Cervical Spine Problems: an image based diagnosis is not the answer

June 21, 2019

I’ve been seeing a number of Facebook assessments by various patients regarding cervical surgeries and cervical problems. Cervical problems are a clinical diagnosis.  Unfortunately, now with MRIs in the picture, it can be the best and the worst case scenario. An MRI is basically a double edge sword; it shows you where a problem is in the cervical spine, but I’d say 50-70% of people over 40 or 50 years old have a degenerative disc at C5-C7.

 

The point is, an image based diagnosis is not the answer. A clinical diagnosis is what we used for almost 10 years when I was practicing before MRI existed.  If someone has neck pain vs. shoulder or arm pain, thats clear. If they only have neck pain, the treatment there is an anti-inflammatory medication, typically naproxen or something similar to that, twice a day or three times a day for 3-4 weeks with a therapy program to normalize and strengthen the neck muscles.  The head weighs 10-12 pounds and holding it up all day long fatigues muscles in people who are reconditioned. If one does have neck pain as well as arm pain then generally arm pain is greater. So, seeing one with arm pain, we’d go through a detail examination in which I’d ask which fingers are numb and which fingers are tingly.   If the index and the thumb are numb or tingly then thats generally a C5, C6 disc. A C6, C7 disc would be the next level below, and that would involve the little finger.
One has to differentiate between that a nerve that comes around the elbow which doesn’t cause a neurological weakness but it does cause numbness and tingling.

 

The C4 route, which is between C4 and C5, would affect the shoulder. One can have shoulder weakness and it needs to be differentiated between a rotator cuff and an actual neurological problem. One needs to be very carefully examined for bicep and tricep muscle strength, breaker radialis; being able to hold wrist up against resistance, Intrinsic muscle strength; spreading the fingers apart, squeezing them together and seeing how strong the intrinsic is, and pinch between the little finger and the thumb. All this determines which muscles are weak and which are not. This examination is paramount and must be done before any MRI is ever ordered, otherwise, most MRIs in normal people over 50 will show something so significant one can operate on it but it does not relate clinically to the problem.

 

So, you can see where the disconnect happens and when surgery is recommended for someone that has an MRI based image diagnosis and yet have no clinical findings to substantiate it. They’ll go ahead with the surgery and find out it didn’t work and as a result resort to a pain management doctor with great dissatisfaction.  This is a very important lesson to learn. In a rare case, one can have cervical stenosis with myelopathy causing a wide base gate, numbness and tingling in the legs, some weakness, some balance problems, and that is something that needs to be dealt with separately from a particular radiculopathy in the neck and differentiate between neck pain and arm pain.

 

Generally speaking, even with a neurological problem in the neck, one can take a steroid pill by mouth for 7-10 days and generally will reduce the symptoms a lot. So, one can clear the dust with a decision making tree and eventually come to a firm decision in where both parties, the patient and the doctor, are satisfied with that decision and its usually reflected by a very good result once surgery is determined.

 

But remember, it is outcome vs. income and one has to pay attention to it and a second opinion is generally strongly recommended when it comes to a cervical spine surgery.