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Neck and Arm pain

What is Neck pain?

Neck pain is extremely common and usually occurs as a result of wear and tear within the middle of the cervical spine. The cervical spine is made up of two unique vertebrae, the first and second, and five more standardised vertebra. The first cervical vertebra is called the atlas because like Atlas, the Greek God and Titan, it carries the world on its shoulders. In this case the “world” is the head.

The second cervical vertebra is called the axis because the atlas can rotate around it. The first two vertebrae account for about half of the flexion and extension and rotation of the head on the neck.

The lower cervical vertebrae, known as the sub-axial cervical spine because it is below the axis, account for the other fifty percent of movement in the cervical spine. The commonest level to be affected is C5/6, which is in the middle of the sub-axial spine. This is entirely to be expected as put very simply the head and neck are a heavy ball on a stick and as the ball rocks back and forth the point of most movement will be half way down the stick.

Neck pain can often radiate up over the back of the head and down between the shoulder blades. This is caused by the additional muscles, which are being recruited, becoming tired and starting to fatigue. These additional muscles are recruited in an attempt to keep the neck strong when the usual neck muscles have also become tired and are starting to fatigue.

Unfortunately with neck pain there is often no surgical solution as it is very difficult to accurately localise the pain generator. Just because the MRI may show a degenerate disc, it does not necessarily follow that this is the cause of the neck pain. As a result of this I don’t routinely operate for neck pain.

The only real exception for this is if there is proven instability with progression. This is identified with flexion and extension views. These are x-rays, taken from the side, in which you will be asked to bend your head forward and then backwards. This is perfectly safe as you do this every day, however what you may not be aware of, is that one vertebra in your neck is sliding forward relative to the one below it. Again this may not be a problem unless it is progressing, so just because it is doesn’t mean you need surgery. By progressing, I mean that the forward slip is getting worse. In order to determine this you will need a second set of x-rays, usually between 3 and 6 months later but obviously only if there is evidence of a slip in the first place.

What is Arm pain?

Arm pain again is very common and like leg pain and sciatica, is usually caused by a disc herniation pressing on a nerve. The medical term for arm pain associated with nerve root compression is “brachalgia”, but this is less commonly used, compared to the medical term “sciatica”.

Arm pain may or may not be associated with neck pain. Pain, which has been present for 6 weeks or more, may need further investigation with an MRI scan. The reason, why I say 6 weeks or more is because the natural history (what happens if you do nothing and let nature run its course) is for it to get better by itself.

It is important to remember that 80% of disc herniations get better by themselves in 6 weeks. This occurs by the body recognizing the disc material as being in the wrong place and sending special cells to the area of the disc herniation to “eat” it up. This is known as disc resorption, in that the disc is resorbed. During this time it will be extremely painful and unfortunately there is no evidence that any form of therapy will speed up the rate at which the disc is resorbed.

During this time it is important to take anti-inflammatories regularly as well as codeine based preparations with Paracetamol. If the pain is very severe you may need morphine based medication.

Having Acupuncture or using a TENS machine may help but it is important to remember that in 8 out if 10 cases the disc will be eaten away by the body’s natural defences in 6 weeks irrespective of what you do and anything you do is to control the symptoms.

It is for this very same reason that I would not consider surgical intervention before this.

The only real exception to this is if the patient has neurological compromise or evolving neurology. By this I mean worsening motor function or weakness with associated pain.

The arm pain is usually sharp and shoots down the arm but it also can present with a constant aching in the arm, which is worse on movement or on lifting the arm. It can be made worse by driving or using a computer mouse for example. Pins and needles (paraesthesia) and numbness can also occur with the pain.

When to operate ?

Being a surgeon, like all surgeons, I enjoy operating, however it is much more important skill to know when not to operate.
It is the “decision rather than the incision” that is most important.

Unfortunately with severe arm pain secondary to a disc herniation I find that most patients cannot tolerate symptoms for longer than 3 months and it is at about this time that I recommend surgery.

I routinely perform an anterior cervical discectomy and fusion using a cage packed with bone graft to replace the disc and fuse the level of the discectomy. On occasions I will augment the cage with an anterior cervical plate.

Most patients will stay in hospital for 3 nights and the first night is spent on a high dependency unit to allow for increased supervision by the nursing staff in the first 24 hours.

Setting new standards in spinal treatment

Professional Memberships

Mr Ishaque is highly experienced and widely recognised as a leading Consultant Spinal Surgeon. He is one of the few surgeons to have been awarded both the British Orthopaedic Association's Robert Jones Gold Medal and a Hunterian Professorship from The Royal College of Surgeons of England. He is one of the youngest surgeons to have achieved this, having been awarded both honours, before the age of 40.

British Orthopaedic Association B A S S BMA Logo;Royal College of Surgeons