsy may be needed. A small piece of muscle is removed and examined under a microscope. A closer look at the muscle fibers can be helpful in making a diagnosis.

In isolated neck extensor myopathy (INEM), the muscle biopsy is non-specific. EMG shows some myopathic changes. Labs are normal.

If no other associated neurologic disorders are found, then the diagnosis of isolated neck extensor myopathy (INEM) is made. It is a diagnosis of exclusion, meaning that everything else that could have caused it has been ruled out. It is not known what causes isolated neck extensor myopathy (INEM).

Some doctors feel that isolated neck extensor myopathy (INEM) is caused by either a non-specific non-inflammatory or inflammatory response that is restricted to the neck extensor muscles. Another possible cause is thoracic kyphosis. When the natural curve of the thoracic spine is increased, it may place the extensor muscles at a disadvantage given the weight of the head. This may cause over stretching and weakness of the extensor muscles.

Prednisone is a potent anti-inflammatory that may be prescribed. It may be beneficial when there is local myositis, or inflammation of the muscles. It can be taken in a pill form by mouth or intravenously.

Speech therapy may also be recommended for swallowing, feeding, and breathing problems. Some people may need to have a feeding tube inserted through the stomach.

Your doctor may want to repeat imaging of the spine. There is the possibility of over stretching or pinching the spinal cord when the neck extensors are so weak. You will need to watch for symptoms such as weakness or numbness in the arms or other portions of the body. Bowel and bladder function could become a problem.

Surgery

Unless fusion is necessary, surgery is usually not recommended in Dropped Head Syndrome.

When there is damage to the nerves in the neck or spinal cord, surgery to fuse the neck may be necessary. This usually requires a fusion from C2-T2. The loss of neck movement after fusion leaves patients unable to see the ground in front of their feet. This makes them at greater risk for falls. The inconvenience caused by having a rigid neck may prove to be a greater problem than the original dropped head deformity.

Osteoporosis, particularly in older females also poses a problem with surgery. The soft bone may allow the metal used to stabilize the spine to pull out.

Welcome to First Choice Physical Therapy’s patient resource about Neck Pain.

Neck pain is a common reason people visit their doctor. Neck pain typically doesn’t start from a single injury. Instead, the problem usually develops over time from the stress and strain of daily activities. Eventually, the parts of the spine begin to degenerate. The degeneration can become a source of neck pain.

Knowing how your neck normally works and why you feel pain are important in helping you care for your neck problem. Patients are often less anxious and more satisfied with their care when they have the information they need to make the best decisions about their condition.

This document will give you a general overview of neck pain. It should help you understand:

• what parts make up the spine and neck
• what causes neck pain
• what tests your doctor may run
• how to decrease your pain and increase your mobility

Anatomy

What parts make up the cervical spine, and how do they work?

The human spine is made up of 24 spinal bones, called vertebrae. Vertebrae are stacked on top of one another to form the spinal column. The spinal column is the body’s main upright support.

Human Spine

The cervical spine is formed by the first seven vertebrae. Doctors often refer to these vertebrae as C1 to C7. The cervical spine starts where the top vertebra (C1) connects to the bottom edge of the skull. The cervical spine curves slightly inward and ends where C7 joins the top of the thoracic spine. This is where the chest begins.

Cervical Spine

Spine Curves

Each vertebra is formed by a round block of bone, called a vertebrae body. A bony ring attaches to the back of the vertebral body. When the vertebrae are stacked on top of each other, the rings form a hollow tube. This bony tube surrounds the spinal cord as it passes through the spine. Just as the skull protects the brain, the bones of the spinal column protect the spinal cord.

Vertebrae Body

Bony Ring

As the spinal cord travels from the brain down through the spine, it sends out nerve branches between each vertebrae called nerve roots. These nerve roots join together to form the nerves that travel throughout the body and form the body’s electrical system. The nerve roots that come out of the cervical spine form the nerves that go to the arms and hands. The thoracic spine nerves go to the abdomen and chest. The nerves coming out of the lumbar (lower) spine go to the organs of the pelvis, the legs, and the feet.

One way to understand the anatomy of the cervical spine to look at a spinal segment. Each spinal segment includes two vertebrae separated by an intervertebral disc, the nerves that leave the spinal cord at that level, and the small facet joints (described later) that link each level of the spinal column.

Spinal Segment

An intervertebral disc is made of connective tissue. Connective tissue is the material that holds the living cells of the body together. Most connective tissue is made of fibers of a material called collagen. In some cases, the collagen fibers join together to form a structure like a rope. In other cases, the fibers are arranged like a piece of cloth, or knitted materials such as you find in a sweater. The disc is a specialized connective tissue structure that separates the two vertebral bodies of the spinal segment. The disc normally works like a shock absorber. It protects the spine against the daily pull of gravity. It also protects the spine during activities that put strong force on the spine, such as jumping, running, and lifting.

An intervertebral disc is made up of two parts. The center, called the nucleus, is spongy. It provides most of the ability to absorb shock. The nucleus is held in place by the annulus, a series of strong ligament rings surrounding it. Ligaments are strong connective tissues that attach bones to other bones.

Two Parts of Intervertebral Disc

There are two facet joints between each pair of vertebrae, one on each side of the spine. A facet joint is made up of small, bony knobs that line up along the back of the spine. Where these knobs meet, they form a joint that connects the two vertebrae. The alignment of the facet joints of the cervical spine allows freedom of movement as you bend and turn your neck.

Facet Joint

The surfaces of the facet joints are covered by articular cartilage. Articular cartilage is a smooth, rubbery material that covers the ends of most joints. It allows the bone ends to move against each other smoothly, without pain.

Two spinal nerves exit the sides of each spinal segment, one on the left and one on the right. As the nerves leave the spinal cord, they pass through a small bony tunnel on each side of the vertebra, called a neural foramen. (The term used to describe more than one opening is neural foramina.)

Neural Foramen

Causes

Why do I have neck pain?

There are many causes of neck pain. Doctors are not always able to pinpoint the source of a patient’s pain. Your doctor will make every effort to ensure that your symptoms are not from a serious medical cause, such as cancer or a spinal infection. Below is a brief overview of some of the most common causes of neck pain.

Spondylosis

Most neck problems happen after years of wear and tear on the parts of the cervical spine. At first, these small injuries are not painful. But over time they can add up. Eventually they begin to cause neck pain.

Doctors sometimes call these degenerative changes in the spine spondylosis. Spondylosis can affect the bones and soft tissues of the spine. However, it is important to know that most problems with spondylosis are a normal part of aging.

Degenerative Disc Disease

The normal aging process involves changes within the intervertebral discs. Repeated stresses and strains weaken the connective tissues that make up a disc. Over time, the nucleus in the center of the disc dries out. When this happens, it loses some of its ability to absorb shock. The annulus also weakens and develops small cracks and tears.

Often these changes are not painful. But larger tears that reach to the outer edge of the annulus can cause neck pain. The body tries to heal the cracks with scar tissue. But scar tissue is not as strong as the tissue it replaces. At some point the disc may finally lose its ability to absorb shock for the spine. Then forces from gravity and daily activities can take even more of a toll on the disc and other structures of the spine.

As the disc continues to degenerate, the space between the vertebrae becomes smaller. This compresses the facet joints along the back of the spinal column. As these joints are forced together, extra pressure builds on the articular cartilage on the surface of the facet joints. This extra pressure can damage the facet joints. Over time, this may lead to arthritis in the facet joints.

These degenerative changes in the disc, facet joints, and ligaments cause the spinal segment to become loose and unstable. The extra movement causes even more wear and tear on the spine. As a result, more and larger tears occur in the annulus.

The nucleus may push through the weakened and torn annulus and into the spinal canal. This is called a herniated or ruptured disc. The disc material that squeezes out can press against the spinal nerves. The disc also emits enzymes and chemicals that produce inflammation. The combination of pressure on the nerves and inflammation caused by the chemicals released from the disc cause pain.

As the degeneration continues, bone spurs develop around the facet joints and around the disc. No one knows exactly why these bone spurs develop. Most doctors think that bone spurs are the body’s attempt to stop the extra motion between the spinal segment. These bone spurs can cause problems by pressing on the nerves of the spine where they pass through the neural foramina. This pressure around the irritated nerve roots can cause pain, numbness, and weakness in the neck, arms, and hands.

Muscle Strain

People with minor neck pain or stiffness are often told they have a muscle strain. However, unless there was a severe injury to the neck, the muscles probably haven’t been pulled or injured. Instead, the problem may be coming from irritation or injury in other spine tissues, such as the disc or ligaments. When this happens, the neck muscles may go into spasm to help support and protect the sore area.

Mechanical Neck Pain

Mechanical neck pain is caused by wear and tear on the parts of the neck. It is similar in nature to a machine that begins to wear out. Mechanical pain usually starts from degenerative changes in the disc. As the disc starts to collapse, the space between the vertebrae narrows, and the facet joints may become inflamed. The pain is usually chronic. (Chronic pain builds over time and is long-lasting.) The pain is typically felt in the neck, but it may spread from the neck into the upper back or to the outside of the shoulder. Mechanical neck pain usually doesn’t cause weakness or numbness in the arm or hand, because the problem is not from pressure on the spinal nerves.

Radiculopathy (Pinched Nerve)

Pressure or irritation in the nerves of the cervical spine can affect the nerves’ electrical signals. The pressure or irritation can be felt as numbness on the skin, weakness in the muscles, or pain along the path of the nerve. Most people think of these symptoms as indications of a pinched nerve. Health care providers call this condition cervical radiculopathy.

Several conditions can cause radiculopathy. The most common are degeneration, disc herniation, and spinal instability.

• Degeneration: As the spine ages, several changes occur in the bones and soft tissues. The disc loses its water content and begins to collapse, causing the space between the vertebrae to narrow. The added pressure may irritate and inflame the facet joints, causing them to become enlarged. When this happens, the enlarged joints can press against the nerves going to the arm as they squeeze through the neural foramina. Degeneration can also cause bone spurs to develop. Bone spurs may put pressure on nerves and produce symptoms of cervical radiculopathy.

• • Herniated Disc: Heavy, repetitive bending, twisting, and lifting can place extra pressure on the shock-absorbing nucleus of the disc. If great enough, this increased pressure can injure the annulus (the tough, outer ring of the disc). If the annulus ruptures or tears, the material in the nucleus can squeeze out of the disc. This is called a herniation. Although daily activities may cause the nucleus to press against the annulus, the body is normally able to withstand these pressures. However, as the annulus ages, it tends to crack and tear. It is repaired with scar tissue. Over time, the annulus becomes weakened, and the disc can more easily herniate through the damaged annulus.

If the herniated disc material presses against a nerve root it can cause pain, numbness, and weakness in the area the nerve supplies. This condition is called cervical radiculopathy (mentioned earlier). And any time the herniated nucleus contacts tissues outside the damaged annulus, it releases chemicals that cause inflammation and pain. If the nucleus herniates completely through the annulus, it may squeeze against the spinal cord. This causes a condition that is even more serious because it affects all the nerves of the spinal cord. This condition is called cervical myelopathy.

Cervical Myelopathy

• Spinal Instability: Spinal instability means there is extra movement among the bones of the spine. Instability in the cervical spine can develop if the supporting ligaments have been stretched or torn from a severe injury to the head or neck. People with diseases that loosen their connective tissue may also have spinal instability. Spinal instability also includes conditions in which a vertebral body slips over the one just below it. When the vertebral body slips too far forward, the condition is called spondylolisthesis. Whatever the cause, extra movement in the bones of the spine can irritate or put pressure on the nerves of the neck, causing symptoms.

Spinal Stenosis (Cervical Myelopathy)

Stenosis means closed in. Spinal stenosis refers to a condition in which the spinal cord is closed in, or compressed, inside the tube of the spinal canal. Spinal stenosis may be caused by degenerative changes, such as bone spurs pushing against the spinal cord within the spinal canal.

Spinal Stenosis

However, stenosis can also develop when a person of any age has a disc herniation that pushes against the spinal canal. When the spinal cord is squeezed in the neck, doctors call the condition cervical myelopathy. This is an alarming condition that demands medical attention. Cervical myelopathy can cause problems with the bowels and bladder, change the way you walk, and affect your ability to use your fingers and hand.

Cervical Myelopathy

Symptoms

What are some of the symptoms of neck problems?

Symptoms from neck problems vary. They depend on your condition and which neck structures are affected. Some of the more common symptoms of neck problems are:

• neck pain
• headaches
• pain spreading into the upper back or down the arm
• neck stiffness and reduced range of motion
• muscle weakness in the shoulder, arm, or hand
• sensory changes (numbness, prickling, or tingling) in the forearm, hand, or fingers

Diagnosis

How will my health care provider find out what is causing my problem?

The diagnosis of neck problems begins with a thorough history of your condition. When you visit First Choice Physical Therapy, you may be asked to fill out a questionnaire describing your neck problems. Then our Physical Therapist will ask you questions to find out when you first started having problems, what makes your symptoms worse or better, and how the symptoms affect your daily activity. Your answers will help guide our physical examination.

Your Physical Therapist at First Choice Physical Therapy will then physically examine the muscles and joints of your neck. It is important for us to see how your neck is aligned, how it moves, and exactly where it hurts.

Our Physical Therapist may also do some simple tests to check the function of the nerves. These tests measure your arm and hand strength, check your reflexes, and help determine whether you have numbness in your arms, hands, or fingers.

The information from your medical history and physical examination will help us decide which tests to run. The tests give different types of information.

Some patients may be referred to a doctor for further diagnosis. Once your diagnostic examination is complete, the Physical Therapists at First Choice Physical Therapy have treatment options that will help speed your recovery, so that you can more quickly return to your active lifestyle.

First Choice Physical Therapy provides services for Physical Therapy in Lynn Haven and Panama City Beach.

Our Treatment

Non-surgical Rehabilitation

Whenever possible, it is preferable to use treatments other than surgery. The first goal of these nonsurgical treatments is to ease your pain and other symptoms.

Nonsurgical treatments can maximize the health of your neck and prolong the time before some type of surgery is needed. At First Choice Physical Therapy, a Physical Therapy program is often prescribed for two to four weeks for patients with neck pain, although each patient’s recovery time varies. Our treatments are designed to help ease pain and to improve mobility, strength, posture, and function.

If your pain is severe, we may recommend a soft neck collar to keep your neck still for short periods of time. Resting the muscles and joints can help calm pain, inflammation, and muscle spasm.

Your Physical Therapist in Lynn Haven and Panama City Beach may also advise you to intermittently place a cold pack on your neck, or you may be shown how to do a contrast treatment. Contrast treatments involve switching between a cold pack and a hot pack.

At First Choice Physical Therapy, we will work with you to improve your neck movement and strength. We will also encourage healthy body alignment and posture. These steps are designed to slow the degeneration process and enable you to get back to your normal activities.

When your Physical Therapy program is nearly completed, we may provide you with exercises to do at home on a regular basis to help control your symptoms and protect your neck in the years ahead.

Post-surgical Rehabilitation

Rehabilitation after surgery is much more complex. Some patients leave the hospital shortly after surgery, but some surgeries require patients to stay in the hospital for a few days.

One of our Physical Therapists can visit you in your hospital room soon after surgery. These initial in-hospital treatment sessions help our patients learn to move and do routine activities without putting extra strain on the neck.

Many surgical patients need Physical Therapy outside of the hospital as well. Although the time required for rehabilitation varies for each patient, as a guideline, you may expect your recovery to take one to three months, depending on the type of surgery. Our Physical Therapy treatments are designed to calm pain and muscle spasm, teach patients to move safely, and help patients develop strength and mobility.

As our Physical Therapy sessions come to an end, your First Choice Physical Therapy Physical Therapist may help you get back to work. We can do a work assessment to ensure you can do your job safely. Some patients may need to modify their work or other activities to avoid future problems.

At First Choice Physical Therapy, our goal is to help you keep your pain under control, improve your range of motion, and maximize strength and control in your neck. When your recovery is well under way, regular visits to our office will end. We will continue to be a resource, but you will be in charge of doing your exercises as part of an ongoing home program.

Physician Review

Radiological Imaging

Radiological imaging tests help your doctor see the anatomy of your spine. There are several kinds of imaging tests.

X-rays

X-rays show problems with bones, such as infection, bone tumors, or fractures. X-rays of the spine also can give your doctor information about how much degeneration has occurred in the spine, by showing the amount of space in the neural foramina and between the discs. X-rays are usually the first test ordered before any of the more specialized tests. Special X-rays called flexion and extension X-rays may help to determine if there is instability between vertebrae. These X-rays are taken from the side as you lean as far forward and then as far backward as you can. Comparing the two X-rays allows the doctor to see how much motion occurs between each spinal segment.

MRI

The magnetic resonance imaging (MRI) scan uses magnetic waves to create pictures of the cervical spine in slices. The MRI scan shows the cervical spine bones, as well as the soft tissue structures such as the discs, joints, and nerves.

MRI scans are painless and don’t require needles or dye. The MRI scan has become the most common test to look at the cervical spine after X-rays have been taken.

CT scan

The computed tomography (CT) scan is a special type of X-ray that lets doctors see slices of bone tissue. The machine uses a computer and X-rays to create these slices. It is used primarily when problems are suspected in the bones.

Myelogram

The myelogram is a special kind of X-ray test where a special dye is injected into the spinal sac. The dye shows up on an X-ray. It helps a doctor see if there is a herniated disc, pressure on the spinal cord or spinal nerves, or a spinal tumor. Before the CT scan and the MRI scan were developed, the myelogram was the only test that doctors had to look for a herniated disc. The myelogram is still used today but not nearly as often. The myelogram is usually combined with CT scan to give more detail.

Bone Scan

A bone scan is a special test where radioactive tracers are injected into your blood stream. The tracers then show up on special X-rays of your neck. The tracers build up in areas where bone is undergoing a rapid repair process, such as a healing fracture or the area surrounding an infection or tumor. Usually the bone scan is used to locate the problem, and other tests such as the CT scan or MRI scan are then used to look at the area in detail.

Other Tests & Treatments

Electromyogram

An electromyogram (EMG) is a special test used to determine if there are problems with any of the nerves going to the upper limbs. EMGs are usually done to determine whether the nerve roots have been pinched by a herniated disc. During the test, small needles are placed into certain muscles that are supplied by each nerve root. If there has been a change in the function of the nerve, the muscle will send off different types of electrical signals. The EMG test reads these signals and can help determine which nerve root is involved.

Laboratory Tests

Not all causes of neck pain are from degenerative conditions. Doctors use blood tests to identify other conditions, such as arthritis or infection. Other tests may be needed to rule out problems that do not involve the spine.

Physical Therapy

Some doctors ask their patients to work with a Physical Therapist. Therapy treatments focus on relieving pain, improving neck movement, and fostering healthy posture. The therapists at First Choice Physical Therapy can design a rehabilitation program to address your particular condition and to help you prevent future problems.

Medications

Many different types of medications are typically prescribed to help gain control of the symptoms of neck pain. There is no medication that will cure neck pain. Your doctor may prescribe medications to ease pain, fight inflammation, and to help you get a better night’s sleep.

Injections

Spinal injections are used for both treatment and diagnostic purposes. There are several different types of spinal injections that your doctor may suggest. These injections usually use a mixture of an anesthetic and some type of cortisone preparation. The anesthetic is a medication that numbs the area where it is injected. If the injection takes away your pain immediately, this gives your doctor important information suggesting that the injected area is indeed the source of your pain. The cortisone decreases inflammation and can reduce the pain from an inflammed nerve or joint for a prolonged period of time.

Some injections are more difficult to perform and require the use of a fluoroscope. A fluoroscope is a special type of X-ray that allows the doctor to see an X-ray picture continuously on a TV screen. The fluoroscope is used to guide the needle into the correct place before the injection is given.

• Epidural Steroid Injection: Neck pain or pain that spreads down the arm may require treatment with an epidural steroid injection (ESI). In an ESI, the medication mixture is injected into the epidural space around the nerve roots. Generally, an ESI is given only when other nonoperative treatments aren’t working. ESIs are not always successful in relieving pain. If they do work, they may only provide temporary relief.

• Selective Nerve Root Injection: Another type of injection to place steroid medication around a specific inflamed nerve root is called a selective nerve root injection. The fluoroscope is used to guide a needle directly to the painful spinal nerve. The nerve root is then bathed with the medication. Some doctors believe this procedure gets more medication to the painful spot. In difficult cases, the selective nerve root injection can also help surgeons decide which nerve root is causing the problem before surgery is planned.

• Facet Joint Injection: When the problem is thought to be in the facet joints, an injection into one or more facet joints can help determine which joints are causing the problem and ease the pain as well. The fluoroscope is used to guide a needle directly into the facet joint. The facet joint is then filled with medication mixture. If the injection immediately eases the pain, it helps confirm that the facet joint is a source of pain. The steroid medication will reduce the inflammation in the joint over a period of days and may reduce or eliminate your neck pain.
• Trigger Point Injections: Injections of anesthetic medications mixed with a cortisone medication are sometimes given in the muscles, ligaments, or other soft tissues near the spine. These injections are called trigger point injections. These injections can help relieve neck pain and ease muscle spasm and tender points in the neck muscles.

Surgery

Only rarely is cervical spine surgery scheduled immediately. Your doctor may suggest immediate surgery if there are signs of pressure developing on the spinal cord or if your muscles are becoming weaker very rapidly.

For other conditions, doctors prefer to try nonsurgical treatments for a minimum of three months before considering surgical options. Most people with neck pain tend to get better, not worse. Even people who have degenerative spine changes tend to gradually improve with time.

Surgery may be suggested when severe pain is not improving.

There are many different operations for neck pain. The goal of nearly all spine operations is to remove pressure from the nerves of the spine, to stop excessive motion between two or more vertebrae, or both.

The type of surgery that is best depends on the patient’s conditions and symptoms.

Foraminotomy

A foraminotomy is done to open up the neural foramen and relieve pressure on a spinal nerve root. A foraminotomy may be done because of bone spurs or inflammation.

Foraminotomy

Laminectomy

The lamina is the covering layer of the bony ring of the spinal canal. It forms a roof-like structure over the back of the spinal cord.

When the nerves in the spinal canal are being squeezed by a herniated disc or from bone spurs pushing into the canal, a laminectomy removes part or all of the lamina to release pressure on the spinal cord.

Laminectomy

Discectomy

In a discectomy, the surgeon removes a problem disc. Surgeons usually do this surgery from the front of the neck. This procedure is called anterior cervical discectomy. In most patients, discectomy is done together with a procedure called cervical fusion (described next).

Cervical Fusion

A fusion surgery joins two or more bones into one solid bone. The purpose for doing spinal fusion is to increase the space between the vertebrae and to keep the sore joint from moving. This is usually done by placing a small block of bone graft in the space where a disc was removed. Opening up more space enlarges the neural foramen, takes pressure off the nerve roots, and eases tension on the facet joints. Cervical fusion is used to treat neck problems such as cervical radiculopathy, disc herniations, fractures, and spinal instability. There are two main types of fusion for neck problems.

• Anterior Discectomy and Fusion: Anterior discectomy and fusion is done through the front of the neck. After taking out the disc (discectomy), the disc space is filled with a small graft of bone. The bone is allowed to heal, fusing the two vertebrae into one solid bone.

Small Graft of Bone

• Posterior Fusion: In posterior fusion, the surgeon lays small grafts of bone over the back of the spine. When these bones heal together, they fuse the two vertebrae into one solid bone. Posterior fusions in the cervical spine are primarily used to treat fractures of the neck.

Posterior Fusions

The bone graft needs time to heal in order for the fusion to succeed. This requires the neck to be held still. After cervical fusion surgery, patients usually have to wear a special neck brace for several months. These neck braces are often bulky and restrictive. Recently, surgeons have begun using metal plates and screws (often referred to as instrumentation) to lock the bones in place. The instrumentation is fastened to the vertebrae, where it holds the bones still while the graft heals.

Locking the Bones in Place

Corpectomy and Strut Graft

A corpectomy relieves pressure over a large part of the spinal cord. In this procedure, the surgeon takes off the front part of the spinal column and removes several vertebral bodies. The spaces are then filled with bone graft material. Metal plates and screws are generally used to hold the spine in place while it heals. A corpectomy is used in cases of severe spinal stenosis and myelopathy.

Welcome to First Choice Physical Therapy’s patient resource about Whiplash.

Whiplash is defined as a sudden extension (backward movement of the neck) and flexion (forward movement of the neck) of the cervical spine. This type of trauma is also referred to as a cervical acceleration-deceleration (CAD) injury. Rear-end or side-impact motor vehicle collisions are the number one cause of whiplash with injury to the muscles, ligaments, tendons, joints, and discs of the cervical spine.

This guide will help you understand:

• what parts make up the spine and neck
• what causes this condition
• how doctors diagnose this condition
• what treatment options are available

Anatomy

What parts of the spine are involved?

The human spine is made up of 24 spinal bones, called vertebrae. Vertebrae are stacked on top of one another to form the spinal column. The spinal column is the body’s main upright support.

The cervical spine is formed by the first seven vertebrae referred to as C1 to C7. The cervical spine starts where the top vertebra (C1) connects to the bottom edge of the skull. The cervical spine curves slightly inward and ends where C7 joins the top of the thoracic spine. This is where the chest begins.

A bony ring attaches to the back of the vertebral body. When the vertebrae are stacked on top of each other, the rings form a hollow tube. This bony tube surrounds the spinal cord as it passes through the spine. Just as the skull protects the brain, the bones of the spinal column protect the spinal cord.

As the spinal cord travels from the brain down through the spine, it sends out nerve branches between each vertebrae called nerve roots. The nerve roots that come out of the cervical spine form the nerves that go to the arms and hands.

Two spinal nerves exit the sides of each spinal segment, one on the left and one on the right. As the nerves leave the spinal cord, they pass through a small bony tunnel on each side of the vertebra, called a neural foramen. (The term used to describe more than one opening is neural foramina.)

Each spinal segment includes two vertebrae separated by an intervertebral disc, the nerves that leave the spinal cord at that level, and the small facet joints that link each level of the spinal column.

An intervertebral disc is made of connective tissue. Connective tissue is the material that holds the living cells of the body together. The disc is a specialized connective tissue structure that separates the two vertebral bodies of the spinal segment. The disc normally works like a shock absorber. It protects the spine against the daily pull of gravity. It also protects the spine during activities that put strong force on the spine, such as jumping, running, and lifting.

An intervertebral disc is made up of two parts. The center, called the nucleus, is spongy. It provides most of the ability to absorb shock. The nucleus is held in place by the annulus, a series of strong ligament rings surrounding it. Ligaments are strong connective tissues that attach bones to other bones.

There are two facet joints between each pair of vertebrae–one on each side of the spine. The surfaces of the facet joints are covered by articular cartilage. Articular cartilage is a smooth, rubbery material that covers the ends of most joints. It allows the bone ends to move against each other smoothly, without pain. The alignment of the facet joints of the cervical spine allows freedom of movement as you bend and turn your neck.

Causes

What causes this condition?

When the head and neck are suddenly and forcefully whipped forward and back, mechanical forces place excessive stress on the cervical spine. Traumatic disc rupture and soft tissue damage can occur. The cartilage between the disc and the vertebral bone is often cracked. This is known as a rim lesion.

Damage to the disc can put pressure on the nerves as they exit the spine. The pressure or irritation can be felt as numbness on the skin, weakness in the muscles, or pain along the path of the nerve. Most people think of these symptoms as indications of a pinched nerve. Health care providers call this condition cervical radiculopathy.

Soft tissue around the facet joint can be injured. Many of the pain-sensing nerves of the spine are in the facet joints. The normally smooth surfaces on which these joints glide can become rough, irritated, and inflamed. Studies show that neck pain often comes from the damaged facet joints.

Low back pain is a common feature after a whiplash injury. Studies show that there is significant electrical activity in the muscles of the lumbar spine when the neck is extended. This effect increases when there is neck pain, possibly as a way to help stabilize the spine when neck pain causes weakness.

More than anyplace else in the body, the muscles of the neck sense sudden changes in tension and respond quickly. Tiny spindles in the muscles signal the need for more muscle tension to hold against the sudden shift in position.

The result is often muscle spasm as a self-protective measure. The increased muscle tone prevents motion of the inflamed joint. You may experience neck stiffness as a result.

Risk Factors

Each year, about three million people experience whiplash injuries to their neck and back. Of these three million people, only about one-half, will fully recover. About 600,000 of those individuals will have long-term symptoms, and 150,000 will actually become disabled as a result of the injury.

There are many factors that come into play when a person is injured in a rear-end motor vehicle accident. Any one or more of the following factors can affect recovery:

• Head turned one way or the other at the time of the impact (increases risk of nerve
  involvement with pain down the arm)
• Getting hit from behind (rear-impact collision)
• Previous neck pain or headaches
• Previous similar injury
• Being unaware of the impending impact
• Poor posture at the time of impact (head, neck, or chest bent forward)
• Poor position of the headrest or no headrest
• Crash speed under 10 mph
• Being in the front seat as opposed to sitting in the back seat of the car
• Collision with a vehicle larger than yours
• Being of slight build
• Wearing a seatbelt (a seat belt should always be worn, but at lower speeds, a lap and shoulder type seat belt will increase the chances of injury)

Symptoms

What are some of the symptoms of whiplash?

• Neck pain or neck pain that travels down the arm (radiculopathy)
• Headaches
• Low back pain (LBP)
• Jaw pain
• Dizziness

Ninety percent of patients involved in whiplash type accidents complain of neck pain. This is by far the most common symptom. The pain often spreads into the upper back, between the shoulder blades, or down the arm. Neck pain that goes down the arm is called radiculopathy.

Low back pain (LBP) can occur as a result of a whiplash injury. The Insurance Research Council reports that LBP occurs in 39 per cent of whiplash patients. Some studies found LBP to be present in 57 per cent of rear-impact collisions in which injuries were reported and 71 per cent of side-impact collisions.

Jaw pain as a result of temporomandibular joint (TMJ) injury can also cause painful headaches. The TMJ is formed by the bone of the mandible (lower jaw) connecting to the temporal bone at the side of the skull. The TMJ is a hinge joint that allows the jaw to open and close and to move forward, back, and sideways. Pain in this joint in called temporomandibular joint disorder (TMD).

Dizziness is quite common with a sense of lost balance being reported. It is caused by an injury to the joints of the neck called facet or zygapophyseal joints. When dizziness is reported, it should be distinguished from vertigo (also known as benign paroxysmal positional vertigo (BPPV), which results from an injury to the inner ear.

Other symptoms often reported include, but are not limited to: shoulder pain; numbness or tingling in the arms, hands, legs or feet; facial pain, fatigue, confusion, poor concentration, irritability, difficulty sleeping, forgetfulness, visual problems, and mood disorders.

It is not uncommon to have a delay in your symptoms. It is actually more common to have a 24 to 72 hour delay as opposed to immediate symptoms or pain. This is most likely due to the fact that it takes the body 24 to 72 hours to develop inflammation. Disc injuries may take even longer to manifest themselves. It is not uncommon for a disc injury to remain pain free and unnoticed for weeks to months.

Simply because there is little or no damage to your car does not mean that you were not injured. In fact, more than half of all whiplash injuries occur where there was little or no damage to one or both of the vehicles involved.

When we see visible damage to a car, it means that the car has absorbed much of that force and less force is transmitted to the occupant. On the other hand, if there is little or no damage to the car, the force is not absorbed but transferred to the driver or passengers, potentially resulting in greater injury.

Diagnosis

At First Choice Physical Therapy, diagnosis of your neck problem begins with a thorough history of your condition and the involved car accident. We may first ask you to fill out a questionnaire describing your neck problem. Your Physical Therapist will then ask you questions to find out when you first started having problems, what makes your symptoms better or worse, and how the symptoms affect your daily activity. The information that you provide us with will help guide the physical examination.

Your Physical Therapist will then physically examine the muscles and joints of your neck. It is important for us to see how your neck is aligned, how it moves, and exactly where it hurts.

We may do some simple tests to check the function of the nerves. These tests measure your arm and hand strength, check your reflexes, and help determine whether you have numbness  in your arms, hands, or fingers.

Some patients may be referred to other healthcare providers, such as a doctor or chiropractor, for further diagnosis and treatment. Once your diagnostic examination is complete, the Physical Therapists at First Choice Physical Therapy have treatment options that will help speed your recovery, so that you can more quickly return to your active lifestyle.

Our Treatment

What treatment options are available?

Whenever possible, treatments other than surgery are preferable. The first goal of these nonsurgical treatments is to ease your pain and other symptoms.

At First Choice Physical Therapy, our Physical Therapists will work with you to improve your neck movement and strength. We will also encourage healthy body alignment and posture. Conservative care may include immobilization and other Physical Therapy applications. These steps are designed to enable you to get back to your normal activities.

Immobilization

At first, your Physical Therapist may prescribe immobilization of the neck. Keeping the neck still for a short time can calm inflammation and pain. This might include one to two days of bed rest and the use of a soft cervical (neck) collar.

The collar is a padded ring that wraps around the neck and is held in place by a Velcro strap. A soft cervical collar is generally used for the first 24 to 48 hours after neck injury to help provide support and reduce pain. There is usually no need for a hard or rigid cervical collar unless the neck is fractured.

Soft collars should not be worn for more than 48 hours without a health care provider’s approval. Studies show that prolonged immobilization can delay healing and promote disability. Wearing it longer tends to weaken the neck muscles and reduces the facet joints’ sense of position (proprioception).

Our Physical Therapist may also recommend a cervical support pillow for additional support while sleeping. This type of pillow helps to keep the neck in a more neutral position. Cervical pillows can be used any time by anyone for improved alignment while sleeping.

Our Physical Therapy Program

Once you begin your Physical Therapy program at First Choice Physical Therapy, your rate of recovery helps determine the length of time you will be in Physical Therapy. Although recovery time is different for everyone, as a guideline, many whiplash patients only need to attend therapy sessions for two to four weeks. Patients with delayed recovery may need longer time in rehab.

When you first visit First Choice Physical Therapy, treatment is focused on easing pain and reducing inflammation. Our Physical Therapists may use ice and electrical stimulation treatments to help with these goals. Electrical stimulation treatments in addition to massage and other hands-on treatment can help calm muscle spasm and pain.

If your injury is deemed stable, we may also recommend traction. Traction is a way to gently stretch the joints and muscles of the neck. It can be done using a machine with a special head halter, or our therapist may apply the traction pull by hand. We may also add active treatments within the comfortable range of motion, and teach you specific exercises to help tone and control the muscles that stabilize your neck and upper back.

Our Physical Therapist will work with you on how to move and do activities. This form of treatment, called body mechanics, is used to help you develop new movement habits. Our training helps you keep your neck in safe positions as you go about your work and daily activities. We will help you learn how to keep your neck safe while you lift and carry items and as you begin to do other heavier activities.

As your condition improves, our Physical Therapist will begin tailoring your program to help prepare you to go back to work. Some patients are not able to go back to a previous job that requires heavy and strenuous tasks. We may suggest changes in job tasks that enable you to go back to your previous job, or provide ideas for alternate forms of work. Our Physical Therapist will help you learn to do your tasks in ways that keep your neck safe and free of extra strain.

There is a strong emphasis on keeping as active as possible, which includes incorporating manual treatments and exercise. Before your First Choice Physical Therapy rehab program ends, we will teach you how to maintain any improvements you’ve made and ways to avoid future problems.

Although each individual heals at a different pace, you should expect full recovery to take up to three months. Rehabilitation and manipulative therapy is central in getting back to your pre-injury status.

At First Choice Physical Therapy, our goal is to help you keep your pain under control, improve your range of motion, and maximize strength and control in your neck. When your recovery is well under way, regular visits to our office will end. We will continue to be a resource, but you will be in charge of doing your exercises as part of an ongoing home program.

Physician Review

How do doctors diagnose the problem?

There are several different types of test that you doctor may order to provide infomration on the extent of your whiplash injury.

Radiological Imaging

Radiological imaging tests help your doctor see the anatomy of your spine. There are many kinds of imaging tests including:

• X-rays
• Magnetic resonance imaging (MRI)
• Computed tomography (CT)
• Digital motion x-ray (DMX)
• Myelogram
• Bone Scan
• Electromyogram

X-rays

X-rays show problems with bones, such as infection, bone tumors, or fractures. X-rays of the spine also can give your doctor information about how much degeneration has occurred in the spine, such as the amount of space in the neural foramina and between the discs.

X-rays are usually the first test ordered before any of the more specialized tests. Special x-rays called flexion/extension x-rays may help to determine if there is instability between vertebrae. These x-rays are taken from the side as you bend as far forward and then as far backward as you can. Comparing the two x-rays allows the doctor to see how much motion occurs between each spinal segment.

Magnetic resonance imaging (MRI)

If more information is needed, your doctor may order an MRI. The MRI machine uses magnetic waves rather than x-rays to create pictures of the cervical spine in slices. MRIs show the cervical spine vertebrae, as well as the soft tissue structures, such as the discs, joints, and nerves. MRI scans are painless and don’t require needles or dye. MRI scan has become the most common test to look at the cervical spine after x-rays have been taken.

Computed Tomography (CT)

CT scan is a special type of x-ray that lets doctors see slices of bone tissue. The machine uses a computer and x-rays to create these slices. It is used primarily when problems are suspected in the bones.

Digital motion x-ray (DMX)

DMX is a new fluoroscopic based x-ray system designed to objectively detect and document soft tissue/ligament injury most commonly associated with whiplash injuries of the spine. DMX evaluates biomechanical relationships and abnormal movements of the cervical spine. Specifically, DMX:

• Shows abnormal movement of vertebral bodies, facets, and other spinal elements
• Shows joint hypermobility, hypomobility, or restriction
• Shows normal or abnormal initiation of cervical motion

Example of DMX diagnostic video fluoroscopy.

DMX uses digital and optic technology now available. DMX is the latest generation of videofluoroscopy (VF) that uses low doses of radiation. The images have improved clarity and resolution over VF and are recorded digitally on CD or DVD disc. DMX digital images can be replayed and studied on standard computer systems. DMX images are simply x-ray images taken at 30 frames per second to form a multiple radiographic array or series that can be run as a movie file to display real time motion of the joints of the body.

DMX radiographic series can be paused at any location and the measurements and interpretation common to radiology can be applied to the still images. These images would be identical to plain film images if plain film radiography were performed at the same location at the same moment in motion. DMX acquires approximately 2700 images for the same amount of radiation as seven regular x-rays.

Myelogram

The myelogram is a special kind of x-ray test where a special dye is injected into the spinal sac. The dye shows up on an x-ray. It helps a doctor see if there is a herniated disc, pressure on the spinal cord or spinal nerves, or a spinal tumor. Before the CT scan and the MRI scan were developed, the myelogram was the only test that surgeons had to look for a herniated disc. The myelogram is still used today but not nearly as often. The myelogram is usually combined with CT scan to give more detail.

Bone Scan

A bone scan is a special test where radioactive tracers are injected into your blood stream. The tracers then show up on special x-rays of your neck. The tracers build up in areas where bone is undergoing a rapid repair process, such as a healing fracture or the area surrounding an infection or tumor. Usually the bone scan is used to locate the problem and other tests such as the CT scan or MRI scan are then used to look at the area in detail.

Electromyogram (EMG)

An electromyogram (EMG) is a special test used to determine if there are problems with any of the nerves going to the upper limbs. EMGs are usually done to see if one or more nerve roots have been pinched by a herniated disc. During the test, small needles are placed into certain muscles that are supplied by each nerve root. If there has been a change in the function of the nerve, the muscle will send off different types of electrical signals. The EMG test reads these signals and can help determine which nerve root is involved.

Grading the Severity of Injury

The physical exam combined with the imaging studies help determine the severity or grade of the injury. There is more than one way to assign a grade to a patient’s whiplash. Here are two examples of the more commonly used models used to classify or grade whiplash injuries:

Croft Guidelines

• Grade I: Minimal – No limitation of motion, no ligamentous injury, no neurological findings
• Grade II: Slight – Slight limitation of motion, no ligamentous injury, no neurologic findings
• Grade III: Moderate – Limitation of motion, ligamentous instability, neurologic symptoms present
• Grade IV: Moderate-to-Severe – Limitation of motion, some ligamentous injury, neurological symptoms, fracture or disc derangement

Quebec Whiplash Classification

• Grade 0: No complaint or physical sign
• Grade I: Neck complaint of pain, stiffness or tenderness, no physical signs
• Grade II: Neck pain and musculoskeletal signs
• Grade III: Neck pain and neurological signs
• Grade IV: Neck pain and fracture or dislocation

Medication

Your doctor may prescribe certain types of medication if the nerves are irritated or compressed and you have neck pain that travels down your arm (radiculopathy). Severe symptoms may be treated with narcotic drugs, such as codeine or morphine. But these drugs should only be used for the first few days or weeks after problems with radiculopathy start because they are addictive when used too much or improperly. Muscle relaxants may be prescribed to calm neck muscles that are in spasm. You may be prescribed anti-inflammatory medications such as aspirin or ibuprofen. Ensure that you consult with your doctor or pharmacist regarding the use of pain relief or anti-inflammatory medication.

Injection

Pain resulting from irritation of the facet joints may be alleviated with injection of an anesthetic agent similar to Novacaine such as Bipuvacaine. Your doctor may use this numbing agent to both confirm the source of pain as coming from the joint and help reduce or eliminate your pain.

Scoliosis is a deformity in the spine that causes an abnormal C-shaped (one curve) or S-shaped (two curves) curvature. The spine is not straight but curves to one or both sides.

Anatomy

Causes

Symptoms

Diagnosis

Treatment

Surgery

Post Surgical Rehabilitation