Patients with neck pain often have trouble sleeping. Sometimes the issue is simple –
after laying in one position for too long, their neck gets sore and they have to change positions, so they toss and turn a bit.
Other times, the problem isn’t really the neck pain, it’s the burning pain or tingling running down the arm (radiculopathy), which suggests more serious nerve compression which may require a visit to the surgeon.
Most often, patients just can’t find a position of comfort, their neck hurts whenever they get into a bad position, and they can’t get to sleep, much less sleep through the night. Sound familiar?
It’s not a minor issue: Inability to get a good night’s sleep leads to exhaustion, exhaustion makes it hard to cope with pain, pain interferes with function, and inability to function leads to depression, anxiety, and more problems sleeping. What can we do to get a better night’s sleep without resorting to surgery?
First, we need to set ourselves up for success - to adopt good sleep mechanics or “hygiene”: stick to a consistent sleep schedule, including weekends, get some good exercise each day, don’t drink coffee or caffeinated pop late in the afternoon, and get outside for at least 15 minutes every day. Also, avoid late night television and evening cocktails – even if you do get to sleep you won’t sleep as well.
Second, get together a good comfortable sleeping arrangement, that works for you. The thing patients ask me about most – the best pillow for your neck.
There is no universal “best pillow” for everyone (no matter what they say in the ads!). Pillows come in all shapes, sizes, styles, and materials. The best pillow for you depends on what type of neck problem you have, what type of sleeper you are, and how you tend to sleep most comfortably – are you a side-sleeper or a back sleeper?
The main goal is to keep your spine in a neutral alignment and allow your muscles to relax while you are asleep. The best pillow is the one that has the proper firmness and height (loft) to help you maintain your best alignment throughout the night. Here are four important points to consider:
1. The wrong pillow is an old one, an overstuffed or worn-out one, or one that’s too flat to support you comfortably in any position. You don’t need to buy an expensive new pillow, but you need one with a firm fill, proper contour, and enough loft to hold your head in good position for hours without settling out.
2. For stomach sleepers, the pillow needs to be thinner. This is a tough position for most neck patients. For side-sleepers, the loft needs to be considerably thicker and the pillow needs to be firm enough not to flatten out while you’re resting. That means a “fluffy” or “soft” pillow may not hold you in good alignment throughout the night. There are a number of pillows that allow you to adjust the amount of filler material so you can customize the perfect firmness and support that works for you. If you are a back-sleeper, you need a pillow soft enough to let your head sink in a bit, but firm enough to support your neck. Some pillows accomplish this by sewing in a preformed divot in the center, providing a firmed roll at the edge under your neck.
3. There are a number of contoured pillows on the market, and a number of websites that “prove” the value of a specific brand, and they may advertise memory foam over latex foam. Check multiple sites to get an unbiased opinion. Most contoured pillows have special ergonomic designs that try to hold your neck in its best natural alignment. They may have a shallow center cavity to gently cradle your head, and a firmer, mounded rim for cervical support. These are pillows primarily intended for back-sleepers.
4. Some people will find that a simple roll-pillow gives them the best comfort during the night. Others may find that they do best with two pillows – one for starting out on their back, and a second one to support when they want to sleep on their side.
You don’t need to buy the most expensive down-stuffed pillow you can find, but don’t skimp. The well-made designs are often available in cheaper versions, but the materials will be different and the support will be lacking.
Obviously, there are no hard and fast rules, and some trial and effort is inevitable. Hopefully this will guide you in the right direction, and help you get a good night’s sleep.
Thanks for reading and let me know what other questions you might have!
Spine surgery has a complex and confusing language. You need to know a little of it...
Patients considering spinal surgery often come to me for a second opinion, having already been told they need an operation, but not really knowing what it is they’re actually having done. Some of this is because spinal disorders are complex, and the anatomy is complex, and the procedures can be complex. That’s why you go to a spine specialist for surgical treatment.
But a lot of the confusion is because the language we use is confusing, and – even though we’re spine specialists – we don’t always explain ourselves very well.
One common question comes up after we’ve discussed the need for spinal decompression – surgery to take pressure off the nerves in the neck or back – and it really distills down to “What did you say??”
Spinal decompression is just that – taking the pressure off of the “neural elements” (nerves or spinal cord) by removing bone and expanding the space the nerves pass through. Sometimes your surgeon may simply inform you that you need a “decompression” without explaining what that means, and the specific terminology can be important. So, ask for more information.
They may tell you you need a Laminectomy.
A laminectomy is a type of decompression that involves removing the bone that forms the roof of the spinal canal, allowing the surgeon to remove bone spurs or disc herniations that may be pinching the nerves in the canal. This is the widest decompression your surgeon can do, and it’s often necessary for patients with spinal stenosis or those needing a fusion as well.
Or maybe they mentioned a Hemilaminectomy?
That’s just a partial laminectomy, performed on one side of the spinal column. Or a Laminotomy? Or a Hemilaminotomy? Those are essentially the same thing - smaller windows still, removing just enough bone around the point of pressure to allow removal of the disc or cyst or spur that’s causing the pain. Microdiscectomy? That just means your surgeon is going to use magnification while operating through a small incision and remove a herniated disc through a hemilaminotomy, to take pressure off the nerve with the least injury to the surrounding tissues as possible.
When cord or nerve compression occurs in the cervical spine, it is common to perform an anterior cervical discectomy and fusion, or ACDF. In this case the decompression is through the front of the neck, removing the entire disc from between two vertebrae, then stabilizing the spine with either a fusion or an artificial disc.
This allows us to take the pressure off the spinal cord and nerve roots without having to move or manipulate the very sensitive cord from behind.
So, if you’ve been told you need a decompression, just ask for more information – what kind and where? Your surgeon should be happy to give you a description of what their plan is. And if you want some good illustrations of exactly what we’re talking about, check out some of the other pages on my website, www.spinesurgerycleveland.com for links to some excellent and reliable resources!
Thanks for reading. Got any questions? Comment to let me know...
Cervical disc disease: My hand and arm are going numb and my Doctor thinks it’s my neck…does that make sense?Read Now
My hand is numb, tingly, and I’m dropping things!
It’s pretty common for neck problems to cause symptoms in the shoulder, arm or even down to the hand and fingers. Any changes in your cervical spine that irritate or compress a nerve can cause symptoms in the part of the arm that nerve goes to. That’s called radiculopathy.
Neck pain and arm pain are really two sides of the same coin. And depending on your “coin”, you may have neck pain, arm pain, or both.
The wear and tear changes of daily life can cause the cervical disc to break down, bulge, or herniate. When the disc degenerates, it loses its ability to be a good shock absorber and support and stabilize the vertebrae that make up the spine. The disc may rupture or may just bulge into the canal and harden. The arthritic disc can cause neck pain, muscle spasm, stiffness, and headaches.
On the other side of the coin, that bulging or herniated disc may press directly on one of the nerves leaving the spinal canal and going into the arm. Worse, a large disc protrusion may press directly onto the spinal cord itself. Even if the disc doesn’t physically compress the nerve, it can irritate it, or it can generate bone spurs that can “pinch” the nerve even years after a recognized injury. When the nerve is irritated or compressed, we get radiculopathy: pain running down the arm in the pattern of that particular nerve. That pain may be severe and electric, may be accompanied by numbness or tingling (usually a very unpleasant numbness and tingling) or actual weakness.
Neck pain can be severe and limit activity, but it’s often that arm pain that drives the patient to the doctor, because it can be intense!
If you’ve got pain in your knuckles, or a sharp pain in your wrist, is that radiculopathy? Probably not. Radicular pain affects the whole distribution of the pinched nerve, and pain or symptoms run down the length of your arm as far as that nerve goes. It’s like an electrical circuit: When one light in the room goes out it’s probably the bulb. When all the lights go out – you’ve blown a fuse!
So, pain running down your arm to your numb, tingly hand – that’s most likely radiculopathy and it’s probably coming from a herniated disc or arthritis in your neck. Your doctor will want to:
And that is where I can come in.
Not-so-obvious signs you’ve got a Neck Problem
If you’ve woken up with a painful stiff neck after a hard day’s work or a slip and fall, you know it’s not hard to figure out where the problem is coming from. Fortunately, most episodes of acute neck pain are muscle-related and will get better with time, stretching, and some anti-inflammatory medications. You’ll usually be feeling better before you can even get around to seeing a specialist.
Symptoms of more serious cervical disease may not be so obvious: Here are five symptoms you might not even recognize as coming from your’ neck, that suggest you may need to see a spine doctor sooner rather than later!
1 Numbness and tingling in the hand or arm – often confused with carpal tunnel syndrome. Numbness, tingling or weakness in one hand or the other may be caused by a nerve being pinched in the arm or in the neck. Sometimes misdiagnosed as neuropathy, if symptoms occurs in one arm and not the other, and if they persist or progress, this needs to be checked out!
2 Frequent headaches – usually at the end of a long day, and localized to the base or back of the skull. Headaches are very common, usually benign, and not given much consideration unless they become frequent or are associated with other neurological problems. Muscular tension caused by cervical disc disease can be a cause of recurrent headaches as well as neck pain.
3 Pain in the thoracic spine – right down between the shoulder blades. This often confuses patients and doctors alike, because the pain and tenderness are focal to the thoracic spine, between the shoulder blades. This is where the muscles that support your neck (the shoulder girdle) tie in to the spine, and this is often a spot where neck muscle irritation or strain is felt.
4 Loss of balance and difficulty walking a straight line – “I walk like a drunken sailor”. When we lose our fine sensory feed-back from feet and hands, we lose our sense of where our feet are in space. Without that fine neural feed-back we tend to stagger about, particularly in the dark when we don’t have our normal visual cues to help us navigate. This is called ataxia, and it’s often the first noticeable symptom of spinal cord compression.
5 Difficulty buttoning buttons – loss of manual dexterity. Even before numbness or pain becomes noticeable, some patients see a change in their hand-writing or their manual dexterity. In one Japanese grading scale of spinal cord function, patients are graded by skill using chop-sticks. If you’ve been using chop sticks all your life, and you suddenly start having trouble handling them – you need to find out what the problem is. It could be arthritis in the hands, and it could be carpal tunnel syndrome, but if it’s not one of those it’s time to examine the cervical spine. The same goes for handwriting and normal daily activities.
Fortunately, the question of whether your neck plays a role in these symptoms can usually be settled with a directed physical exam and a set of plain x-rays, things your family doctor or physician’s assistant can accomplish easily. If there’s still concern after that, an MRI will most often establish the diagnosis and tell us whether this is something that can be managed simply, or whether there needs to be a discussion about surgery.
And, that’s where I come in!
Things you should know about Disc Replacement Surgery:
Disc replacement surgery is growing in popularity, but there is still a lot of misinformation out there, and it’s sometimes hard to figure out what facts are FACTS! Here are five things that you should know about disc replacement surgery before you have any operation on your spine:
1. Disc replacement surgery and disc arthroplasty surgery are the same thing. Also referred to as an “artificial disc” the implants used in these surgeries are designed to preserve motion in the spine after a discectomy (removal of the disc) and they have been shown to maintain motion and reduce the likelihood of degeneration at adjacent levels of the spine, something that often occurs in the years following a fusion. They are recommended for patients aged 18 – 70 years, but I, and other surgeons, have had excellent success in selected patients over the age of seventy.
2. Artificial discs are placed in the neck or back through the front of the spine (an anterior approach) after a damaged disc has been surgically removed to treat neck or back pain associated with radicular pain – the arm or leg pain caused by a “pinched” nerve. In the neck, this is the same approach we use for most disc surgeries, but in the lumbar spine the approach is often assisted by a vascular surgeon to limit the risk to the large vessels and other important structures in the abdomen.
3. Disc arthroplasty implants have been in development for over 40 years and have been available for patient care for nearly 2 decades. There are implants specifically designed for the cervical spine (neck) and for the lumbar spine (lower back). They have very specific applications – treatment of degenerated or herniated discs in otherwise healthy patients. There are no discs designed for the thoracic spine, and they are not intended to treat fractures, infections, scoliosis, or spondylolisthesis. And you can’t undo an old fusion and put in an artificial disc later!
4. Artificial disc replacement can be carried out as an outpatient surgery, and utilizes many minimally invasive techniques, but it is not “minor surgery”. When it comes to the spine, nothing is! The importance of surgeon experience and skill is reflected in the careful diagnosis and plan for treatment, and the skillful approach and placement of the implant. Surgeon experience with disc replacement procedures is important to the outcome here. Ask.
5. Disc replacements last a long time. How long? We don’t really know, because – unlike artificial hips and knees – we haven’t seen any of the ones we use today wear out. I’ve seen a suggestion that they will last 70 years, but that’s pure speculation! We have had the opportunity to observe patients in Europe who have had disc implants in place for 35 years without failures. And I have followed my own patients for more than 18 years without seeing any cases where the disc has worn out or deteriorated.
So: There have been over 150 peer-reviewed publications of long-term trials and studies of total disc replacements, including investigational FDA trials, long-term follow-up studies, and large multicenter studies to ensure the safety and effectiveness of these implants. These studies have shown that, when used for the correct indications in the right patients, disc arthroplasty can provide significant advantages over traditional fusion procedures. They are not experimental or investigational, and their effectiveness is proven.
So, if you’ve been told you need to have a neck fusion, or a lumbar spine fusion, it’s ok to ask “is there another way to do this?”.
You can learn more about disc replacement surgery, and other types of spine surgery and treatment, by checking out more sections of this website, or find me on Linkedin or Facebook at Robert McLain MD.
When Does “Early” Spine Surgery Make Sense?
When should you consider surgery for your back or neck? The old “rule of thumb” was that surgery for your back should be the very last thing you consider – when everything else has failed! Like most “rules of thumb” though, that’s only good advice some of the time. In certain situations, putting off surgery can lead to problems down the road, or be down-right dangerous. Here are FIVE CONDITIONS that need surgery earlier rather than later:
Conditions that destroy bone are usually more serious medical conditions, like tumors or infections, and require your Medical Specialists and your Spine Surgeon to work together. While the medical management is often the key to controlling the underlying disease, delaying surgery can lead to bone collapse and cause a much greater problem. Modern surgical techniques can provide stability with an overnight stay, keeping patients on their feet and minimizing pain during medical management.
Spinal deformities should not be allowed to progress. A curvature of the spine or a slip of one vertebra relative to another that progresses in adulthood is most likely going to keep progressing! Early treatment will be less difficult and more successful than surgical reconstruction when the problem is severe.
Nerve compression or spinal cord compression may be observed by your doctor for a while, but if symptoms of arm or leg pain are severe and persistent, or if any symptoms of spinal cord compression develop, there is no role for continued physical therapy or pain management. Spinal cord or nerve injury may become permanent, and surgery then - as a “last option” - may not do much good.
Finally, there are some options available to patients with neck and back pain that just didn’t exist 20 years ago. Disc replacement, or disc arthroplasty surgeries lead to fewer re-operations and complications than traditional fusion procedures, and they protect the adjacent levels from degeneration often seen after fusion. However: total disc replacement operations PRESERVE MOTION, meaning that earlier surgery, while the spine is still mobile, is crucial. Waiting until the “last option” may mean there’s no motion left to preserve.
And then, fusion is the right thing to consider.
People usually don’t worry about aches and pains that come on after a fall or moving a piano.
It’s pretty typical to be sore, so… no worries, right? But, when pain sticks around longer than you’d expect, it’s also pretty natural to start worrying – ‘could this be something worse?’. That thought comes on even quicker if you’ve ever known someone who did have pain due to cancer or another serious problem. And while we try to look cool and very calm, your healthcare providers – doctors, nurses, physical therapists – are the quickest to come in for a check-up if their pain lasts too long! They worry about the same things you do.
The important thing for you to know is that, while 80-90% of EVERYBODY will have an episode of persistent back or neck pain at some point of their life, almost all of those episodes will result from muscle strain, disc degeneration, or other manageable causes of back injury. Almost all of these episodes will start to improve after 3 -4 weeks of rest, and some appropriate anti-inflammatory's. If your pain persists for more than 6 – 8 weeks, bothers worse at night than when you are up and active, is causing numbness, weakness, or pain in your arm or leg, however, it’s probably time for a check-up.
To be honest, my own Grandfather was an exception to this rule. At age 65, a 3 pack-per-day smoker, his mid-thoracic back pain had none of the symptoms of a back strain and he had all the risk factors for trouble. So, if you:
- have a history of cancer,
- are at high risk for cancer because of heredity or heavy smoking,
- have been losing weight, or
- are running fevers
along with your symptoms of back or neck pain, then you shouldn’t put off that visit to your doctor. A careful examination and appropriate imaging will either identify the problem or help put your mind at ease.
For the rest of us, it’s worth knowing that a muscular back or neck injury can take several weeks to completely calm down. That’s NORMAL. The best treatment remains – rest, ice and heat, anti-inflammatory medications, time, and exercise, once you start getting back to normal. A visit to your primary doctor, physical therapist, or chiropractor can help get you back on track in most cases. And if it doesn’t, well…that’s where I come in.