Interview with Dr. Blionas, published in Proto Thema

Cervical spine pathology and the significance of the spinal cord

The fundamental difference between pathology of the cervical spine and pathology of the lumbar spine is that the neck houses the spinal cord. The cord is a critical structure, in the sense that it does not simply serve the nerves emerging at one particular level, as is the case in the lower back.

It controls the entire body from any given level downward. In simple terms, a problem in the mid-cervical spine may cause dysfunction throughout the body below that point — affecting the arms and the legs, and in severe cases even respiration.

This is what makes cervical pathology so significant.

“All patients should know that any neck discomfort radiating to the arms or legs must be investigated. MRI of the cervical spine is an essential step whenever cervical pathology is suspected,” explains Dr. Alexandros Blionas, neurosurgeon.

Another important difference between the cervical and the lumbar spine is the urgency of treatment. When leg symptoms arise from a problem in the lower back, we can wait, apply conservative measures, and observe the course.

In the neck, however, once spinal cord function is affected — numbness in both the arms and legs, accompanied by weakness, a picture known as cervical myelopathy — the condition must be addressed promptly and decisively. The consequences of ignoring it may extend as far as paralysis. Whenever such symptoms are present, evaluation by a neurosurgeon and the necessary imaging must take place, so that appropriate management can begin without delay.

Treatment options

A neurosurgical lesion in the neck may be a disc compressing the spinal cord, or hypertrophy — thickening — of the ligaments or bone doing the same. The compression may also affect the nerve roots leaving the cord, which supply the arms (cervical radiculopathy).

The available options initially include, as in the lower back, conservative management with medication: analgesics and anti-inflammatory agents. The difference is that when there are symptoms indicating spinal cord involvement, we proceed directly to surgical decompression in order to protect the cord.

Epidural injections play a considerably smaller role in the neck than in the lower back. The principal reasons are the risk of injuring the spinal cord during the injection, and the risk of allowing an evolving cord injury to progress in the meantime.

When spinal cord injury is already present — numbness and weakness in both arms and legs, usually with some degree of neck discomfort — our therapeutic options are limited.

Surgical management

“There are essentially two surgical approaches to the neck: anterior and posterior decompression. In both, using specialized instruments, we remove the bone, ligaments, and disc material compressing the spinal cord — either through an incision at the front of the neck or at the back,” Dr. Blionas adds.

The essential difference between them relates to how effective each is depending on the severity and extent of the problem. When the cervical spine is affected at multiple levels — across a substantial portion of its length — the posterior approach is usually the better option. When fewer levels are involved but the degree of stenosis is severe, the anterior approach is generally preferable.

Many other factors influence the decision, but in every case a small incision is made at the front or the back of the neck, through which specialized instruments are passed to remove the structures compressing the neural elements.

When the operation is performed anteriorly, implants are always required: a device must be placed at the operated level to support the vertebrae. Posteriorly this is not always necessary — but it becomes so when several levels are addressed and there is a risk of postoperative instability, meaning movement of the vertebrae relative to one another that alters their normal anatomical relationship and can cause severe pain and symptoms.

Can surgery be avoided?

What patients need to know is that neck pain accompanied by pain in the arms or legs — or neck symptoms such as numbness and weakness together with symptoms in both arms and legs — must always draw attention and must always be investigated. The consequences of ignoring serious cervical pathology can be severe.

The second essential point is that cervical pathology requires surgery considerably more often, requires it more urgently, and responds considerably less to conservative treatment than lumbar pathology — which leaves to conservative management a more limited role.

“So, to the common question of whether surgery can be avoided when there is neck pain or a neurological symptom combined with symptoms in the arms or legs: quite often it cannot be avoided, and it should not be. If the symptoms are limited to pain alone, then yes — but the tools available for managing that pain are relatively limited.

In conclusion, when there is a problem in the neck accompanied by pain or symptoms in the arms, legs, or neck, an MRI should be performed to confirm or exclude cervical pathology, and the patient should be examined by a neurosurgeon.

Where there is compression producing numbness or weakness in the arms and legs, it must be managed surgically. Conservative treatment has a role when the patient has pain alone; even then its efficacy is moderate, and the role of alternatives such as epidural injections is very limited,” Dr. Blionas concludes.