In patients with neck arthritis, also called spondylosis, the risk of spinal cord injury from a fall is a concern of both patients and physicians.
The spinal cord is essentially an extension of the brain, which constitutes the central nervous system. If the spinal cord is damaged, it likely cannot be repaired and the neurological deficits may be permanent. After the nerve roots have left the spinal cord, they are part of the peripheral nervous system, which potentially can recover.
Not all patients with neck pain or other symptoms have spinal cord compression. In many cases, arthritis of the cervical spine, including disc bulges/ herniations, ligament thickening, osteophytic bone spurs, or facet joint enlargement simply presses into the nerves and not the spinal cord. This can cause pain, weakness and numbness, but if the nerve inflammation resolves or the nerves repair, then the symptoms can improve or resolve. “Cervical myelopathy”, on the other hand, is a specific condition in which the spinal cord itself is compressed and malfunctioning.
In patients with severe symptoms of “cervical myelopathy”, it is clear that surgery is recommended to decompress the spinal cord and nerves. About 2/3rds of these patients will show some improvement, although the degree of improvement is variable. However, there are many patients who have mild symptoms, but undergo spine imaging showing significant arthritis, spinal cord compression, and radiologic signs of “cervical myelopathy”. The management of these patients is tremendously difficult. The natural history could be a slow step-wise decline or there could be stable symptoms for years.
Traditionally, many spine surgeons recommended surgery as a precautionary measure. The risks of surgery may be fairly low in relation to the consequence of not doing surgery and developing disabling weakness, numbness or walking problems. “If you fall, get in a car wreck, or hyper-extend your neck, you could become paralyzed”.
Interestingly, it turns out that the risk of falling may be low and may not result in much of anything.
A 2015 study was performed, specifically following patients with known cord compression to see if they would fall, and then if they would develop any neurologic injury after the fall. 55 patients were prospectively studied. 35% of these patients showed evidence of bruise on their spinal cord at baseline. 56% of these patients were told by another surgeon that they should undergo surgery and 47% were told they would be paralyzed by a fall or car accident.
45 of the 55 patients did not suffer any falls. This indicates that patients with cord compression may not be overly susceptible to falling. The remaining 10 patients did experience a fall, but none of them suffered paralysis or spinal cord injury. Several of these patients developed other injuries, though, including broken bones. This indicates that even with pre-existing severe neck arthritis and cord compression, there may not be an increased risk of spinal cord injury after minor trauma. Of course, this study did not look at major trauma, which could injure the spinal cord of even normal individuals.
Some surgeons present gloom and doom scenarios to encourage patients to undergo surgery. Fortunately, the true rate of gloom or doom seems low.