Cervical / Vertigo/ Dizziness Spondylosis

CERVICAL SPONDYLOSIS (NECK OSTEOARTHRITIS) WITH/ WITHOUT NUMBNESS/WEAKNESS/DIZZINESS

Symptoms include:Cervical spondylosis is a condition that is caused by the wear and tear of facet joints in the neck. The spinal disks might prolapse, dehydrate and shrink and signs of osteoarthritis may be present on Xray.

Symptoms

• Pain and stiffness in the neck.
• narrowing of the space in the spinal cord
• Tingling, numbness and weakness in the hands or legs
• Lack of coordination/ dizziness/ vertigo             

Causes: With the increase in age, the bones and cartilage that make up the spine and neck gradually undergo wear and tear. These changes include dehydration and herniated disks, bone spurs and stiff ligaments making neck less flexible.
Diagnosis: The doctor performs a physical examination that may include:

• Checking the range of motion in the neck
• Testing the reflexes and muscle strength
• Neck X-ray to show abnormalities such as bone spurs, tumors, infections or fractures.
• MRI scans to pinpoint areas where nerves are pinched.
• Nerve function tests:  Electromyography (EMG) and Nerve conduction study

Conventional Treatments
Treatment method depends on the severity of the symptoms. The purpose of the treatment is to help relieve pain, help in activities of daily living and prevent injury to the nerves and spinal cord. These factors are conventionally achieved by:

• Medications (Nonsteroidal anti-inflammatory drugs, Corticosteroids, Muscle relaxants, Anti-seizure medications,  Antidepressants, Prescription pain relievers)
• Surgery procedures are performed to:
• Removal of a herniated disk
• Remove part of a vertebra
• Fuse a segment of the neck using bone graft

ALTERNATIVE TREATMENT METHODS AT BETH YEHUWDAH ARTHRITIS CENTRE, PULLAD & DAYSTAR CLINIC, ALAPPUZHA

The root cause of most neck pain including Cervical Spondylosis & Cervical disc prolapse is Cervical Spinal Instability. The stable cervical spine behaves like a see saw with its fulcrum at the facet joint. The disc in front is partly balanced by ligaments and muscles at the back. If there is damage to the ligaments/muscles in the form of strain, more weight is transferred to the disc region in the front which may lead to disc prolapse. In Dr Tejaz John’s experience Platelet Rich Plasma Prolotherapy and Dextrose Prolotherapy offer the best results by stimulating the body’s immune system to repair and naturally tighten these ligaments and muscles at the back of the facet joint, thereby relieving stress in front of the facet joint namely the disc region.

 Symptoms caused by Cervical Instability

• Progressively worsening symptoms.
• Frequent recurrence of catching/ locking neck pain & muscle spasms.
• Feeling of dizziness, neck instability or giving way.
• Pain on neck movements.
• Need to crack or click the neck frequently to reduce symptoms.
• Temporary relief with cervical collar.

Chronic Conditions caused by Cervical Instability: Radiculopathy, Cervical Canal Stenosis, Degenerative disc disease, Herniated disc, Numbness/ Weakness in upper limb & Cervical Spondylosis.

Many times a patient with neck pain; despite various treatments still has pain and now has been recommended a neck surgery because “MRI shows something”. But is it in fact the disc prolapse on MRI always the cause of the patient’s pain? Medical researchers are asking, “Maybe we should look at the spinal ligaments?”

In our practice we often see patients who are in severe neck pain. They have an MRI, X-ray and/or scan that may show an inaccurate picture of what is causing their pain. The MRI cannot show muscle spasms from a simple cervical strain which can cause excruciating pain. Neither can it detect early microstructural damage at the ligament bone junctions/ enthesitis nor can it detect nerve sheath CCPs (chronic constricting points) along the course of various nerves. Conversely, a herniated disc may be seen on MRI which may be completely painless. Yet that herniated disc will send the patient to surgery. Dr Tejaz John has observed in his clinical practice that at times patients may bring MRI showing disc prolapse towards one side whereas the symptoms are experienced on the opposite side.

Here is a statement from the medical journal Childs Nerv Syst. 2015: “As important as the vertebral ligaments are in maintaining the integrity of the spinal column and protecting the contents of the spinal canal, a single detailed review of their anatomy and function is missing in the literature.” Unlike muscle tissue, ligaments and tendons have a poor supply of blood to regenerate them. This is why ligaments can remain in a weakened and irritable inflammatory state and may not heal. The chronic neck pain patient may have history of trauma or overuse to the neck that results in injury to various spinal ligaments that hold the vertebrae and spinal processes in place. Ligaments can bear a normal amount of stress that causes them to stretch up to their natural limit, returning back to their normal length once the stress is removed. If added (traumatic) stress is applied on the ligament, it is stretched beyond its natural range of extension, and subsequently fails to return to its original length but instead remains permanently overstretched resulting in plastic deformation, diminishing its integrity and attachment to the bone. This causes ligament and soft tissue loosening and subsequent cervical instability.

1) PRP for Cervical Spondylosis/Cervical Instability Platelet-Rich Plasma Therapy (PRP) has been found to be effective in treating degenerative disc disease by medical researchers by dealing with the problem of spinal ligament instability. The sooner the spinal ligament instability as well as the degeneration is addressed, the better the results in patient satisfaction. In fact, abnormal stress on the spinal ligaments could be an important cause for most pain in degenerative disc disease.PRP is an effective means of alleviating neck pain because it eliminates pain by stimulating the local immune response to heal the underlying tissues and may help avoid surgery in cases of cervical ligament instability.
PRP prolotherapy is a combination treatment where PRP as well as Dextrose Prolotherapy is administered at the same time in the neck region. This treatment may help a patient who does not want surgery and helps to overcome the disease condition with minimally invasive injection techniques. The treatment method stimulates the natural immune repair mechanisms of the body and delivers the building block essential to build and repair damaged tissues.

How does PRP work? Blood components are of four major types - plasma, platelets, white blood cells and red blood cells. Platelets assist in clotting and are also the “first-responders” of the body post injury; helping repair an injured region and in building up of new tissue and thereby promoting the healing process. Once platelets contact collagen in damaged tissues, the platelets release various biological growth factors (Table 1 as given below) to promote healing in soft tissues locally. Activated platelets commonly release the following growth factors:

Table 1: Various biological growth factors released by PRP when activated

PRP injection delivers a high concentration of autologous (patient’s own) platelets to to the joints and soft tissues in the neck/ cervical region, where Spondylosis is present. Platelets present in the blood are the first responders to an injured area and helps build up new soft tissues. Introducing high concentration of platelets directly into the joint using PRP injection stimulates the healing process and faster recovery from the joint condition.  
      
Patient Benefits of PRP Prolotherapy

• Minimally invasive treatment method
• Almost painless injection technique using very thin needles under local anesthesia
• For those who wish to avoid if not delay Neck Surgery.
• Significantly reduces the symptoms associated with Cervical Spondylosis in most patients
• Reduced risk of adverse events
• Assists in repair and tightening of ligaments and muscle attachments improving joint stability.
• Safe and effective treatment method
• Assists in healing and recovery

2) Comprehensive Dextrose Prolotherapy for Cervical Spondylosis/ Cervical Instability
Neck pain is one of the leading causes of disability, yet most of the people suffering from it do not know that Cervical spinal instability is most likely the real cause of the problem! We see, most patients take pain tablets and muscle relaxers to cover the pain, which only masks further degeneration and leads to an endless “pain management” cycle. This is like treating the symptoms versus correcting underlying spinal instability. Comprehensive Dextrose Prolotherapy can break this cycle by assisting the regeneration of weakened and stretched-out soft tissue structures of the cervical spine, alleviating pain and instability. Using Prolotherapy, these conditions can be treated properly and safely to give a more desirable symptomatic outcome. If you want to get off the neck pain bandwagon, try Prolotherapy; which is a natural and cost effective alternative method to surgery.

Prolotherapy is an almost painless injection technique under local anesthesia where very thin needles are used to inject high concentrations of dextrose solution (sugar similar to glucose) in to loose and damaged ligaments, tendon and muscle attachments around the osteoarthritic joint/ entheses. Prolotherapy works by increasing the glucose concentration in the fluid outside the cells. This results in movement of fluid from inside the cells to the outside of the cells thereby shrinking the cells and causing temporary cell damage (hyperosmolar damage). As the cells are temporarily damaged, they release many biosignals to the body which results in stimulation of the immune system of the body to accelerate the inflammatory process locally resulting in increased local blood circulation, fibroblast (fibrous cell) proliferation, ligament regeneration, tightening and repair. In Dr Tejaz John’s experience, Prolotherapy is an effective non surgical treatment method used successfully in cervical instability. This treatment method has the ability to strengthen the existing intact, but weakened, ligamentous and tendinous structures in the neck region. Along with the treatment technique, it is important to perform series of movement and muscle strengthening exercises to strengthen the already weakened muscles in chronic cervical Spondylosis.

Patient Benefits of Comprehensive Dextrose Prolotherapy

• Minimally invasive treatment method
• Almost painless injection technique using very thin needles under local anesthesia
• For those who wish to avoid if not delay Surgery
• Significantly reduces the symptoms associated with Cervical Spondylosis/ Neck Instability, indirectly helping to prevent recurrence of Neural symptoms like numbness, tingling and weakness secondary to cervical instability.
• Reduced risk of adverse events
• Repairs and tightens ligaments improving spine stability and reducing pain.
• Safe and effective treatment method
• Faster healing and recovery

Neural & Soft Tissue Infilteration Therapy (NESTIT)

Low Dose Steroid Infilteration/ Neural & Soft Tissue Infilteration Therapy (NESTIT):  Steroid tablets and injections of the group Corticosteroids, (which are very different from Anabolic steroids misused by some athletes) have been repeatedly proven medically for the last 70 years in the successful treatment of inflammatory conditions due to its potent anti-inflammatory effect. Though corticosteroids are very effective in reducing inflammation, they carry numerous potential side effects, which are undesirable. To circumvent this problem, and in order to utilize the potent anti-inflammatory effects of steroid injections, at the same time taking appropriate measures to considerably lower its side-effects, Dr Tejaz Koshy John in 2010 while working as an Orthopaedician in his private clinic in Guyana, South America developed NESTIT. NESTIT stands for (Juxta) Neural and Soft Tissue Infilteration Therapy. It consists of injecting small amounts of diluted anti inflammatory steroid solution indirectly near (juxta) nerve CCPs- (chronic constricting points) in the lower back/ hip/ neck/ shoulder regions, in order to reduce juxtaneural and perineural inflammation, as well as in certain soft tissue sites including but not limited to trigger points (painful muscle “knots”)/ myofascial syndrome and/or enthesitis (inflammation of soft tissue-bone junctions) and/or sites of nerve inflammation (neuritis/ radiculitis) and/or bursitis (inflammation of fluid filled cushions called bursa) and/or additional sites causing pain referrals (referred pain) to distant sites; in order to obtain a reduction in inflammation and pain in the concerned joint/ region/ limb. It is preferably given for those patients who have Rheumatoid Arthritis, Inflammatory Arthritis, Synovitis, Inflammatory Low Back Pain, Spondyloarthropathy & Nerve and Nerve root irritation. It is not a substitute for DMARDS (Disease modifying anti rheumatoid drugs), however when given with low dose DMARDS, in Dr Tejaz John’s clinical experience it may result in significant reduction of local inflammation, pain and improvement of joint function in most cases, also indirectly reducing side effects of high dose DMARDS.

NESTIT involves 

1. Administeration of low dose local steroid via infilterative type of injection technique rather than giving oral steroids (as cumulative daily dosage of oral steroids over a 6 week period could exceed the dose of local steroid injection by almost 5 to 10 times) or conventional single injection into joints directly.
2. Reduce the dosage of Steroid given via injection and the use of a sliding scale according to patient’s body weight and height to regulate dosage. A 40 kg woman of 4 feet 9 inches should not receive the same dosage as a 100 kg male of 6 feet height.
3. Dilute the low dose steroid injection upto 80% with sterile water and local anesthetic.
4. Administer relatively insoluble low dose steroid via multiple infilterations locally in inflamed tissues in very small amounts indirectly near (juxta) nerve CCPs- (chronic constricting points) in the lower back/ hip/ neck/ shoulder regions as per requirement, in order to reduce juxtaneural and perineural inflammation, as well as in certain soft tissue sites including but not limited to trigger points (painful muscle “knots”)/ myofascial syndrome and/or enthesitis (inflammation of soft tissue-bone junctions) and/or sites of nerve inflammation (neuritis/ radiculitis) and/or bursitis (inflammation of fluid filled cushions called bursa) and/or additional sites causing pain referrals (referred pain) to distant sites; in order to obtain a reduction in inflammation and pain in the concerned joint/ region/ limb.
5. Identification of high risk patients and risk stratification to reduce possibility of side effects, for eg. Patients suffering from serious heart & liver conditions tuberculosis, infections, significant osteoporosis, immuno-compromised patients, menstrual irregularities, already having Cushing’s syndrome, ongoing significant hair loss etc.
6. Regular monitoring of body weight and physical appearance for early detection of Cushingoid features, if it occurs (rarely), to delay/ avoid further injections.
7. Control of High Blood Pressure and Diabetes prior to giving injections.
8. Doing skin sensitivity tests to rule out allergic reactions to the drugs.
9. Explaining possibilities of common & rare side effects to the patient and taking precautions regarding other common side effects wherever possible.
10. Opting for/ Shifting to regenerative treatments like Platelet Rich Plasma and Dextrose Prolotherapy wherever there is secondary degenerative disease / soft tissue damage, once the severe inflammation subsides.

In Dr Tejaz John’s clinical experience, the patient benefits of Low Dose Steroid Infilteration/ Neural & Soft Tissue Infilteration Therapy (NESTIT) treatment are:

• Minimally invasive treatment method
• Almost painless injection technique using very thin needles under local anesthesia
• Avoid if not delay Surgery in Inflammatory conditions in the cervical spine leading to numbness and weakness in upper limb/(s).
• Significantly reduces the symptoms associated with nerve/ nerve root inflammation in cases of Cervical Spondylosis.
• Reduced risk of adverse events compared to oral steroid tablets which are usually taken daily, due lower dosage (very low steroid dosage compared to cumulative oral steroids over 6 week period).
• Reduced risk of side effects/ adverse effects due to prior risk stratification and identification of high risk patients vs. low risk patients by doing precautionary steps and tests prior to giving injection.
• Reduced incidence of post-injection pain due to highly diluted steroid solution.
• Reduces stiffness.
• More effective treatment method in inflammatory musculoskeletal diseases.
• Faster recovery.

At Beth Yehuwdah Arthritis Centre, Pullad & Daystar Clinic, Alappuzha we provide a variety of options for patients suffering from Cervical Spondylosis with or without neural symptoms and Vertigo/ Dizziness. To know more book an appointment now.