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Cervical Disc Herniation

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Ovid: 5-Minute Orthopaedic Consult

Editors: Frassica, Frank J.; Sponseller, Paul D.; Wilckens, John H.
Title: 5-Minute Orthopaedic Consult, 2nd Edition
> Table of Contents > Cervical Disc Herniation

Cervical Disc Herniation
Karl A. Soderlund BS
David B. Cohen MD
A. Jay Khanna MD
Basics
Description
  • Cervical disc herniation is a condition
    in which retropulsion of disc material occurs, with resulting
    compression of the neural elements (nerve root[s] and/or spinal cord),
    resulting in neck pain, radiculopathy, and/or myelopathy.
  • Classification
    • Herniation is classified as acute or chronic.
    • The classification of myelopathy is based on physical function.
General Prevention
  • No good evidence exists regarding
    preventive measures, but smoking cessation may help decrease the
    chances of neck pain and radiculopathy.
  • However, nonsmoking is a predictor of positive outcome after anterior cervical decompression and fusion (1).
Epidemiology
  • Most common in individuals >30 years old, with a mean age of 50 years (2)
  • Radiculopathy rarely progresses to myelopathy.
Incidence
  • 107.3 males and 64.5 females per 100,000 population (annual age-adjusted incidence) (3)
  • 203 per 100,000 population is the age-specific annual incidence rate for 50–54-year-olds (3).
Prevalence
  • Up to 2/3 of adults will have at least 1 major episode of neck pain in their lifetime (4).
  • Radiographic evidence of disc degeneration is seen in nearly 60% of individuals >40 years old (5).
Risk Factors
  • Repetitive lifting
  • Smoking
  • Overhead work
Genetics
The risk of disc herniation is higher in a person with a positive family history than in a patient without such a history.
Pathophysiology
  • The mechanical nature of neural element compression is well understood.
  • Substance P concentration is elevated in compressed nerve roots.
  • Decreased blood flow in a compressed nerve root also may play a role in pain.
Etiology
Cervical disc herniations may be traumatic or nontraumatic.
Associated Conditions
  • Congenital cervical stenosis
  • Ossified posterior longitudinal ligament
  • Cervical spine spondylosis
Diagnosis
Signs and Symptoms
  • Symptoms can develop acutely or insidiously.
  • The spectrum of symptoms includes neck
    pain, occipital pain, shoulder girdle pain, and regional upper
    extremity symptoms (pain, paresthesias, hypesthesia, or weakness).
  • Symptoms often are exacerbated by particular neck motions and positions.
  • Nerve root compression at a specific level may cause ‘classic’ findings of motor, sensory, or reflex symptoms.
  • The Spurling test (axial loading of the
    neck while the head is rotated and laterally bent toward the affected
    side) often recreates the radicular symptoms.
  • Cervical myelopathy usually presents insidiously, with a wide variety of symptoms, including:
    • Gait deterioration (unsteadiness and falls)
    • Deterioration of manual dexterity
    • Generalized weakness
    • Bowel and bladder dysfunction
  • Patients may complain of losing balance or of ‘jumpy’ legs.
  • A Babinski reflex in the lower extremities or a Hoffmann reflex in the upper extremities may be seen.
History
  • Patients may present with pain, paresthesias, and motor weakness.
  • Pain in the trapezial and scapular region may accompany radicular pain.
  • Sensory abnormalities do not necessarily follow a dermatomal pattern.
  • Pain generally worsens when the neck is tilted to the affected side (because of narrowing of the neural foramina).
  • Patients with C6 and C7 radiculopathy often complain of breast pain or anginal symptoms.
  • Myelopathic patients complain of gait abnormalities, weakness, and motor skills problems.
Physical Exam
  • Neck ROM
  • Motor examination to evaluate for weakness
  • Sensory examination
  • Reflexes
    • C5: Biceps
    • C6: Brachioradialis
    • C7: Triceps
  • Evaluate for myelopathy.
Tests
  • Spurling maneuver
  • Babinski: A positive test is indicated by
    extension of the great toe with noxious stimulation of the plantar
    surface of the toes.
  • Hoffmann reflex: Elicited by pinching the nail of the middle finger.
    • Positive Hoffmann reflex: Reflexive contraction of the thumb and index finger
    • The Hoffmann reflex is absent in a normal patient (6).
  • Finger escape sign: Indicated by
    spontaneous abduction of the small finger secondary to greater
    involvement of hand intrinsic muscles because of cervical myelopathy.
Lab
Electrodiagnostics, including electromyography and nerve
conduction velocities, can be used as objective diagnostic tools but
are recommended only for patients with inconsistencies in history,
physical examination, and radiographic studies.
Imaging
  • Conventional radiographs:
    • Allow assessment of skeletal alignment and the presence of degenerative changes in disc spaces.
    • Oblique views visualize the neural foramina.
    • Flexion and extension views can be used to assess stability.
    • However, because almost 50% of all people
      ≥40 years old show degenerative changes, radiographs should be reserved
      for patients with acute trauma or for whom nonoperative therapy has
      failed.
  • CT myelography:
    • Allows accurate evaluation of the degree of neural compression from bony and soft tissues
    • Myelography, an invasive procedure, should be reserved as a tool for surgical planning.
  • MRI of the cervical spine:
    • Noninvasive
    • Involves no radiation exposure
    • Provides excellent images
    • Should be reserved for patients who do
      not respond to nonoperative interventions because up to 30% of people
      ≥40 years old have an asymptomatic disc bulge or foraminal stenosis (5).
Diagnostic Procedures/Surgery
Selective injections can be used to localize the source
of pain in patients with multiple sites of neural compression and
unclear findings.
Pathological Findings
Disc material (nucleus pulposus) herniates through the
disc annulus and compresses a nerve root, causing radiculopathy, or
compresses the spinal cord, causing myelopathy.

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Differential Diagnosis
  • Intrinsic disease of the shoulder, elbow,
    or wrist (degenerative joint disease, impingement, rotator cuff
    disease, or instability)
  • Peripheral nerve entrapments (CTS, cubital tunnel, Guyon canal, TOS)
  • Neurologic disorders (brachial plexopathy, multiple sclerosis, amyotrophic lateral sclerosis, spinal cord or brain tumors)
  • Infectious discitis
  • Vertebral osteomyelitis
  • Metastatic cancer
Treatment
General Measures
  • Most patients can be treated nonsurgically with the following:
    • Rest (activity modification)
    • Medication (analgesics, NSAIDs, and muscle relaxants)
    • Intermittent mobilization (soft collar)
    • Physical therapy (exercises or traction)
  • Patients for whom a minimum of 6 weeks of
    nonsurgical care fails, who develop increased symptoms or neurologic
    deficit, or who present with a myelopathy or a progressive or severe
    motor deficit should be referred for possible surgical treatment.
Special Therapy
Physical Therapy
  • Cervical traction, either in therapy or at home, may help reduce radicular symptoms.
  • Initially, passive modalities may help decrease acute pain.
  • Subsequent active stretching and exercises may help patients return to normal activities.
Medication
No role for maintenance opiates
First Line
  • NSAIDs (as long as no gastrointestinal side effects are noted)
  • Enteric coated aspirin (fewer gastrointestinal side effects)
  • Acetaminophen
Second Line
  • COX-2 inhibitors (Be aware of changing side-effect profile.)
  • Cervical epidural steroids
Surgery
  • Anterior cervical discectomy and fusion
    or posterior laminotomy and foraminotomy can be used to treat a
    herniated disc that is refractory to nonoperative treatment.
    • A recent study showed that the fusion
      rates of 1-level anterior cervical decompression and fusion with plate
      fixation and with bone allograft or autograft are equal (7).
  • Anterior cervical decompression and
    fusion is the preferred surgical treatment for cervical radiculopathy
    when the herniation is located centrally or when kyphosis or axial neck
    pain is present (8).
  • Posterior laminotomy and foraminotomy may be performed for lateral soft disc herniation with arm pain (8).
  • Laminoplasty provides a good alternative
    to laminectomy or anterior cervical decompression and fusion for
    multilevel cervical spondylotic radiculopathy (9).
Follow-up
Disposition
Issues for Referral
  • Shoulder pathology can present with symptoms similar to those of cervical spine disease.
  • Patients with shoulder pathology must be
    referred to a general orthopaedic surgeon or a shoulder specialist for
    additional evaluation.
Prognosis
In a population-based study of cervical radiculopathy,
~90% of patients were treated satisfactorily with surgery or
nonoperative procedures (3).
Complications
  • Complications of surgical treatment:
    • Infection
    • Persistence of neurologic deficit
    • New onset neurologic deficit, particularly C5 nerve root palsy
    • Worsening deficit
  • Moderate and severely myelopathic patients are likely to remain myelopathic.
  • Patients having an anterior cervical discectomy may complain of:
    • Dysphagia (usually improves over 6 months)
    • Pain from pseudarthrosis
    • Late degeneration at an adjacent disc
    • Adjacent level degeneration secondary to anterior plate impingement
    • Hoarseness secondary to injury of the recurrent laryngeal nerve
Patient Monitoring
No regular monitoring is needed.
References
1. Peolsson A, Hedlund R, Vavruch L, et al. Predictive factors for the outcome of anterior cervical decompression and fusion. Eur Spine J 2003;12:274–280.
2. Kokubun S, Sakurai M, Tanaka Y. Cartilaginous endplate in cervical disc herniation. Spine 1996;21:190–195.
3. Radhakrishnan
K, Litchy WJ, O’Fallon WM, et al. Epidemiology of cervical
radiculopathy. A population-based study from Rochester, Minnesota, 1976
through 1990. Brain 1994;117:325–335.
4. Wolsko
PM, Eisenberg DM, Davis RB, et al. Patterns and perceptions of care for
treatment of back and neck pain: results of a national survey. Spine 2003;28:292–297.
5. Boden
SD, McCowin PR, Davis DO, et al. Abnormal magnetic-resonance scans of
the cervical spine in asymptomatic subjects. A prospective
investigation. J Bone Joint Surg 1990;72A:1178–1184.
6. Denno JJ, Meadows GR. Early diagnosis of cervical spondylotic myelopathy. A useful clinical sign. Spine 1991;16:1353–1355.
7. Samartzis
D, Shen FH, Goldberg EJ, et al. Is autograft the gold standard in
achieving radiographic fusion in one-level anterior cervical discectomy
and fusion with rigid anterior plate fixation? Spine 2005;30:1756–1761.
8. Albert TJ, Murrell SE. Surgical management of cervical radiculopathy. J Am Acad Orthop Surg 1999;7:368–376.
9. Herkowitz HN. Cervical laminaplasty: its role in the treatment of cervical radiculopathy. J Spinal Disord 1988;1:179–188.
Additional Reading
Garvey TA, Eismont FJ. Diagnosis and treatment of cervical radiculopathy and myelopathy. Orthop Rev 1991;20:595–603.
Levine MJ, Albert TJ, Smith MD. Cervical radiculopathy: diagnosis and nonoperative management. J Am Acad Orthop Surg 1996;4:305–316.
Miscellaneous
Codes
ICD9-CM
  • 722.0 Displacement, intervertebral disc (with neuritis, pain, or radiculitis)
  • 722.71.1 Displacement, intervertebral disc (with myelopathy)
Patient Teaching
  • Patients should be informed that, in the
    absence of neurologic changes, this condition can be treated
    nonoperatively with fairly good results.
  • For most patients unable to attain pain relief with medications and/or steroids, surgery has excellent results.
FAQ
Q: Which provocative physical examination maneuvers can be used to help evaluate for a herniated cervical disc?
A: The Spurling test (radiculopathy), Babinski sign (myelopathy), and testing of the Hoffman reflex (myelopathy).

Q: Which reflexes should be evaluated at C5, C6, and C7?
A: C5, biceps; C6, brachioradialis; C7, triceps.

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