Sexual function and cervical spine instability

Ross Hauser, MD

When assessing the degree of success of cervical spine treatment, we assess the quality of life standards the patient wishes to re-achieve and restore. One of those quality of life issues is the ability to be sexually active with their spouse or partners.

We often see patients who come in for a second opinion following a recommendation to cervical spinal surgery. We often see patients who have already had the surgery. These people have the familiar problems of cervical instability and diseases of cervical vertebrae that often manifest themselves in other symptoms and disorders of the body. For men, this is true with cervical instability, erectile dysfunction and retrograde ejaculation (you are ejaculating backwards into the urinary bladder). For women and men there is a fear of sex causing more cervical spine damage.

The ability to resume sexual activity is seen as a positive outcome of cervical spine treatment

Surprising there is not a lot of research on this important patient concern. Evidence presented is mostly empirical that is observational and discovered during a discussion of the patient’s medical history. We have found that the ability to have regular and unafraid intimacy with a spouse is very important to many patients. Having said this, this ability to resume intimacy is one of the important underlying factors of getting treatment. We do confess, that it is very rare that this will be the number one reason for seeking neck pain treatment.

Degenerative cervical myelopathy and the ability to have sex as a recovery priority

But how important is it to be able to have sex when you have been diagnosed and recommend to treatments for degenerative cervical myelopathy and symptoms related to compression of the spinal cord?

In October 2019, an international team of researchers lead by the University of Cambridge in the United Kingdom published a survey in the medical journal BMJ Open.(1) What the surgery asked was what were the most important symptoms that they wanted addressed in their cervical myelopathy related problems.

In a clinic like ours, where we see many cervical spine patients. One out of 20 patients looking for improvement in sexual function as the main priority of their neck pain is a significant number.

Neurologists find erectile dysfunction, walking difficulties, urinary hesitation as curious aspects of neck problems

Many patients think sexual dysfunction, or in the case of men, erectile dysfunction, are seeming unrelated to their neck problems. For some this has been reinforced by their medical professionals who look at problems of the neck as problems of the neck and problems of erectile dysfunction a problem that needs to be recommended to a urologist. While the recommendation to a urologist is seen as a precautionary measure to rule out other problems, once the referral is made to the urologist and the report comes back that there does not seem to be a problem in this area, the problems of erectile dysfunction will then simply be dismissed or ignored.

A 51-year-old man went to the hospital

A report in the medical journal Neurology (2) reveals how doctors are now seeing erectile and sexual dysfunction as components of a cervical spine, neck problem.

In this report a 51-year-old man went to University Hospital at the University of Athens in Greece. He had neck pain, right hand weakness, and progressively deteriorating gait. Onset of symptoms occurred 1 month before admission with cervical pain that worsened during neck flexion the movement of chin on chest). A few days later he noticed reduced dexterity and numbness of his right hand. During the following 3 weeks, his gait became increasingly unstable. Additionally, he reported erectile dysfunction and urinary hesitancy. No previous trauma was recalled. In other words he did not know how this started but it was getting worse fast.

This turned out to be a very complicated case. But for the purpose of this article the example is that this patient’s erectile dysfunction and walking problems were related to spinal cord compression and the the patient has excellent response to steroids, however the response was short-lived and the symptoms got that much worse.

Erectile dysfunction can be a problem of the cervical spine.

Does cervical surgery improve sexual function? Successful surgery likely yes. Unsuccessful surgery will make it worse

As is our habit, when we talk about the problems of surgery, we bring in the surgeons for their opinion.

Doctors at the University of California, San Francisco reported on sexual function problems in patients who underwent cervical spine surgery.

Writing in the Journal of Clinical Neuroscience, (3)

the UCSF researchers documented the following:

  • They noted: Sexual function is an important component of patient-focused health related quality of life.
  • In men, worse neck disability and the number of operated on cervical levels were associated with lower sexual function scores.
  • In women, higher total number of medications and pain medications were associated with lower sexual function scores.
  • 46% of patients reported difficulty performing a sexual position after surgery that they had previously enjoyed.
  • Men and women who underwent cervical spine surgery had lower sexual function scores than age-matched peers, likely attributable to general mental health, regional neck disability, back pain, and medications.
  • A large portion of patients reported subjectively worsened sexual function after surgery.

Again. let’s point out that people do experience better sexual function after surgery.

Cervical surgery and erectile dysfunction

Providing that there is a good surgical outcome. An October 2018 (4) paper from  The Ohio State University Wexner Medical Center researchers she light on this: “Sexual function is an important determinant of quality of life, and factors such as surgical approach, performance of fusion, neurological function and residual pain can affect it after spine surgery.. . . Despite limited evidence from high-quality articles, there is a general trend towards improvement of sexual activity and function after spine surgery.”

The paper ends with the suggestion that “future studies incorporating specific assessments of sexual activity will be required to address this important determinant of quality of life so that appropriate pre-operative counselling can be done by providers.”

We often find in a medical history and examination that men do want to resume sexual activity stunted by cervical spine disorders. We do discuss this aspect with patients especially when there is an extensive history of painkiller and opioid use. Please see our article: Opioids and painkillers cause low testosterone syndrome.

Treating the problems of cervical instability can treat the problems of erectile dysfunction. In the above research, a myriad of problems for the patients resulted in lower sexual function because of post-surgical outcomes. In past research doctors found that successful cervical surgery, had as a side-effect, improved symptoms of erectile dysfunction.

In 2006 researchers looked at older men who had Cervical spondylotic myelopathy (neck pain).(5)

  • A total of 22 patients with combined cervical spondylotic myelopathy and sexual dysfunction on admission were treated with surgery for their neck problems.
  • Most of these patients had an abnormal psychogenic erection (18/22, 82%) before surgery. These are erection difficulties related to emotional and psychological problems such as depression and anxiety.
  • but only few had an abnormal reflexogenic erection (4/22, 18%). This is the regular erection response to stimuli.
  • The positive results with erectile dysfunction was attained post surgery because the patient had less depression and anxiety. Waiting for surgery does cause depression and anxiety.

In our opinion treating cervical neck pain can be effective in helping some patients restore erectile function, however while studies suggest a casual, indirect benefit of cervical surgery on erectile dysfunction, we believe the same results can be achieved non-surgically.

Caring Medical research on alternatives to Discectomy and Fusion

In our practice, we continue to see a large number of patients with a myriad of symptoms related to cervical neck instability including to but not limited to severe neck pain, sexual dysfunction, problems of balance, headaches, and loss of mobility. These people are often confused, many times frightened by recommendations to complicated cervical neck surgeries they don’t understand.

Many of these people have been told that their problem is a problem of degenerative cervical disc disease. After years of prolonged pain and conservative care options such as chiropractic, massage, physical therapy, anti-inflammatories, pain medications, cortisone injections, and cervical epidurals that eventually fail, the only recourse, these people are told, is neck surgery.

Surgical recommendations are described in a way to the patient that seemingly makes sense as the only solution to their problems.

  • The surgery will help, the patient is told, because it will cut away the cervical vertebrae bone that is pressing on the nerves
  • The surgery will fuse the cervical vertebrae in place so the vertebrae do not shift out of place and press on the nerves again.
  • The cervical disc that has been flattened or herniated is replaced with an artificial implant or bone from the pelvis. Please see our article: Cervical artificial disc replacement complications.

Surgical recommendation for degenerative disc disease may not address the patient’s real problems – cervical neck ligament damage

In 2014 we (Caring Medical) published these findings in The Open Orthopaedics Journal.(1)

  • The cervical capsular ligaments are the main stabilizing structures of the facet joints in the cervical spine and have been implicated as a major source of chronic neck pain. Such pain often reflects a state of instability in the cervical spine and is a symptom common to a number of conditions such as disc herniation, cervical spondylosis, whiplash injury, and whiplash-associated disorder, post-concussion syndrome, vertebrobasilar insufficiency, and Barré-Liéou syndrome. (In some patients these concurrent symptoms can lead to sexual dysfunction).

When the capsular ligaments are injured, they become elongated and exhibit laxity, which causes excessive movement of the cervical vertebrae.

  • In the upper cervical spine (C0-C2), this can cause symptoms such as nerve irritation and vertebrobasilar insufficiency with associated vertigo, tinnitus, dizziness, facial pain, arm pain, and migraine headaches.
  • In the lower cervical spine (C3-C7), this can cause muscle spasms, crepitation, and/or paresthesia in addition to chronic neck pain.
  • In either case, the presence of excessive motion between two adjacent cervical vertebrae and these associated symptoms is described as cervical instability.

Therefore, we propose that in many cases of chronic neck pain, the cause may be underlying joint instability due to capsular ligament laxity. Furthermore, we contend that the use of comprehensive Prolotherapy appears to be an effective treatment for chronic neck pain and cervical instability, especially when due to ligament laxity. The technique is safe and relatively non-invasive as well as efficacious in relieving chronic neck pain and its associated symptoms.

Prolotherapy is an injection technique utilizing simple sugar or dextrose.

Summary and contact us. Can we help you? How do I know if I’m a good candidate?

We hope you found this article informative and it helped answer many of the questions you may have surrounding possible conditions caused by cervical spine instability. Just like you, we want to make sure you are a good fit for our clinic prior to accepting your case. While our mission is to help as many people with chronic pain as we can, sadly, we cannot accept all cases. We have a multi-step process so our team can really get to know you and your case to ensure that it sounds like you are a good fit for the unique testing and treatments that we offer here.

Please visit the Hauser Neck Center Patient Candidate Form

References for this article:

1 Davies B, Mowforth O, Sadler I, Aarabi B, Kwon B, Kurpad S, Harrop JS, Wilson JR, Grossman R, Fehlings MG, Kotter M. Recovery priorities in degenerative cervical myelopathy: a cross-sectional survey of an international, online community of patients. BMJ open. 2019 Oct 1;9(10):e031486. [Google Scholar]
2 Rallis D, Tsirigotis P, Arvaniti C, Sgouros S, Foukas PG, Oikonomopoulos N, Andronas N, Panayiotides IG, Kouloulias V, Papageorgiou S, Voumvourakis K, Stamboulis E. Clinical reasoning: a 51-year-old man with cervical pain and progressively deteriorating gait. Neurology. 2013 May 28;80(22):e230-4. doi: 10.1212/WNL.0b013e318294b2bf. PMID: 23713091; PMCID: PMC3716403.[Google Scholar]
3 Keefe MK, Zygourakis CC, Theologis AA, Canepa E, Shaw JD, Goldman LH. Sexual function after cervical spine surgery: Independent predictors of functional impairment. J Clin Neurosci. 2017 Feb;36:94-101. [Google Scholar]
4 Malik AT, Jain N, Kim J, Khan SN, Yu E. Sexual activity after spine surgery: a systematic review. European Spine Journal. 2018 Oct 1;27(10):2395-426. [Google Scholar]
5 He S, Hussain N, Zhao J, Fu Q, Hou T. Improvement of sexual function in male patients treated surgically for cervical spondylotic myelopathy. Spine. 2006 Jan 1;31(1):33-6.  [Google Scholar]

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