Parts of the cervical spine that may be involved include

Muscle sprain / strain is a common cause of neck pain. Such disorders are self-limiting and usually improve in days to a few weeks. There are conditions which muscle spasm may not improve on their own and may require treatment, such as torticollis. Cervical facet joints or zygapophyseal joints allow the neck to flex, extend, and rotate. These small joints are susceptible to arthritis and injury.

Cervical intervertebral discs may bulge, herniate, and prone to degeneration. Degenerative disc disease may start with an initial injury and progress to degeneration, or secondary to over-use or and age-related or genetic condition. Cervical disc bulges or herniations may cause nerve irritation or impingement resulting in pain and symptoms as previously described.

Degenerative disorders of the cervical spine develop over time, over-use, and abnormal wear and tear, such as repeated heavy lifting, or continued bad positioning. Such abnormal wear and tear over time may cause micro-traumas that can weaken soft tissues in the neck. Traumas such as falls, or acceleration deceleration movements such as whiplash are sudden in onset and may present immediately or days to weeks later.

Other findings include

• Spondylosis is a generalized term to refer to injury to the posterior elements (the joints, spinous process, or ligaments. Cervical spinal osteoarthritis is a common cervical degenerative disorder which would fall into this category.
• Osteophytes are bony overgrowths. An osteophyte may irritate or impinge a spinal nerve causing inflammation and pain. Ostephytes that do not contact neural tissue may be asymptomatic as well.
• Cervical radiculopathy is pain described as electric or shooting pain. Disc herniation and osteophyte formation are common causes.

Why is it common for a pinched nerve in the neck to be more painful and possibly more severe than an impinged low back nerve? Because the cervical spine is a very mobile, is made up of structures that are smaller, and has less supportive musculature. Within the cervical canal is the spinal cord itself with a small layer of cerebrospinal fluid, surrounded by Dura matter. There is little wiggle room as we may have in the lumbar spine as the spinal cord ends at L1-2 and the canal is filled with fluid and the spinal nerve roots.

When a cervical disc bulges or herniates, nerve roots may become irritated and possibly impinged causing neck pain that radiates (travels) into the shoulders, upper back and arms. Severe spinal cord impingement can cause symptoms throughout the body and legs and may be a surgical emergency. Signs and symptoms of cord impingement range from being asymptomatic to wobbliness or unsteadiness on the feet, loss of bowel or bladder function, and paralysis.

When Pain Does Not Improve: Treatments

Initial conservative efforts include over-the-counter medications such as anti-inflammatories and Tylenol. Physical therapy, chiropractic manipulations, and home exercises are common conservative care modalities that be utilized to assist in improvement. It is important to understand that it is not uncommon for a disc to naturally resorb – pull back into normal position within the upper and lower vertebral bodies. Pain and related symptoms may diminish. Often in the management of disc herniations it is a pain physicians role to assist in the healing process, in essence ‘buying time’ to allow one to heal on their own. However, sometimes neck and upper body pain does not resolve, becomes persistent, and may worsen.

Epidural Injection

An epidural injection is a common treatment to relieve cervical pain associated with a herniated disc. The goal of the epidural is to relieve neck pain, as well as pain that radiates into the shoulders, upper back and arms.

An epidural injection is performed using fluoroscopic guidance — a fluoroscopy unit is similar to real-time x-ray. Using fluoroscopy, a very small needle is guided as close to the disc herniation as possible.

The needle enters the epidural space and a very small amount of saline and steroid is injected into the space. Because the needle is precisely placed within the irritated area, only a small amount of medication is needed. Steroid is the strongest anti-inflammatory medication and our hopes is that this medication would facilitate improvement. The amount of pain and symptom relief a patient experiences depends on the susceptibility of the underlying pathology to the effects of the injected medications. Many patients experience pain relief from minutes to days after a procedure, however there are times the response does not reach clinical effect.

Disc herniations, bulges, arthritis, and a genetically narrow canal are all factors that can decrease the cervical canal width, leading to cervical spinal stenosis. The cervical canal, which contains our spinal cord, is an average of 1.3 cm in diameter. This already small area can be affected by any of the structures that form its walls.  Canal narrowing can place pressure on the spinal cord and/or the exiting spinal nerves. While some patients are born with a congenital narrowing, most cases of cervical stenosis occur to patients over the age of 50 and are multifactorial. Many patients with cervical stenosis have a history of injury or trauma to the neck, however this trauma may have occurred many months or even years before the onset of stenosis symptoms.

Symptoms

The symptoms of cervical spinal stenosis may include the following:

• Neck pain; not always severe.
• Pain, weakness, or numbness in the shoulders, arms, and legs.
• Hand clumsiness.
• Gait and balance disturbances.
• Burning sensations, tingling, and pins and needles in the involved extremity, such as the arm or leg.
• In severe cases, bladder and bowel problems.
• Although rare, severe cases can also cause significant loss of function or even paraplegia.

Diagnosis

Good treatment is always based on an accurate diagnosis. The comprehensive diagnostic process includes:

• Medical history. Your doctor will talk to you about your symptoms, how severe they are, and what treatments you have already tried.
• Physical examination. You will be carefully examined for limitations of movement, problems with balance, and pain. During this exam, the doctor will also look for loss of reflexes in the extremities, muscle weakness, loss of sensation or other signs of spinal cord damage.
• Diagnostic tests. Generally, doctors start with plain x-rays, which enable them to rule out other problems such as tumors and infections. CT scans and MRIs give three-dimensional views of the cervical spine and can help detect osteophytes (bony growths) and herniated discs. Occasionally doctors use a myelogram. This is a test that involves injecting liquid contrast dye into the spinal column to show where the spinal cord pressure is occurring.

Non-Operative Treatment

Most cases of cervical stenosis are successfully treated with non-surgical techniques such as pain medications and anti-inflammatory medications. Depending on the extent of nerve involvement, some patients may need to temporarily restrict their activities and wear a cervical collar or neck brace for a time. However, most patients only need to rest for a brief time. Physical therapy exercises will also be prescribed to help strengthen and stabilize the neck as well as build endurance and increase flexibility.

Cervical Epidural Steroid injections may be a means of avoiding surgery. These injections can decrease the inflammatory component of the stenosis, thus potentially holding off surgery until absolutely necessary.

Surgical Treatment

If non-surgical measures do not work, your doctor may recommend surgery to treat your stenosis. There are a number of surgical techniques that can be used to treat this condition. The goal of each of these surgical decompression treatments is to widen the spinal canal and relieve the pressure on the spinal cord by removing or trimming whatever is causing the compression. However, since all surgical procedures carry a certain amount of risk, your doctor will discuss all of your options with you before deciding which procedure is best for you.

In the cervical spine, decompression of a herniated or bulging disc mat be required to increase canal space or remove the disc from pressing on a nerve. Sometimes the foramen (the area where the nerve roots exit the spinal canal) also need to be enlarged. This procedure is called a foraminotomy. In the cervical spine, the typical approach to remove the disc is from the front of the neck. Surgeons remove the disc material from the anterior approach because the spinal cord occupies the spinal canal, so it makes the discs difficult to access from the posterior approach. After the disc is removed, bone material is required to fill the space of the removed disc. That bone can either be taken from the patient (often from the bones of the pelvis) or from a cadaver; and a plate is placed in the front screwed into the cervical vertebrae. This is called a cervical anterior decompression and fusion, or ACDF. Another option would be placement of an artificial disc, called a disc arthroplasty.

Some cases that require multilevel decompression from the posterior aspect or are unstable may require posterior spinal hardware (called instrumentation) such as ‘screws and rods’ to support the spine and provide additional stability.

The articular joints are of the cervical spine are called facet joints or zygapophyseal joints. Facet joints are found in the cervical, thoracic, and lumbar spine. These joints allow the spine to flex, extend, and rotate. The joint spaces are small and thin, with a diameter of 10-13 mm and a width of 0.5 to 0.75 mm, and covered in a fibrous capsule. Their structure is similar to the other joints in our body.

The cervical facet joints are innervated by small sensory branches of the spinal nerve roots above and below the joint. As we age, or secondary to traumas or whiplash, the facet joints can become damaged, lose their structural integrity and cushioning, and lead to the development of arthritis, similar to other body joints.

Facet joint pain presents as neck pain although it can refer (travel) to other areas, such as the posterior (back) aspect of your head, shoulders and upper back where the rhomboid muscles attach your shoulder blades to your spine. While arthritis is commonly detected by x-ray or MRI, the presence of arthritis/facet hypertrophy (increased joint size) does not always mean it is the cause of neck pain. The other end of the spectrum may hold true after trauma or whiplash, where the small joint does not show damage on imaging, and it is the cause of pain.

Diagnosis of Facet Joint Pain

• In the cervical spine, the cervical facet joint gets its innervations from the medial branch nerve. Pain sensation from an arthritic joint is sent along these nerves to the spinal cord and brain. A cervical medial branch nerve block is performed to confirm that a facet joint is the source of your pain, and therapeutically decrease pain in the region. The medial branch block is performed by placing less than 0.5 cc of a local anesthetic (numbing agents such as Lidocaine) with or without a small amount of steroid on the nerve.
• The diagnostic portion of the procedure is determined by the effects of the local anesthetic. If the pain is improved by 80% or so after the procedure, then it diagnostically indicates the facet joints are the cause of pain. The physiologic action of the local anesthetic is for several hours to a day after the block. Therefore, the most important period diagnostically, is the amount of pain relief over this period. The small amount of steroid may provide a prolonged therapeutic pain relief, however, if the first several hours after the block do not provide relief, it is less important diagnostically.
• Before the cervical medial nerve block, you have the option to recieve medications to relax you (optional). Most patients do not need anesthesia (twilight) because the needles are very small (25 or 27 gauge). The risks are very low and these can be discussed with your physician prior to the procedure.
• The skin area is numbed using a local anesthetic. Using fluoroscopy (real-time x-ray), the physician guides the needle into the proper area of your cervical spine. Once the needle is positioned near the median nerve, a small amount of the medication is injected onto the medial branch nerve. The entire procedure typically takes less than 10 minutes.
• You will be given a pain diary to fill out to document the amount of relief you have from the injection.

Pain after Cervical Spine Surgery: Post-Laminectomy Syndrome

Very often our hope is to use interventional procedures to delay or avoid surgery, however there are many times that surgery cannot be avoided or is necessary. Underlying pain is the most common driving force for one to undergo surgery. Unfortunately, surgery may correct an underlying condition, but pain may not always improve or potentially return in the future. It is not uncommon to have surgery on your neck and continue to have pain in the neck and/or radiating pain to the arms. Sometimes the pain can be severe and debilitating.

Pain Treatment Options

If you suffer from persistent or recurrent pain after surgery, there are treatment options available other than repeat spine surgery. The first step is epidural injections, which provides adequate pain relief for many patients. In addition, there are different ways to administer an epidural injection to ensure it pain-relieving medication is precisely injected. Depending on the type of your surgery, certain injections may be more appropriate and effective than others.

Other causes of pain may be pain secondary to the facet joints. Facet joint pain responds favorably to medial branch blocks and potentially provides long term pain relief. Sometimes the sacroiliac joints (behind the pelvis) become irritated and generate pain. Sometimes, the implanted spinal instrumentation causes pain and may be relieved with an anesthetic and steroid injection.

When injections do not provide adequate long-term pain relief, spinal cord stimulation (neuromodulation) may be considered. Several studies prove that spinal cord stimulation is more effective in relieving pain that repeat surgery. Advances in neuromodulation technology enable this device to be effective in the treatment of low back and leg pain.

If you have ever been in a car crash and experienced pain in your neck, you have most likely had whiplash. Whiplash, also something referred to as a neck sprain/strain, however, it is also possible that there is an underlying injury to the structures of the neck. This type of injury is an acceleration/deceleration injury, and can occur from a sudden thrusting of the neck, such is in traumas or seen as a result of car crashes. Whiplash can include injury to the cervical facet joints, discs, ligaments, muscles and nerve roots. The most common structure injured in whiplash is the cervical facet joint.

Each year, over 2 million North Americans are injured and suffer from whiplash. Whiplash can be caused by:

• Motor vehicle accident. The most frequent cause of whiplash is a motor vehicle accident (MVA). The speed of the cars involved in the accident or the amount of physical damage to the car may not relate to the intensity of neck injury; speeds as low as 8 miles per hour can produce enough energy to cause whiplash in occupants.
• Sports injury
• Fall
• Being struck by a falling object
• An assault

Whiplash, although not technically a medical term, is very real and can be very painful. It is called whiplash because your neck really can whip back and forth—first backward (hyperextension) and then forward (hyperflexion). The specific biomechanics of this injury are far more complex than this, but these details are beyond the scope of this discussion.

The key symptom of whiplash is neck or upper back pain. If you have whiplash you might feel:

• Neck pain
• Shoulder pain
• Upper back pain
• Tightness or spasms of the neck or upper back muscles
• Burning or tingling
• You may also experience other symptoms, such as:
• Numbness and/or tingling
• Headaches
• Dizziness
• Nausea
• Blurred vision
• Ringing in the ears or blurred vision
• Difficulty concentrating or remembering
• Irritability, sleep disturbances, fatigue

Pain can start immediately, or it can develop days, weeks, and sometimes even months after the accident. Some people only have a little pain, but some experience a lot. Traditionally, it was believed that most people with whiplash recover fully. We now know that a significant number of whiplash injuries fail to improve without further intervention.

Anatomy of Whiplash

In a whiplash injury, it is possible to injure the joints, discs, vertebrae (bones), ligaments, nerve roots, and even the spinal cord. However, in 80% of patients, the source of pain can be isolated to one of three main structures:

• The cervical facet joints (~55%)
• The cervical intervertebral discs (~20%)
• The cervical nerve roots (~5%)

Diagnosis

It is critical to understand one major concept: from the clinical assessment alone, it is very difficult for your physician be certain which particular structure in your cervical spine is injured. To make an accurate diagnosis, your doctor needs a combination of clinical presentation, physical exam findings, and imaging results. After reviewing your x-rays and MRI, listening to your history and performing a proper physical exam, your physician may form a strong suspicion that you are suffering from a specific spine pain disorder.

Treatment

• Physical therapy: Passive (i.e. ice, heat, massage) and active therapies (exercise) is typically prescribed. Your physical therapy program is designed for you and your needs. PT typically involves:
• Stretching exercises
• Strengthening exercises
• Scapular (shoulder blade) stability training. The shoulder girdle provides a platform or base for your cervical spine. Proper rehabilitation starts with a good foundation
• Medications may help alleviate inflammation and severe pain.
• Anti-inflammatory medications help reduce swelling and pain
• Pain medications may considered for patients with severe and disabiliy

Interventional Pain Treatment Options

Although whiplash pain and symptoms usually resolve in 6 to 8 weeks, if pain persists or worsens, interventional pain treatments are considered. Cervical medial branch nerve block injections can be considered for diagnostic and therapeutic purposes for suspected facet joint-related pain. Cervical facet joints may be sprained or damaged in much the same way other joints are injured in a high velocity “stop and go” movement.

Cervical epidural steroid injections treat pain secondary to a disc disorder / pinched nerve. Your physician may perform electromyography (EMG), nerve conduction study (NCT), and MRI to confirm the cause of pain. Electromyography measures electrical activity in muscles. A nerve conduction test (NCT) to studies nerve function. If pain returns after a cervical medial branch block, a longer-term treatment option (radiofrequency ablation) of these nerves can be considered for longer term relief.

Medical acupuncture involves the insertion of tiny needles in key locations of the body — or acupressure. It is a valid medical tool that can change a person’s energy, or “chi,” from within. It does not involve the injection of any medication. It’s not a therapy that necessarily means a lifetime commitment. Everything depends on the patient’s response and the doctor’s ability to understand the patient and his or her history. It has been established that neurotransmitters in the body, called endorphins, decrease a patient’s perception of pain. Endorphins are produced by the pituitary gland and the hypothalamus in vertebrates, in response not only to pain, but to exercise, excitement, consumption of spicy food and love. Endorphins resemble opiates in their ability to produce a feeling of well-being. In fact, the word “endorphins” comes from shortened versions of the words “endogenous” and “morphine,” which when put together mean “a morphine-like substance originating from within the body.

Acupuncture in and of itself may not be enough for many patients, but when combined with other therapies — many that have nothing to do with opioid pharmaceuticals that are great in certain situations, but sometimes abused — a patient’s quality of life can usually be significantly improved.

To expand the breadth of treatment options offered to her patients, Dr. Kiran V. Patel completed training in medical acupuncture at Harvard Medical School and Brigham Women’s Hospital. She is certified by the State Medical board of New York to practice Medical Acupuncture and performs it in both our Manhattan and New Hyde Park (Long Island) offices. Currently, Dr. Patel is the only physician in our Practice to perform medical acupuncture to treat chronic pain.

The iovera° treatment is the new way to immediately relieve your pain without the use of habit-forming drugs or systemic side effects. The iovera° treatment harnesses the power of cold to naturally reduce pain for up to 3 months.

The iovera° treatment works by applying targeted cold to a peripheral nerve which immediately prevents the nerve from sending pain signals. The effect of the cold on the nerve is temporary and does not cause permanent damage because it leaves the structural components of the nerve intact. The nerve is restored to function after several months.

The iovera° treatment is very precise and when targeted cold is applied to a specific nerve, it will immediately interrupt that nerve’s ability to signal. Duration and degree of pain relief is dependent on each patient’s unique condition. We will discuss your specific case with you.