There are many people with pain that radiates into the shoulder, arm or hand who get an MRI and find out that they have cervical foraminal stenosis (narrowing) in the cervical spine that compresses one or more nerves in the foraminal canals.
Various Treatments for Cervical Foraminal Stenosis
The treatment for cervical foraminal stenosis is progressive and starts with the easy things first, so start conservative and advance treatment as needed. Your treating doctor will likely determine the initial treatment. There will be some variation in initial approach depending on whether you see an MD or DC.
Anti-inflammatories, narcotics and physical therapy would be a common initial treatment from an MD, while a DC might recommend an adjustment and/or traction as well as physical therapy.
Traction units may be recommended and are usually of two types, an over the door pulley system or a distraction unit.
The next level of treatment would probably be a steroid injection, usually called an “epidural”. These injections are usually administered in a medical facility with X-ray or CT guidance and some sedation. The injections contain some local anesthetic and cortisone. The idea is that the cortisone will shrink any tissues that are inflamed, thus relieving some of the pressure on the nerve.
Two Types of Epidural Injections
There are ones you inject into the central canal and the ones that are called transforaminal. The literature shows that transforaminal injections are more effective, but may be more risky to perform. CT guidance makes the injection process safer.
All the above (conservative) treatments may buy you some time and in some cases, a lot of time. However, in many cases, the stenosis will progress with increased symptoms, and surgery will become a good option with good results.
There are three surgical approaches to the problem of stenosis.
- The fusion
- Disc replacement
- Decompression without a fusion.
One very common, and successful, treatment for cervical stenosis is a fusion.
There are seven cervical vertebrae with five possible discs to fuse. The fusion that you had was performed at the level or levels that were contributing to your symptoms of neck, shoulder, or arm pain. When we talk about a certain disc, we always talk about its location in terms of a pair of numbers. The pair of numbers refers to the vertebrae above and below the disc, thus identifying the disc location. If someone were to talk about the C5 disc, it would be confusing. I would wonder if you were talking about the C4-5 or C5-6 disc.
Let’s say the disc location (C5-6) describes the level or location of the disc that is the problem area. Most likely there was some problem with degeneration or boney overgrowth contributing to some narrowing (stenosis). This narrowing or stenosis can occur in the area of the central canal, foraminal canal or both. The pain results from pressure on the nerves that can cause shoulder, arm, or hand pain.
The fusion addresses the problems mentioned above from two perspectives. The disc is replaced with some bone graft or spacer to “jack open” the disc space. This “opening or widening” of the disc space also opens the foraminal canals somewhat and can open the central canal as well. The second thing a fusion is supposed to do is to eliminate any motion that used to occur where the disc used to be. This occurs by joining the two separate vertebrae together by means of the bone graft or an implant. This elimination of motion generally helps with neck pain that came from the disc, which is removed in the process of the fusion.
Remember that there are five discs in the neck to accommodate all the motion requirements of twisting, turning, flexing and extending. For each disc that is fused, it means that those motion requirements will have to be shared with whatever discs remain. I think it is reasonable to assume that the remaining discs might be exposed to some additional work requirements to compensate for the fused segments. And these additional work requirements may result in some extra wear and tear or “degenerative changes” and are referred to as “adjacent disc disease” in the long term.
It should make sense that adjacent disc disease and its effects occur more often as time goes along. For example, cervical foraminal stenosis is often a result of degenerative overgrowth of the facets that produces spurs. These spurs, even when tiny, can grow into the foraminal canals and compete for space with the nerves, causing radiating pain.
It is in this way that a fusion can increase the incidence of cervical foraminal stenosis in the levels above or below the fusion site. Long- term studies indicate that adjacent disc disease occurs over 25% of the time ten years after a cervical fusion has been performed and probably more as time passes.
The Second Type Procedure
A second surgical procedure for treatment of foraminal stenosis is an artificial disc replacement. This procedure is similar to a fusion in that it uses an implant to “jack open” the disc space and will open the foraminal canals as well. The big difference from a fusion is that the artificial disc can move, and thus eliminate or reduce “adjacent disc disease”. It is a demanding procedure in terms of technique and the very long term studies about wear need to be fully evaluated, but shorter term studies with four year studies show overall success rates higher than a fusion 85% versus 72%.
(J Bone Joint Surg Am. 2011 Sep 21;93(18):1684-92. doi: 10.2106/JBJS.J.00476. )
Another recent paper shows no difference between a fusion and disc replacement results at four years, so sometimes hard to know.
(J Neurosurg Spine. 2013 Jan;18(1):36-42. doi: 10.3171/2012.9.SPINE12555. Epub 2012 Nov 9.)
The Third Type of Procedure
A third surgical procedure is that of foraminal decompression. This addresses the stenosis issue directly without having to do a fusion or use an implant, and can be done endoscopically. Surgery is directed at the problem area instead of restructuring the surrounding anatomy. Soft tissue disruption is at a minimum and there is usually an improved range of motion, without adjacent disc disease as a long-term complication. A study in my practice with two-year follow-up demonstrated 85% good to excellent results with minimal complications.
(J Neurosurg Spine. 2009 Apr;10(4):347-56. doi: 10.3171/2008.12.SPINE08576.)