Neck pain is a common symptom and although we may pull a muscle in the neck most prolonged pain probably has at its source a problem with the joints of the neck.
There are seven cervical (C) or neck vertebrae which form the flexible top of our spinal column carrying our heavy human heads on the relatively immobile thoracic spine (ribs attached). It is rare for the vertebrae themselves to have problems and most neck pain comes from damage to the joints of the neck through wear and tear. The lower joints are more commonly affected between the 5th and 6th (C5/6) and 6th and 7th vertebrae (C6/7).
If the pain is localised to the neck the nervous system is not involved but if a joint should expand such as a slipped (herniated, prolapsed) disc and irritate, impinge or compress a nerve different symptoms would occur. Typically this would be pain radiating into one or both arms or the head but may also be weakness of the limbs; numbness, tingling and poor function of the hands or even restless and weary legs.
Most slipped disc problems would settle with conservative management over 6 weeks and as long as the situation is improving conservative management should see you through the problem. If your symptoms persist beyond this time, keep reoccurring or should worsen investigations are warranted in the form of x-rays or scans (MR or CT).
If the spinal cord (the main nerve pathway from the brain into the body conveying the electrical life-force) is pressed upon by a slipped disc, ligament or bony spurs (osteophytes) surgery is probably recommended. The alternative is to risk slow, irreversible nerve damage with consequent disability. Surgery itself entails a small risk and the balance of risks has to be judged in each individual case.
The usual operation is in the form of an anterior (front) cervical (neck) discectomy (total removal, ACD) to enable a good decompression of the spinal cord. Sometimes two or three discs joints are removed to achieve decompression and rarely part of the front of the vertebra (vertebrectomy). Implants a used to rebuild the neck with disc or vertebral cages, fixation plates, bone graft and even disc replacements.
An alternative operation called a cervical laminectomy from the back of the spine (posterior) is sometimes recommended to decompress the build up of ligament and bony spurs from the facet joints.
The recovery is very quick with the intravenous drip and surgical drain removed the day after surgery. The team of nurses and physios help your mobility and posture and you should be discharged after 2-4 days. You will need to convalesce gently for 2 weeks before returning for physio assessment for driving and work. Most people would have 4-6 weeks off work before returning on a phased return basis. Gentle low impact exercise can start at this time but heavy work or impact exercise has to wait for 3 months.
The benefits of surgery are mainly to prevent neurological harm although it is hoped there may be some improvement. The risks are small but the general anaesthetic carries a small risk of complications, which may affect your voice or even carry a risk to life (1/1000). The anterior approach to the spine carries a small risk of damaging the nerve to the voice box affecting the strength or pitch of the voice( <1%); the gullet altering or preventing swallowing (<1%); problems with implants that may require further surgery or neurological damage (weakness, numbness, paralysis) form bleeding or infection (<1%).
The sensitive nerve roots that serve the skin and muscles of the back of the head originate in the upper neck (C2/3 and C3/4) and similar nerves to the arms come from C4/5 to C7/T1 segments. Pressure causes sharp, shooting pain associated with numbness, pins and needles and weakness.
Medical treatment with anti-inflammatory drugs, pain-killers and nerve blockers is best tried first but if the pain is intractable or recurrent then invasive treatments are indicated.
Steroid/cortisone injections are effective at helping symptoms settle but may only be short term but do offer a good chance of avoiding surgery in 50% patients with nerve root impingement. These are easily performed under sterile conditions and x-ray guidance in theatre but a carry a very small risk of severe headache, infection or bleeding that can worsen the situation (1/1000).
The simplest and most effective operation which preserves the disc joint is a posterior cervical microscopic foraminotomy (PCF) with relief of pain in 95% cases. This requires a general anaesthetic, with your head held very still in a clamp, whilst a small wound is made on the back of your neck and under microscopic magnification and x-ray guidance the nerve root is decompressed. The surgery is takes one hour and you may need a night or two in hospital, 7 days gentle convalescence at home and a phased-return to work after 3 weeks.
An alternative, and usually recommended if the disc joint is very worn and/or there is compression to the spinal cord, is the ACD described above which is also very effective to decompress the nerve roots but does sacrifice the disc joint.
The benefits of surgery relieve pain (95%) and improve strength (75%) and feeling (60%) in the affected nerve root(s). The risks are small but the general anaesthetic carries a small risk of complications, which may affect your voice or even carry a risk to life (1/1000). The posterior approach to the spine carries a small risk of neck pain from instability (1%) and also nerve damage (weakness, numbness, paralysis) form bleeding or infection (<1%).
Some people are born with a fused disc joint in their necks and almost all elderly people will have a joint that has worn so much it has naturally fused. This causes stiffness and extra force on the adjacent joints in the neck. The same problem can happen following cervical fusion and to prevent this cervical arthroplasty has been developed using mechanical (titanium on plastic) devices to maintain movement. There is scientific evidence that over 5yrs there is a reduction in adjacent segment problems, which supports the use of these implants particularly for two or three level discectomies (ref).
Ref: Eur Spine J. 2014 May;23(5):1115-23:
Mid- to long-term outcomes after cervical disc arthroplasty compared with anterior discectomy and fusion: a systematic review and meta-analysis of randomized controlled trials.