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Pain Structures Neck
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Causes Chronic Neck Pain
Bogduk, 1993
• Facet alone 23% (31%)
• Disc alone 20% (12%)
• Facet and Disc - 41%
• ? 17%
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Facets as Source Neck Pain
01020304050607080
% Facet Origin
Barnsley, 1995
Lord, 1996
Speldewinde,2001Manchikanti,2002Gibson, 2000
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Does Whiplash Damage Discs?
• Disc Pathology After Whiplash Injury: A Prospective Magnetic Resonance Imaging and Clinical Investigation.
• Spine. 22(3):283-287, February 1, 1997. Pettersson, Kurt MD et al
• Followed up with MRI’s from injury to 2 years
• Those with symptoms and disc bulges at two years had them at time of injury.
• Those requiring surgery had MRI evidence of
of the disc injury from the start.
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Metanalysis of Cervical Discogram Literature
• DIAGNOSTIC VALUE OF CERVICAL DISCOGRAPHY IN MANAGEMENT OF CERVICAL DISCOGENIC PAIN SECONDARY TO WHIPLASH INJURIES AND ITS PREDICTIVE VALUE FOR CERVICAL FUSION
• American Journal of Physical Medicine & Rehabilitation. 84(3):204, March 2005.Isaac, Victor W. MD; Zaman, Faisel M. MD; DePalma, Michael J. MD;
Slipman, Curtis W. MD
• “Approximately 84% of chronic whiplash patients have discographically proven painful discs”
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Disc Levels (Zheng, 2004)
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Levels Affected (Espersen ‘84)
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Discogram Results (S. Grubb Spine (2000))
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MRI vs Discogram Neck
• Neck pain vs asymptomatic• Schellhas, Spine 1995
• “Conclusions: Significant cervical disc anular tears often escape magnetic resonance imaging detection, and magnetic resonance imaging cannot reliably identify the source(s) of cervical discogenic pain.”
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Long Term Neck Pain - Normal; Disc on MRI
• [in] group of pain sufferers, 10 of 11 MR-normal discs proved to have substantial anular tears at discography, with two of these intensely and concordantly painful.
• Fits with Bogduk’s findings that 20% chronic neck pain is disc alone, much of rest becomes facet related.
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Disc or Facet Somatic Referral
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Stages of Mrs. Rempel’s Condition
• Stage 1 - Somatic Pain Neck - Posterior Shoulder Girdle
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Pattern Dec. 94-Aug. 97
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Pattern 1997 - Radicular “Sciatica”
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Mrs. Rempel’s Pattern Aug. 1997
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Anterior Surgery Approach
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Neck Surgery Recent
• Investigation of clinically important benefit of anterior cervical decompression and fusion
• A. Peolsson, Eur Spine J (2007) 16:507–514
• Approximately 70% of the patients had persistent pain and disability at 6-year follow-up.
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Causes Continued Pains
• E. F. Eriksen & Eperson 1980’s
• - 1106 patients treated by anterior approach with fusion
• “Disabling symptoms were still present in
approximately 45 % of the patients after operation.”
• Early relapse in first year - revision
• Late - new level
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Persistence after surgery
• “It appears that during the first year after the 1st operations about 3/4 of the reoperations are performed as revisions. After the first year ¾ of the reoperations are performed at a new level and this indicates most of the true relapses.” J. O. Espersen et al, 1987
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Rempel 3 month+ post-op
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Mrs. Rempel’s Post-op Condition
• J. O. Espersen et al - Need revision?
• “Fused” levels appeared still mobile ?pseudoarthosis - may have contributed
• More likely - facets and other levels involved
• Poorer results if over 3 month from start
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Mrs. Rempel’s Case
• Multiple facet level injections required to achieve any results
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Cervical Discs - multilevelsGrubb et al., 2000
“(47%) had symptomatic discs at three ormore levels... Surgical management was considered appropriate in only 20%”
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Disc Levels (Zheng, 2004)
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Pseudoarthrosis Can Hurt
• Anterior Cervical Pseudarthrosis: Natural History and Treatment.
• Spine. 22(14):1585-1589, July 15, 1997• Phillips, Frank M. MD et al
• “67% with pseudarthroses were symptomatic”
• “A pseudarthrosis after anterior cervical discectomy and fusion is frequently associated with a poor clinical outcome”
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Evidence Continuing Radiculitis
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Deterioration and symptoms above levels fused
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Borderline Spinal Stenosis
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Alar Ligament Laxity Left