Tuesday, August 16, 2011

GMA's Pain in the Neck


Almost everyone in our orthopedic circle is talking about former President Gloria Macapagal-Arroyo's neck surgeries. We all know that GMA was diagnosed with cervical spondylosis and has undergone two neck surgeries so far and may have more surgeries in the future. 

"Was her neck surgery necessary, in the first place?" This question has been asked by my patients, family, friends and even colleagues in the profession, several times the past few weeks.

Although many people think that there may be some political reason for GMA undergoing this procedure at this particular time when evidences for her alleged corruption have piled up, I will leave that up to the political pundits to determine. As much as I’d like to remain apolitical in this blog though, I may have to touch politics a bit because an orthopedic problem is in the center of the discussions.

            I am not a spine surgeon (I am a hip and knee specialist), but as an orthopedic surgeon knowledgeable enough on this matter, please allow me to explain some things in order to give you some assurances that you most likely won’t face the same fate and to empower you to help explain these things to friends and family.

What is cervical spondylosis?


Also called arthritis of the neck, cervical spondylosis  is a broad term referring to the wear and tear (degeneration) of the cervical or neck spine, including the cushions between the neck vertebrae (cervical disks) and the joints between the bones of the cervical spine. "Spurs" on the bones of the spine (vertebrae) may develop as small, rough areas on their edges. These changes can, over time, reduce the size of the canal around the nerves, press down or impinge on the latter. Since these nerves travel from the spine to the arms, symptoms may radiate down to the arms. In advanced cases, the spinal cord may be involved and legs may be affected as well.


What are the symptoms of cervical spondylosis?


More common symptoms are:
  • Neck pain (as mentioned may radiate to the arms or shoulder).  Neck pain is probably one of the most common problems that one encounters in day to day life. It is probably as common as the common cold.
  • Neck stiffness
  • Loss of sensation or abnormal sensations in the shoulders, arms
  • Weakness of the arms or (rarely) legs
  • Headaches, particularly in the back of the head


Aside from aging, are there other causes of cervical spondylosis?


The major risk factor is aging. By age 60, most women and men show signs of cervical spondylosis on x-ray. Other factors that can make a person more likely to develop spondylosis are:
  • Past neck injury (often several years before)
  • Severe arthritis
  • Past spine surgery
Mrs. Arroyo’s doctors said her condition was triggered by her “continuing to work countless hours despite her stresses."  Well, in my opinion, it is difficult to say if this is true.  Although it may contribute to the perceived pain and muscle spasm, this is not the main reason. In general, mental or emotional stress DO NOT have any effect on spondylosis. Spondylosis is not normally caused by external factors; rather it is part of the normal aging process. Unless the stress that they are talking about is a physical stress associated with certain occupations which involve repeated bending and lifting heavy objects, which is, however, not the work of GMA.


I am not exactly sure what the symptoms of GMA were before the operation that made her doctors decide on the surgery, but let us give the benefit of the doubt to her doctors.  After all, I still believe that no doctor, in his or her right mind, would do something against the welfare of the patient.


How is cervical spondylosis treated?


Treatment is usually conservative in nature; the most commonly used treatments are nonsteroidal anti-inflammatory drugs (NSAIDs), muscle relaxants, physical therapy, cortisone injections, cervical collars, and lifestyle modifications aimed at reducing the symptoms and preventing permanent spinal cord and nerve injury. Surgery is occasionally performed only. Many of the treatment modalities for cervical spondylosis have not been subjected to rigorous, controlled trials. Surgery is advocated for patients who have intractable pain, progressive symptoms, or weakness that fails to improve with conservative therapy. It should be the last resort because of the risks of the surgery.


So what are these risks of the surgery?


The usual complications of any surgery will be infection, accidental nicking of any blood vessel, nerve or surrounding vital structures.  Having trained in revision surgeries of the hip and knee, I know pretty well how difficult it is to treat infected orthopedic cases, especially if the infection has spread to osteoporotic bones. Arroyo, unfortunately, developed this infection and is now taking heavy doses of antibiotics. Her metal implants, which apparently loosened due to the infection, were removed and she was subsequently fitted with a metal contraption to immobilize her head and neck.


So, was GMA’s surgery necessary?


Surgery is used if other treatments fail and if pain or weakness gets worse. Apparently, GMAs symptoms were deteriorating (we are not sure). One study done abroad noted that 79% of patients with neck pain and/or referred pain syndromes and cervical spondylosis improved or became asymptomatic by the 15-year follow-up point.

Remember, the primary goal of surgery is to decompress the spinal cord, thus giving the nerves more breathing room. The orthopedic or neurosurgeon will remove bone spurs or a herniated disk, align neck bones and put in an implant where bones or disks were removed. These implants used will stabilize the neck so the neck spine will not move around and dislocate.

Summary


Cervical spondylosis is a common cause of disability in older persons. It is important to note that bone degeneration process cannot be cured, nor can be entirely prevented.  To an extent, we all develop a degree of degeneration in the spine bones and discs as we become older.


The process can only be minimized through healthy diet and lifestyle, exercises and good structural posture. Because spondylosis is a universal finding as patients age, it is important to correlate clinical history and neurologic findings with the diagnostic studies. MRI is the most useful radiographic study for quantifying the degree of nerve impingement and excluding other pathologies.


Current treatment remains controversial with regard to surgical and nonsurgical management. It is a risky surgery, indeed, and has its complications, just like what happened to GMA. In the future, prospective randomized trials may be required to definitively establish treatment guidelines. Currently, surgical decompression is accepted for many symptomatic patients who are not responding to non-surgical measures.

Personal Message


I would like to wish Representative Arroyo well.  As a person of medicine and a compassionate Christian, I hope that you will eventually have a successful surgery. However, as a concerned Filipino citizen eager to know only the truth, I hope that the cases filed against you will prosper in court so that you can defend yourself in the proper forum. 


Our noble field of profession (medicine) should never be corrupted and used in derailing the administration of justice.

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