2. Pain Structures Neck

3. Causes Chronic Neck Pain Bogduk, 1993 Facet alone 23% (31%) Disc alone 20% (12%) Facet and Disc - 41% ? 17%

4. Facets as Source Neck Pain

5. Does Whiplash Damage Discs? Disc Pathology After Whiplash Injury: A Prospective Magnetic Resonance Imaging and Clinical Investigation. Spine. 22(3):283-287, February 1, 1997. Pettersson, Kurt MD et al Followed up with MRI’s from injury to 2 years Those with symptoms and disc bulges at two years had them at time of injury. Those requiring surgery had MRI evidence of of the disc injury from the start.

6. Metanalysis of Cervical Discogram Literature DIAGNOSTIC VALUE OF CERVICAL DISCOGRAPHY IN MANAGEMENT OF CERVICAL DISCOGENIC PAIN SECONDARY TO WHIPLASH INJURIES AND ITS PREDICTIVE VALUE FOR CERVICAL FUSION American Journal of Physical Medicine & Rehabilitation. 84(3):204, March 2005. Isaac, Victor W. MD; Zaman, Faisel M. MD; DePalma, Michael J. MD; Slipman, Curtis W. MD “Approximately 84% of chronic whiplash patients have discographically proven painful discs”

7. Disc Levels (Zheng, 2004)

8. Levels Affected (Espersen ‘84)

9. Discogram Results (S. Grubb Spine (2000))

10. MRI vs Discogram Neck Neck pain vs asymptomatic Schellhas, Spine 1995 “Conclusions: Significant cervical disc anular tears often escape magnetic resonance imaging detection, and magnetic resonance imaging cannot reliably identify the source(s) of cervical discogenic pain.”

11. Long Term Neck Pain - Normal; Disc on MRI [in] group of pain sufferers, 10 of 11 MR-normal discs proved to have substantial anular tears at discography, with two of these intensely and concordantly painful. Fits with Bogduk’s findings that 20% chronic neck pain is disc alone, much of rest becomes facet related.

12. Disc or Facet Somatic Referral

13. Stages of Mrs. Rempel’s Condition Stage 1 - Somatic Pain Neck - Posterior Shoulder Girdle

14. Pattern Dec. 94-Aug. 97

15. Pattern 1997 - Radicular “Sciatica”

16. Mrs. Rempel’s Pattern Aug. 1997

17. Anterior Surgery Approach

18. Neck Surgery Recent Investigation of clinically important benefit of anterior cervical decompression and fusion A. Peolsson, Eur Spine J (2007) 16:507– 514 Approximately 70% of the patients had persistent pain and disability at 6-year follow-up.

19. Causes Continued Pains E. F. Eriksen & Eperson 1980’s - 1106 patients treated by anterior approach with fusion “Disabling symptoms were still present in approximately 45 % of the patients after operation.” Early relapse in first year - revision Late - new level

20. Persistence after surgery “It appears that during the first year after the 1st operations about 3/4 of the reoperations are performed as revisions. After the first year ¾ of the reoperations are performed at a new level and this indicates most of the true relapses.” J. O. Espersen et al, 1987

21. Rempel 3 month+ post-op

22. Mrs. Rempel’s Post-op Condition J. O. Espersen et al - Need revision? “Fused” levels appeared still mobile ?pseudoarthosis - may have contributed More likely - facets and other levels involved Poorer results if over 3 month from start

23. Mrs. Rempel’s Case Multiple facet level injections required to achieve any results

24. Cervical Discs - multilevels Grubb et al., 2000 “(47%) had symptomatic discs at three or more levels... Surgical management was considered appropriate in only 20%”

25. Disc Levels (Zheng, 2004)

26. Pseudoarthrosis Can Hurt Anterior Cervical Pseudarthrosis: Natural History and Treatment. Spine. 22(14):1585-1589, July 15, 1997 Phillips, Frank M. MD et al “67% with pseudarthroses were symptomatic” “A pseudarthrosis after anterior cervical discectomy and fusion is frequently associated with a poor clinical outcome”

27. Evidence Continuing Radiculitis

28. Deterioration and symptoms above levels fused

29. Borderline Spinal Stenosis

30. Alar Ligament Laxity Left