Pain Structures Neck

Causes Chronic Neck Pain

Bogduk, 1993

• Facet alone 23% (31%)

• Disc alone 20% (12%)

• Facet and Disc - 41%

• ? 17%

Facets as Source Neck Pain

01020304050607080

% Facet Origin

Barnsley, 1995

Lord, 1996

Speldewinde,2001Manchikanti,2002Gibson, 2000

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.

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”

Disc Levels (Zheng, 2004)

Levels Affected (Espersen ‘84)

Discogram Results (S. Grubb Spine (2000))

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.”

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.

Disc or Facet Somatic Referral

Stages of Mrs. Rempel’s Condition

• Stage 1 - Somatic Pain Neck - Posterior Shoulder Girdle

Pattern Dec. 94-Aug. 97

Pattern 1997 - Radicular “Sciatica”

Mrs. Rempel’s Pattern Aug. 1997

Anterior Surgery Approach

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.

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

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

Rempel 3 month+ post-op

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

Mrs. Rempel’s Case

• Multiple facet level injections required to achieve any results

Cervical Discs - multilevelsGrubb et al., 2000

“(47%) had symptomatic discs at three ormore levels... Surgical management was considered appropriate in only 20%”

Disc Levels (Zheng, 2004)

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”

Evidence Continuing Radiculitis

Deterioration and symptoms above levels fused

Borderline Spinal Stenosis

Alar Ligament Laxity Left