Fusion Surgery for Axial Neck Pain

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CHAPTER 68 Fusion Surgery for Axial Neck Pain

Timothy A. Garvey

INTRODUCTION

For those suffering from cervical radiculopathy or myelopathy, there is little debate that an anterior cervical discectomy and fusion (ACDF) is a viable treatment option.1–20 However, patients who present with their chief complaint being ‘neck pain,’ with or without referred or radicular symptoms, often are told that there is nothing that can be done surgically. This is wrong! The purpose of this chapter is to enhance the reader’s understanding of the surgical peer-reviewed literature, which leads to a rational decision-making process (Fig. 68.1). For many patients, that decision will be that surgical intervention is a reasonable option with a predictable statistical chance of success. The time-honored adage ‘that it is the decision, not the incision, which is most important,’ cannot be overemphasized.

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Fig. 68.1 Algorithmic approach.

INDICATIONS – PATIENT SELECTION

While covered in previous chapters, a brief review of the epidemiology and natural history of neck pain is in order. Prevalence studies have noted 35% of the general Norwegian population to have neck pain complaints within the preceding year, with 14% of respondents reporting those symptoms to have lasted longer than 6 months.21 In the Saskatchewan Health and Back Pain Survey, reported in 2000, it was documented that 54% of respondents had experienced neck pain in the preceding 6 months, with almost 5% perceiving themselves to be ‘highly disabled’ by their pain.22 When one looks at the literature of whiplash-associated disorders, it is apparent that while the majority of injured individuals do have spontaneous resolution of their symptoms, a small percentage, yet a significant number of human beings, do develop chronic neck pain.23,34

As with all medical ailments, it is important to appreciate the natural history of a condition. One approaches the patient with a ‘common cold’ with a vastly different sense of urgency than in comparison to an individual with suspected acute meningitis. We must then realize that in studies of natural history many with neck pain never seek out evaluation. Therefore, there is an inherent selection bias to more self-perceived impairment in those who seek out medical care. In an average 15.5-year follow-up study, Gore et al. reported on those presenting with neck pain.35 Seventy-nine percent of patients noted improvement with nonoperative care, with 43% reporting pain-free status and 32% continuing to report modest to severe pain. The severity of initial presenting symptoms, and the report of a significant injury, were more indicative of those with long-term complaints.

In a series of patients with neck-only, or neck and arm pain, DePalma et al. noted 45% of those treated nonoperatively to have satisfactory long-term outcome.36,37 In a surgical series report, DePalma et al. reported that at 3-month follow-up those presenting with dominant neck pain had 21% complete relief and 22% no relief with nonoperative care.36 At a 5-year follow-up time, Rothman noted 23% of patients continued to be partially or totally disabled due to significant cervical symptoms stemming from disc degeneration.36,38 In a review of those presenting with cervical radiculopathy, it was noted that while patients do not typically progress to myelopathy with nonoperative care, they often (two-thirds of the group) will have persistent symptomatology of some degree.39,40

The whiplash literature reveals a common pattern of a small group reporting persistent intrusive symptoms.23,34 In a textbook chapter, McNab and McCulloch summarized ‘about those who had suffered a whiplash injury, approximately 10–20% are left with discomfort of sufficient severity to interfere with their ability to do work and to enjoy themselves in leisure hours.’41 Thus, it must be acknowledged that while many who seek out medical care for neck pain will improve with nonoperative management, a finite low percentage of patients will still have symptoms of sufficient magnitude to cause them to seek out a surgical solution. It is for this group of patients that we need to have a rational surgical decision-making process.

OFFICE EVALUATION

History

When a patient presents for initial evaluation, we ask for their chief complaint, as this will focus our line of questioning and examination. In this chapter, we are concerned with those who complain of ‘axial neck pain.’ However, the typical patient does not say, ‘I have dominant axial pain;’ they state rather that they have neck pain, with or without arm pain. Patients who yield an ultimate diagnosis of myelopathy or radiculopathy will often present with a complaint of neck pain.8,40,42,43 It is up to the medical evaluation to elicit the historical features that will lead to a specific diagnosis.

Several critical decisions must be made at the initial evaluation. Is this mechanical or non-mechanical pain? Mechanical pain is typically worse with certain activities, i.e. flexion usually increases discogenic pain, while extension increases the pain from facet arthrosis, and the patient can usually find a position of comfort. Non-mechanical pain suggests tumor, infection, or other etiologies which require a different investigation. This often is the patient with rest pain, night pain, no position of comfort, and they may present with constitutional symptoms of weight loss, fever, chills, malaise, etc. One needs to answer, is this pain local, referred, or radicular? Local pain is just that, focal, localized neck pain. Referred pain, that is pain felt away from the tissue of site of origin, is often inter- or periscapular, upper trapezial, or basioccipital. Radicular pain is the classic radiating pain along the course of the nerve root. This typically is into the brachium with radiation distally such as to the dorsal radial forearm, thumb, and index finger to suggest a C6-type distribution. It is often forgotten, however, that while this classic distribution is along the course of the ventral rami, there also does exist the dorsal rami along which path patients can also perceive pain. This ‘dorsal radicular’ pain can/does often get lumped together with axial symptomatology.

One needs to assess whether the patient is intact neurologically or has deficits. From the historical perspective, we ask about paresthesias, numbness, weakness, ataxia, and bowel and bladder dysfunction. For those with significant myelopathy or progressive loss of neurologic function, an urgent surgical consultation is recommended. We finally need to answer whether there are significant psychosocial contraindications to elective surgical treatment for pain management. This is based on depression, frank psychosis, secondary gain issues, or unrealistic expectation, all of which need to be considered.

Thus, this chapter is focusing on the individual who has dominant axial mechanical neck pain that is primarily local or referred, who is intact neurologically, and who has no obvious psychosocial contraindication to proceed with a surgical work-up. We must realize that patients present with signs and symptoms on a continuum. Some will have 100% arm pain in a C6 distribution while others will present with 100% neck pain with no periscapular or arm pain. Most, however, will have some combination of both. I believe it is vital to have the patient decide if the neck pain is greater than, the same as, or less than the arm pain. I query specifically about a percentage, i.e. 70% neck pain and 30% arm pain. While this is not exact, it does help us understand what the patient wants addressed. Simplistically, we think the more arm pain there is, the more nerve root decompression is required; the greater the neck pain, the more the patient has a joint problem which can be addressed with a fusion of the affected joint (in the near future, potential arthroplasty). I typically ask about fevers, chills, night pain, etc. If tumor or infection is suspected, the patient needs an urgent laboratory evaluation and a magnetic resonance imaging (MRI) diagnostic work-up. Questions about the timing of onset, that being acute and/or traumatic, i.e. whiplash, versus gradual or progressive onset help in the differential diagnosis. Provocative or ameliorative motions can suggest a source, i.e. worsening pain with flexion activities with progressive pain throughout the day that is relieved with rest, tends to suggest a discogenic etiology. Patients who cannot turn to one side and describe unilateral pain when looking over their shoulder (i.e. Spurling’s maneuver) suggest a foraminal radicular etiology.

I question about neurologic function. For myelopathy, I ask about generalized weakness, decreased fine motor dexterity, stumbling or ataxia, sphincter dysfunction such as urinary urgency, and paresthesias which may be nondermatomal. For radiculopathy, often a specific root pattern of numbness, pain, or specific weakness can be elicited. If these symptoms are present, they can help focus the differential to a specific cervical diagnosis. For psychosocial issues, we review the patient intake forms for depression, look for expectations of treatment, and solicit information about worker’s compensation status and litigation as these all may have a bearing on the patient-perceived pain. Specific psychologic treatment may be recommended. It is of interest that our last cervical fusion study did not correlate the presence of worker’s compensation or litigation with poor outcome.9

Physical examination

The physical examination should be straightforward. Range of motion is documented. If flexion hurts more than extension, think discogenic; if extension hurts more than flexion, think facet arthrosis or stenosis. If rotation or lateral flexion is preferentially limited to one side, it suggests a unilaterality of pathology. Spurling’s maneuver, i.e. lateral flexion, extension, and rotation which causes provocation of symptoms, suggests foraminal nerve root compression. If this reproduces the patient’s ‘neck pain,’ particularly into the upper trapezial or periscapular region, think nerve root pain. Assess the reflexes: hyperactive suggests upper motor neuron pathology, hypoactive suggests lower motor neuron pathology; and compare right side versus left side. Check for strength and sensation. If the examination documents pathology to suggest myelopathy or dense radiculopathy, the evaluation focuses on the neurologic deficit. An MRI or myelogram computed tomography (CT) scan should then be sought out. Often, those with dominant neck pain will have some component of arm symptomatology, just as those with ‘radiculopathy’ often have substantial complaints of neck pain.2,7,8,19,44,45

IMAGING

After a history is obtained and a physical examination is performed, one should start with basic radiographs. I prefer anteroposterior (AP), lateral, and flexion extension cervical spine radiographs. I do not routinely obtain an open mouth view or oblique views. One looks to exclude the obvious destruction of tumor and/or infection. We check for dynamic instability by the measurement of listhesis and angular deformity.43,46 We note obvious spondylosis by assessing disc space height, sclerosis, and osteophyte formation.47–49 While it is recognized that with increasing age there is an increasing presence of radiographic spondylosis, the films are helpful. If a young patient has multilevel spondylosis, we think less of a surgical approach; if a single level is involved, we think more of a surgical solution. If gross instability is seen, the patient needs to be counseled about the risks of nontreatment.

The MRI is now my next recommendation. Exquisite detail about tumors, infection, neurologic compression, and disc morphology is obtained. However, for this group of patients with axial neck pain, the history and physical examination did not suggest tumor or infection. The disc spaces are assessed for morphology, annular tears, and frank herniations. If the patient has a contraindication to MRI, i.e. pacemaker, metal in the eye, etc., a myelogram CT scan would be recommended and should yield similar diagnostic value.

ADVANCED INVASIVE DIAGNOSTICS

Based upon the evaluation, when one has a patient with chief complaint of neck pain, who is grossly normal neurologically, who has failed a prolonged course of nonoperative management, who has no psychosocial contraindication, and who believes the symptoms are severe enough to contemplate surgical intervention, advanced invasive diagnostic testing can be critical in objectifying the pathologic source of the patient’s symptoms. Surgeons cannot ‘cut out pain.’ They can decompress nerves or spinal cords, stabilize unstable joints, and fuse (replace) bad joints. It is the objectification process which allows us to educate a patient about the statistical chance of success for a given procedure.

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