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Sayonara Neck Surgery: Conservative Treatment May Suffice in Some Cases

Posted on: 12/12/2001
In the right circumstances, neck surgery can provide relief of pain and other symptoms. Sometimes surgery may be the only option. This is often the case when a disc herniation in the neck puts pressure against the spinal cord, causing a condition called myelopathy. Myelopathy can lead to problems with the bowels and bladder. It can change the way a person walks and affect the ability to use the fingers and hands. Doctors take this condition very seriously because if left untreated, severe pressure on the spinal cord can cause permanent damage to the nerve tissues.

But what if symptoms from the pressure are only mild? Is conservative treatment--treatment without surgery--an equally good option, with fewer risks? Unfortunately, these questions are often left unanswered. Due to their doctors' concerns about irreversible nerve damage, patients with cervical myelopathy typically have surgery. Yet these questions have merit because studies have shown that some disc herniations shrink with time.

In this study, the authors looked at patients with cervical disc herniations. A cervical disc herniation (CDH) occurs when a disc ruptures out of its normal space in the neck. In this study, CDH caused mild symptoms in patients from the pressure against the spinal cord. The authors wanted to learn whether conservative treatment alone would provide good results for the patients.

Twenty-seven patients participated in the study, which took place in Japan. The patients were mostly male. Their average age was 44. At the time of treatment, they didn't require canes to walk as is sometimes the case with cervical myelopathy. However, they had numbness in both hands and couldn't stretch their legs out completely. 

Treatment involved wearing a neck brace for at least eight hours a day. This lasted for three months. After that, patients wore their braces as needed. They were also told not to do activities that were hard on their necks.

Seventeen of the patients (63 percent) improved or stayed the same when they followed this regimen. In fact, ruptured discs healed on their own in 10 of these patients. The other 10 patients either did not improve or got worse over a six-month period. These patients had surgery to remove pressure from their spinal cords.

At follow-up, both groups (the patients who had surgery and those who didn't) had the same level of function. They also functioned just as well as an additional group of surgery patients who hadn't started with conservative treatment.

Both groups were satisfied with their treatment. Seventy-seven percent of patients who had only conservative treatment were satisfied with their results. Ninety percent of those who had conservative treatment plus surgery were satisfied. Yet the difference in satisfaction between the groups was only slight.

MRI scans showed that certain kinds of disc herniations were related to how well patients did with conservative treatment. Patients who benefited from conservative treatment tended to have discs that herniated toward the front of the spinal cord. In the neck, the spinal canal is bigger in the center, so the spinal cord isn't squeezed as easily by a disc that herniates into the front of the spinal cord. Herniations that press into the spinal cord from the side tend to cause bigger problems, as the spinal canal is narrower at this point.

Also, "diffuse" herniations that spread out were more likely to improve without surgery. These herniations tend to get smaller with time. As they shrink, the pressure against the spinal cord is relieved. But a rupture that is focused in a confined area may not trigger the body's corrective responses. As a result, this form of herniation often continues to cause problems and usually requires surgery.

In conclusion, the authors feel that conservative treatment has good results for patients with mild symptoms of myelopathy from CDH. Also, MRI scans can be helpful in predicting whether patients will benefit from this kind of treatment. If patients get worse after three months of conservative treatment, surgery should be considered.

Morio Matsumoto, MD, et al. Relationships Between Outcomes of Conservative Treatment and Magnetic Resonance Imaging Findings in Patients with Mild Cervical Myelopathy Caused by Soft Disc Herniations. In Spine. July 15, 2001. Vol. 26. No. 14. Pp. 1592-1598.

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