suffering from Athritis?
Types of Arthritis
Facts about Arthritis
Neck arthritis can be caused by any number of different arthritic conditions, including rheumatoid arthritis, osteoarthritis, fibromyalgia, as well as others. By far the most common form of neck arthritis is neck osteoarthritis (also called cervical arthritis or cervical spondylosis). This condition often presents simply as neck pain. As with all arthritic conditions, if left untreated, it begins to worsen and degenerate over time. So what is osteoarthritis? Simply put, it’s a form of arthritis where the cartilage in the joint wears away as a result of injury to the area, the natural aging process, or a combination of both. There are many components of this condition that are vital to understand in order to communicate better with your physician. To begin this learning process you must first start with the basics of anatomy in the neck.
The vertebral column, backbone, or spine is a complex structure that extends from the skull to the pelvis which serves many critical functions in our anatomy. These functions include protecting the spinal cord and its nerve roots, locomotion, posture, and support of body weight. Some of the spine’s components include bony structures (vertebrae), soft cartilaginous disks (intervertebral disks), the spinal cord and its nerve roots, ligaments, and musculature. Each of these components maintains a significant role in the proper functioning of the spine.
The first of these components, the vertebrae, are arranged in 5 regions and consists of 33 parts. These regions from top to bottom include the cervical region which has 7 vertebrae (C1-C7) and make up the portion of the vertebral column from the base of the skull to the upper back, the thoracic region which has 12 vertebrae (T1-T12) and extends from the upper back to the mid-lower back, the lumbar region which has 5 vertebrae (L1- L5) and makes up the lower back portion of the vertebral column, the sacrum which is composed of 5 fused vertebrae and make up the bottom of the lower back and pelvic portion of the vertebral column, and the coccyx which is composed of 4 fused vertebrae at the base of the sacrum. The spinal structure is formed by these bones.
The intervertebral disks, which play a role in cushioning, are located between all vertebrae at the cervical, thoracic, and lumbar levels except the first and second cervical vertebra (C1, C2). The intervertebral disks can be thought of as shock-absorbers. They have a tough outer rim (the annulus fibrosus) and a soft inner jelly (the nucleus pulposus). Also, the ligaments and musculature found in this area function to stabilize and move the vertebra respectively. Finally, the vertebral column as a whole protects the spinal cord and its nerve roots. The spinal cord and its nerve roots, of course, serve as the information highway of our bodies, bringing messages from our brain to our bodies, and from our bodies to our brain.
As mentioned previously, the neck (cervical) region of the vertebral column, also known as the C-Spine, is composed of 7 vertebrae. These vertebrae form the bony portion of the neck. This area is the most flexible yet least stable area of the spine. Motion in this area occurs in three different planes. As you know, you can nod your head to say yes (Flexion and Extension), shake your head to say no (Rotation), and tilt your head as if you were to place your ear on your shoulder (Side-bending.) The C-Spine is unique because the varying aspects of motion occur, for the most part, at separate areas.
The top portion of the C-Spine (C1), where your skull attaches, is the area primarily responsible for nodding yes. As you proceed down to the area between the first two vertebrae (C1-C2) the primary motion is rotation. C1-C2 is most commonly affected in rheumatoid arthritis. Again, when you are shaking your head “no,” this is the point at which rotation occurs. The remaining segments (C3-C7), which are the lowest portion of the C-Spine, primarily move to side-bend the head. These motions are particularly important for you to recognize, because limitations at any level of these vertebrae can make simple daily activities difficult. Moreover, as an educated patient, you can inform your healthcare provider of your limitations to help make a more accurate diagnosis.
Now that you understand the anatomy of the spine, the topic of cervical arthritis (spondylosis) starts to become a little easier to comprehend. As previously mentioned, this is a degenerative condition which is seen in the aging population. What does that mean? Simply put, as we age, wear and tear occurs slowly in the C-spine over the course of time. The cushioning from the intervertebral disks between the vertebrae begins to flatten out as if you were pressing a balloon between the palms of your hands. This flattening brings the vertebrae closer together, compressing the spinal cord and its exiting nerves. Furthermore, to help accommodate the decreasing shock absorbance of the disks, the vertebrae develop bony overgrowths called osteophytes. The osteophytes are the bones’ way of trying to deal with the extra stress. Bones are constantly growing and shrinking on a microscopic level and bones react to stress by building more bone to get stronger. Unfortunately, these bony overgrowths end up getting in the way more than they end up helping. They pinch nerves and ligaments and tendons and generally act as a potential source for inciting inflammation and pain. They also inhibit the flexibility of the neck causing further compression on the spinal cord. Finally, two of the joints at which the vertebrae communicate with one another (the facet joints), may also increase in size (hypertrophy), adding to the problem. These joints, as they are forced to bear more and more weight, can also become arthritic and painful.
Through the use of radiographs, a majority of the population over the age of 50 will show evidence of wear and tear on the spine, however, not everyone will develop the symptoms of pain. In fact, 70% of the population over age 70 show physical changes to the spine on x-rays, but do not exhibit any symptoms. This evidence suggests that the natural process of aging is occurring. It also suggests that although changes in bony structure may occur, symptoms are not inevitable and should not be simply attributed to “the natural aging process.” Symptoms can and should be treated. Although changes in the spinal column occur earlier in men than in women, both are equally affected.
The symptoms of cervical arthritis may be wide ranging due to the anatomic complexity in the area. By far, however, the most common symptoms of cervical arthritis are pain and stiffness in the neck. These symptoms may be exacerbated by standing as opposed to lying down due to the effects of gravity on the spine. Sleeping also often aggravates symptoms because at night, the muscles in the neck relax and cannot provide additional support to the spine. Without the support of the neck muscles, an arthritic neck may end up with even more pressure on already compressed and irritated small nerves, which may result in further inflammation and pain.
Pain is not always limited to the neck area; it can spread to areas such as the upper back, shoulder blades, chest wall, arms, and the head. Yes, the source of the pain does originate in the neck; however, due to the compression of nerves in the neck, pain can be manifested in other areas. That is to say, sometimes the brain cannot tell exactly where the source of pain is, and so perceives pain in multiple area. This is what is known as “referred pain.” Another example of referred pain is when someone experiences arm pain as the first symptom of a heart attack.
Patients with cervical arthritis may also experience neurological signs. These signs may include weakness, numbness, burning, tingling, and shooting, electric pains down the arm, forearm, and hand. When these symptoms become progressive and continue to worsen, emergent medical care should be sought. This may be an indication of spinal cord damage and it is critical to receive emergent medical treatment.
Headache may also be a symptom of cervical arthritis. When it is a symptom from cervical arthritis, the headache is typically experienced towards the back of the head. Finally, dizziness, which is a complaint of patients in the more advanced stages of the disease, may be experienced as a feeling of “spinning or loss of balance.” This manifestation occurs due to a decreased blood supply to the brain and is another indication for emergent medical attention. To summarize, the major complaints of cervical arthritis are:
Pain and stiffness located in the neck
Pain, numbness, and weakness in distant areas including the face shoulders, arms, hands, fingers
Less common complaints include:
Trouble swallowing (Dysphagia)
Ringing in the ears (Tinnitus)
Chest pain near the heart (Pseudoangina)
Trouble with walking due to weakness in legs
The physical exam is the point at which you doctor integrates your complaints with his/her objective findings on examination and determines how you should proceed with labs, imaging studies, and/or treatment. During the exam many subtleties are observed that often correspond with your complaints. Again, one of the major indicators will be neck pain with a limited range of motion. This is evaluated through motion testing.
Specific tests may be performed by your physician to evaluate spinal cord/nerve compression. For example, a test that your physician will use is known as the strength test. The test is executed simply by gripping your physicians’ fingers. While gripping, he/she will evaluate the discrepancies in strength between both of your hands. All the muscles of your shoulders and arms should be tested by your physician for a thorough neurological examination. Another test to evaluate spinal cord/nerve compression is called the two-point discrimination test (pin-prick test) which estimates touch sensation in the extremities.
In severe cases of cervical arthritis, spinal cord/nerve compression can be significant enough to affect the way you walk. Your physician may ask you to walk a straight path, gait testing, to evaluate if your walk is clumsy or unsteady. If this is so, it indicates the possibility of significant compression. The outcome of your physical exam and your complaints may prompt your physician to order certain tests to confirm or dispute the diagnosis.
The initial test ordered for patients with suspected cervical arthritis (spodylosis) is often an X-ray. This helps your physician asses the bony structure of the vertebra by visualizing any degeneration or bony overgrowth (osteophyte) formation, discrepancies in the size of the intervertebral disks, and possible compression into foraminal space where the nerve roots exit the spinal cord. Often following the X-ray, if nerve root compression is suspected, a CT scan or MRI may be ordered for confirmation.
A CT scan with myelography shows much of the same information that an X-ray would with some added benefit. With the CT myelography, you gain the ability to create cross-sectional images, three-dimensional images, and the images are displayed at higher resolution and also demonstrates the soft tissues of your neck. X-ray, by contrast, is good at demonstrating bony structures but is not good at showing soft tissues. However, CT myelography is considered invasive because a dye must be injected directly into the spinal canal. Furthermore, CT scans require subjecting the patient to radiation. Because of the invasiveness of CT myelography, and the radiation exposure, an MRI is the usual test ordered following an X-ray.
An MRI is a noninvasive procedure that utilizes magnets and radio waves to create pictures of the components that make up the spine. With the MRI, other structures within the spine can be visualized in many views, and the soft tissues of the neck can be optimally visualized..
Another test that may be used if there neurological impairment is suspected is an EMG. What is a neurological impairment? If a patient is experiencing “pins and needles,” or weakness in the extremities, a neurological impairment is considered. These symptoms may be due to compression of the nerves exiting the spinal cord. In summary, the primary tests ordered for diagnosing cervical arthritis are an X-ray followed by an MRI if neurological impairment is suspected. CT myelography and EMG are considered under special circumstances. The results from these tests, your complaints, and your physicains’ physical findings help dictate the course of treatment.
A final test that is often considered includes injecting anesthetic over the facet joints in the neck. Facet joint pain is the most common cause of chronic neck pain. Facet joints may become painful because of arthritis, or other causes that have not been defined. Whatever the underlying cause, facet joints cause more than 40% of neck pain lasting longer than 3 months. In people who have a history of a high speed motor vehicle accident, facet joints account for as much as 80% of neck pain lasting longer than 3 months. The way to diagnose facet pain in the neck is to anesthetize the individual joints. This is done under fluorscopic guidance. Fluoroscopic guidance means that your doctor uses an x-ray while injecting your neck in order to see where the needle is exactly. This allows your doctor to inject at the precise location of the nerves. While nerves cannot be seen on x-ray, they do run in predictable patterns and bony landmarks in your neck can be used to guide the injection. When a facet joint is the cause of your neck pain, anesthetizing it should remove 100% of the pain. If multiple facet joints are involved, you may require multiple injections. The anesthetic is short-acting and so does not provide long term relief. For long-term relief, the nerves must be severed. This will be discussed in the treatment section.
There are a multitude of treatment modalites ranging from rest to surgery depending on the severity of the symptoms and the underlying cause that is identified. A majority of cases cervical arthritis respond to exercises. Also, while it is of vital importance to maintain active range of motion of the neck, often a neck collar may be used for a short time at night. The collar should not generally be worn during the day because you don’t want to lose the mobility in your neck. However, at night, when the muscles of the neck relax and are not supporting your spinal structures, a collar may be used for a short period of time for extra support to relieve some of the inflammation. An anti-inflammatory, anti-arthritis diet may also be helpful in treating the symptoms. Heat, massage, ice and controlled exercises are generally sufficient to treat most cases of uncomplicated neck arthritis. Gentle manipulation may also be helpful. Once the pain resolves, it is important to continue the exercises to keep the pain from returning. Ideally, a physician should prescribe an exercise program tailored for you. A physical therapist can then work with you in a gym until you understand the mechanics of the exercises to the point where you can continue in the gym, or adapt the exercises to your home (depending on personal preference, time, etc). Physicians who specialize in prescribing exercises are called physical medicine and rehabilitation physicians. Other physicians who may be able to help prescribe an exercise regimen for you include orthopedists, rheumatologists, and family practitioners.
Additional treatments for cervical arthritis leading to neck pain may include trigger point injections (in which anesthetic is injected into a painful, taut muscular band in the neck). Also, for select patients, chiropractic manipulations performed by an experienced chiropractor may be helpful to relieve pain and stiffness.
For patients with chronic neck pain (pain lasting more than 3 months) in whom facet joint pain is diagnosed, a radiofrequency neurotomy may be performed. This is a procedure performed under fluoroscopic guidance in which the small nerves that innervate the facet joints are essentially burned. Once the nerves are burned (or cut), the joints can’t transmit painful signals via the spinal cord to your brain. These nerves do regenerate and may need to be cut again in about 6 months to a year. However, when the procedure is done on the right patient population and performed correctly, there is a very high success rate.
When there is significant nerve compression or neurological symptoms from cervical arthritis, an epidural steroid injection may help calm the inflammation in the neck. This is performed under fluoroscopic guidance. When neurologic compromise is progressive or severe, surgery may be indicated.
Many medications exist for the treatment of the pain from cervical arthritis. All of them, of course, including Tylenol and Advil, carry side effects and should be taken only under the direct supervision of your physician. In general, pain medications may be needed in the short term, however it is better to address the underlying biomechanical issues and pathologies than to treat only the symptom of pain. If you address the underlying pathology (facet arthritis, etc), the need for pain medication, and all of the side effects of pain medications, may not be needed.
Authors: John Kafel, BA, New York College of Osteopathic Medicine, Old Westbury, NY
Grant Cooper, MD, New York-Presbyterian Hospital, The University Hospital of Columbia and Cornell, New York, NY