Cervicogenic Headaches - Nitin Bhatia, MD

Dr. Sechrest: Hello, I’m Dr. Randale Sechrest, your host for eOrthopod.TV. Today I have with me, Dr. Nitin Bhatia. Dr. Bhatia is a spine surgeon, who is the Chief of Spine Surgery, at the University of California Irvine. Dr. Bhatia did his undergraduate training at Stanford. He then went on to Baylor College of Medicine where he completed his M.D. degree. From there, he did orthopaedic surgery training at UCLA. From there, he finished a spine fellowship at the University of Miami. Today, he practices complex spine surgery at University of California Irvine. Good day, Dr. Bhatia.

Dr. Nitin Bhatia: Thank you for having me.

Dr. Sechrest: Dr. Bhatia, today what I would like to talk about during this session is a relatively common problem, and that is pain in the neck that also causes headaches, what we call cervicalgenic headaches. The neck can hurt in lots of different places, we can get pinched nerves, we can get a herniated disc, but there is this specific problem that occurs with some patients where they just have this excruciating headache right in the back of their neck, and it tends to involve the upper neck, not so much the lower neck. What’s going on there?

Dr. Nitin Bhatia: Well, unfortunately, it’s quite a common problem as you mentioned. People describe neck pain that then goes up into the back of their head, what we call the occipital area, because of the occipital bone lies beneath it, and, as you mentioned, we call these cervicalgenic headaches, because these are headaches that come from the cervical spine or from the neck area. It usually involves the upper bones in the neck, especially C1, C2, sometimes down to C3 and 4, although classically we talk about C1 and 2.

Dr. Sechrest: When we say it’s involving those two vertebrae, what parts of the vertebrae are causing the pain? What’s going on in that section?

Dr. Nitin Bhatia: That’s one of the hardest parts about this problem is that a variety of different problems can cause this kind of pain. Overall, some irritation, frequently either an arthritic change, or a compression on one of the nerves there, irritates the nerve that comes up behind the head in this occipital area and creates the pain.

Dr. Sechrest: The patients that I see with this, they complain of pain at the base of the skull, here. Sometimes the pain comes up in behind the eye, and they also have tenderness and pain in these muscles, and usually it’s in the upper neck. Again, it’s not down in the shoulders like you see with the lower segments. What structures do you think are causing those things to occur?

Dr. Nitin Bhatia: Well, I think you’ve probably hit on some of them. I think some of the pain is definitely muscular in nature, because the muscles in the neck are working extra hard to try to stabilize the painful areas. So, even in the underlying problem, say, is arthritis, the muscles are working extra hard to stabilize those arthritic bones from rubbing on each other. Additionally, that muscle pain can radiate up into the head as well as some of the nerve-related pain from nerves that can be irritated from these same problems.

Dr. Sechrest: Well, what type of patient do you commonly see this? Is this a problem with young people? Is this a problem in the elderly? What’s your ideal typical patient that’s going to come in with this problem?

Dr. Nitin Bhatia: It’s usually a patient who is somewhat older, patients in their 50s, 60s, 70s, and older. The reason it’s not a young patient problem is because the arthritic changes that frequently cause these problems we just don’t see in young patients. But as we get older we see more of this arthritis, whether it’s regular osteoarthritis, or even rheumatoid arthritis affecting these top levels.

Dr. Sechrest: So we’re not talking about a herniated disc or some type of an injury. We’re talking about a wear and tear problem in these segments.

Dr. Nitin Bhatia: That’s right. It’s usually more of a wear and tear problem. Usually it’s not a disc herniation causing this.

Dr. Sechrest: Well, one thing I would like for you to clarify, and that is, the articulation, the way the skull sits on the 1st vertebra, and then the way the 1st vertebra sits on the 2nd vertebra is totally different than the rest of the neck. Describe that for patients.

Dr. Nitin Bhatia: Right. It’s a completely different system. The way the skull sits on the 1st vertebra is almost like a scoop of ice cream on an ice cream cone. The skull ends up having a round bottom that sits in a cup on C1 or cervical 1. Because of this alignment, it allows lots of flexion and extension and provides almost half of our ability to move our chin up and down. The next vertebral segment, C1 and C2, have more of a rotational alignment, and what happens is C2 has a portion called the dens, or odontoid, two names for the same structure, which looks like a little peg that comes up from it. C1, which is the topmost vertebra, essentially is just a ring that sits around. With this structure, C1 can rotate around the rim and allow 50% of the rotation that we get in the neck.

Dr. Sechrest: Now one thing that people fail to recognize, I think sometimes, is that the spine has joints just like our knees and our hips, and, as I understand, there are two joints that are between the skull and the 1st cervical vertebra, that have synovial tissue, cartilage, and that sort of stuff, and can affected by arthritis, of course. Then there are also two joints or more between C1 and C2. Are these the joints that you are really targeting when you’re worried about this wear and tear phenomena? Is this where the pain is coming from?

Dr. Nitin Bhatia: I think usually, yes, that’s where the pain is coming from. At C1 and C2, as you mentioned, there are two main joints called the facet joints, but there is also a very important joint where that ring and that odontoid meet in the front here; and problems in any of those areas can cause this occipital cervicalgenic headache.

Dr. Sechrest: Okay. Tell me a little bit about how you would go about trying to figure out whether this is the case or not. When the patient comes into your office, what are you looking for? What are you trying to get as far as history from the patient that would tip you off that this is what’s going on?

Dr. Nitin Bhatia: Well, this can be somewhat of a diagnostic dilemma, and the reason it can be tough to diagnose is because there are multiple things that can be causing the pain. As you mentioned, there are multiple joints, there are multiple areas that can have arthritic change, and so it can be somewhat challenging to figure out exactly what’s causing it. A good history from the patient is very important for the physician to take. On physical exam, what we want to look for is, are there any restrictions in motion? We know that the occiput and the C1 joint provide a significant amount of the flexion and extension, which is forward bending and bending backwards, whereas C1-C2 provide significant rotation. So if a patient has the pain only when they are rotating, say, towards the right, I’m really focused into that C1-C2 level to see what’s causing it. Frequently, once we get a good picture from the history and physical of what’s going on, we’ll then get imaging studies, including both MRI scans and CAT scans to look at that area.

Dr. Sechrest: So you, and this is again one instance where the MRI scan alone doesn’t tell the whole story. Now the other piece to this is the headache.

Dr. Nitin Bhatia: That’s right.

Dr. Sechrest: The other piece to this is the headache, and let’s go back and focus a little bit on the headache, because I think a lot of patients come in and that’s their main complaint. They come in and they say my head hurts. I have a headache. Some of them will even come in and tell you, “ I have migraines all the time.” So they interpret this as a migraine, they may have even been told they have migraine headaches. That is something totally different than what we’re talking about here, right?

Dr. Nitin Bhatia: That’s correct. And it’s very important for us to make sure that what the patient’s having is not a migraine headache. And sometimes, we work with our pain management doctors and our neurologists to ensure that the headache is in fact coming from the neck.

Dr. Sechrest: Now have you ever seen folks who have a combination of cervicalgenic headaches and migraines? I guess they could both occur in the same patient.

Dr. Nitin Bhatia: They sure can.

Dr. Sechrest: So you have to distinguish what’s what, for the most part. Let’s go back to the diagnostics. The CT scan and the MRI scan, what are you looking for?

Dr. Nitin Bhatia: What we’re looking for, they both provide somewhat different information. The CT scan is a great test for looking at bones. So it will show us arthritic changes in the joints; it will show us how many bone spurs there are and whether or not those joints can be causing the pain. The MRI scan shows us things that are softer. Although we can see the bones on the MRI scan, it’s extremely good at looking at the synovium from the joints; at the spinal cord, and at the spinal nerves, so we can see if the synovium has increased in size, if it’s causing abnormal pressure, or if there are even erosions of the bone from some of these.

Dr. Sechrest: With the erosions and that sort of stuff, you’re more interested in the patient with rheumatoid arthritis rather than just the wear and tear.

Dr. Nitin Bhatia: That’s exactly right.

Dr. Sechrest: The bone scan, or the Spect bone scan; what role does that play in the diagnosis of these diseases?

Dr. Nitin Bhatia: A bone scan is a great test that gives us a general view of the spine or even the whole skeleton if we need to. What the bone scan can show us is inflammation and abnormal bone turnover, in areas that are irritated whether from fracture, infection, tumor, or significant arthritis. So if get a bone scan with Spect imaging, which is a good 3-dimensional version of the bone scan, we can see if there are particular joints that are more inflamed than others.

Dr. Sechrest: In all parts of the spine, we’re always worried about a couple of different things. One is instability or movement or some sort of irritation from bone rubbing on bone or arthritic surfaces rubbing together, and then we’re also worried about what this doing to the nervous system. What’s this doing to the nerves? Are we pinching nerves? Are we damaging the spinal cord? Distinguish in this condition, what are we looking at?

Are we looking at both? Which symptoms are caused by what?

Dr. Nitin Bhatia: Frequently, an underlying problem causing these symptoms is an instability. We do see a fair number of patients for a diverse variety of reasons that have C1-C2 instability, where those bones are moving a little abnormally on each other. It can be caused by significant arthritis. It can be caused by rheumatoid arthritis, which is an inflammatory disease. It can be associated with other problems like Downs’ syndrome, or it can be associated even with fractures of the neck. Fortunately, the spinal cord is not frequently affected at this area because the space for the spinal cord is actually somewhat large at the top of the spine, at the occiput C1 and C2. But the nerves that exit the spinal cord can be irritated and those are frequently a cause of the pain that comes up the head and over towards the front towards the eye as you mentioned previously.

Dr. Sechrest: So that’s more, I mean, it’s pinched nerves that are causing most of the headaches.

Dr. Nitin Bhatia: Yep.

Dr. Sechrest: Okay. That makes sense. Now let’s go back and sort of look at what our options are for trying to define what’s causing that pain, what we call sometimes the pain generator. How do you get at that?

Dr. Nitin Bhatia: That is a tough problem when we’re dealing with these cervicalgenic headaches because we want to make sure we identify what’s causing the pain. As you mentioned, we call it the pain generator. Frequently, that involves doing a series of diagnostic injections into certain joints to numb them up and see if the pain goes away.

Dr. Sechrest: So basically you put the needle under fluoroscopic control with the x-ray so you know you’re in the spot, put a little dye in there, and then once you know you’re in the spot, fill it up with Novocain or some type of anesthetic, and see if that relieved the pain.

Dr. Nitin Bhatia: Exactly. Sometimes we’ll even use a CT scanner to do it if we really want to make sure we’re 100% in the right spot.

Dr. Sechrest: What about the nerves? How do you decide whether they’re getting pinched? How do you decide whether they’re involved?

Dr. Nitin Bhatia: Well, frequently when we do these kind of blocks we’ll also do a nerve block where we put some lidocaine and maybe even a little cortisone around the nerve we think is being blocked to see if that pain gets better. By numbing those nerves or those joints, we have a good idea how much of the pain is coming from each of those specific areas.

Dr. Sechrest: So let me paraphrase this and see if I’ve got it right. Basically, what you’re trying to do is a process of elimination. You make a hypothesis, you look at the scans and you look at the history and the physical exam; you look at the scans, the bone scan, and you pick the most likely sources of pain what you think is the pain generator, and then essentially you eliminate them one at a time by injecting them with cortisone, Novocain, some sort of anesthetic, and see if it gets better.

Dr. Nitin Bhatia: That’s exactly right.

Dr. Sechrest: Now, is that a treatment as well? Does that benefit the patient or are we just doing diagnostic blocks?

Dr. Nitin Bhatia: It can be therapeutic as well. So, when you do the injections you can also inject some cortisone steroid to try to get them a longer term of relief. Now it’s probably not a permanent solution, but for patients who’ve had maybe mild pain that now has gotten a lot worse, that kind of injection treatment, can provide them significant mid- and long-term relief.

Dr. Sechrest: Once you’ve figured that out, once you’ve sort of got your diagnosis, you understand what the pain generator is, what are my options in terms of nonsurgical treatment? Other than injections, is there anything that you find really works consistently to reduce the headache and reduce the neck pain?

Dr. Nitin Bhatia: Well, we do a variety of treatments and each treatment may work different and each treatment may work different now in each patient. Physical therapy to try to stabilize the neck muscles, maybe some oral medicines like anti-inflammatories and even a little cervical traction can sometimes help. Unfortunately, it’s not consistent which of these treatments help which patients but hopefully by treating each patient individually we can find a good conservative treatment that can relief a lot of their pain.

Dr. Sechrest: What about the headaches? What helps that?

Dr. Nitin Bhatia: Well, the headaches, again, are treated by this symptomatic treatment. If we can stabilize the arthritic areas, or the areas that are moving are abnormally, frequently some of the headaches can get better.

Dr. Sechrest: So you’re really, you’re doing a couple of things, I guess, the referred pain that comes into the base of the skull from just that arthritic process, that’s relieved if you can hit the arthritic process. The other thing is that if you can somehow reduce the inflammation on the nerves that go into the back of the scalp that relieves the headaches.

Dr. Nitin Bhatia: Exactly.

Dr. Sechrest: So the headaches should get better if you focus attention on the neck.

Dr. Nitin Bhatia: Exactly.

Dr. Sechrest: Which a lot of patients can’t understand. They can’t understand why they’re having a headache from their neck. So it’s hard to try to get them understanding what you’re doing.

Dr. Nitin Bhatia: Exactly.

Dr. Sechrest: Well, let’s say all this fails. What drives you to begin to talk to a patient to a patient about considering a surgical option for these problems in the upper cervical spine?

Dr. Nitin Bhatia: Really, there are two kinds of patients. One kind who has such significant instability or abnormal motion that now their spinal cord is at risk. Fortunately, that’s a minority of the patients. The other group of patients is patients who have some problems, some arthritis or mild instability, but their spinal cord and nerves are safe. For those patients we have time. There is no rush for surgery and really surgery for them is elective. When the pain gets bad enough, when they have tried the other treatments and they haven’t worked, we talk about doing surgery. Now for the other group, the unfortunate group with significant instability and risk to their spinal cord, we have to really judge the risks and benefits of doing surgery and of waiting. Sometimes, waiting puts the patient at such significant risk of injury to their spinal cord, that it doesn’t make any sense, and probably isn’t prudent.

Dr. Sechrest: So if you feel like nerves are at risk, you’re going to recommend surgery. If you feel like they’re not, you’re going to leave that decision up to the patient and pain is going to drive their decision for surgery, for the most part.

Dr. Nitin Bhatia: Exactly.

Dr. Sechrest: Okay, let’s say we’ve decided that this patient needs an operation to fix this. What do you do?

Dr. Nitin Bhatia: Well, usually the problem is at the C1-C2 level, and it’s usually from abnormal motion and arthritis. The goal is to stop that abnormal motion and stop the arthritic changes and bone spurs that are causing the pain. What we have to do is a fusion which locks those bones together and stops this abnormal motion, so we go in, usually from a small incision in the back of the neck, and put screws into both C1 and C2 and then lock them together. That stops the motion and allows the bones to actually heal in that position that you put them in. By stopping the motion and allowing the healing, it eliminates the pain and eliminates that pain generator.

Dr. Sechrest: Now, I think you mentioned earlier that 50% of our neck motion occurs at that. I assume that eliminates 50% of our neck motion as well.

Dr. Nitin Bhatia: It sure does, and that’s one thing that I make sure I really talk with patients about before that “some of your motion will be restricted”. Now, if the pain has gotten that bad, frequently the patients aren’t moving their neck that much anyways. If it hurts them to turn their neck to the right or the left, they’ve probably stopped doing those motions anyways. So a lot of these patients, although we do take away half of their motion, they don’t notice any change from where they were before surgery; and some of them even say that their motion gets better because with what remaining ability to move that they have, they’re able to use it more because now they’re pain free.

Dr. Sechrest: Now we’re really talking about rotation left and right, and most of us with no arthritis can probably move, let’s say, 80° maybe even closer to 90°. So we’re looking at having 45° or so. Now that still makes it very difficult to turn your head to drive and those sorts of things, so I’m assuming that those patients are going to have a little bit of a problem, going to have to use the mirrors more than anything else.

Dr. Nitin Bhatia: They do.

Dr. Sechrest: What about tilting the head forward and back? How much restriction occurs when you fuse C1 and C2 with that motion?

Dr. Nitin Bhatia: Really, none. So that motion, 50%, comes from the occiput to C1, but if we don’t have to fuse that which, fortunately, we usually don’t have to, you don’t affect the tilting the head backwards and forwards at all.

Dr. Sechrest: How good is this operation for two things: 1) relieving the neck pain; and 2) relieving the headaches?

Dr. Nitin Bhatia: Well, the most important thing in regards to the success of the operation, as with any spine surgery, is to identify the pain generator. We have to make sure we know that we’re operating on the thing causing the pain. If we’re not sure of that, our success rates go way down. But, if we have isolated the pain generator, and we’re very confident about that, the success rates are extremely high.

Dr. Sechrest: So, you would expect that if the injections have proven that the only problem, or at least the majority of the problem is between C1 and C2, and you fuse those joints, you would expect to see significant improvement if not elimination of the headache and significant improvement of the neck pain.

Dr. Nitin Bhatia: Exactly.

Dr. Sechrest: If you still have some arthritis, I mean all of us, very rarely do we have arthritis restricted to one joint; if you had some arthritis in those joints between the C1 and the skull, you’re still going to have a little bit of pain.

Dr. Nitin Bhatia: You will, and you’re right. People who have arthritis tend to have arthritis at multiple areas. We can’t cure all of the arthritis but what we will do is improve the worst areas that are really causing the majority of the pain. So I usually tell patients that, yes, like everyone else who hasn’t had spine surgery or neck surgery, we all get neck pain from time to time, and they probably will throughout their lives, get neck pain, or at least have a low level pain. But, hopefully, we can improve that significantly maybe from a 9 or a 10 rating to a 2 or 3.

Dr. Sechrest: Oh, so significant improvement.

Dr. Nitin Bhatia: Yes.

Dr. Sechrest: Now, a little bit about the procedure itself. You have eluded to the fact that it’s a fairly small incision, pop in two screws, put a little bone graft in there, we’re done. How long does it take to heal?

Dr. Nitin Bhatia: For the fusion to really take, it can take 6 months to 9 months. But, because of the screws that we use, that are so strong, it’s essentially locked into the place almost immediately. We’ll usually let patients do almost any activity that they want to do within 2 months after surgery.

Dr. Sechrest: How long does this operation take? Is it fairly quick? Or is this a long operation?

Dr. Nitin Bhatia: It’s fairly quick. It usually takes a couple of hours.

Dr. Sechrest: And outpatient surgery? Do you have stay in the hospital overnight? What do you normally see?

Dr. Nitin Bhatia: I usually have the patient stay in the hospital for a night or two. Their neck will be sore because, to do this surgery you have to obviously make an incision in the skin and spread the muscles a little, so the neck gets somewhat sore for a few days; and I just find it easier to let the patients relax in the hospital, have the nurses take great care of them for a few days, and then they go home. We’ll usually put them in a neck collar for a few weeks while their skin and muscles heal, and then take the collar off once the skin well healed.

Dr. Sechrest: Now, this is a little bit more serious problem, it sounds like, than a lot of things that we see in the neck and a lot of the operations that we have in the neck. When we do an anterior cervical discectomy and fusion, once that’s healed, pretty much let the patient do anything they want. Is this the same? I mean, once you’ve had a C1-2 fusion, is there something different about these patients that you would tend to put more restrictions on them? Or are they just more restricted by the nature of the disease process?

Dr. Nitin Bhatia: I think more restricted just by the nature of the disease process. Also, as we mentioned, these patients tend to be a little older, so they’re no longer playing, say contact sports, or doing some of the crazy things that, people in their 30s who have had an anterior cervical procedure may have had or may be doing. But once they’re healed, I let them go and do anything that they want to do.

Dr. Sechrest: So you don’t put any restrictions on them other than what the condition itself puts on them.

Dr. Nitin Bhatia: Exactly.

Dr. Sechrest: Well, let’s talk about complications. We’re obviously very close to the spinal cord. We’re very close to spinal nerves; we’re right up under the skull. What are the complications of this procedure?

Dr. Nitin Bhatia: Well, the big risks with it, that people worry about are injuries to the spinal cord, and the spinal cord is sitting right there. Fortunately with our new techniques and microscopes that we use and spinal cord monitoring which check the nerves during surgery; and, as I eluded to earlier, there is actually more space up in this area, the occiput, C1, and C2, for the spinal cord than there is lower in the spine. So it’s actually somewhat safer to do the surgery for the spinal cord here.

Dr. Sechrest: So you’ve got room to work up there?

Dr. Nitin Bhatia: Exactly. Exactly. Now there is one other structure called the vertebral artery, which is a big artery that feeds the spine and then goes up into the skull that is in that area. So, you want to make sure that if you’re having that surgery, you go to a surgeon who is very experienced with upper cervical work, and is comfortable and familiar with the anatomy.

Dr. Sechrest: So you’re worried a little bit about bleeding or damaging that artery and that’s something you want to avoid obviously.

Dr. Nitin Bhatia: Exactly.

Dr. Sechrest: Any other comments or anything that we haven’t covered with this fairly complex problem, that is, luckily, not that common.

Dr. Nitin Bhatia: Right.

Dr. Sechrest: How would you advise a patient who thinks they may be having cervicalgenic headaches? How should they proceed if they hear this and they say, “ I think that sounds like me”, where do they start?

Dr. Nitin Bhatia: Well, I think a great place to start is always with your primary doctor and talk with them about it, make sure you don’t have headaches from another cause – migraines or another issue going on. If, in fact, it’s coming from the neck it’s probably worthwhile seeing a spine specialist. Someone who can work with you and really make a diagnosis with a team approach, with a surgeon, injection physician who is usually a pain management doctor, a group of physical therapists, and rehab specialists to really make sure we isolate that pain generator. If it is isolated and we do know it’s coming from the neck, as I said, most patients, fortunately, do not require surgery, it’s more elective depending on how bad the pain becomes. But, if surgery is needed, our new techniques really work wonderfully and allow to perform the surgery very safely.

Dr. Sechrest: Well, excellent advice. Thanks for really trying to clarify what I’ve always considered a very complex problem very difficult to diagnose and very difficult to treat. You make it sound simple.

Dr. Nitin Bhatia: Well, hopefully it is. Thank you.

Dr. Sechrest: Thank you. Thanks for watching today. If you have questions about the topic that we discussed today, or any orthopaedic topic, be sure to visit eOrthopod.com. If you’re an orthopaedic surgeon or healthcare provider interested in participating as a guest on eOrthopod TV, you’ll also find instructions on how to apply to become a guest on eOrthopod TV. Thanks for watching.