The neck is not a smaller lower back
Seven vertebrae, eight pairs of nerve roots, two arteries running inside the bone, and the spinal cord itself passing through the middle of it. This page explains why the cervical spine is assessed on its own terms, and what is worth asking when you are choosing a surgeon in Brisbane.
7 and 8
Seven cervical vertebrae, eight pairs of nerve roots. The numbering does not line up.
17-18mm
Normal canal width at mid-cervical levels. Symptoms often begin once it narrows past about 13mm.
50%
Roughly half the rotation when you turn your head comes from a single joint, C1 on C2.
2 arteries
The vertebral arteries reach the brain through channels inside the vertebrae, from C6 upward.
ANATOMY
Four things that make the cervical spine its own problem
Every one of these is a reason a decision that would be routine in the lower back needs more thought in the neck.
01
The spinal cord itself is in the way
Below roughly the first lumbar vertebra the cord has already ended, so lumbar surgery works around a bundle of separate nerve roots that tolerate being gently moved aside. In the neck, the cord runs straight through the middle, and it tolerates almost nothing. Pressure on it causes a different problem from a pinched nerve: clumsy hands, buttons and keys becoming difficult, unsteady walking. That is cervical myelopathy, and it is the main reason some neck problems should not simply be watched.
02
There is almost no spare room
The mid-cervical canal is normally 17 to 18mm from front to back, and symptoms commonly begin once it narrows past roughly 13mm. A few millimetres decides whether a bulging disc is an incidental finding on a report or the actual cause of your symptoms. The equivalent measurement in the lower back leaves far more margin, both in the diagnosis and in the operation.
03
The arteries to the brain run inside the bone
From C6 upward, each vertebra carries a vertebral artery through a channel in its own transverse process on the way to the brain. Their course varies from person to person, and occasionally quite markedly. Any decompression or instrumentation in this region is planned from that individual’s imaging rather than a textbook diagram.
04
It is built to move, and it needs to keep moving
Around half the rotation involved in turning your head comes from a single joint between C1 and C2, and the rest of the neck carries the weight of the head through a large range all day. Fusing a level in the neck therefore costs something that fusing a level in the lower back does not, which is why motion-preserving options such as cervical disc replacement and posterior foraminotomy matter here more than almost anywhere else in the spine.
Most of the decision is made long before anyone reaches an operating theatre
A scan shows what is compressed. It does not say whether that compression is what you are actually feeling, whether it is going to get worse, or whether an operation is the right answer for you. That part is judgement, and it rests on the examination, the imaging and how your symptoms have behaved over time rather than on the scan alone.
PUBLISHED RESEARCH
What the research says about how often a surgeon operates
The relationship between how frequently a surgeon performs cervical spine operations and how those operations go has been studied directly, in cervical surgery specifically, using national datasets large enough to detect small differences.
24,461
Patients, ACDF, MarketScan 2006 to 2010
Surgeons averaging at least 30 anterior cervical discectomy and fusion procedures a year had lower rates of difficulty swallowing (2.22 per cent against 3.08 per cent), neurological complications (0.33 against 0.64) and wound complications (0.06 against 0.22). Rates of revision surgery and readmission were no different between the two groups.
Clinical Spine Surgery, 2017
419,212
Patients, anterior cervical fusion, US Nationwide Inpatient Sample 2003 to 2009
Surgeons in the lowest volume quartile, around five cases a year, had higher rates of adverse events and hospital stays averaging 2.3 days longer. Surgeons in the highest quartile, around 67 cases a year, had fewer adverse events and shorter stays. The study is graded level 4 evidence.
Spine, 2017
How to read this
These are population studies describing averages across thousands of surgeons and hundreds of thousands of operations. They cannot predict what will happen in any individual case, and how often a surgeon operates is only one factor among many, alongside patient selection, the hospital, the anaesthetic and critical care support available, and the specific problem being treated.
Treat them as a good reason to ask any surgeon about their experience with the operation being proposed, and about what their own results look like. They are not a guarantee of anything, here or anywhere else, and no honest surgeon will offer you one.
Dr Tollesson's qualifications and appointments
Dr Tollesson holds specialist qualifications from Sweden, Norway and Australia. He obtained specialist neurosurgical registration in Sweden and Norway in 2003 and is a Fellow of the Royal Australasian College of Surgeons. He is Chairman of the Neurosurgical Society of Queensland and Secretary of AOSpine, and was the neurosurgical representative on the Royal Australasian College of Surgeons Queensland State Committee from 2016 to 2019.
He is a fully qualified neurosurgeon rather than a neck-only practitioner: his practice covers brain and spinal surgery for adults and children through Brain and Spine Surgery Queensland. His full background, training and hospital appointments are set out on the about page.
References
Surgeon Procedure Volume and Complication Rates in Anterior Cervical Discectomy and Fusions: Analysis of a National Longitudinal Database. Clinical Spine Surgery, June 2017.
Effect of Surgeon Volume on Complications, Length of Stay, and Costs Following Anterior Cervical Fusion. Spine, 2017.
Cervical Stenosis, knowledge base of the American Academy of Physical Medicine and Rehabilitation, for normal cervical canal dimensions and stenosis thresholds.
IN PRACTICE
What a cervical spine assessment involves
01
Imaging is read against your symptoms
A scan is interpreted alongside your history and your examination, not instead of them. Where the radiology report, the images and the findings on examination disagree, working out which of them explains your symptoms is the substance of the assessment.
02
Non-surgical options come first
Most cervical problems settle without an operation, so non-surgical treatment is the starting point for the majority of people. Surgery is considered when those measures have not worked, or when the spinal cord is at risk.
03
A useful recommendation names the level and the reason
Not simply that you need neck surgery. Which level is involved, which structure is compressing what, which of your symptoms that explains, and what is likely to happen if nothing is done.
04
Your GP stays in the loop
The doctor managing your care day to day needs the plan, the reasoning behind it, and what to watch for. Information for referrers.
BEFORE YOU DECIDE
Six questions worth asking any spine surgeon
These are reasonable questions and any surgeon should be comfortable answering them. Ask them here too.
How often do you do this specific operation?
Not spine surgery in general. The operation being proposed, at the level being proposed, and how recently.
What happens if I do nothing?
There should be a real answer. For a lot of neck pain it is that it will probably settle. For myelopathy it usually is not.
What are the alternatives, including not operating?
If a fusion is proposed, ask whether a motion-preserving option was considered and what ruled it out.
What does success look like, and by when?
Arm pain, neck pain, numbness and weakness do not respond in the same way or on the same timeline. Ask which of your symptoms the operation is aimed at.
What are the risks specific to operating on a neck?
Swallowing and voice changes after an anterior approach, among others. Ask for the numbers, not just a list of words.
Who is actually operating, and who do I call afterwards?
Including who to contact out of hours in the first couple of weeks if something does not feel right.
IN FAIRNESS
Where this is not the point
Most neck problems never need a surgeon
The large majority of neck pain, and a good proportion of arm pain from a pinched nerve, settles with time, physiotherapy, medication and sometimes a targeted injection. A surgeon's most useful contribution is often a clear explanation and a well-argued reason not to operate. If that is your situation, you should hear it in those words.
General spine surgeons treat necks competently
Plenty of excellent surgeons operate across the whole spine and get good results in the neck. This page is not an argument that they do not. It is an argument that the cervical spine is different enough to be worth asking about, alongside everything else you would consider.
General information, not medical advice. Everything on this page describes the cervical spine in general terms. It cannot tell you what is happening in your neck, and it is not a substitute for assessment by your GP or a specialist. If you develop sudden weakness, loss of coordination, or loss of bladder or bowel control, seek emergency care immediately or call 000.
Not sure whether your neck needs a surgeon at all? That is a reasonable place to start.
A consultation will tell you what is causing your symptoms, whether an operation would help, and what the alternatives are. You will need a referral from your GP or another specialist for a Medicare rebate.