A common question posed to those of us treating cervical herniated discs is the role of physical therapy as a way to treat the herniated disc.  The other modalities that frequently come into question are the role of manual therapy or traction. The bone and joint task force on neck pain and its associated disorders published in European Spine in 2008 by Hurwitz, Carroll LJ et al. determined that manual therapy and exercise did seem to provide some benefits to patients with cervical radiculopathy (pain, numbness or tingling down the arm) while traction and various passive modalities did not offer benefit beyond usual care. In our own experience, we find Physical Therapy useful in those patients who have either preoperatively and/or postoperatively developed specific muscle weakness. Many of those patients end up having surgery, but physical therapy does play an important role in the return of muscle strength. Although to the best of our knowledge, we know no randomized trial evaluating the effects of physical therapy during the postoperative period following cervical spine surgery.

Jack Stern, MD PhD

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A common problem that we face in our practice treating cervical herniated discs is of those patients who present with cervical myelopathy. Myelopathy is compression of the spinal cord by disc or osteophytes (bony ridges).

Generally, there have been two well-accepted treatment modalities to approach this problem. One is ananterior cervical discectomy and subsequent fusion.  That is a procedure that will decompress the spinal cord from an anterior approach followed by fusion.

The second common operative procedure is what is called a posterior laminoplasty. With that procedure,   the spinal cord is decompressed by opening up the bone in the back of the spinal canal called the lamina.

It has been debatable as to which approach is preferable in patients with cervical myelopathy. It was then with some interest that Dr. Sang et al from the Singapore General Hospital reported on a prospective two-year study of patients treated either with multilevel anterior cervical decompression and fusion with plating or posterior laminoplasty. This was published in an excellent peer-reviewed journal called The Spine Journal in 2013. The results demonstrate that patients with multilevel cervical myelopathy when treated with laminoplasty do well and compared favorably with those patients treated with an anterior approach with a followup of two years.

They report the posterior laminoplasty surgery was associated with a shorter operating time, better range of motion, and the tendency towards fewer complications. They also conclude that a larger randomized study needs to be done to support these findings.

This study is important because so many surgeons and patients alike are faced with the option of one or another approach.

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In some instances, the most direct approach to the upper cervical spine is through the oral cavity. One of the challenges of the transoral approach has been the possibility of infection because the mouth is clearly not a sterile area. A recent paper by Dr. Shousha in the journal Spine reports that the infection rate is 3.6%. This is much less than had previously been thought and puts into greater perspective the risk for those patients who require this approach.

Dr. Jack Stern

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One of the most common issues that arise in our practice is well discussed by Dr. Neubardt in the educational video and relates to the choice we the surgeons and US patients have between an anterior cervical discectomy with fusion versus an artificial disc also called an arthroplasty. It has been noted that with cervical spine fusion and the passage of time, adjacent disc level seemed to deteriorate faster. On the simplistic level, this may represent the fact that with two vertebrae fused the adjacent levels have to do more of the “work.” The rationale therefore with an arthroplastic mobile device is that it would decrease the incidence of adjacent segment disease. Therefore, one of the most elementary issues to ask is, what is the incidence and rate of the development of adjacent segment disease? Most studies would indicate that with the single-level fusion, the rate of an adjacent level developing degeneration is 1% per year. Those studies would also indicate that it is more likely to see adjacent segment disease in those patients in whom that the adjacent level already demonstrates some evidence of degeneration.

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One of the possible complications of either an anterior cervical discectomy and fusion and/or artificial disc replacement is damage to the vertebral artery. A recent paper by Courtney O’Donnell in the journal Spine concludes that the course of the vertebral artery varies very little (less than 1.5%). Based on that finding, she and her colleagues feel that a CT angiogram prior to surgery is unnecessary. This paper is important in that it will obviate the need for many patients to undergo the angiogram procedure.  That test can now be deemed unnecessary.

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What is adjacent segment disease?

Adjacent segment disease being the appearance of degeneration of the disc at the level either above or below a fused disc level, so what that means is if someone had a disc degeneration and fusion at C5-C6, it was generally considered that the adjacent segments, i.e., C6-C7 or C4-C5 would be more likely to develop this degeneration. This concept was in large part the basis of why we were so excited about artificial disc replacement because by preserving motion we hope that the adjacent disc would not degenerate or certainly not degenerate as fast. This actually may be a non-issue. A recent article on  comparing anterior cervical discectomy and fusion, artificial discs and found no difference at least not in a short-term followup. So, I think it is best if you have been considered for disc replacements or motion preserving device– that is to say an artificial disc versus fusion– that you discussed this with your surgeon reviewing carefully the pros and cons.

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• Cervical discectomy with replacement or fusion: which is better?
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A message from Dr. Jack Stern about playing football with a herniated disc:

Because of all the media attention to football players and concussions, I was wondering what there is in the medical literature that might guide us in terms of decision making on football players who develop herniated discs. I did find a very interesting paper in the Spine Journal from 2011. It was a retrospective study of lead athletes of the NFL (National Football League) who had developed cervical disc herniation. The results actually surprised me and in just a few sentences, I would say that when the two cohorts, surgical versus nonsurgical were compared, the patients who had surgery did better. 72% of players who had surgery successfully returned to play for an average of 29 games over almost three-year period whereas those who did not have surgery, the non-operative group, only 46% of those players successfully returned to the field for 15 games on an average of 1.5 years. Of note also is the fact that defensive backs had the poorest prognosis after cervical disc herniations compared with players of all other positions. I usually think of defensive backs are the smallest, quickest players on the field, but I guess they are also most likely to have a lasting injury of this kind.

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