I regularly see patients who have been told by another doctor that they need surgery for neck instability, or who have already had a failed cervical spine surgery.
Why do so many patients undergo neck surgery? One reason is their fear that symptoms may progress. Another is that they are sometimes told they may be risking paralysis without it. Most commonly, though, it is because the doctor does not know how to heal neck pain due to ligament injury.
Do patients rush to cervical neck surgery because of fear?
Degenerative spondylolisthesis refers to a slipped vertebrae caused by vertebral fracture or attenuation of the pars inarticularis, a part of the vertebra. Because spondylolisthesis is commonly thought to result in instability of the cervical spine, spinal fusion surgery (arthrodesis) is sometimes considered the appropriate treatment.
Research has strongly suggested that many patients decide on cervical fusion surgery because they fear a progression of their problem that will lead to permanent disability. However, follow-up data on patients with degenerative disease of the upper (cervical) spinal vertebrae show little or no evidence of worsening degeneration over time. Doctors at the Medical College of Hallym University, South Korea published findings that suggested that the majority of these patients may be stable and do not develop progression of disease or catastrophic neurologic deficits.
The South Korean researchers identified 27 patients with cervical degenerative spondylolisthesis for inclusion in their study.
- Eleven patients had cervical spondylolisthesis at C4-C5,
- Nine at C3-C4,
- Six at C5-C6,
- and one at C2-C3.
- Initially, 6 had anterolisthesis (disc forward displacement) and 21 had retrolisthesis (disc backward displacement)
- At baseline, 3 of 6 patients with anterolisthesis and 7 of 21 patients with retrolisthesis had translation of more than 2 mm on dynamic views.
- At baseline, 11 had no cervical symptoms, (This is a scenario I talk about often, MRI shows disc displacement, but the person shows no sign of pain or loss of motion. Should this person be scared into an unnecessary surgery?)
- 8 had cervicalgia (sharp neck pain that is felt in back and shoulders)
- 7 had radiculopathy (radiating pain into the elboes and hands)
- and 1 had myelopathy. Myelopathy needs a surgical consultation as paralysis and incontinence are at risk.
Same patients, on average, seen more than three years later
- At the final visit, none of the anterolistheses or retrolistheses had progressed.
- At the final visit, 7 of 10 patients with initial translation of more than 2 mm on dynamic views had no change.
- Of 17 patients with less than 2 mm of initial dynamic motion, 3 patients progressed to have more than 2 mm of dynamic translation. All 3 of these had retrolisthesis initially. None had clinical worsening of symptoms at the final visit.
The natural history of cervical degenerative anterolisthesis and retrolisthesis seems to be stable during 2 years to nearly 8 years. Although those with retrolisthesis seem to have a higher propensity to increase their subluxation, none experienced dislocation or neurological injury.1
OBSERVATION, NOT A RUSH TO SURGERY ENDORSED BY RESEARCHERS
Doctors at the Rothman Institute, Thomas Jefferson University and Hospitals found: “With many surgeons expanding their indications for cervical spine surgery, the number of patients being treated operatively has increased. Unfortunately, the number of patients requiring revision procedures is also increasing, but very little literature exists reviewing changes in the indications or operative planning for revision reconstruction.”2
What these researchers are saying in their study is that doctors have broadened the criteria for neck surgery so more can be justified. However, the literature is not keeping up with ways to help the increasing new group of failed neck surgery patients.
Compounding this is the always present rush to surgery spurred on by MRI. Doctors at Yale University suggested to doctors not to solely rely on MRI readings when evaluating patients for neck pain treatment: “Physicians should be aware of inconsistencies inherent in the interpretation of cervical MRI findings and should be aware that some findings demonstrate lower agreement than others (in recommending surgery).”3 This agrees with the first study showing a majority of patients with clearly defined MRI abnormalities who were not at all bothered by neck pain.