Is neck surgery designed to prevent further degeneration of the cervical spine always necessary?

I frequently see patients who have been told by another physician that they require neck surgery. This procedure, they are told, is necessary to avert further deterioration of their cervical spine. Many of these patients are frightened by the information provided by their doctor. Some have been warned that if their symptoms worsen, they may face the risk of irreversible damage to their functional abilities, potentially leading to paralysis.

“I am worried if I do not get surgery my neck will get worse”

Studies have indicated that a lot of patients opt for cervical fusion surgery due to their fear of their condition worsening. Yet, follow-up information on patients suffering from degenerative issues in the upper (cervical) spine reveals slow, minimal or no signs of rapid deterioration over time. Recently, medical professionals released results suggesting that most of these patients tend to remain stable and do not experience disease progression or severe neurological problems.

The researchers identified 27 patients with cervical degenerative spondylolisthesis (a slipped disc causing nerve pressure) for inclusion in their study.(1)

Here is what they found. For many of you, this terminology may sound familiar and you may recognize that your MRI included many of these terms.

• Eleven patients had cervical spondylolisthesis at C4-C5,
• Nine at C3-C4,
• Six at C5-C6,
• and one at C2-C3.

Initially, 6 had anterolisthesis (disc forward displacement) and 21 had retrolisthesis (disc backward displacement). At baseline, 3 of 6 patients with anterolisthesis and 7 of 21 patients with retrolisthesis had translation of more than 2 mm on dynamic views.

At baseline,

• 11 had no cervical symptoms. (MRI shows disc displacement, but the person shows no sign of pain or loss of motion. Should this person be scared into an unnecessary surgery?)
• 8 had cervicalgia (sharp neck pain that is felt in back and shoulders),
• 7 had radiculopathy (radiating pain into the elbows and hands),
• and 1 had myelopathy. Myelopathy needs a surgical consultation as paralysis and incontinence are at risk.

Same patients, on average, seen more than three years later show limited or no progression of cervical spine disease

• At the final visit, none of the anterolistheses or retrolistheses had progressed.
• At the final visit, 7 of 10 patients with initial translation of more than 2 mm on dynamic views had no change.
• Of 17 patients with less than 2 mm of initial dynamic motion, 3 patients progressed to have more than 2 mm of dynamic translation. All 3 of these had retrolisthesis initially. None had clinical worsening of symptoms at the final visit.

The natural history of cervical degenerative anterolisthesis and retrolisthesis seems to be stable during 2 years to nearly 8 years. Although those with retrolisthesis seem to have a higher propensity to increase their subluxation, none experienced dislocation or neurological injury.

In June 2020, researchers (2)  cited the above research suggesting cervical spondylolisthesis patients typically have cervical spine compression from both the anterior and posterior aspects, have more levels of spinal cord compression, and receive surgery on a greater number of cervical levels that is more commonly performed with a posterior approach. Furthermore, while these patients experience a significantly lower than the improvement experienced by other degenerative cervical myelopathy patients without spondylolisthesis. Overall, these findings suggest that the presence of cervical spondylolisthesis may indicate a more advanced state of degenerative cervical myelopathy pathology and is more likely to result in a suboptimal surgical outcome.

“It was notable that despite having this increased severity spectrum, cervical spondylolisthesis presented on average with a 5-month shorter duration of symptoms, and though not statistically significant, it could suggest that these patients may have a more precipitous (steep decline) course owing to potential instability. (The people of this study had sudden onset of degeneration), It was also notable that, on average, patients with cervical spondylolisthesis did not complain of significantly increased neck disability. This is despite the finding of a previous systematic review that neck pain is the first symptom to occur in most patients with degenerative spondylolisthesis.” But many went to surgery with suboptimal results.

In July 2023, (3) researchers looked to find out if cervical degenerative spondylolisthesis is linked to higher baseline neck and arm pain, as well as poorer health quality. The researchers looked at 315 anterior cervical decompression and fusion patient charts. All at least one year after surgery. Patients were divided into two groups based on whether they had spondylolisthesis or not.

• Out of 242 patients, 49 (20%) were diagnosed with degenerative spondylolisthesis, most frequently at the C4-5 level.
• The spondylolisthesis group was significantly older than the non-spondylolisthesis group (average 58.0 to 51.9)
• The spondylolisthesis group showed a higher degree of C2 slope but there were no differences in preoperative visual analogue scale (VAS) neck pain or NDI disability scale.
• While earlier studies have indicated a link between cervical degenerative spondylolisthesis and neck pain, the researchers could not find a connection between degenerative spondylolisthesis and increased baseline neck or arm pain. Instead, degenerative spondylolisthesis seems to be a common age-related condition (20% in this study) that reflects radiographic changes rather than necessarily clinical issues.