Neck Pain - Justin Paquette, MD
Sechrest: Hello, I am Dr. Randale Sechrest your host for eOrthopodTV. Today I have with me as my guest Dr. Justin Paquette. Dr. Paquette is a neurosurgeon who practices complex spine surgery in Los Angeles, CA. Dr. Paquette did his medical training at Albany Medical College. He then went on to complete a residency in neurosurgery at the Harvard Tufts Combined Program in Boston, MA. From there he completed a fellowship in complex spine surgery in Los Angeles at Cedar Sinai. Good afternoon Justin.
Paquette: Good afternoon.
Sechrest: Dr. Paquette, today what I would like to focus on is neck pain. We all hear about back pain and how prevalent it is in our society and how it's almost an epidemic, but I think people overlook how many patients really come in with neck pain. So, tell us a little bit about, how big a problem is this?
Paquette: Neck pain is definitely a huge problem and it probably is just less numberwise than the people come in complaining of back pain. I see many, many patients every week with complaint of neck pain. What it really comes down to is the neck is a very mobile structure and if you think about it we have to turn, twist, bend, flex our neck in all different directions and we do it thousands and thousands of times a day and so there's lots of little joints and structures at risk for injury in our neck. By far the most common injury that we can have in our neck is just a musculoskeletal problem. So, a whiplash injury or a pulled muscle, strained muscle, over exertion can cause the muscles to clamp up, to stiffen and can cause severe neck pain.
Sechrest: Now do you think that that's the most typical patient you see if that type of patient with primarily a musculoskeletal strain or sprain?
Paquette: I think probably numberwise that it is. I think that a lot of people just sleep wrong or are very stressed out and just teak it one little move and that actually is a very common thing. People are concerned because it is their neck and the pain that comes from it can actually last for months. You know, even if it's just musculoskeletal, it's still going to take a long time for it to improve. They'll see some chiropractors, some other physicians, still have the pain and ultimately come to a spine surgeon for further evaluation.
Sechrest: And how do you evaluate these patients? When a person with neck pain ends up in your office, what are you looking for on that first visit?
Paquette: When a patient comes in complaining of neck pain, there is essentially three things that we need to look at to help to determine what's going on. The first thing is going to be his examination as well as his clinical history and then finally any kind of radiologic studies we might need to do. And so first I'll just start asking simple questions. When did the pain start? Where is the pain? What makes it worse? What makes it better? Does it travel anywhere else? Those kinds of simple questions will start to give me an idea on potential sources for pain. In other words if it's just a very localized pain to one side it could very well be a pulled muscle. Pain shooting down the arm would be more classically a nerve pain. Once we've got a full history then we move on to the examination. This will involve a variety of things including testing the strength of all the muscles of the upper extremities as well as the sensation in the upper extremities as well as the sensation in the upper extremities as well as other issues like balance, abilities to walk and then range of motion in the neck as well. Certain joints will limit your motion in one particular direction and so all these different maneuvers that we have help to further hone in our ideas of what might the problems be. Then ultimately we would try to get some radiologic studies to really focus on this. It could be an x-ray, could be an MRI scan, could be a CT scan. Each of them have their pros and cons but all of them help to show us where the problem might be. Whether it's from a degenerative disc, whether it's from a little slip in the bones, whether it's from a pinched nerve.
Sechrest: Now, as a neurosurgeon specializing in the spine, do you always proceed on with plain x-rays or an MRI scan or a CAT scan or some type of radiological test the first time you see the patient? Are there patients that you would say, you know, I don't think that this needs any x-rays or, I don't think that this needs an MRI scan?
Paquette: That often times may be the case. If somebody comes in with a history of, I just had a little car accident, or I just woke up wrong and twisted my neck a little bit, they've got minimal symptoms, no symptoms in the arms, no numbness, no weakness, no difficulties holding objects __????__ in the arms. Just some focal slight weakness and it's getting better as the day goes on it may be unnecessary to do x-rays on that because obviously that means you're exposing people to x-ray and the cost of the x-ray as well. If there's anything concerning or red flags meaning severe pain in the neck, the pain is getting worse, limited range of motion or certainly any kind of nerve symptoms, again numbness, pain or weakness in the upper extremities, those things would definitely require either x-rays, MRIs or CTs at that point for further evaluation.
Sechrest: Now you mentioned the distinction between neck pain. Just plain old neck pain that doesn't go anywhere and neck pain that involves either arm pain or perhaps weakness, numbness, or something like that. What's the difference? I mean, what are we looking at when we're trying to make that distinction?
Paquette: Sure. So, part of it comes on what the patient complains of. So, if you've got just pure neck pain, neck is very stiff, pops once in a while when you're turning around, it's probably a lot of focal arthritis or muscle spasms that you're dealing with. If, however, they're complaining of pain just searing down the arms, that is much more related to a nerve problem and when we do examinations, we're particularly testing for areas of numbness or particularly areas of weakness that would be related to those nerves and that's on easy way of kind of distinguishing between the two.
Sechrest: And the reason that that's important, I'm assuming, is that we're more concerned about that person who has potential nerve damage or spinal cord compromise or something like that.
Paquette: Yeah, absolutely. If it's purely a musculoskeletal disorder in the neck and we can prove that to be the case, you just treat with anti-inflammatories and physical therapy and it will get better. But, it's a whole different scenario when their nerve or especially the spinal cord is being pinched. That needs to be accurately diagnosed as fast as possible and then treated as soon as possible as well.
Sechrest: Okay. And, when we're dealing with neck pain as opposed to something we tend to think of as more common like low back pain, are there any differences in neck pain the way we do that from the rest of the spine? I mean, do you distinguish neck pain as a separate entity or are we still dealing with the same problem, wear and tear degeneration of the cervical spine?
Paquette: Yeah, it's all interlinked. It's all really the same thing and it's much more prevalent in the neck a lot of times because again it's a hypermobile structure. It's moving all the time. Muscles are being stretched and tweaked and the back pain is in essence almost the same thing as the neck pain. You've got wear and tear there, muscles are having to accommodate for the wear and tear and they start to spasm and start to really bother you. It doesn't necessarily mean there's a huge problem in the neck, but certainly there's enough issues with the muscles and ligaments that are causing significant discomfort.
Sechrest: Now a term that a lot of folks probably hear in relationship to the spine is degenerative disc disease or even degeneration of the spine. What exactly is degenerative disc disease as it pertains to the neck?
Paquette: Well, just in general, degenerative disc disease refers to the wearing out of the intervertebral discs. The shock absorbers of the spine. And, we have one of those between all the bones in our spine from the cervical to the thoracic and the lumbar. They do the most work however, in parts of the spine that are mobile which includes the neck and the lumbar spine. Thoracic spine is immobilized by the ribs and so discs aren't that important, but in the neck for sure, there's so much motion in the neck that you need to have those discs to help to buffer the spine and buffer those bones as they rotate twist flex and extend. The structure is essentially an outer fibrous tough core with a very watery, jelly interior. Degenerative disc disease essentially refers to the wearing out over time of these discs. The discs wear out, they dry out, they start to collapse down a little bit. Sometimes they can crack and leave little fishers. Then ultimately the discs can actually herniate how and start to hit the nerve roots.
Sechrest: Earlier you talked about arthritis in the neck. When we use the term arthritis in the neck, what are we really referring to?
Paquette: Arthritis equals wear and tear, equals degeneration. That's all it is. Arthritis is exactly the same thing no matter where it is in the body, whether it's arthritis of our fingers, arthritis of our knees, arthritis of our hips. It refers to the fact that when there's a joint that gets older, the cartilage that is usually separating the two bones starts to wear out. A disc is a piece of cartilage between a joint, a joint is a disc so as the disc wears out, the bone now starts to grind on the bone and the same thing happens in the neck. That disc, the large joint, wears out, the neck bones start to rock and roll on top of each other and cause a lot of pain.
Sechrest: And the neck, I'm assuming is a little bit different in terms of it's structure than the lumbar spine and the thoracic spine. You've alluded to a couple of things, one is with the ribs in the thoracic spine. Can you define for the listener, a little bit about the specialization of the cervical spine is it attaches to the head and then down through the cervical spine as those vertebra change as we go lower and lower? And, what does that mean for degeneration of the spine?
Paquette: Sure. So, the neck itself is made of seven cervical vertebrae and it spans the distance between the head, or the occiput, and the thoracic spine. The top two cervical vertebrae one which is called the atlas and one which is called the axis are predominantly responsible for the no rotation and the yes rotation. They have joints but there is a significant laxity in the joints which really allows massive rotation. As we go down beyond that, the third to the seventh cervical vertebrae, each of them gets a little bit larger so that they can sustain more of the force of gravity that gets put on them but they also have joints that are aligned in a special direction that allows for significant forward and back motion and also to restrain the vertebrae together so that they are linked together into a harmonious curve. But, people ask, you know, if I get my 5-6 disc fused am I going to lose all the motion in my neck, again most of the motion comes from the first and the second vertebrae.
Sechrest: So if you fuse, for example, the sixth and the seventh vertebrae, the patient's not going to really notice a big restriction.
Paquette: It would be a very minimal change, especially since, if you're fusing it, that meant there was a problem there to begin with, they probably already had lost most of their normal motion at that level before surgery.
Sechrest: Okay. Now, if I'm a patient with neck pain and I have had neck pain for six months and it, you know, like you said, when I turn my head I hear this grinding noise and it's not very painful, I can't quite turn my head to look over my shoulder on either side, I'm a little concerned because I might have a headaches once a week that starts in the back of my head, should I be concerned? Should I be seeing a neurosurgeon at that point?
Paquette: Unless there are other symptoms of balance problems, weakness problems or arm symptoms, it is probably not a concerning situation. What it sounds like this would be is a run of the mill arthritic condition in the neck and the headaches are very commonly related to neck pain. As the neck muscles spasm trying to lock the spine in position, that transcends into a headache which usually goes over the top of the head into the eyes. However, that being said, certainly it's a situation that should be evaluated at least. Somebody should see that as a baseline structure. Make sure that on the evaluation there aren't any subtle signs of nerve or spinal cord involvement that you yourself may not be able to identify. So, a formal evaluation and maybe some potential x-rays I think would be a good next step.
Sechrest: Okay, now let's talk a little bit about our treatment options for neck pain. You had mentioned a good physical therapy program, medications, anti-inflammatories for the arthritis, in addition to that, do we routinely use any braces for the neck? Are you a proponent of neck braces? What type of physical therapy do you think is best for the cervical spine? And, I think one thing that comes up a lot with patients is traction. Is traction beneficial for cervical spine problems? What are your thoughts?
Paquette: So, first of all, as far as bracing goes, I think bracing can a lot of times help individuals, especially if a lot of their pain comes from deformity. If somebody's normal curve of their neck has been lost and they are leaning forward like this, their muscles are now spasming all the time to try to hold them back. A neck collar will give a little extra support and may be beneficial. The problem is though, that if you try to wear a collar too long, it can actually work against you and lead to deconditioning of the muscles just by leaving it there all the time. So, I recommend to patients if they're going to wear it, maybe wear it a couple of times a day or just when you're off and do a lot of walking, but when you're around your house, sitting there, taking it easy, don't wear the collar and let the muscles kind of have to do some of their work. Next question was about physical therapy. I believe very strongly that the physical therapy that everyone needs, whatever part of the body it's for, must be an active physical therapy. Physical therapy is not when you go someplace, get a massage for a half hour and then go home. You have to be actively involved and developing your muscles. So, working on the neck muscles in all different directions, working on the upper shoulder muscles in the shoulder girdle and the core muscles as well. The reason being is that the stronger you can get your muscles, the easier it is for your muscles to compensate for spinal problems. So, even though physical therapy won't reverse the changes you have in your neck, it will at least make you be able to take care of it better and have less pain from it.
Sechrest: Now in terms of the other modalities that sometimes are used by the physical therapists, I would like to get your opinion on how useful these modalities are. One is there is always a controversy as to whether heat or cold is better. All of our patients ask us should I use heat or should I use cold. With neck pain, if I'm dealing with a patient who I think has the typical muscle strain for example, or the typical axial neck pain. Meaning that the pain is all in the neck, not radiating and I think it's related to arthritis, do I recommend heat or do I recommend cold?
Paquette: Okay. So in those situations, I mean first of all, anti-inflammatories as you mentioned, but when it comes to the heat versus cold controversy, I always recommend cold and the reason being is that cold itself is an anti-inflammatory. It will get some of the fluids out of the area and actually speeds up the healing process. Now the problem is that most people don't like to put ice on themselves because it hurts but I tell them basically no more than 20 minutes at a time, use a towel or something like that as a buffer for it and do it a few times a day. That actually is very affective in decreasing the inflammation whether it be in the nerve, whether it be in the muscles, the joints, wherever it is. The problem with heat, although it feels good to put it on there and it relaxes the muscles a little bit, actually perseverates the inflammation. It keeps the fluid in the area. If somebody really loved putting on heat, I would tell them, okay, you can keep doing that but make sure you use ice alternatingly just to kind of compensate for that situation.
Sechrest: And what about other things like muscle relaxants. Again, a lot of patients ask, well if this is a muscle related problem, should I be taking a muscle relaxant? Do you find muscle relaxants beneficial in neck pain?
Paquette: With regard to the use of muscle relaxers in neck pain, I do feel they can be very affective. I think you have to be a little bit cautious though in prescribing it. What I usually tell folks is, this will definitely make you feel better, but it also can make you very drowsy. The best time to use it is at night to give yourself a good nights rest, relax the muscles over the evening so that when you wake up you're feeling better. If you have a severe flare, take it during the day but don't operate any kind of machinery and be prepared to be knocked out. The only other thing is I don't like anybody using it on a long-term basis. The reason being again is that he best thing you can do, the long-term spine health is to make your muscles as strong as possible. If you're constantly taking muscle relaxers, you're basically fighting that desire. So, take them when you need them and then come off of them and then work more on the core muscle strengthening.
Sechrest: You know, there's a couple other things that I see more and more now a days and I think we're starting to see actually available without a prescription. One is the cervical traction units and there's several different types. There are some that you actually hang with a halter over the door and then there's the newer ones that are more pneumatic where you blow up something around your neck and stretch the neck out. What do you think about cervical traction? Is that a useful tool for people with axial neck pain?
Paquette: When it comes to cervical traction, I think there's a couple of very important points that need to be discussed. Number one, I think it's very unsafe to start any kind of cervical traction until there's a definitive diagnosis made on the patient based upon radiology, whether it be x-rays, MRIs or CTs. The reason being is that if you put somebody into traction who has a certain type of spinal deformity, it's possible that they could pinch off a nerve or even worse, really bruise the spinal cord. This has happened in the past and obviously is a catastrophic event. And, so I always recommend that you make sure, 100% sure, that the spinal cord is safe during the traction. Now, the other question is, is does traction work? Well, the reason why people feel better during traction is that it distracts the joints and the discs which have collapsed down during the course of the day. You know, not only does the disc collapse down during degenerative disc disease but the facet joints, which are the joints in the back also collapse down. And, so it's painful when that happens. The distraction, or traction rather, helps to elevate those off, makes it feel better. The problem is that as soon as you're out of the traction machine, by the next day everything is back to where it was. So, in no way, shape or form is this actually a treatment to reverse or to ameliorate the problem, but it is at least a short-term help, but in general for most spine patients, I say try to stay away from any kind of chiropractic or traction manipulation of the neck.
Sechrest: Okay, so you're not in favor of chiropractic treatment of the cervical spine.
Paquette: I am not.
Sechrest: Okay. In any circumstances.
Sechrest: The last thing I wanted to ask you about in terms of the modalities that we're seeing more are TENS units. And, again, I think these are beginning to become available in the United States even without a prescription so I think we're going to see people start to use these. What is your position on TENS units? Do you feel that they help with some of the symptoms of neck pain?
Paquette: You know, it's hard for me to say for sure because I really haven't had enough experience with them. I have had a bunch of patients who have used them. I would say about 75% said that it helped them, 25% said that it didn't. It basically works just upon electrical stimulation through the skin along nerves, the muscles to try to reverse some of the spasm that's going on inside of them. I think it probably works on a person to person basis. If somebody wanted to try it, I'd say go right ahead and give it a shot because if it works for you that's great. But, I wouldn't be convinced that everybody's going to get a good response from it.
Sechrest: You don't see any down sides to using a TENS? No contraindications to using a TENS unit for neck pain?
Paquette: No I don't.
Sechrest: Now, one thing that patients are commonly asking is about the headache and the relationship of headaches to neck pain. I think we all see patients who have neck problems and develop headaches on the basis of their neck problem. What's that about? Where are we getting that headache?
Paquette: It all comes down to stress and referred stress essentially. The neck pain again is coming from persistent and constant muscle spasms and also sometimes from the nerves that can be irritated from the back of the joints as well and that just seems to travel many times up into head and over into both eyeballs. Either called an occipital headache or a stress induced headache but we see this all the time and the two are correlated. Whether or not it's directly caused by a nerve or it's just kind of referred pain by the stress coming up the back of the neck is hard to say. There are certain nerves, for example the occipital nerve, that comes out of the second cervical vertebrae which when irritated causes pain in the same area over the back of the head. But, that usually is related to sometimes direct pressure on that nerve. I think probably there's just a relationship between stress begets stress and muscle spasms in one area here just cause these stress headaches in the head right __????__.
Sechrest: Okay. Now, let's go back a little bit and look at the patient that has had neck pain for a long time and maybe is starting to have some other symptoms. For example, maybe their having some radiation into their shoulder or something like that. At that point in time, how does that change what you're looking for and trying to determine what's going on the in patient?
Paquette: Right. Well, once we start to get radicular symptoms, in which we're referring to, any kind of symptoms into the arms, we now know that it's more than just mechanical changes in the neck. Something is actually __????__ that nerve. Now, it could be something chemical like chemical radiculitis from a torn disc, or it could be something directly pressing on the nerve such as a herniated disc, bone spur etc. Once you get arm symptoms like this, it definitely warrants a more in depth work up so you need to get an MRI scan or a CT scan which will allow us to specifically look at each nerve at every level and see which ones are being effected.
Sechrest: So when you start seeing anything that would suggest that nerves are being compromised, and what we're talking about now and I think we ought to clarify for the listener is, there's a difference between when we think that the spinal cord is in danger and when the nerves that leave the spinal cord and go out of the spine are in danger. One causes problems normally in the arms, the other can cause problems of gait, of your ability to walk, your balance and legs, arms and everything.
Sechrest: So, distinguish for me the different types of nerve entrapment or nerve compromise that we see in people who have neck problems.
Paquette: Well, first and probably the most common ones are the radiculopathies which are straight to the nerve. A nerve pinch. A nerve pinch is the peripheral process not the spinal cord which leaves the spine and goes down to the arm. It carries the three main functions of strength, of sensation and the reflexes as well in a particular distribution. So, each nerve kind of does certain parts of the arm and it's reproducible. We can guess which nerve it is based upon where exactly the symptoms are. The good thing about that is that a nerve is a potentially recoverable entity. It can regenerate. So, if a nerve has been bruised very badly, even to the point of weakness, sometimes that nerve will recover and will have good function. The other type of nerve injury is the main nerve, the spinal cord which runs right down the middle of the spine and gives off the nerves. The spinal cord basically comes from the brain and through it carries all of the processes which control motor strength, sensation, reflexes and everything else to the entire body. So, from the shoulders down everything comes from the spinal cord. The spinal cord also is unique in the fact that only it and the brain cannot regenerate. It does not have the ability to grow back as do the nerves, as does our skin etc. So, if there's a severe injury to the spinal cord it's permanent. Bruises do have the chance to recover but not an actual true injury where cells are dead and so it really is extremely important if we ever determine there to be pressure to the spinal cord that gets taken care of. The way to determine the difference between the two is that a nerve in the arm when pinched is only going to cause symptoms along that nerve. So, for example, if you pinch your C6 nerve in your arm, you get symptoms of pain going down your arm and into your fingers here. Nothing into these fingers here, just into these fingers here with maybe some associated weakness. The other arm would be fine. If the spinal cord is injured at the same level you may have total numbness of both hands and maybe total weakness as well. You may have weakness of the entire body from the level of C6 all the way down with walking problems, gait problems, weakness of the legs, maybe even bowel and bladder problems. So, an injury to the spinal cord causes a much wider range of symptoms with also unfortunately a less chance of recovery.
Sechrest: And so that's why you say that's a more serious injury in the sense that you're going to want to consider surgical intervention to get the pressure off the spinal cord to try to, maybe not prevent, but at least stop the progression of the damage to the spinal cord because you're not expecting that to come back. It's not going to regenerate.
Paquette: Correct. In my discussions with patients I'll tell them that we need to operate on this as soon as possible with the main goal of helping the progression of the symptoms. At least keeping what we have now and tell them we can't, unfortunately guarantee that anything is going to get better unless some of the injury is just a bruise. Sometimes when the spinal cord is being bruised, as long as it's not dead, some of that can come back but it can take a long time to come back and it's certainly never guaranteed that it would.
Sechrest: Okay, let's go back and sort of summarize for the listener when neck pain becomes a more serious problem, that you would begin to think about surgical options. At what point in a patient that you're following for neck pain, at what point would you decide we need to get more tests and we need to consider surgery?
Paquette: Okay. There's essentially two types of patients when on the side you know, maybe you should consider surgery at this point. The first one is certainly anybody who presents or develops any kind of neurologic deficit whether it be from the nerve or the spinal cord. So, in other words, if there's a new or progressive weakness, numbness, walking problems, gait problems or other signs of spinal cord compression, those patients need to be operated on. The other category are patients who don't necessarily have pressure on the nerve or on the spinal cord but have some kind of deformity in their neck or source of pain in the neck that is so incredible and so painful that it affects their daily life, they can't work, they can't exercise, they can't enjoy any of their daily activities and we've tried all of the conservative things including medications, therapy, epidural injections etc. and it hasn't made an appropriate relief in their pain. That's the second kind of person who may be ready for surgery also.
Sechrest: As we bring this discussion about just neck pain and a general approach to neck pain and degenerative changes to the spine to a close, I want to try to talk about surgery in generic terms on the neck. In general, if you choose to operate on the cervical spine, what are you're goals? What are you trying to accomplish, and I'm certain there's numerous different types of operations meant for specific things and we're going to discuss those. But, in general, what are you trying to do when you choose to operate on the cervical spine? In general.
Paquette: Sure. So the main goals of operating on the spine are to take the pressure off of any associated nerves, to help the patient's pain get better. We may not be able to relieve the pain totally, it usually means that there's other problems in the neck as well, but to at least make their pain much better and more tolerable, try to get them down if not off of the pain medications, get them back to a functional quality of life and then lastly make as little damage to the other areas of the spine as possible. Just to focus on the one level that's bad or the levels that are bad and everything else is okay, don't do any kind of damage that might hasten their degeneration as well.
Sechrest: Okay. Well, I think we should definitely take a look at all the different types of surgery that are available for the cervical spine but I think you've laid the groundwork for a real understanding of how you, as a neurosurgeon sort of attack the whole problem of neck pain, where it comes from, how you you perceive what's going on with the patient and then how you get to a point to where this patient may have failed conservative therapy and be ready for an operation. So, anything else that you would like to point out to patients before we move on to actually discussing specific surgical procedures? Anything else you want patients to know who have neck pain and advice you would give them in terms of how to either treat this or what they should be concerned with as their neck pain progresses? What to look out for.
Paquette: Just to reassure them that it is very common to hear popping in the back of your neck. Everyone always seems to think that they're the only people who have had that happen. It's just a little bit of arthritis, everybody's got it. Don't be too upset about that. Again, anti-inflammatories are probably one of the best first line agents to use in treating this arthritic condition.
Sechrest: Okay. Wonderful discussion, I think that's very good useful information for patients with neck pain. Thank you.
Paquette: Thank you.
Sechrest: Thanks for watching today. If you have questions about the topic that we discussed today, or any orthopedic topic, be sure to visit eOrthopod.com and if you're an orthopedic surgeon or health care provider interested in participating as a guest on eOrthopodTV, you'll also find instructions on how to apply to become a guest on the eOrthopodTV. Thanks for watching.