Biomechanical and ergonomic risks associated with cervical musculoskeletal dysfunction amongst surgeons: A systematic review.

INTRODUCTION: Surgeons are at high risk of developing musculoskeletal symptoms due to a range of factors including, maladaptive positioning and surgical ergonomics. Cervical muscle strain and biomechanical load is most prevalent due to repetitive motions and prolonged static neck positioning. This issue is apparent through reports of prevalence between 10 and 74.4% among surgeons. The aim of this systematic review is to provide an objective assessment of the clinical evidence available and a descriptive analysis of the effects of kinematics and surgical ergonomics on the prevalence of surgeons' cervical musculoskeletal pain. METHODS: This is PRISMA-compliant systematic review of clinical studies assessing the prevalence of cervical musculoskeletal dysfunction in surgeons by searching PUBMED and Ovid EMBASE databases from inception to 19th October 2023. Study quality was graded according to the National Institutes of Health study quality assessment tools. RESULTS: A total of 9 studies were included in the final qualitative analysis. The use of loupes, open surgery and excessive neck flexion (>30°) were associated with cervical dysfunction. Comparison of study outcomes was challenging due to heterogeneity within study methods and the paucity of methodological quality. CONCLUSION: The current literature assessing ergonomic and biomechanical factors predisposing surgeons to cervical musculoskeletal dysfunction is insufficient to provide reliable guidance for clinicians. Although the literature identifies factors contributing to work-related cervical dysfunction, few attempt to evaluate interventions for improved surgical ergonomics. An objective assessment of interventions that prompt postural correction with the aim to improve neck pain in surgeon cohorts is warranted.

The effect of a neck-specific exercise program on cervical kinesthesia for patients with chronic whiplash-associated disorders: a case-control study.

INTRODUCTION: Cervical kinesthesia is an important part of movement control and of great importance for daily function. Previous research on kinesthesia in whiplash-associated disorders (WAD) has focused on grades I-II. More research is needed on WAD grade III. The aim of this study was to investigate cervical kinesthesia in individuals with WAD grades II-III before and after a neck-specific exercise intervention and compare them to healthy controls. METHODS: A prospective, case-control study with a treatment arm (n = 30) and a healthy control arm (n = 30) was conducted in Sweden. The WAD group received a neck-specific exercise program for 12 weeks. The primary outcome to evaluate kinesthesia was neck movement control (the Fly test). Secondary outcomes were neck disability, dizziness and neck pain intensity before and after the Fly test. Outcomes were measured at baseline and post-treatment. The control arm underwent measurements at baseline except for the dizziness questionnaire. A linear mixed model was used to evaluate difference between groups (WAD and control) and over time, with difficulty level in the Fly test and gender as factors. RESULTS: Between-group analysis showed statistically significant differences in three out of five kinesthetic metrics (p = 0.002 to 0.008), but not for the WAD-group follow-up versus healthy control baseline measurements. Results showed significant improvements for the WAD-group over time for three out of five kinaesthesia metrics (p < 0.001 to 0.008) and for neck disability (p < 0.001) and pain (p = 0.005), but not for dizziness (p = 0.70). CONCLUSIONS: The exercise program shows promising results in improving kinesthesia and reducing neck pain and disability in the chronic WAD phase. Future research might benefit from focusing on adding kinesthetic exercises to the exercise protocol and evaluating its beneficial effects on dizziness or further improvement in kinesthesia. IMPACT STATEMENT: Kinesthesia can be improved in chronic WAD patients without the use of specific kinesthetic exercises. TRIAL REGISTRATION: ClinicalTrials.gov (NCT03664934), first registration approved 11/09/2018.

The Prevalence and Influence of New or Worsened Neck Pain After a Sport-Related Concussion in Collegiate Athletes: A Study From the CARE Consortium.

BACKGROUND: Neck pain in a concussion population is an emerging area of study that has been shown to have a negative influence on recovery. This effect has not yet been studied in collegiate athletes. HYPOTHESIS: New or worsened neck pain is common after a concussion (>30%), negatively influences recovery, and is associated with patient sex and level of contact in sport. STUDY DESIGN: Cohort study; Level of evidence, 2. METHODS: Varsity-level athletes from 29 National Collegiate Athletic Association member institutions as well as nonvarsity sport athletes at military service academies were eligible for enrollment. Participants completed a preseason baseline assessment and follow-up assessments at 6 and 24 to 48 hours after a concussion, when they were symptom-free, and when they returned to unrestricted play. Data collection occurred between January 2014 and September 2018. RESULTS: A total of 2163 injuries were studied. New or worsened neck pain was reported with 47.0% of injuries. New or worsened neck pain was associated with patient sex (higher in female athletes), an altered mental status after the injury, the mechanism of injury, and what the athlete collided with. The presence of new/worsened neck pain was associated with delayed recovery. Those with new or worsened neck pain had 11.1 days of symptoms versus 8.8 days in those without (P < .001). They were also less likely to have a resolution of self-reported symptoms in ≤7 days (P < .001). However, the mean duration of the return-to-play protocol was not significantly different for those with new or worsened neck pain (7.5 ± 7.7 days) than those without (7.4 ± 8.3 days) (P = .592). CONCLUSION: This novel study shows that neck pain was common in collegiate athletes sustaining a concussion, was influenced by many factors, and negatively affected recovery.

Comparison of the Outcomes of Anterior Cervical Discectomy and Fusion and Cervical Disc Replacement for Cervical Disc Disease.

OBJECTIVE: To compare the radiological outcome and development of heterotopic ossification (HO) following single-segment anterior cervical discectomy and fusion (ACDF) and cervical disc replacement (CDR) for cervical disc herniation and evaluate their impact on surgical success. STUDY DESIGN: Descriptive comparative study. Place and Duration of the Study: Neurosurgery Department at Bozyaka Education and Research Hospital, Izmir, Turkiye, between January 2020 and June 2022. METHODOLOGY: Patients aged 18-70 years with radicular neck pain unresponsive to conventional medical treatment and an MRI-confirmed diagnosis were included. Patients with osteoporosis (OP) were excluded. Patients were randomised into two treatment groups (ACDF and CDR) and stratified by age and symptom severity. Radiographic assessments and HO classification according to McAfee were performed. RESULTS: Among the included patients, 56 underwent ACDF and 45 underwent CDR. The mean patient age was 48.29 ± 9.530 and 41.84 ± 7.239 years in the ACDF and CDR groups, respectively (p <0.001). The postoperative disc height increased in both groups. The T1 slope was significantly higher preoperatively and in the early postoperative period in the CDR group than in the ACDF group (p = 0.001). HO was graded as 1, 2, 3, and 4 in 28 (27.7%), 6 (5.9%), 7 (6.9%), and 4 (3%) patients, respectively. CONCLUSION: ACDF and CDR provided similar improvements in radiological measurements and pain relief. Although both procedures significantly enhanced the patient's quality of life and disability scores, HO was more prevalent following CDR during long-term follow-up. KEY WORDS: Cervical disc replacement, Anterior cervical discectomy and fusion, Spinal surgery techniques, Heterotopic ossification.

Vitamin B12 deficiency presenting as neck pain and cervical radiculopathy.

Vitamin B12 is required for the formation of haematopoietic cells and the synthesis of myelin. Deficiency typically presents with fatigue and megaloblastic anaemia. Prolonged deficiency can cause neurological symptoms such as paresthesia, which can progress to subacute combined degeneration of the spinal cord. We describe an unusual presentation of B12 deficiency in a young man who was initially diagnosed and treated for cervical radiculopathy. This case highlights the challenges of diagnosing B12 deficiency in patients with neurologic but without haematologic, abnormalities. While the current incidence of B12 deficiency in developed countries is low, cases are likely to rise with the increased adoption of veganism. Clinicians should be aware of the variable presentations of B12 deficiency because delayed diagnosis and treatment increases morbidity and can cause irreversible neurological deficits.

Neck pain, disability and mobile phone usage among physiotherapy students - a cross-sectional study.

INTRODUCTION AND OBJECTIVE: Modern mobile devices have become tools used for educational, research, business or recreational purposes. Incorrect position during excessive use of a smartphone can lead to biomechanical changes, the most visible of which is the position of the head in protraction, characterized by the protrusion of the head and neck forward in relation to the shoulder girdle and trunk. The aim of the study was to analyze the relationship between disability, neck pain (NP), use of phones before bedtime, and hours of using smartphones. MATERIAL AND METHODS: The study involved 146 physiotherapy students aged 18-26. Students were asked to complete pain surveys (VAS pain scale), and Neck Disability Index (NDI). Participants were also asked if their pain lasted longer than 3 months, how long they used their smartphone during the day, and whether they used it before bedtime. RESULTS: Statistically significant differences were found between groups with and without neck pain regarding NDI score (p<0.001). Participants who suffered from neck pain longer than 3 months had greater NDI scores (p=0.03), greater intensity of symptoms (p=0.04), greater problems with reading (p<0.01) and driving (p=0.04) than participants who experienced pain for less than 3 months. Using phones before bedtime was related to problems with focusing (p<0.01). There were statistically significant correlations between the time of phone use and disability in terms of reading (p=0.04), focusing (p<0.001), work (p<0.001) and sleeping (p=0.02). CONCLUSIONS: Dysfunctions associated with pain in the cervical section may affect the learning abilities of students and thus the acquisition of professional competencies. Not using a smartphone before bedtime is recommended, as it causes poorer concentration. The longer the time spent using the phone, the more significant the disability.

Is new tech a pain in the neck? The impact of introducing new technologies in home-care on neck pain: a prospective study.

BACKGROUND: Home healthcare services are increasingly utilizing novel technologies to enhance quality and efficiency of caregiving, to reduce workloads and compensate for expected labor shortages in the future due to ageing populations. However, rapid, ongoing implementation of new technologies may demand considerable adaptation for employees. The objective of this study was to prospectively examine associations of newly introduced work technologies with neck pain complaints. METHODS: With a nationally representative prospective sample of home-care workers in Norway (N = 887), we estimated effects of 1) introducing new technologies and 2) the appraised quality of training during implementation on neck pain eight months after. RESULTS: A majority of employees reported new technologies having been introduced the previous 12 months (73.8%). This was not by itself associated with neck pain. However, perceived high quality of training was associated with less subsequent neck pain, also after adjustment for job demands and job control. The strongest effect was seen for "very good" versus "very poor" quality training (OR 0.35, 95% CI 0.17,0.71, in the fully adjusted model). Cross-lagged path analyses ruled out potential reverse causation stemming from the influence of pain on needs for or appraisals of training. CONCLUSION: The present findings suggest the introduction of new work technologies has a significant impact on home-care workers' health, depending on the quality of training during implementation. This highlights the need to include training programs in risk assessments when implementing new technologies.

Higher Neck Pain Intensity and Pain Catastrophizing Soon After A Whiplash Injury Partially Explain the Presence of Persistent Headache: A Prospective Study.

OBJECTIVE: To understand whether pain-related factors soon after a whiplash injury can explain the presence of chronic headache. MATERIALS AND METHODS: A prospective study with a follow-up of 6 months was performed, including 42 patients with acute whiplash-associated disorders. Neck pain intensity, the Neck Disability Index, the Tampa Scale of Kinesiophobia, the Pain Catastrophizing Scale, and the Anxiety State-Trait Scale were assessed at baseline. Differences in clinical characteristics between those with and without headache at 6 months were determined. The relative risk of presenting with headache was evaluated. A logistic regression model was performed to assess which factors at baseline could explain the presence of headache at 6 months. RESULTS: At 6 months, one-third of the sample presented with chronic headache. Significant differences were found for several outcome measures when people with and without headache were compared ( P <0.001). The highest relative risk of presenting with headache was found for moderate/severe levels of pain catastrophizing during the acute phase (RR=15.00, 95% CI=3.93, 57.22). The level of neck pain intensity and pain catastrophizing at baseline partially explained the presence of headache at 6 months ( R2 =0.627). DISCUSSION: The risk of presenting with persistent headache attributed to a whiplash injury is increased when people present with higher neck pain intensity and pain catastrophizing soon after a whiplash injury. Evaluating neck pain intensity and pain catastrophizing at baseline may assist in identifying those more likely to develop chronic headache, potentially providing an opportunity for early targeted interventions.

Massage for neck pain.

BACKGROUND: Massage is widely used for neck pain, but its effectiveness remains unclear. OBJECTIVES: To assess the benefits and harms of massage compared to placebo or sham, no treatment or exercise as an adjuvant to the same co-intervention for acute to chronic persisting neck pain in adults with or without radiculopathy, including whiplash-associated disorders and cervicogenic headache. SEARCH METHODS: We searched multiple databases (CENTRAL, MEDLINE, EMBASE, CINAHL, Index to Chiropractic Literature, trial registries) to 1 October 2023. SELECTION CRITERIA: We included randomised controlled trials (RCTs) comparing any type of massage with sham or placebo, no treatment or wait-list, or massage as an adjuvant treatment, in adults with acute, subacute or chronic neck pain. DATA COLLECTION AND ANALYSIS: We used the standard methodological procedures expected by Cochrane. We transformed outcomes to standardise the direction of the effect (a smaller score is better). We used a partially contextualised approach relative to identified thresholds to report the effect size as slight-small, moderate or large-substantive. MAIN RESULTS: We included 33 studies (1994 participants analysed). Selection (82%) and detection bias (94%) were common; multiple trials had unclear allocation concealment, utilised a placebo that may not be credible and did not test whether blinding to the placebo was effective. Massage was compared with placebo (n = 10) or no treatment (n = 8), or assessed as an adjuvant to the same co-treatment (n = 15). The trials studied adults aged 18 to 70 years, 70% female, with mean pain severity of 51.8 (standard deviation (SD) 14.1) on a visual analogue scale (0 to 100). Neck pain was subacute-chronic and classified as non-specific neck pain (85%, including n = 1 whiplash), radiculopathy (6%) or cervicogenic headache (9%). Trials were conducted in outpatient settings in Asia (n = 11), America (n = 5), Africa (n = 1), Europe (n = 12) and the Middle East (n = 4). Trials received research funding (15%) from research institutes. We report the main results for the comparison of massage versus placebo. Low-certainty evidence indicates that massage probably results in little to no difference in pain, function-disability and health-related quality of life when compared against a placebo for subacute-chronic neck pain at up to 12 weeks follow-up. It may slightly improve participant-reported treatment success. Subgroup analysis by dose showed a clinically important difference favouring a high dose (≥ 8 sessions over four weeks for ≥ 30 minutes duration). There is very low-certainty evidence for total adverse events. Data on patient satisfaction and serious adverse events were not available. Pain was a mean of 20.55 points with placebo and improved by 3.43 points with massage (95% confidence interval (CI) 8.16 better to 1.29 worse) on a 0 to 100 scale, where a lower score indicates less pain (8 studies, 403 participants; I2 = 39%). We downgraded the evidence to low-certainty due to indirectness; most trials in the placebo comparison used suboptimal massage doses (only single sessions). Selection, performance and detection bias were evident as multiple trials had unclear allocation concealment, utilised a placebo that may not be credible and did not test whether blinding was effective, respectively. Function-disability was a mean of 30.90 points with placebo and improved by 9.69 points with massage (95% CI 17.57 better to 1.81 better) on the Neck Disability Index 0 to 100, where a lower score indicates better function (2 studies, 68 participants; I2 = 0%). We downgraded the evidence to low-certainty due to imprecision (the wide CI represents slight to moderate benefit that does not rule in or rule out a clinically important change) and risk of selection, performance and detection biases. Participant-reported treatment success was a mean of 3.1 points with placebo and improved by 0.80 points with massage (95% CI 1.39 better to 0.21 better) on a Global Improvement 1 to 7 scale, where a lower score indicates very much improved (1 study, 54 participants). We downgraded the evidence to low-certainty due to imprecision (single study with a wide CI that does not rule in or rule out a clinically important change) and risk of performance as well as detection bias. Health-related quality of life was a mean of 43.2 points with placebo and improved by 5.30 points with massage (95% CI 8.24 better to 2.36 better) on the SF-12 (physical) 0 to 100 scale, where 0 indicates the lowest level of health (1 study, 54 participants). We downgraded the evidence once for imprecision (a single small study) and risk of performance and detection bias. We are uncertain whether massage results in increased total adverse events, such as treatment soreness, sweating or low blood pressure (RR 0.99, 95% CI 0.08 to 11.55; 2 studies, 175 participants; I2 = 77%). We downgraded the evidence to very low-certainty due to unexplained inconsistency, risk of performance and detection bias, and imprecision (the CI was extremely wide and the total number of events was very small, i.e < 200 events). AUTHORS' CONCLUSIONS: The contribution of massage to the management of neck pain remains uncertain given the predominance of low-certainty evidence in this field. For subacute and chronic neck pain (closest to 12 weeks follow-up), massage may result in a little or no difference in improving pain, function-disability, health-related quality of life and participant-reported treatment success when compared to a placebo. Inadequate reporting on adverse events precluded analysis. Focused planning for larger, adequately dosed, well-designed trials is needed.

Heterotopic ossification, osteolysis and implant failure following cervical total disc replacement with the M6-C™ artificial disc.

INTRODUCTION: A recent study reported a 34% mid-term revision rate after M6-C™ cervical total disc replacement (CTDR) for wear-related osteolysis. Here, we aim to investigate the prevalence, risk factors, and radiographic characteristics of periprosthetic bony changes and implant failure of the M6-C™ artificial disc. METHODS: We retrospectively analysed radiographic (conventional X-ray, CT scan) and clinical outcomes (EQ-5D-5L, Neck Disability Index (NDI), and Visual Analog Scale (VAS) for neck and arm pain) data collected during routine follow-up of patients who underwent CTDR with the M6-C™ between 2011 and 2015. RESULTS: In total, 85 patients underwent CTDR with the M6-C™. Follow-up data were available for 43 patients (54% female, mean age 44 years) with 50 implants and a mean follow-up of 8.1 years (6.5-11 years). Implant failure with the presence of severe osteolysis was identified in 5 (12%) patients who were all male (p = 0.016) and implanted at the C5/6 level (p = 0.11). All failed implants required revision surgery. The overall prevalence of osteolysis was 44% (22/50 implants) and 34% (17/50 implants) for significant heterotopic ossification. Patients with high-grade osteolysis showed higher VAS arm pain (p = 0.05) and lower EQ-5D-VAS health VAS (p = 0.03). CONCLUSION: We report a lower reoperation rate for failed M6-C™ implants than previously published, but confirmed that osteolysis and heterotopic ossification are common following CTDR with the M6-C™ and may be asymptomatic. Therefore, we strongly recommend ongoing clinical and radiographic monitoring after CTDR with the M6-C™, particularly for male patients implanted at the C5/6 level.

C-arm CT guided percutaneous vertebroplasty for pain release in cancer patient with cervical 1 vertebral metastases: A case report.

OBJECTIVE: To evaluate the efficacy and treatment outcome of C-arm CT percutaneous vertebroplasty in the treatment of cervical 1 (C1) vertebral metastases. METHODS: This report recruited a male patient diagnosed with hepatocellular carcinoma and C1 vertebral metastases, who had suffered from severe neck pain symptoms and the analgesic showed little soothing effect. Under the guidance of C-arm CT, an 18G coaxial needle was used to puncture the left lateral mass of C1 vertebral metastases from lateral space between thyroid cartilage and the left carotid sheath, with 2 ml bone cement injected. RESULTS: Postoperative C-arm CT three-dimensional reconstruction scan showed that the bone cement was well filled and distributed in the left lateral mass of C1 vertebral body, and no leakage of bone cement was observed. The neck pain of the patients was significantly relieved one week after the operation. CONCLUSION: Under the guidance of C-arm CT, cement augmentation using percutaneous vertebroplasty in an anterior cervical direction could serve as a safe and effective pain relief approach for patients with C1 vertebral metastases.

Chronic neck pain in a child: a case of osteoblastoma of the C5 cervical vertebra.

Osteoblastoma is a primary bone-forming tumour that usually occurs in the second decade with an affinity to the posterior elements when found in the spine. Its occurrence in the early first decade is uncommon and often causes a diagnostic dilemma. It usually has a late presentation and the symptoms may be non-specific which may lead the clinician to overlook this particular entity. We present a case of osteoblastoma of the posterior elements of the C5 vertebra in a pre-adolescent child who was diagnosed and successfully managed with surgical resection in a timely fashion that led to favourable recovery postoperatively.

Iatrogenic Vertebral Artery Dissection with Posterior Fossa and Lateral Medullary Stroke After Uncomplicated Cervical Nerve Ablation.

BACKGROUND: A cervical radiofrequency ablation is a procedure that can be performed to treat arthritis-related pain in the neck and upper back. There have been no large studies reporting complications after this procedure. We report a case of a 55-year-old woman with iatrogenic vertebral artery dissection of C3-C4 with segmental occlusion leading to a posterior fossa stroke and lateral medullary stroke after a high-grade cervical nerve ablation. CASE REPORT: A 55-year-old woman presented to the Emergency Department with vomiting, neck pain, temperature changes, dizziness, and dysarthria after undergoing C2-C3, C4-C5 nerve ablation 30 min prior to arrival. The patient was found to have a vertebral artery dissection with posterior fossa and lateral medullary stroke. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Vertebral artery dissection and subsequent stroke should be considered with recent cervical facet joint injections, such as intra-articular facet joint injections, medial branch blocks, or medial branch radiofrequency nerve ablation. The case we report shows devastating outcomes that can result from what many consider a relatively simple procedure.