Is Neck Pain a Surgical Problem

Now the second thing that I was taught was that you should never operate for neck Pain because neck Pain is not surgically treatable. And I would say definitely that is the case for a lot of different kinds of neck Pain. I've taught this myself for 20 years and said you should never operate for neck Pain.

But the neck Pain that I'm talking about that you shouldn't operate for are people who have Pain right in the middle of their neck or at the base of their neck, and that's all. They don't have radiating Pain. They don't have any Other areas that hurt because it's hard to localize Pain that's dead center right in the middle.

The neck Pain is very, very common, and most people don't have that kind of neck Pain. It's very rare to see somebody with Pain just right in the middle of their neck. They say about 30% of young people in their twenties end up having neck Pain, and by the time you're in your forties, at least half the people suffer from neck Pain, and neck Pain is very important to patients. This was a study that we did years ago and we compared neck Pain.

Um, that is associated with radiculopathy and myelopathy treated either with an artificial disc replacement or with a fusion.

So, this is the preoperative neck Pain. The neck Pain is in yellow and arm Pain is in blue. You can see that the neck Pain scores are actually worse than the arm Pain scores. And after the Surgery, both the neck Pain and the arm Pain go away very nicely, and that's with the artificial disc. With the fusion, the same thing. You have higher scores for neck Pain than for arm Pain, and after the Surgery, both neck Pain and arm Pain scores drop precipitously.

So what we concluded is that if you have neck Pain, along with radiculopathy or myelopathy, then you can reassure the patient that both the neck Pain and the arm Pain is all gonna go away. Any surgeon who has done a lot of cervical Spine Surgery knows that a lot of patients complain about neck Pain before the Surgery and it goes away. But we are much more wary about operating on patients who have no arm symptoms and only have neck Pain.

But I would tell you there are some kinds of neck Pain that are amenable to treatment with Surgery. You can treat this. For instance, C12 Osteoarthritis.

These patients have severe Arthritis of the C12 joint, as you can see on the CAT scan and as you can see on the open mouthhodontoid view. Their joint is completely obliterated and they will complain about Pain just behind the mastoid process and it gets worse on rotation. So if it's on the left side, they will say, I can only turn about this much and then their eye starts to

Uh, to squint and they have, oh, it really hurts. And then when you ask them to look to the right, they say, well, I can get to about here, but once I get to here, it starts to hurt here again, so I don't wanna turn. It won't hurt as much looking up or down as it does looking left and right. And the amazing thing is most of these patients have severe Arthritis of all the levels in the cervical Spine. As you can see on the CT scan.

This patient is auto-fused at 2.3 and 3.4, and their 4.5 level has severe facet Arthritis on the CT scan, but for some reason, they never have Pain there. I've operated on maybe 40 patients with C12 Osteoarthritis. All of them had terrible Arthritis at all of the levels in the cervical Spine.

I've only had to operate on one of those patients for a subaxial below C2 problem. All the Other patients, no matter how terrible their Arthritis was below the C12, had no Pain whatsoever. I can't tell you why that's the case, but I can tell you that these patients just do not have Pain despite the fact that they have terrible, terrible Arthritis.

Now the C1-2 joint is a diarthrodal joint. It's like a Hip joint. It has cartilage on both sides and it's a very, uh, it has no disc obviously, and that's why it doesn't break down often.

But all the diseases that break down Hip joints and Knee joints and finger joints like Osteoarthritis, rheumatoid Arthritis, like lupus, uh, like, uh, uh, calcium pyrophosphate, pseudogout and gout can cause Arthritis of this joint and cause severe problems.

And if you operate at that level and you fuse the C1-2 joint, it is amazing. It will take away the Pain. Now it also takes away left and right rotational motion. So I tell patients.

If the Pain is bad enough that you say, I don't care if I can't look left and right, uh, and I want that Pain to go away, we can fuse that joint. You won't be able to look left and right, but the Pain will go away. And eventually, 95% of the patients opt to have that level fused, and the resulting Surgery is about 98% of the patients are extremely happy with the results of the Surgery.

Other types of neck Pain that are amenable to surgical treatment is not really neck Pain. I was sitting with my mentor, Henry Bowman at the Cervical Spinine Research Society when a neurosurgeon who was the presidential guest lecturer said, this is a kind of neck Pain that you can cure with a foraminotomy. So patients who have Pain that go up behind the ear and into the temple or behind the ear and into the eye.

That is a high cervical radiculopathy. That's a pinched nerve, that's a pinched nerve, either the C3 or the C4 nerve root. And we did this study and published it a number of years ago, where we took 35 patients.

And uh 23 had, um, you know, greater than 1 year followup, and they had Pain that was behind the ear, headaches back here and into the temple. And we found that all of these patients did very nicely, and they all had foraminal stenosis. It would get worse with Sperlings. We did a nerve root block to see if the Pain would go away and found that this resulted in excellent relief of the symptoms.

This patient was told that they have fibromyalgia and uh she had Pain in the suboccipital region, retraoricular Pain going this way and in the trapezi. And, uh, and people told her that uh there's nothing you can do about it. We just did an ACDF at that one level and it took her uh Pain away completely. That is a very typical Pain uh that you get with a C4 radiculopathy.

You can also treat neck Pain when it is associated with a pseudoarthrosis. So you can see in this patient, the graft is fractured. They put in the screws that are way too short, the graft is too small, and the patient went on to a non-union. And uh so when you fix the pseudoarthrosis, often these patients have been suffering for years and they've had terrible Pain. You fix it, the Pain is gone almost instantaneously.

And these patients are very, very happy. So that's yet another type of neck Pain that will go away with an operation.

And then patients also say neck when they have interscapular Pain, they have Pain radiating over the shoulders and into the trapezii.

And when I first started out, I said, I can't really tell which level is causing the Pain in these uh areas. And so I rarely did surgeries for this kind of Pain. And then when patients would come in and they said, I have Pain over here, I started listening to them and said, OK, show me exactly where the Pain is. And then often they would have that Pain along with the arm Pain. And if that Pain would go away with a one-level ACDF.

I would say, OK, now I know what causes that Pain. And every time I saw a patient with, let's say a C6-7 herniated disc, and I did an ACDF and it made that Pain go away, I would say, OK, this is the area where that neck Pain is, even though it's not neck, it's uh down here. So if you look on the, um, uh, on the slide, patients who complain about Pain in this red area right there, this is the Spine of the scapula.

And if they're complaining about Pain right there, that level in about 95% of the time, that is the C67 level. A C7 radiculopathy will cause Pain right medial to the Spine of the scapula. If it is the C5-6, it'll be here and over the supraspinatus fossa up here.

And the C4-5 level will be over the trapezius and coming down into the deltoid. But patients say, this is neck Pain, that's neck Pain, and that's neck Pain.

The C7T1 level will be down here and T1 T2 will be towards the tip of the scapula. And this is as accurate a way to diagnose the level as the dermatomes and the myotomes.

I have found that if the patient has a C6-7 radiculopathy, they will complain about Pain here. They also will complain about Pain in the anterior chest and in the axilla. That's another very common place for patients with C67 and C7T1 down a little bit lower and down a little bit lower in the axilla. They will complain about Pain when it's the C7T1, but this is a very common level for the C6-7 level patients to complain of.

And the next time you see somebody with a C6-7, if you go to them and say, does it hurt right here? You'll find that if it hurts there, not everybody hurts there, only about maybe 50 or 60% of the patients who have a C6-7 herniated disc or radiculopathy will have Pain. But if the Pain is there, over 90% of the time, it'll be coming from the C6-7 level.

Now, there are many different things that can cause pains here and here. You can have a sub-diaphragmatic abscess. You can have problems with your shoulders. You can have the problems with the scapula. You can have a, a tumor, a pancosas tumor can uh cause uh Pain in that area. So just because it hurts there doesn't mean that all of the pains there are due to the cervical Spine. But

The cervical Spine does cause a lot of pains in those areas and patients call that neck Pain. They don't say Shoulder Pain or Pain in between my Shoulder blades. So when somebody says I have neck Pain, you have to listen to them and ask them, what do you mean by the neck Pain? Where exactly is it hurting?