Nonoperative Management of Cervical Disc and Degenerative Disorders

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CHAPTER 38 Nonoperative Management of Cervical Disc and Degenerative Disorders

Degenerative, or spondylotic, cervical conditions comprise a spectrum of disorders including degenerative disc disease with axial neck pain, cervical radiculopathy from root compression, and cervical myelopathy from compression of the spinal cord. In most cases, the underlying pathoanatomy begins with degeneration of the cervical disc. Subsequently, the disc can herniate or bulge, causing spinal cord or nerve root compression. Significant loss of disc height may lead to segmental kyphosis. Abnormal kinematics in the motion segment can lead to instability or to the formation of compensatory osteophytes at the level of the disc space and in the uncovertebral joints, which can also cause neural compression. Facet joints may hypertrophy, causing foraminal stenosis, and the ligamentum flavum can hypertrophy or buckle, leading to spinal canal stenosis.

Patients with cervical disc and degenerative disorders often seek medical attention for relief of neck pain, arm pain, weakness, or numbness. Except for individuals with myelopathy or severe, progressive weakness, most patients are initially treated nonoperatively because many have a self-limited course that resolves without surgery. This chapter examines the role of nonoperative management in the treatment of degenerative cervical disorders.

Epidemiology

Population-based cross-sectional surveys have shown that acute and chronic neck pain is widely extant in the general population.¹^–³ From the Norwegian registry, Bovim and colleagues¹ showed an overall prevalence of neck pain of 34.4%, with 13.8% of these individuals reporting chronic neck pain of greater than 6 months’ duration. Similar numbers were reported for chronic neck pain in Finland.³ In 2000, Cote and colleagues² found that 54% of 1131 subjects had experienced significant neck pain in the previous 6 months, with nearly 5% reporting being highly disabled from neck pain. Many cases of acute neck pain may arise from soft tissue sprains and muscle strains, but ongoing neck pain is more suggestive of a spondylotic source.

Natural History

The natural histories of most nonmyelopathic spondylotic cervical disorders are statistically favorable. In a study of 205 patients with axial neck pain ⁴ and an average follow-up of 15.5 years, 79% noted improvement with nonoperative care, 43% reported a pain-free state, and 32% continued to complain of moderate to severe persistent pain. The severity of the symptoms at initial presentation and a history of a specific injury were suggestive of long-term persistent symptoms.

In the classic study by Lees and Turner,⁵ the natural history of cervical radiculopathy was also shown to be generally favorable. Of 51 patients with radiculopathy and long-term follow-up (2 to 19 years), 45% had only a single episode of pain without recurrence, 30% had mild symptoms, and only 25% had persistent or worsening symptoms. No patients with radiculopathy progressed to myelopathy in their series. On the basis of this study and clinical experience and because it is impossible to identify at the onset of symptoms patients who will or will not improve, nonoperative treatment is generally the initial approach for most patients with cervical radiculopathy. Surgery is reserved for patients with neurologic deficits, progressive dysfunction, or failure to improve after an appropriate course of nonoperative treatment. The definition of what constitutes an appropriate course of nonoperative treatment (in terms of duration and actual regimen) has not been standardized, however.

Although nonoperative treatment is the initial “default” pathway for most patients with nonmyelopathic cervical disorders, it is unclear whether commonly used nonoperative regimens improve on natural history. No controlled trials have compared the various nonoperative regimens (e.g., physical therapy, modalities, traction, medications, manipulation, and immobilization) versus the natural history (i.e., no treatment at all). It is also unclear whether nonoperative treatment outcomes can equal outcomes of surgery.

One series of cervical radiculopathy reported that 20 of 26 (77%) patients had good to excellent results with a progressive program of nonoperative treatment consisting of immobilization, ice, rest, nonsteroidal anti-inflammatory drugs [NSAIDs], traction, postural education and strengthening, oral steroid tapers, acupuncture, and transcutaneous electrical nerve stimulation.⁶ Based on comparisons with previously published surgical series, the authors suggested that their nonoperative outcomes were comparable to surgical outcomes and superior to the natural history of cervical radiculopathy. This interpretation of the study is limited, however, by the absence of true controls in the surgical or natural history categories.

Another study retrospectively compared outcomes of surgical versus nonsurgical treatment and found favorable outcomes with the latter ⁷; however, meaningful comparisons could not be made between the groups in this study because the surgical patients initially presented with more severe disease. In contrast, the real issue is not whether surgery “works” under the appropriate circumstances: Any surgeon who has treated a patient with cervical radiculopathy who has suffered for months despite conservative treatment who wakes up immediately after surgery with complete resolution of symptoms can attest to that fact. The unresolved question remains, however: Given that many patients improve without surgery, when and in whom should surgery be recommended—and is there a way to predict who needs surgery at the outset to avoid delays in delivering the ultimately needed treatment?

Other factors may affect the natural history of cervical spondylosis. Smoking has been well documented as a risk factor for neck pain ⁸^–¹⁰ and has been shown to advance degeneration of the intervertebral disc and connective tissues. Smoking also may contribute to accelerated deterioration of an individual’s aerobic fitness. Occupations requiring excessive cervical motion and overhead work may accelerate the process of disc degeneration, as can vibration caused by heavy equipment.^8,¹⁰^–¹² For these individuals, a change in occupation may be necessary to alleviate symptoms. Active litigations claims (e.g., motor vehicle accidents) may provide the patient with incentive to have continued complaints. Likewise, active workers’ compensation claims have long been recognized to have an adverse effect on the outcomes of injuries sustained on the job.

Cervical myelopathy, by contrast, is generally considered to be a surgical disorder because myelopathy has been shown to be progressive over time.¹³ Surgery has also been shown to have better functional and neurologic outcomes than nonoperative care in myelopathy.¹⁴ It is commonly held that early surgery may improve prognosis in myelopathy by limiting the extent of irreversible spinal cord damage. Nonoperative management of myelopathy is reserved for patients with mild cases, in whom careful follow-up is necessary, or patients with prohibitive surgical risk factors.

Goals of Treatment

The immediate goals of treatment are to control the patient’s pain and to minimize the disruption of the patient’s everyday life. In addition to treatment, education is important in helping the patient to understand the problem and what to expect in the future.

For patients presenting with an acute problem, pain control is generally the first concern. Although medication is commonly the first line of defense, it needs to be viewed as a temporary measure. Because a painful, immobile cervical spine can limit nearly any activity, return of function may be a slow process in cervical degenerative disease. The longer the patient’s activity level is limited, the greater the impact on deconditioning. Activity levels may decline even further as the patient becomes fearful that any motion may cause recurrence or exacerbation of the symptoms. This combination of pain and inactivity may result in a patient with chronic pain if left untreated. Table 38–1 summarizes available nonoperative treatments for cervical degenerative disorders.

TABLE 38–1 Nonoperative Modalities for Treatment of Cervical Disc and Degenerative Disorders

Modality	Pros	Cons
Cervical collars	Immobilization may decrease inflammation and muscle spasm	Muscle atrophy from prolonged use
Ice or heat	Ice may relieve acute pain and spasm; heat beneficial when regaining motion	Heat may exacerbate pain in acute period
Traction	With neck in flexion may relieve foraminal compression	Avoid in myelopathic patients; if neck extended, may worsen compression of narrowed foramen
NSAIDs	Safe, cost-effective method to decrease inflammation	Gastrointestinal side effects, cardiovascular risks with COX-2 inhibitors
Narcotics	Rapid pain relief in acute period	Constipation, sedation, depression, and potential for abuse
Corticosteroids	May decrease radicular pain acutely	Avascular necrosis, increased blood glucose, unproven long-term benefits
Muscle relaxant	Acute relief of muscle spasms	Sedation, fatigue, abuse potential, limits participation in rehabilitation
Exercise and physical therapy	Well tolerated, aerobic conditioning	No long-term pain benefits shown, forceful passive range of motion may lead to further injury and increased pain
Cervical manipulation	Some anecdotal reports of relief	No objective evidence of improvement in pain; rare potential complications including myelopathy, spinal cord injury, vertebrobasilar artery injury
Cervical steroid injections	Anti-inflammatory effect, interruption of nociceptive input/sympathetic blockade, mechanical disruption of adhesions	Rare complications include dural puncture, meningitis, epidural abscess, intraocular hemorrhage, epidural hematoma, adrenocortical suppression, paralysis

COX-2, cyclooxygenase-2; NSAIDs, nonsteroidal anti-inflammatory drugs.

Bracing, Immobilization, and Rest

A short course of bed rest is used to treat patients with lumbar disorders; cervical collars are analogously used to manage patients with cervical pathology. Immobilization of the neck is thought to diminish inflammation around an irritated nerve root. Immobilization may also diminish muscle spasm. Alternatively, the warmth provided by wearing the collar may be therapeutic.¹⁵ The efficacy of collars in limiting the duration or severity of problems such as radiculopathy has not been shown, however.¹⁶ In one study of patients with whiplash injury, soft collars did not have an effect on the duration or degree of neck pain.¹⁷

Although short-term use of collars may be beneficial, prolonged immobilization should be avoided to prevent atrophy of the cervical musculature. Most authors recommend weaning off of the collar over no more than 2 weeks. Because extension can often be more painful than flexion for many patients with acute neck spasm, patients may be more comfortable wearing a traditional soft collar “backwards.” Wearing the collar this way promotes relative flexion of the neck and enlargement of the neuroforamina. Similarly, use of an inverted-V–shaped pillow during sleep may be beneficial by promoting neck flexion. Nighttime collar wear may be helpful by maintaining proper cervical alignment during the entire night and protecting the discs from abnormal loads associated with poor sleeping posture. After a few days, the collar may be discontinued from wear in the daytime but may be maintained for longer term at night if the patient desires. Hard collars are typically not used because they can be uncomfortable and too rigid.

Ice, Heat, and Passive Modalities

Cold therapy such as ice often provides quick relief of discomfort for patients with acute pain and spasm. Heat may exacerbate the pain during this immediate period. When motion has started to return, heat is more likely to be beneficial. These measures can generally be tried by the patient at home and do not require the attention of a physician unless they are used directly to facilitate an active rehabilitation program. Massage, ultrasound, and iontophoresis all have failed to be of proven long-term efficacy.¹⁸ Other passive modalities that require no effort on the part of the patient may also be of limited value because the patient is not an active participant in his or her own recovery.

Traction

Anecdotally, intermittent home traction is said to help relieve symptoms temporarily in patients with axial neck pain or radiculopathy. Traction has failed to show long-term benefit, however, for patients with axial neck pain or cervical radiculopathy.¹⁹^–²² Traction should be avoided in myelopathic patients to prevent stretching of a compromised spinal cord. Some instruction sheets for commonly used home traction units still show the patient with his or her back to the door, leading to an extension traction vector; this may worsen arm pain in patients with radiculopathy if the compromised foramen is narrowed further as a result. Instead, traction with the neck in relative flexion is more likely to lead to symptom relief in the patient with radiculopathy. If there is no response during the first few applications, use of traction should be discontinued.

Medications

The most commonly used medications in the treatment of cervical disc disease are anti-inflammatory agents (including corticosteroids), narcotics, muscle relaxants, and antidepressants.²³

Nonsteroidal Anti-inflammatory Drugs

NSAIDs are commonly used to treat various musculoskeletal conditions including cervical disc disease. The mechanism of action is related to their anti-inflammatory and analgesic effects. Although these medications are generally very safe, patients who are on long-term NSAID therapy should be monitored for potential liver, kidney, and gastrointestinal problems. Aspirin and ibuprofen are readily available over-the-counter and have good effectiveness at low cost. Selective cyclooxygenase-2 inhibitors are now widely accessible and may diminish the incidence of side effects such as stomach upset, but in controlled trials of osteoarthritis, they do not seem to be any more efficacious than nonselective NSAIDs.²⁴^–²⁶ Cyclooxygenase-2 inhibitors also work without inhibiting platelet function. Although many of these agents seem to be well tolerated by most patients even with a history of gastrointestinal problems, potential cardiovascular risks have tempered their routine use.²⁷

Narcotics

Narcotic analgesics may be necessary for symptom relief in the early, severe stages of cervical disc disease. Although mild narcotics are a reasonable choice for a patient with acute pain, they are contraindicated for the long-term management of most patients because of their addictive potential and development of tolerance. Narcotics generally should be used in the acute setting as breakthrough treatment to supplement NSAIDs or in patients who cannot tolerate NSAIDs. They should be weaned off as soon as possible. The side-effect profile of narcotics is well established and includes constipation, sedation, and the possibility of abuse. In addition, little attention is paid to the depressant qualities of narcotics, particularly for patients with chronic pain. This depressant quality may be a particular problem for a patient with a preexisting diagnosis of depression.

As patients develop more tolerance to their current narcotic level, the dosage may need to be increased in a continuous cycle. Newer, extended-release narcotics are attractive because they provide a more even blood level for longer periods. More recent trends have been toward formal pain management programs run by various medical specialists, most commonly anesthesiologists, for the treatment of patients in chronic pain, particularly nonspecific axial neck pain, which generally does poorly with surgery. True multidisciplinary pain programs should include a psychological evaluation and emotional support, while seeking to decrease the patient’s pain level and teaching the patient to deal with unresolved pain.

Antidepressants and Anticonvulsants

Antidepressants and anticonvulsants are used in the treatment of chronic neuropathic pain syndromes. Amitriptyline is the antidepressant most commonly used for patients with cervical disc disease.²³ It has an effect on depression and may help to improve sleep patterns, a common problem for patients with pain disorders. It has also shown a modest analgesic benefit in a placebo-controlled trial of lower back pain and lumbar radiculopathy.²⁸ To the authors’ knowledge, no such studies exist for the treatment of cervical radiculopathy, however. There is commonly a time lag of several weeks between the onset of administration of these medications (e.g., gabapentin or amitriptyline) and clinical symptom relief. The role of these agents in acute cervical radiculopathy is unclear.

Oral Corticosteroids

Systemic corticosteroids are often administered to patients with acute neck or arm pain.²³ Oral corticosteroid tapers are most commonly used with good anecdotal results but little clinical data. They may diminish radicular pain acutely, but no long-term benefit in altering the natural history has been shown. Corticosteroids are believed to be more effective, however, in patients with radicular arm pain than in patients with axial pain. Because rare but significant complications such as avascular necrosis of the femoral or humeral head can occur, corticosteroids should be used judiciously. They may be contraindicated in patients with severe diabetes because of effects on blood glucose, and patients being administered steroids need to be counseled appropriately.

Muscle Relaxants

Muscle relaxants are also commonly prescribed for patients with cervical disc disease. As a group, muscle relaxants tend to cause significant sedation and fatigue, and they are increasingly being recognized for their abuse potential. Their depressive effect may be more pronounced when administered simultaneously with narcotics. Muscle relaxants should be used as short-term treatment because they may impair the patient’s ability to participate in rehabilitation.

Exercise and Physical Therapy

Physical therapy has not been shown to alter the natural history of cervical radiculopathy.^29,³⁰ A graduated program of physical therapy is commonly prescribed for patients after an initial period of short-term rest or immobilization. Passive modalities have not been proven to be beneficial in the long-term,³¹ but they are well tolerated by patients and may reduce pain in the short-term when patients are too symptomatic to participate in an active therapy regimen. As the acute pain resolves, isometric exercises to strengthen the cervical musculature are instituted. The concept of isometric exercises is appealing because the muscles may be strengthened without painful motion of the cervical spine. The concern with isometrics is that contraction of the local musculature, most often the trapezius, results in increased loading of the intervertebral discs, which could exacerbate local pain.

Passive motion is to be avoided in general because patients may be unable to protect themselves from injury at the end point of comfortable motion. Forcible passive motion may result in worsening of pain and further motion loss. Aerobic conditioning may also be helpful in relieving symptoms. Aerobic exercise for individuals with spine pain is generally best limited to low-impact activities. Stationary bicycling, walking, use of a Stairmaster machine, and other nonimpact aerobic exercises are preferred to avoid jarring the cervical spine. Active range of motion and resistive exercises may be added as tolerated. This is the phase of rehabilitation when the patient often notices the most gains. It requires the subject to be an active participant in the treatment of his or her own problem, yet education and assurance from the therapist may be needed to keep the patient participating in the program. It is best for the patient to be involved in a whole-body exercise program with special attention to the shoulder girdle and neck musculature.³⁰ For a patient with cervical disc disease, special attention should be given to the scapular stabilization muscles, including the trapezius, deltoids, latissimus dorsi, and rhomboids.

The final step in the rehabilitation protocol is a home exercise program. This can be thought of as preventive maintenance for the neck. The home program should include a simple exercise program that does not require fancy equipment but rather inexpensive, accessible items. Postural education, ergonomics, and lifestyle modifications may also be beneficial in preventing recurrences.

Cervical Manipulation

No solid evidence exists of clinical effectiveness of manipulative therapy on the cervical spine.³² Its efficacy for the treatment of cervical radiculopathy has also not been established.³³^–³⁵ The possible mechanisms of action for manipulation are poorly understood, although there are numerous theories.³⁶ Although very rare, the potential for catastrophic vascular or spinal cord injury exists. For neck pain and cervicogenic headaches, manipulation probably provides short-term benefits, with a complication rate of 5 to 10 per 10 million manipulations.³³ Reported complications of cervical manipulation include radiculopathy, myelopathy, spinal cord injury, and vertebrobasilar artery injury.⁷ The actual incidence of these complications is unknown but probably low. Nevertheless, in the absence of objective evidence showing any proven benefit and given the known (albeit low probability) risks, cervical manipulation is not routinely recommended for patients with cervical radiculopathy and should be avoided in patients with known myelopathy.

Cervical manipulation probably should not be undertaken without an adequate radiographic examination to screen for potential instability. Absolute contraindications for spinal manipulation include vertebral fracture or dislocation, infection, malignancy, spondylolisthesis, myelopathy, vertebral hypermobility, Marfan and Ehlers-Danlos syndromes, osteoporosis, spondyloarthropathies, severe diabetes mellitus, anticoagulation therapy, and objective signs of spinal nerve root compromise.³²

Cervical Steroid Injections

Although epidural steroid and nerve root injections are commonly described in the nonoperative treatment of lumbar disorders including radiculopathy, they are less commonly reported in the treatment of cervical radiculopathy. One potential reason for the disparity may be the intrinsically greater risks of performing steroid injections into the cervical spine. Because the pathophysiology of disc disease and radiculopathy in the cervical spine is presumably similar to that in the lumbar spine, local steroid injections in the cervical spine should work by the same mechanisms postulated for the lumbar spine. These potential mechanisms include (1) an anti-inflammatory effect, with inhibition of prostaglandin synthesis; (2) interruption of nociceptive input from somatic nerves; (3) a direct membrane-stabilizing effect; (4) blockade of neuropeptide synthesis; (5) sympathetic blockade; (6) the mechanical effect of the injectant breaking up epidural adhesions; and (7) blockade of C fiber activity in the dorsal root ganglion.

The clinical use of cervical epidural and nerve root injections is based largely on these theoretical and other anecdotal considerations because well-designed, placebo-controlled studies are lacking. Few randomized studies have been performed. Stav and colleagues ³⁷ performed a randomized, prospective study in 42 patients with complaints of neck pain with or without radiculopathy. Of patients, 25 received methylprednisolone and lidocaine cervical epidural steroid injections at the C5-6 or C6-7 level, and 17 received the same injectant into the posterior cervical musculature. At 1 week after injection, patients receiving epidural steroids had 76% good to excellent outcomes as assessed by a visual analog scale compared with 36% good to excellent outcomes in patients receiving muscle injections. The results were comparable at 1 year (68% good to excellent results for epidural injections vs. 12% for muscle injections). This study was not blinded, however, and fluoroscopy was not used to localize the injection. The results were not stratified further according to whether the patient presented with neck pain, arm pain, or both.

There are several retrospective studies on the efficacy of cervical epidural injections, but none are conclusive. Cicala and colleagues ³⁸ found 56% to 80% good to excellent results at 6 months after C7-T1 epidural steroid injections. Most of the patients in the study had neck pain rather than radiculopathy arising from a wide variety of diagnoses. Because the natural history of neck pain is a tendency toward resolution in most patients with time, the lack of a control group in this study makes the results difficult to interpret. In a group of 25 patients with a clinical diagnosis of radiculopathy, Rowlingson and Kirschenbaum³⁹ showed 64% good to excellent results at 15 months after C6-7 or C7-T1 epidural steroid injections. The interpretation of this study was also impaired by the lack of a control group because the natural history of radicular pain is also one of resolution in most cases. Ferrante and colleagues⁴⁰ performed a retrospective analysis of 100 patients to determine which characteristics predicted a favorable outcome with cervical epidural steroid injection. They found that patients older than 50 years and patients with radicular rather than axial neck pain had significantly better outcomes at an average of 13.5 months. Patients with radiculopathy arising from cervical disc herniation did statistically worse.

Selective nerve root blocks are a variant of epidural steroid injections. Instead of coating the epidural space with steroids, the selected root or roots are injected. Proposed advantages over epidural injections include (1) specific targeting of problematic roots, resulting in a greater local concentration of steroid at the desired location; (2) diagnostic information obtained by blocking the pain associated with a symptomatic root, which can be used in surgical planning; and (3) avoidance of the spinal canal and of potential complications associated with entry into the epidural space. Slipman and colleagues ⁴¹ reported 60% good to excellent results at 21 months in a retrospective study of selective root blocks. In a prospective study, Vallee and colleagues⁴² found 50% good to excellent results at 12 months.

Complications of cervical steroid injections are very rare but can occur. Potential complications include dural puncture, meningitis, epidural abscess, intraocular hemorrhage, adrenocortical suppression, and epidural hematoma. A particularly devastating complication is intrinsic spinal cord injury as a result of improper needle placement. Reports exist of patients who sustained cord injury as proven by magnetic resonance imaging (MRI) after cervical epidural injections, presumably because of oversedation and inability to inform the injectionist of pain related to cord irritation during injection.

Several strategies exist for minimizing the incidence of complications. Interlaminar epidural injections are most safely done at C6-7 or C7-T1 because the epidural space is typically larger there. Epidural injections should also be avoided at the level of a large herniated disc, where the cord may be displaced more posteriorly into the epidural space and preclude safe needle entry. Finally, if a dural puncture inadvertently occurs during attempted epidural steroid injection, the procedure should be aborted rather than repeating it at another level because of the potential for neurotoxicity with introduction of certain medications (e.g., Depo-Medrol formulation of methylprednisolone acetate, which contains ethylene glycol, a substance associated with arachnoiditis) into the cerebrospinal fluid. Reports of complications associated with cervical selective nerve root blocks are rare.

Based on the available data, cervical epidural injections or selective root blocks can be expected to yield 50% to 80% good to excellent results in patients with cervical radiculopathy. It is unclear, however, how these results compare with either the natural history of radiculopathy or surgical management. Selective root blocks are theoretically safer than epidural injections, although both have relatively few reported complications.

Some surgeons use selective root blocks to provide confirmatory diagnostic information for preoperative planning, but evidence showing the validity of doing so has been limited. In their analysis of 101 patients, Sasso and colleagues ⁴³ found that a diagnostic selective nerve root injection could safely and accurately discern the presence or absence of cervical radiculopathy. They noted that in cases in which MRI findings are equivocal, multilevel, or do not agree with the patient’s symptoms, the result of a negative diagnostic injection becomes superior in predicting the absence of an offending lesion.