one time or another, most people have experienced neck pain.
In the vast majority of cases, this is a benign, self-limited
complaint. Symptoms are commonly described as a soreness or
stiffness of the neck, which may or may not be associated
with a minor injury. Patients often attribute this to a "sleeping
wrong" that may or may not be a factor. Most commonly,
degenerative disorders of the spine are responsible. Degenerative
"disease" includes the changes associated with spinal
wear and tear or age. Even though it is among the most frequent
causes of neck pain, degenerative arthritis is often difficult
to treat. Other possible disorders that can cause neck pain
are rheumatoid arthritis (room-ah-toyed arth-rye-tis), infection,
or cancer. It is rare that such conditions cause only neck
pain, as they are usually associated with other warning signs
such as profound or unintentional weight loss, fevers, or
pain in other joints such as the hip or knee.
focus of this discussion is better understanding of degenerative
disorders of the cervical spine. These affect adult patients
of any age, with a tendency for particular disorders to
affect certain age groups. Cervical disk herniations are
more characteristic in the young (less than forty-years
old), while cervical spondylosis (spon-dee-low-sis) and
stenosis (sten-oh-sis) are typically found in older patients.
Treatments vary from observation, medications, and therapy
to injections or operative intervention. Treatment depends
on the severity of the condition as well as the expertise
of the doctor.
a patient, the first question is obvious. "What is
degenerative disease of the spine?" In all honesty,
the academic leaders of the spine world are currently pondering
this same question. What we mean is that spine doctors can
recognize and treat degenerative disorders of the spine
but are often unclear how the disorder actually arises except
to attribute it to age. To date, most theories about how
the spine degenerates remain just that-theories. Although
these theories are often well thought out and reasonable,
it is exceedingly difficult to prove them. Regardless, it
is worthwhile trying to understand them, as they are the
best explanation we have to explain degenerative disease
of the spine at this time.
disease of the spine refers to a breakdown of the normal
architecture of the various components of the cervical spine.
Normally, the neck is very flexible. As you may demonstrate
on yourself, the neck allows the head to rotate from side
to side nearly 180 degrees, to flex forward to touch your
chin to your chest, and extend backwards to almost touch
the back of the head to your upper back, as well as bend
your head toward your shoulder (and all ranges in between
these basic motions). These motions are afforded by the
various joints of the cervical spine. If you do not have
these normal ranges of motion, you should see Dr. Cady for
are seven cervical bones in the spine. Known as vertebrae
(ver-ta-bray), they can be likened to the cars of a passenger
train. The cars of the train, by themselves, are stiff with
no ability to bend. Each car (i.e. vertebra) is joined to
its neighbor by a joint. The joint allows motion between
the cars. As in the spine, joining a number of cars together
can allow overall motion. The more joints and vertebrae
(the plural of vertebra), the more motion is allowed. In
contrast to the joints of the car, the cervical vertebrae
are connected by three joints. This gives the spine more
stability, while still allowing motion. The extremes of
motion must be limited because of the fragile "freight"
that the vertebrae hold-the spinal cord. Like the people
in the cars of the train, the spinal cord is located in
the center of the vertebrae.
this point, clarification of terms is important. "Spine"
refers to the bony parts. These are the vertebrae that were
described above. "Spinal cord" is the nerve elements
that travel within the spine from the brain down to the
rest of the body. The spinal cord transmits signals (bioelectrical
and biochemical) that control all the functions (muscles
and sensation) below that level. The function of the spine
is to protect the spinal cord from injury during motion
are comprised of two opposing surfaces of bone. Some joints
are covered with smooth, glistening cartilage. The slippery
properties of cartilage (car-til-ledge) make the two surfaces
move easily in relation to each other. The facet joints
of the cervical spine have these properties.
contrast, the main joint between two cervical vertebrae
is made up by a large spongy mass, the intervertebral disc.
This disc sits between the two broad flat surfaces of the
vertebral bodies. The disc is made up of specialized materials
that act as a soft "glue" between the bones, while
still allowing them to move. The disc is extremely important
to spinal stability. However, it is a frequent site of degeneration
another way the disc can be considered as a pillow in between
two bones. The pillows can softly resist the downward forces
placed on the vertebrae from the weight and movement of
the head. A good pillow is thick and soft and functions
best. It allows some movement between the vertebrae. Because
the pillow is well fixed to both bones, it resists the tendency
of the bones to become misaligned. With time and use the
pillow can become flattened.
this state the disc no longer provides adequate cushioning
between the vertebrae. The bones then come closer and closer
together. Because the disc is no longer sustaining the forces
that it usually does, the other joints of the spine are
forced to take on these extra loads. The two smaller sliding
joints (facet joints, fah-set) have greater demands placed
they were designed to sustain only a small portion of the
forces of the spine, the previously glistening, healthy
cartilage starts to breakdown. As the cartilage degenerates,
the underlying bone becomes exposed and an inflammatory
reaction begins. This causes irritation of the joint, which
can lead to pain. This sets up a vicious cycle of events.
The more the facet joints become degenerated, the less they
are able to tolerate the increased demands. Thus, greater
demands will then be placed on the intervertebral disc,
causing it to further degenerate (or breakdown) as well.
The changes in the intervertebral disc and facet joints
are not reversible at this time.
important feature of disc degeneration is the reaction that
the bone undergoes. Because the normal relationships of
the bones are lost, there is a condition of instability.
This refers to one vertebra moving in an abnormal manner
in relation to the next vertebra. To attempt to stabilize
this excess motion, bone grows outward. These outward growths
are called osteophytes (os-t-o-fights). Osteophytes can
be found near the disc spaces and around the facet joints.
Osteophytes take up space. If they grow in areas where nerves
or the spinal cord are nearby, they can impinge or compress
these structures. This can cause pain, numbness, tingling,
or weakness to varying degrees. If significant enough to
cause nerve dysfunction, it is known as cervical stenosis.
degeneration can sometimes follow a slightly different course.
In the process of sustaining increased mechanical loads,
the outer aspect of the disc, known as the annulus (an-you-lus),
can become stressed. With time, small tears can form in
the anulus. This outer ring normally keeps the soft, gel-like
center of the disc contained. The gel center, known as the
nucleus, can be ejected from the disc through an annular
tear. This is called a disc herniation (her-knee-aye-shun).
If the disc herniates in the direction of the spinal cord
or nerve root, it can cause neurological compromise. Disc
herniations in the cervical spine can be serious. If significant
enough, they can cause paralysis of both the upper and lower
extremities, though this is extremely rare.
most cases, a patient complains of neck pain associated
with radiating pain to one arm. This is caused by compression
of a nerve root, rather than the spinal cord itself. With
time some herniated discs resolve or shrink by themselves.
Sometimes, disc herniations can persist, causing prolonged
symptoms and neurological problems, which may lead to surgical
the ongoing process of subluxation, and the effect time
plays on the subluxated spine.
is a representation of one type of subluxation. A subluxation,
as defined by the Association of Chiropractic Colleges is:
"A subluxation is a complex of functional and/or structural
and/or pathological articular changes that compromise neural
integrity and may influence organ system function and general
health." When a subluxation is present, it causes nerve
interference in some portion of the body affected by those
nerves. The subluxation causes changes to the structure
as well as the nerves. These changes get progressively worse
as time is allowed to work on the subluxated area of the
spine. These changes take the form of ongoing degeneration
known as "subluxation degeneration". By understanding
the type and amount of changes, it is possible to reasonably
estimate the time subluxations have been present in a spine.
Having this information is useful in understanding the time
and effort needed for correction.
is a side x-ray view of the neck. As with all the pictures
you will see on this page, the patient is looking to the
right of the screen, so you are viewing the right side of
their neck. We will call this picture a "near normal"
spine. Compare this spine with the ones you will see below
on this page. Notice the normal forward curve of the neck.
This curve helps absorb shock. Notice how each of the disc
spaces between C2 (second bone in neck) and C7 are thick
and even, this again is normal. Also notice how the front
portions (right on the x-ray) of each of the vertebrae (called
the 'body' of the vertebrae) are fairly square with clear
and well defined borders. This type of arrangement is normal
in the neck. Normal vertebrae in other parts of the spine
also have similar characteristics to what we see here. When
subluxations occur and are left uncorrected, ongoing relentless
changes occur that result in damage to the structure and
function of the spine along with nerve damage and the resulting
problems caused from improper nerve supply.
One Subluxation Degeneration
One Subluxation Degeneration is seen in subluxations that
have been present for up to twenty years. This phase is
characterized with a loss or change in the normal curve
in the spine. On this example you can see that the normal
forward (lordotic) curve is lost. This spine even has developed
a reverse curve in the neck. The disc spaces have also begun
to exhibit a slight change in shape. One good point is that
the bodies of each of the vertebrae (the square part in
front) still exhibits clean clear borders. Segmental motion
may be abnormal but overall motion is probably not affected.
Chiropractic reconstructive care for a phase one can take
from 6 to 18 months. More than 80% of people with Phase
One Subluxation Degeneration have no pain. Therefore, if
left uncorrected, phase one continues to progress with time
until it eventually reaches the next phase.
Two Subluxation Degeneration
two subluxation degeneration is normally seen in subluxations
that have been present between 20 and 40 years. This phase
has some of the same characteristics of the previous phase
including a loss of normal curvature and position as well
as an alteration in segmental motion. In addition, spines
with Phase Two Subluxation Degeneration many times show
a reduction in the patient's range of motion in that area.
X-rays of a phase two begin to show calcium changes or buildup
at certain levels of the spine. These changes are sometimes
called by many names including spurs and arthritis. Disc
spaces between the affected vertebrae are noticeably narrower
and may appear to be flattening out. Although most people
with Phase Two Subluxation Degeneration may not exhibit
any symptoms, some may start to feel stiff or achy. Chiropractic
reconstructive care for patients in phase two ranges from
1.5 years to 2.5 years. Again, if Phase Two Subluxation
Degeneration is left uncorrected it slowly advances to the
Three Subluxation Degeneration
Three Subluxation Degeneration is caused by subluxations
that have been continuing on for between 40 and 65 years.
This phase has all of the attributes of the previous phases,
only worse. The curvatures are abnormal. The disc spaces
are vastly decreased and changed. Calcium changes on the
spine are abundant in this phase. Normally, people in phase
three have a restricted range of motion and probably exhibit
symptoms of some kind. In phase three the vertebrae show
obvious changes and mutations in shape. Projections made
of calcium, sometimes referred to as "spurs or lipping",
can be readily seen on x-ray. Chiropractic reconstructive
care for patients in phase three ranges from 2.5 years to
3.5 years. This does not mean that at the end of this time
that any or all of the calcium changes will be gone. In
many instances the body adapts to the presence of the calcium
and positive changes can only be measured from a functional
standpoint. As before, if Phase Three Subluxation Degeneration
is left unchecked it slowly advances onward into the next
Four Subluxation Degeneration
four subluxation degeneration is seen with subluxations
that have been raging on uncorrected or altered for over
sixty five years. Phase four is a grave condition that will
negatively affect the patientís longevity and quality of
life. The massive amount of neurological damage caused by
years of subluxation that have lead to phase four are probably
taking a serious toll on this person's health status. X-rays
in phase four show serious severe structural changes. Vertebrae
exhibit massive calcium changes, disc spaces appear blurred,
and the bones themselves appear fused. In this scenario
the patient will have a severe restriction of range of motion
in addition to probably a number of other health issues.
Reconstruction may not be possible in phase four, but care
can be directed to some reduction in subluxation with the
goal of improvement in the quality of life remaining. Patients
in Phase Four Subluxation Degeneration have a serious situation
both structurally and neurologically, but they are certainly
not beyond hope. Many patients in phase four report significant
improvements in symptoms, conditions, mobility and quality
should be noted that the above are common guidelines and
not hard rules. Every person is dynamic and different. People
degenerate at different rates and heal at different rates.
The further along your spine may be with subluxation degeneration
the more strenuous and time consuming your road to improvement
will be. For this reason we always stress early care to
stop and prevent the advancement of subluxation degeneration.
Of course, if you're not under chiropractic care, the best
time to start is NOW!
else can be causing my neck pain? Diagnosing degenerative
disorders of the spine starts with a good history and physical
examination. Typically, patients have neck pain. This is
the most common complaint. Unfortunately, neck pain is a
common complaint in the vast majority of people who have
nothing more than a stiff neck. It is important to differentiate
neck pain related to degenerative spinal disorders from
other more serious ailments.
strains can cause mild pain. This can vary from the occasional
"stiff neck" (from keeping your neck in one position
too long, such as during sleep) to neck soreness associated
with a low-speed motor vehicle collision (whiplash). The
pain and tenderness is not deep and is usually limited to
the surrounding muscles around the neck. Often, one side
is more symptomatic than the other. Muscle strains are differentiated
from degenerative disorders by their self-limited course.
Muscle strains usually resolve, or at least dramatically
improve, within a couple of days to weeks. Pain that continues
for more than three weeks without improving may not be a
muscle strain and other diagnoses should be considered.
with rheumatoid arthritis (room-ah-toyed arth-rye-tis) can
have neck pain. It is important to recognize this. Any patient
with rheumatoid arthritis should have neck x-rays taken.
These patients can develop instability in the upper cervical
spine that can endanger the spinal cord. This is easily
recognized on plain x-rays.
pain can be a presenting symptom of meningitis, an infection
of the brain and spinal cord linings. Meningitis can have
many causes and may be contagious. Although neck pain is
probably the most common symptom, it is important to recognize
the others signs. Patients often are extremely sensitive
to light, irritable, have high fevers, and actually tolerate
very little movement of the neck. Though it is rare, this
diagnosis is very serious and should prompt an individual
to seek urgent medical care. Other types of infection can
also occur in the neck. Infection can occur in the bone
or intervertebral disc. This is more common in older patients
who may have a weak immune system. Again, as with meningitis
a history of fever could be important, but there is not
hypersensitivity to bright light.
can also cause neck pain. One way to clinically differentiate
tumor from degenerative disorders is the presence of generalized
or constitutional, symptoms. Unintentional weight loss,
feeling of extreme lethargy, persistent low grade fevers,
and night sweats are typical constitutional symptoms. A
history of cancer elsewhere is also a clue, as the majority
of neck tumors are metastases (or spread) from a cancer
in the lung, prostate, kidney or breast.
discussed above, cervical stenosis means, literally, tightening
or narrowing of the canal around the spinal cord. Of the
degenerative disorders discussed in this chapter, it is
potentially the most serious. If the cervical stenosis is
profound enough, it can cause dysfunction of the spinal
cord known as myelopathy (my-il-lop-ah-thee). The typical
person who has cervical stenosis and myelopathy may be in
his or her fifties or early sixties. The patient often has
complained of neck pain for many years. In some cases, the
pain can actually be mild. Therapy may have been prescribed,
in addition to medications, for the pain. The other features
of this disorder will be demonstrated in an illustrative
as in the lumbar spine, cervical spine discs can herniate
and cause pain, numbness, tingling, or even spinal cord
compression. Typically, patients complain of neck pain associated
with pain radiating to one arm. This is termed radiculopathy
(rah-dick-u-lop-ah-thee). Patients who have herniated cervical
discs are younger and often more active than those with
cervical stenosis. The disc herniation may be associated
with a particular incident, such as a sudden jerking movement
or positioning of the neck. Both operative and non-operative
methods of treatment can be effective in relieving symptoms.
spondylosis (spon-dee-low-sis) can be thought of as "grey
hair" of the spine. This means that if you live long
enough (and that may only mean forty- to fifty-years of
age in some populations) x-rays of your spine will eventually
show signs of cervical spondylosis.
described above, the term refers to osteophytes (os-t-o-fights),
or bony overgrowths, that protrude from the vertebral bodies
as well as narrowing occurring across the disc spaces as
the disc degenerates. Though they can compress the spinal
cord or a spinal nerve root, the vast majority of these
osteophytes do not cause any nerve problems. They are a
sign, however, that the disc between the vertebrae and the
facets (fah-sets) has become degenerative.
discs can cause pain. The mechanism of pain is, unfortunately,
not well understood. It is thought to be transmitted by
tiny nerve endings that innervate the back part of the disc
and facet joints. Degeneration can cause pain from the disc,
facet joint, or both concomitantly. Diagnostic efforts are
aimed to determine which of these structures are generating
pain. Therapy is directed to relieving stresses being placed
on these areas.
disorders of the spine continue to be a significant cause
of neck pain in today's population. Understanding of these
problems continues to grow. With that, patients' understanding
should follow suit. Affected patients should be aware of
the possible treatment modalities, including medication,
therapy, braces, selective injections, and surgery. The
best patient is an informed one who understands the natural
progression of these disorders, as well as the benefits,
risks, and complications of available treatments. Call us
today at 408-739-2273 to make an appointment.
article is an excerpt from a book titled Save Your Aching
Back and Neck, A Patient's Guide (Second Edition, May 2002,