Outcome Study of Surgical Treatment for Axial Neck Pain.

ABSTRACT

Background. We reviewed our surgical treatment of chronic axial cervical pain over a 4-year period to determine whether surgery in selected cases was associated with favorable outcomes.

Methods. We retrospectively studied 27 consecutive cases (20 patients with follow-up) of longstanding axial cervical spine pain treated surgically by a single surgeon from June 1994 through August 1998. Diagnostic workup included the following when appropriate: Minnesota Multiphasic Personality Inventory (MMPI) with interview, provocative diskography (with a nonpainful control level), single photon emission computed tomography (SPECT), and diagnostic facet injection. Twenty patients (74%) responded to a postoperative telephone survey.

Results. For general outcome measures, 85% of patients reported satisfaction with pain relief and surgical result. Ninety-five percent stated they would repeat the procedure; 85% manifested improvement in Prolo score.

Conclusions. Surgical treatment of chronic axial neck pain, when preceded by thorough evaluation, can yield excellent clinical results.

CHRONIC AXIAL NECK PAIN is an important public health concern. Although the Quebec Task Force on Whiplash-Associated Disorders considered whiplash to be essentially a benign and self-limited condition, nevertheless 13% of patients continued to have neck pain at 6 months after injury, with decline to 3% at 1-year follow-up. [1] Annual incidence of compensated cases in Quebec for 1987 was 70 per 100,000, with a total of more than $18 million in reimbursements. In this study, chronic and recurrent neck pain accounted for 15.7% of total costs. In a 10-year follow-up, Gore et a1 [2] reported poor correlation with radiographic abnormalities and found that 32% of cases of neck pain will progress to chronic pain syndromes. The anatomic basis of axial neck pain has been well reviewed by Swezey. [3]

One of us (R.M.V.) has previously described a nomenclature for chronic axial neck pain, or type III syndrome. [1] These cases encompass patients who have neck pain with only axial symptoms, in the absence of radiculopathy (type I syndrome) or myelopathy (type II syndrome). Similar clinical findings and presenting complaints have been described as internal disk disruption, discogenic pain syndrome, motion segment pain, and facet syndrome. As noted in the earlier study, [4] the surgical treatment of this entity is unpredictable and often unsatisfactory.

A variety of diagnostic interventions useful in evaluation of neck pain have been described, including magnetic resonance imaging (MRI), facet injection with or without concomitant local anesthetic block, and diskography. The clinical efficacy of these diagnostic modalities is unclear. [5-12] Efficacy of diagnostic cervical diskography also remains debatable. [10,11,13,14]

Preoperative evaluation in our series included various combinations of diskography, facet injection with local anesthetic block, SPECT, Mm, computed tomography (CT), and flexion-extension radiographs. Both anterior and posterior surgical approaches were used, depending upon the type of disease noted on preoperative evaluation. To standardize our outcomes measurement, we used four separate scales: a general outcomes scale; a modification of the Prolo scale, originally presented as an outcomes measure for posterior lumbar interbody fusions as an economic and functional outcomes indicator [15]; the short-form McGill Pain Questionnaire, as presented by Melzack [16] to assess continued neck pain at time of follow-up; and the Medical Outcomes Study Short-Form 36 as a measure of general health at time of follow-up. The subjective nature of patient health perception has been previously described. [17-19] A separate measure of patient satisfaction and subjective opinion of operative outcome and pain resolution is offered.

Our findings show that excellent clinical results may be obtained via surgical intervention for axial neck pain. Thorough preoperative evaluation and patient selection are important predicators of operative success.

MATERIALS AND METHODS

A retrospective review of cases in our private clinical database from June 1994 through August 1998 revealed 138 cervical operations, exempting surgeries for acute trauma, preoperatively diagnosed infection, neoplasm, and severe degenerative disease requiring anterior and posterior combined approach. Review of this subset of patients disclosed 27 operative cases of type III syndrome (20% of total cases) all operated on by a single surgeon (R.M.V.). Chart review provided general patient information and details of preoperative evaluations. Patient characteristics are presented in Table 1. All patients had a chief complaint of axial neck pain with minimal or no radiculopathy and no evidence of myelopathy on physical examination.

A total of 43 levels were fused, 31 levels via 19 anterior approaches and 12 levels via 8 posterior approaches. Three foraminotomies were included in the posterior cases. Anterior cervical diskectomy and fusion (ACDF) was accomplished via Smith-Robinson technique using the operative microscope in all cases. Autograft harvested from the anterior iliac crest was used in 25 of 31 anterior levels fused (81%). One anterior cervical plate was used in a two level ACDF case. Posterior surgeries included interspinous wiring with foraminotomy (4 cases), foraminotomy alone with unilateral facet denervation (1 case), and lateral mass plating (Axis Fixation System, Sofamor Danek, Memphis, Tenn) with facet denervation (3 cases).

Psychiatric interview and MMPI examination were done before provocative testing in all diskography cases. Because diskography relies on a subjective response, objective confirmation of each patient's mental stability and reliability was deemed necessary. Significant abnormalities on either interview or MMPI examination were considered a contraindication to diskography and further evaluation. Use of psychometric examination in the evaluation of chronic pain has been supported by previous studies. [20,21]

Diskography was executed in accordance with previously published interventional technique. [22] Results of diskography were considered positive only when it was provocative of concordant pain, which occurred with at least one pain-free control level. Changes in disk morphology in the absence of pain generation on injection were not considered positive findings in the preoperative evaluation of our patient cohort. Findings on anesthetic injection were not clear and are not included in this data set. Magnetic resonance imaging findings, included loss of normal disk hyperintensity on T2-weighted images. Disk "bulges," normally considered incidental findings, were not considered by themselves to be indications for surgical intervention. Single photon emission computed tomography was used to assess increased uptake in the posterior vertebral elements. Clinical relevance was confirmed by response to facet injection and anesthetic block. Computed tomography examinations were reviewed with emphasis on degenerative fa cet changes. Flexion/extension examinations were considered positive when increased motion segment mobility--increased kyphosis on flexion, spinous process flaring, or translational slip-was present. Using criteria established by White et al, [23] no patient's condition was considered unstable on radiographic grounds.

Twenty-one patients (78%) had positive findings on 2 or more radiographic examinations or provocative tests before surgical intervention. Of the 6 patients operated on after a single positive examination, 4 had positive disko-grams in isolation, comprising 15% of the total patient series and 67% of patients with a single positive examination.

Two patients had complications as a result of preoperative evaluation or surgical intervention. One patient had postoperative Homer's syndrome after an otherwise routine C4-5 ACDF. This deficit had resolved completely at the most recent follow-up. Another patient had diskitis and osteomyelitis due to methicillin-sensitive Staphylococcus aureus after diskography at C3-4 through C6-7. The infection was discovered during ACDF at C4-5 and C5-6. The patient responded well to antibiotics and had no permanent sequelae. Complication rate for the entire series was 7%. Complication rate for diskography was also 7%. No complications resulted from facet injection. No pseudoarthroses were noted on postoperative flexion/extension radiographs.

Via telephone survey, a general outcomes survey (Table 2), Modified Prolo outcomes scale (Table 3), short-form McGill Pain Question-naire, and Short-Form 36 Health Survey [19] were completed. The preoperative Prolo score was retrospectively obtained through chart assessment and patient responses. Twenty patients were successfully contacted and participated in the study, yielding a response rate of 74%. Two patients refused to participate in the study, and 5 patients were unavailable for assessment. Short-Form 36 scores were evaluated by an independent assessor (IMF Consultants, Sharon, Ontario). Two software packages were used for statistical analysis: Primer of Biostatistics, McGraw-Hill, New York; and SimStat for Windows, Provalis Research, Montreal.

RESULTS

General Outcomes Scale

On a general outcomes scale, patients indicated being "very satisfied" or "somewhat satisfied," with pain relief reported in 17 of 20 cases (85%) (mean, 1.7 [+ or -] 1). Findings with respect to surgical outcome were similar, with 85% indicating "very" or "somewhat satisfied." Nineteen of 20 patients said they would repeat surgery (95%), and 18 of 20 would recommend surgery to a friend or family member with similar preoperative symptoms (90%). Three patients unemployed before surgical intervention had returned to work at time of follow-up. The remaining 3 unemployed patients were either on disability or had workers' compensation cases pending. Eight patients (40%) were still taking prescription pain medication at follow-up.

Prolo Scale

The preoperative Prolo score obtained retrospectively via combination of chart review and patient questioning presents a source of possible bias in our results. Prolo results are presented in Table 4. Average improvement in Prolo score, when comparing patients' individual changes in Prolo grading, was 2 [+ or -] 1.6. Seventeen scores improved, with maximal improvement of 5 points (85% rate of improvement, mean improvement 2.5 [+ or -] 1.1 points). One patient's score remained unchanged. Two patients' scores became worse by 1 point. In one of these, postoperative physical activity restrictions limited work activity, reducing economic score from 4 to 3. In the other, continued neck pain prevented return to preoperative employment and again decreased economic score by 1 point. No decrease in functional status was evidenced. Postoperative Prolo improvement was statistically significant via assessment with paired t test (t=-5.71, P[less than].001).

Short-Form McGill Pain Questionnaire

The short-form McGill Pain Questionnaire was used to assess postoperative persistence of neck pain. Because of the retrospective nature of our study, no preoperative data were available for comparison. Patients were asked to describe their pain over the previous week. Average sensory score was 8.7 [+ or -] 7.7, (range, 0 to 33), average affective pain score was 2.3 [+ or -] 2.7 (range, 0 to 12), and total score was 10.9 [+ or -] 10.2 (range, 0 to 45). Three patients (15%) were completely pain free (McGill score = 0), and 7 patients (35%) had scores of 5 or less.

Medical Outcomes Survey Short-Form 36

Short-form 36 health assessment survey was administered as described by Ware and Sherboume. [19] Individual patient results assessed by an independent examiner were compared with normative data provided by the Medical Outcomes Study Group (IMF Consultants, Sharon, Ontario). Separate median-age controlled comparison was made to a subject series of more than 9,000 working-age adults from the Health Services Research Unit, Oxford. [24] The only factors significantly lower than norms provided by the Medical Outcomes Study Group were physical functioning (P = .03), physical problems (P[less than].001), and bodily pain (P[less than].001). Similar findings in patients with low back pain were reported by Garratt et al. [25]

DISCUSSION

Preoperative Evaluation

Rationale for Choice of Preoperative Assessment. The most important single factor in achieving excellent clinical outcome in surgical treatment of axial neck pain is patient selection. The quality and severity of each individual's pain complaints, patient motivation, and patient perception of surgical therapy and expected outcome are each important. In obtaining informed consent for surgical therapy of type III syndrome, we advise patients that the chance of success is "at best 2 out of 3." Unreasonable expectations of surgical outcome are corrected preoperatively.

Our patient population had chronic axial neck pain, the average duration of pain before surgery being 33.6 [+ or -] 34.5 months (median 22 months, mode 36 months) and ranging from 3 months and to more than 10 years. Patient motivation and evidence of significant secondary gain were assessed before initiating workup. The included patients were then subjected to multiple radiographic analyses, invasive diagnostic testing, and, for diskography patients, formal psychiatric evaluation. Surgery was offered only after assessment of psychiatric profile (when obtained), review of radiographic findings, and lengthy discussion with each patient.

Minnesota Multiphasic Personality Inventory. Each diskography patient had a formal psychiatric interview with full MMPI evaluation that was completed and reviewed by psychiatric personnel. Validity of the MMPI in assessing patients with chronic pain has been established. [21,26]

Using MMPI assessment before diskography obviates possible subjective responses or hysterical reaction to disk space injection, similar to using control levels in the procedure. Realizing the inherently subjective nature of individual patient pain response, we believe that MMPI evaluation as a screening tool increases the probability of achieving a reliable preoperative assessment. Significant findings of psychopathology on MMPI examination or psychiatric evaluation were deemed contraindications to diskography and surgical intervention.

Radiographic Evaluation

Single Photon Emission Computed Tomography. In seven cases, SPECT examinations were done to assess facet arthropathy and to localize possible facet joint pain generators. Positive results were correlated in all cases with response to facet joint injection with local anesthetic. SPECT scanning has been correlated with response to facet joint injections [27] and assessed in spondylosis and spondylolisthesis [28] in the lumbar spine. SPECT evaluation of pseudoarthrosis has been analyzed. [29]

Radiography, CT and MRI. Flexion/extension films demonstrated motion segment abnormalities in 8 patients. No evidence of gross instability was found. [23] Flexiorn/extension findings were correlated with diskography and facet injection results, and CT findings were reviewed with emphasis on facet degeneration and foraminal anatomy. Magnetic resonance imaging was used to assess disk morphology. We did not attempt to correlate diskography and MRI findings, as have Schellhas et al [14] and Parfenchuck and Janssen. [10]

Invasive Testing

Facet Injection. The existence and prevalence of zygapophyseal joint pain are highly controversial topics. Test of a null hypothesis by Aprill and Bogduk [30] revealed that 25% of 318 patients referred to a diagnostic pain clinic had symptomatic zygapophyseal joint pain. Use of zygapophyseal joint blocks in chronic cervical pain has been reported. [5,7,8,12,31] Barnsley et al [31] documented a significant difference in duration of pain relief with various anesthetic agents. Patients who received bupivacaine manifested significantly longer pain relief than those treated with lidocaine. In a randomized, prospective study of 24 patients, Lord et al [9] used radiofrequency neurotomy to treat chronic cervical zygapophyseal joint pain diagnosed by doubleblind, placebo-controlled local anesthetic administration. Their results showed significant improvement in pain scores among patients who were treated by radiofrequency neurotomy.

Dwyer et al [6] evaluated joint injection in normal physician-volunteers who evidenced pain generation in 9 of 11 joints, with consistent patterns of referred pain distribution. In a similar study of 61 patients, Fukui et al [32] found a comparable pattern of referred pain distribution. It is postulated that zygapophyseal joint pain arises via innervation from the medial branches of the cervical dorsal rami. Two branches, ascending and descending, supply the facet joints above and below the respective root foramina. [5,12] The technique of radiofrequency neurotomy, which produces lesions in these neural elements, has been described. [7]

We believe the cervical zygapophyseal joint can occasionally be a genuine source of cervical pain. Thorough evaluation, including CT examination of facet architecture, SPECT scanning, and invasive diagnostic testing, must be completed before operative intervention is considered.

Diskography. Efficacy of diagnostic disk injection has been a topic of great contention in the literature since its introduction by Cloward [33] in 1955. Roth [34] introduced the addition of local anesthetic to diagnostic injection, now a standard feature of cervical diskographic examination. Surgical outcomes after this protocol featured 93% good to excellent results. Whitecloud and Seago [35] reported 70% good to excellent results in their series of surgically treated patients with positive cervical diskograms. These series do not assess psychologic evaluation of their patient cohort. Complications from diskography can occur. [13] Some researchers maintain that diskography has no role in the evaluation of cervical spine disorders.

Multiple authors have noted the poor correlation of diskographic findings with the MRI assessment of cervical disk morphology.[10,11] Abnormal disks are the norm on diskographic examination. [36] This high rate of abnormal findings, with high sensitivity and lack of specificity, has called into question the diagnostic efficacy of diskography. [14,37,38]

We consider diskography positive only when injection produces concordant pain and only when supported by adjacent, pain-free control levels. When considering the subjective nature of the pain response, we believe that augmentation with formal psychologic evaluation and MMPI testing is necessary in preoperative evaluation. Only when these conditions are met and only when MMPI testing falls within previously stated norms do we use diskography as a diagnostic test to identify a diskogenic pain generator.

Outcomes Assessment

Rationale for Choice of Outcomes Assessment. Various outcome measures have been described in the literature, and specific modifications for spinal surgery have been presented. [30-41] After considering a variety of assessments in planning our study, [42-44] we chose 4 separate outcome scales that would thoroughly assess the postoperative status of our patient population. We obtained a standard general outcome study, assessing patient opinion of surgical success or failure, return to work, and continued use of prescription pain medication (Table 2). The Prolo score, originally presented with reference to outcome from posterior lumbar interbody fusions, was modified for cervical pain. Within the neurosurgical community, this scale is well known and is widely used to summarize postoperative functional and economic status. [15] Persistence of cervical pain is assessed with use of the short-form McGill Pain Questionnaire, a brief and easily executed assessment of sensory and affective pain. Addition of a verbal a nalogue scale, similar to the visual analogue scale presented by Melzack, [16] and a present pain intensity value provide further information on the type, severity, and character of individual patient pain perception. [45] Subjective view of global health is provided by the Medical Outcomes Study (MOS) SF-36, a widely accepted outcome study that has shown statistical validity when used by a variety of examiners in numerous clinical situations. [17-19,24,25,46,47]

An important consideration in choosing these outcome studies was time of administration. A reasonably complete assessment of either preoperative or postoperative patient condition may be obtained with this combination of studies, all of which maybe completed in roughly 15 minutes. Continued use of this paradigm in preoperative evaluation of axial neck pain is being considered at our institution.

Prolo Scale. The Prolo scale, a simple and easy to use measurement of economic and functional status, was modified for use in our study by concentrating on cervical as opposed to lumbar pain. No modification of the economic status scale was deemed necessary. Correlation with anatomic result of posterior lumbar fusion is offered by Prolo et al [15] in describing the study. Inclusion of the Prolo score provides a scale well known in the neurosurgical and orthopedic literature.

Short-Form McGill Pain Questionnaire. The short-form modification of the McGill Pain Questionnaire, as presented by Melzack, [16] provides qualitative assessment of pain via 15 descriptive terms, 11 categorized as sensory and 4 as affective. [16] A score of 0 (no pain) to 3 (severe pain) is assigned to each term, and a global score is obtained. We used the short-form McGill Pain Questionnaire to assess quality and severity of persistent cervical pain at follow-up. This measurement has limited usefulness in isolation; the retrospective nature of our assessment yields lack of preoperative scoring.

Medical Outcomes Study Short-Form 36. The MOS short-form 36 is a 36-item survey designed for use by direct interview or telephone contact, or for self-administration. This scale assesses conception of health in 8 separate categories: physical functioning, role limitations due to physical problems, role limitations due to emotional problems, social functioning, bodily pain, general mental health, vitality, and general health perceptions. [19] It has been validated in numerous studies and enjoys widespread use as a general outcomes measure. [17,24,25,47] It has also been used as a quality of life measurement. [46] The SF-36 has been described for use in spinal operations. [28,48,49]

SUMMARY

Our results show that surgical treatment of axial neck pain or type III syndrome can yield excellent clinical outcomes. All our patients presented with chronic axial neck pain of nearly 3 years' mean duration. No patients with myelopathy or significant radicular complaints were included. Each patient had an extensive preoperative evaluation, as reviewed previously. We believe quality of operative outcome is directly related to preoperative assessment and patient selection. Through rigorous evaluation, patients with a significant possibility of improvement from surgical intervention were selected.

A global assessment of operative results, using 4 separate measures, confirms these suppositions. Our general outcome scale shows that a large majority of patients were satisfied with their postoperative result and level of pain control, which is confirmed by the low values recorded on administration of the short-form McGill Pain Questionnaire. Documentation of improved functional and economic status is provided by the Prolo scale, which showed improvement of 2.5 [+ or -] 1.1 points in 17 of 20 patients (85%). Further documentation of patient status is provided by the SF-36, where in 5 of 8 categories our patient population was not statistically different from normal control groups. A small but significant deviation was noted in physical functioning score, and more pronounced impairment of scores was documented in physical role limitation and bodily pain scales. These findings are similar to those previously observed in chronic low back pain patients from the National Health Service. [25]

CONCLUSION

This study shows that with rigorous preoperative evaluation, excellent clinical results can be obtained though surgical treatment of axial neck pain. We present a model of postoperative patient evaluation that assesses pain, functional and economic status, quality of general health, and satisfaction with surgical outcome through combining a general outcomes measurement, Prolo score, short-form McGill Pain Questionnaire, and Short-Form 36 testing. These results support a prospective, controlled study of surgical therapy in cases of axial neck pain.

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TABLE 1. General Patient Characteristics
Age (years)                            46 [+ OR -] 11
                                      (range, 23 to 71)
Sex
 Male                                      9 (33%)
 Female                                   18 (67%)
Preoperative employment status
 Employed                                 16 (70%)
 Homemakers                                3 (11%)
 Retired                                   2 (7%)
 Unemployed                                6 (22%)
Returned to work after surgery             3 (50%)
Involved in litigation                     6 (22%)
Workers' compensation cases                8 (30%)
Inciting event
 Automobile accident                       8 (30%)
 On-the-job injury                         8 (30%)
Duration of pain before surgery (mo)   34 [+ OR -] 35
 Range                                     3-140
 Median                                   22
 Mode                                     36
Length of follow-up (mo)               24 [+ OR -] 25
 Range                                     4-52
 Median                                   22.5
 Mode                                      7
Previous spinal operations
 Cervical                                  4 (15%)
 Lumbar                                    5 (19%)
Symptomatic pseudoarthroses                3 (11%)
Anterior approach                         19 (70%)
 Levels fused                             31
 Autograft                                25 *
 Allograft                                 6 +
Posterior approach                         8 (30%)
 Levels fused                             12
Preoperative diagnostic tests
 Diskography                              14
 SPECT                                     7
 MRI                                      10
 Flexion/extension radiographs             8
 CT                                        3
 Facet injection with block               15
Number of positive examinations
 4                                     1 patient (4%)
 3                                    10 patients (37%)
 2                                    10 patients (37%)
 1                                    6 patients (22%)
Complications                              2 (7%)
(*) 81% of anterior levels fused.
(+) 19% of anterior levels fused.
SPECT = Single photon emission computed tomography,
MRI = magnetic resonance imaging. CT = computed tomography.
TABLE 2. General Patient Outcomes Scale
Pain relief                Very Satisfied  Somewhat Satisfied
                                 1                 2
Surgical outcome           Very Satisfied  Somewhat Satisfied
                                 1                 2
Would you repeat surgery?  Definitely Yes     Probably Yes
                                 1                 2
Would you recommend        Definitely Yes     Probably Yes
 surgery to a friend.            1                 2
 or family member?
Return to work if               Yes                No
 unemployed/disabled?
Presently using pain            Yes                No
 medication?
Pain relief                 Neutral    Somewhat Unsatisfied
                               3                4
Surgical outcome            Neutral    Somewhat Unsatisfied
                               3                4
Would you repeat surgery?  Don't Know      Probably No
                               3                4
Would you recommend        Don't Know      Probably No
 surgery to a friend.          3                4
 or fnmily member?
Return to work if
 unemployed/disabled?
Presently using pain
 medication?
Pain relief                Very Unsatisfied
                                  5
Surgical outcome           Very Unsatisfied
                                  5
Would you repeat surgery?   Definitely No
                                  5
Would you recommend         Definitely No
 surgery to a friend.             5
 or fnmily member?
Return to work if
 unemployed/disabled?
Presently using pain
 medication?

TABLE 3. Modified Prolo Outcomes Scale

Economic states

El Complete invalid

E2 No gainful occupation (including housework, retirement activity)

E3 Able to work, but not at previous occupation

E4 Working at previous occupation on part-time or restricted status

E5 Able to work at previous occupation with no restrictions of any kind

Functional status

Fl Total incapacity

F2 Mild to moderate level of neck pain, but able to perform all activities of daily living

F3 Low level of pain and able to perform all activities except sports

F4 No pain, but patient has had at least one recurrence of neck pain

F5 Complete recovery, no pain, able to perform previous sports activities

TABLE 4. Results Using the Modified Prolo Outcomes Scale
Economic/Functional               No. of
Categories                Score  Patients
Preoperative Assessment
E2/F2                       4       1
E3/F2                       5       7
E3/F3                       6       1
E4/F2                       6       4
E4/F3                       7       3
E5/F2                       7       3
E5/F3                       8       1
Postoperative Assessment
E3/F2                       5       5
E3/F3                       6       1
E4/F3                       7       3
E4/F4                       8       1
E5/F3                       8       2
E5/F4                       9       6
E5/F5                      10       4
Average preoperative score, 5.95 [+ or -] 1
Average postoperative score, 8 [+ or -] 1.7

KEY POINTS

* Surgical treatment of axial neck pain or type Ill syndrome can yield excellent clinical outcomes.

* On a general outcomes scale, patients indicated being very satisfied or somewhat satisfied with pain relief.

* Nineteen of the 20 patients said they would repeat surgery, and 18 of the 20 individuals said they would recommend surgery to someone with similar preoperative symptoms.

* The quality of operative outcome is directly related to preoperative assessment and patient selection.