The cervical herniated disk can cause a variety of symptoms or even no symptoms. It can cause aching in the neck, arm and/or hands, or radiate into these areas with electric-like pain. It is possible to feel weakness or numbness in the arm or hands. Although a cervical herniated disk may be caused by trauma or neck injury to the neck, most symptoms appear spontaneously.
Symptoms of cervical herniated disc pain, and other signs that can be associated with it, are usually felt in one arm. The symptoms can vary depending upon which disc has burst and which nerve root is pinched or inflamed. Rarely, the symptoms of pain, tingling and/or numbness can spread to both arms, or lower, depending on the severity of the spinal cord injury. It is possible to lose bladder and/or bowel control, but this is rare.
Introduction
The vertebral column or spine is formed by the intervertebral and vertebral discs. The spine extends from the base to the coccyx, including the cervical, sacral, lumbar and thoracic regions. It plays a number of important roles in the body, including protection of the spinal cord, branching spinal nerves, structural supports, and flexibility and mobility. Intervertebral disks are cartilaginous structures that lie between adjacent vertebrae and support the spine by providing shock-absorbing cushions for the body’s axial load.
Seven vertebral bodies make up the cervical spine. They are numbered C1 through C7 and run from the base to the thoracic spine. C1, C2, C7 and C7 are unique structures that differ from the C3 to C6 typical cervical vertebrae. C3 through C6 anatomy consists of a vertebral arm, a vertebral bone arch, and seven processes. The vertebral is made up of the pedicles and lamina, which are bony processes that extend posteriorly from the vertebral bodies.
These bone segments make up most of the arch. The spinal canal is surrounded by the pedicles and lamina. Seven processes make up the typical vertebra. They include two superior articular aspects, two inferior, one spinous, and two transverse procedures that allow passage of the vertebral vessels.
Three atypical vertebrae are found in the cervical region. C1 (atlas), which articulates with C1 (base of the skull), is unique in that it doesn’t contain a body because it fuses with C2 (axis)vertebrae. This allows the atlas pivot to turn. C2 vertebra’s most distinguishing feature is its presence of an odontoid (dense) process that rises from its superior aspect and connects with the posterior arch of C1. Two distinct characteristics make C7 different from a normal cervical vertebra are that the vertebral vasculature doesn’t traverse its transverse foramina and second, it includes along the spinous process. This makes C7 commonly known as “vertebra prosens.”
There are seven cervical vertebrae. However, there are eight cervical nerve pairs, numbered from C1 through C8. There are seven cervical vertebrae. However, there are eight pairs of cervical nerves, numbered C1 to C8.
What does ‘Herniated” mean?
A gel-like substance is found in the middle of disks between vertebrae. The gel is kept contained in the outer portion of a disk by fibrous cartilage. Gel can pop out of the outer layer if it is split or tears. This is how a disk can become herniated. A herniated disc is also known as a “ruptured” disk or a slipped disk. It can be compared to a jelly doughnut with its filling squirted out.
Treatment for Cervical Herniated Disk Pain
A cervical herniated disk can cause neck and/or arm pain that lasts for only a few days or may become chronic and last months. The pain can be intermittent or severe, depending on the activity. A herniated disc can cause arm and neck pain. Symptoms usually resolve within four to six months.
The majority of cervical herniated disk pain can be managed non-surgically. These include over-the-counter pain medication, physical therapy to strengthen the neck and stretch the spine, heat packs or ice packs and activity modifications to minimize painful movements until the pain subsides. Sometimes, an epidural injection or selective nerve root injection using x-ray guidance with contrast might be necessary to relieve pain and facilitate rehabilitation.
How to Remove Cervical Disc Herniates
The cervical spine has 6 intervertebral disks. Each cervical disc is located between two adjacent vertebrae (one below and one above) to cushion the vertebral bodies. They also help to distribute the load from the neck and head. There are two basic components to a disc.
- Annulus fibrosus. The outer layer of the disc is made up of concentric collagen fibers. This makes it strong enough to protect its soft inner layer. The spine’s heavy loads are absorbed by the annulus fibrosus.
- Nucleus pulposus. This gel-like interior is made up of a loose network fibers that are suspended in mucoprotein gel, and then protected by the annulus fibrisus. Additional cushioning and flexibility are provided by the nucleus pulposus, which provides additional mobility.
A herniated disk is when the disc’s outer layer breaks down and some of the nucleus pulsus leaks into it. The most painful part of a herniated disc is when the nucleus pulposus (which contains inflammatory proteins) leaks from the disc onto the nerve root. A herniated disk may also leak onto the spinal cord.
Risk factors for a Cervical Herniated Disk
As we age, the risk of developing a herniated disk tends to increase. According to some estimates, a cervical herniated disk is more likely between the ages of 30 and 50. While most studies show that cervical herniated discs are more common in men, a new study indicates that women may be at greater risk.
According to estimates, the rate of cervical herniated disks in adults is between 0.5% and 2.2%. Many cases of cervical herniated disk may not be diagnosed and could result in different estimates depending on the population.
A Cervical Herniated Disk Is Severe
Rarely, symptoms and signs of a cervical herniated disk may get worse over time rather than stabilizing and eventually resolving itself. A pinched or inflamed cervical nerve root can cause tingling, numbness and/or weakness in the arm. The same applies to a herniated cervical disc. This can cause problems with coordination, walking, bladder control, and/or coordination. These neurological problems require immediate medical attention in order to avoid them becoming more severe or permanent.
Etiology
An intervertebral disk is a cartilaginous structure that consists of three components: an outer annulus fibrosus, inner nucleus pulposus and endplates. These are used to anchor the discs to adjacent vertebrae. When part or all the nucleus pulposus protrudes into the annulus fibrosus, disc herniations can occur. This can happen either acutely or chronically. Chronic herniations are caused by the intervertebral disk becoming degenerated and desiccated during the natural aging process. Symptoms of gradual or insidious onset tend to be milder. Acute herniations, on the other hand, are usually the result of trauma. The nucleus pulposus is forced through the annulus fibrosus. A sudden onset of severe symptoms will be more common in acute herniations than in chronic.
Epidemiology
For both men and for women, the prevalence of cervical disc herniation rises with age. It is most common among people in their third and fifth decade of life. Females are more likely to experience it, with more than 60% of cases. Both sexes were most commonly diagnosed in patients aged 51-60.
Pathophysiology
Herniated discs are caused by a combination mechanical compression of nerves by the bulging nucleus, and an increase in inflammatory cells. Microvascular damage can be caused by compression forces.
These can cause varying degrees of compression. Nerve irritation and herniated disc material can cause the release of inflammatory cytokines. These cytokines include interleukin (IL),-1 and IL-6, substance, bradykinin and tumor necrosis factors-alpha. Stretching on the nerve root may play an additional role in reproduction of symptoms. As the cervical nerve exits the neural foramen, its trajectory makes it vulnerable to stretching and compression due to a herniation. This arrangement may explain in part why some patients feel pain relief from the abduction, which decreases the amount the nerve experiences stretch.
Posterolateral herniations are more common because the annulus fibrosus is thinner and does not have the support of the posterior longitudinal ligament. Radiculopathy can occur in the dermatome associated with radiculopathy due to the close proximity of the herniation and the traversing cervical nerve roots.
History and Physical
Most cervical disc herniations occur between the C5-C6 vertebral bodies and the C6-C7 vertebral body. This will lead to symptoms at C6-C7 and C7, respectively. These patients need to have a history that includes the main complaint, onset and aggravating factors, radicular symptoms and past treatments. Most common subjective complaints include axial neck pain, ipsilateral pain in the arm or paresthesias in dermatomal distribution.
It is important to recognize red flags in neck pain that could indicate underlying conditions such as malignancy or inflammation. These are:
- Chills, fever
- Night sweats
- Unexplained weight loss
- History of inflammatory arthritis or malignancy, systemic infections, tuberculosis and HIV, immunosuppression or drug use
- Inexplicable pain
- Point tenderness on a vertebral body
- Cervical lymphadenopathy
- Physical Examination
As this may indicate the severity and degree of pain or degeneration, the clinician should evaluate the patient’s range-of-motion (ROM). To evaluate sensory disturbances, motor weakness and deep tendon reflex abnormalities, a thorough neurological exam is required. Any sign of spinal cord dysfunction should be taken into consideration.
A typical finding of single nerve lesions caused by compression in the cervical spine by a herniated disk
- C2 Nerve – Eye or ear pain, headache. History of rheumatoid or atlantoaxial instability
- C3, C4 Nerve — vague neck, trapezial tenderness and muscle spasms
- C5 Nerve – neck, shoulder, and/or scapula pain. Lateral arm paresthesia. Elbow flexion and shoulder abduction are the primary motions affected. You may also notice weakness in shoulder flexion, external rotation and forearm supination. Diminished biceps reaction.
- C6 Nerve – neck, shoulder, and scapula pain. Paresthesia of the lateral arm, lateral hand and lateral two fingers. Wrist extension and elbow flexion are the primary motions affected. You may also notice weakness in shoulder abduction, external rotation, forearm supination, and pronation — decreased brachioradialis.
- C7 Nerve – neck and shoulder pain. Paresthesia of the third digit and posterior forearm. The primary motions affected are wrist flexion and elbow extension. Diminished reflexes of the triceps
- C8 Nerve – neck and shoulder pain. Paresthesia in the medial forearm and medial hands, as well as the medial two fingers. You may feel weak during thumb extension, finger flexion, and handgrip.
- T1 Nerve – Neck and shoulder pain. Paresthesia in the medial forearm. Paresthesia of the medial forearm.
- The Spurling test, Hoffman and Lhermitte signs are all probative tests. Spurling test can help diagnose acute radiculopathy. To perform this test, extend the neck as far as possible and rotate towards the affected side. Then compress the head to load the cervical spine. This will reduce the size of the neuroforamen, which can lead to radiculopathy symptoms. The Hoffman test and Lhermitte sign are useful tools to determine if there is spinal cord compression or myelopathy. Holding the long finger in your hand, flick the distal tip down and perform the Hoffman test. If the thumb is in flexion or adduction, it’s a positive sign. Lhermitte is a sign that the patient flexes their neck. This may cause an electrical sensation to travel down the spine and into the extremities.
Evaluation
A majority of cases of spinal injury or herniation are resolved within four weeks. This is why imaging is not recommended. The management of these cases will not usually be altered. If there is any clinical suspicion of serious pathology, or neurological compromise, imaging should be done during this time. Patients who fail to respond to conservative treatment within a time period of 4 to 6 week warrant further evaluation. Patients with the red flag symptoms mentioned above may be eligible for lab markers evaluation. These could include:
Lab values:
- Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP): These are inflammatory markers that should be obtained If a chronic inflammatory condition is suspected (rheumatoid arthritis, polymyalgia rheumatica, seronegative spondyloarthropathy). If an infectious cause is suspected, these can be helpful as well.
- A complete blood count (CBC) and differential: This is useful in cases where infection or malignancy are suspected.
- X-rays are the first test that’s commonly performed. They can be obtained at most outpatient clinics. The AP, lateral and oblique views allow you to assess the alignment of your spine, as well as any degenerative or spondylotic conditions. To assess for instability, these views can be supplemented by lateral flexion or extension views. A computed tomography scan (CT) or magnetic resonance imaging (MRI are required for any imaging that shows an acute fracture. The open mouth (odontoid view) may be helpful in diagnosing atlantoaxial instability.
- CT Scan: This is the most sensitive imaging test that can examine the bony structures in the spine. It can show bony destruction or calcified discs. CT myelography is an alternative method to visualize a herniated disk in patients who are unable or unwilling to undergo an MRI.
- MRI: MRI is the preferred imaging modality for a herniated disk. It has the highest ability to show soft-tissue structures as well as the nerve exiting the foramen.
Patients with equivocal symptoms, imaging findings, or nerve conduction studies can electromyography (or electrodiagnostic testing) to rule out peripheral mononeuropathy. Electrodiagnostic testing can detect cervical radiculopathy at a sensitivity between 50% and 71%.
Treatment / Management
- Conservative Treatments: Patients suffering from acute cervical radiculopathy secondary to a herniated disk are usually treated with non-surgical methods as most patients (75 to 90%) will recover. There are many options available:
- Collar Immobilization: A short course of collar immobilization (approximately a week) may be helpful for patients suffering from acute neck pain.
- Traction: Can be helpful in reducing the symptoms of disc herniations. Theoretically, traction could widen the neuroforamen, relieve stress on the affected nerve and improve symptoms. The therapy involves applying approximately 8-12 lbs of traction to the affected area at an angle of approximately 24-degrees of neck flexion for a period of about 15 to 20 minutes.
- Pharmacotherapy: No evidence has been provided to support the effectiveness of non-steroidal antiinflammatory drugs (NSAIDs), in the treatment and prevention of cervical radiculopathy. They are used frequently and may be of benefit to some patients. While the COX-1 and COX-2 inhibitors do not affect the analgesic effects, there may be a decrease in gastrointestinal toxicities with COX-2. In severe acute pain, doctors may recommend steroidal anti-inflammatory drugs (typically prednisone). Prednisone 60-80 mg/day for five consecutive days. This can be gradually tapered over the next 5 m to 14 day. A tapered prepackaged dose of Methylprednisolone is another option. It tapers from 24 mg up to 0 mg in 7 days. Opioid medication should be avoided because there is not enough evidence to support its use and they have a higher profile of side effects. A muscle relaxant might be worth consideration if muscle spasms are a frequent occurrence. At a dose of five mg, cyclobenzaprine can be taken orally three days a day. To treat neuropathic pain, antidepressants (amitriptyline and pregabalin), can be used. They may provide moderate analgesic effects.
- Physical Therapy: Commonly recommended after a brief period of immobilization and rest. There are many options available, including strengthening exercises, range of motion, heat, ultrasound and electrical stimulation therapy. There is no evidence to support their effectiveness over placebo, despite their widespread use. Their use is not recommended in the absence of myelopathy. However, there are no known harms and they may be of some benefit.
- Cervical manipulation: Although there is not much evidence to suggest that cervical manipulation can provide benefits in the short-term for neck pain or cervicogenic headaches, it has been suggested. These complications are uncommon and may include myelopathy, worsening radiculopathy, and spinal cord injury. These complications can occur in between 5 and 10 per 10,000,000 manipulations.
- Interventional Treatments: Spinal steroids are an alternative to surgery. With pathological confirmation by MRI, perineural injections (translaminar or transforaminal epidurals and selective nerve root block) are an option. Radiologic guidance should be used for these procedures. These procedures should be performed under radiologic guidance. These devices are an effective treatment option for patients who cannot undergo surgery.
- Surgical Treatments: These are indications for surgery. Based on pathology, there are many techniques. Anterior cervical discectomy with Fusion is the best option. It allows for the removal of pathology and prevents recurrent neural compression. Patients with anterolateral herniations may consider a posterior laminoforaminotomy. While there are still questions about the indications for total disc replacement, it is an emerging treatment option.
Differential Diagnosis
There are several types of differential diagnoses:
- Brachial plexus injury
- Degenerative cervical spondylosis
- Muscle strain
- Parsonage-Turner syndrome
- Peripheral nerve entrapment
- Tendinopathies of shoulder
Prognosis
Radiculopathy, pain, restricted motion and restricted movement that are caused by a herniated disk usually subside over six weeks in most patients. This is due to the enzymatic or phagocytosis process of the extruded material. You may notice a change in the extruded material’s hydration or decrease in local edema. This can lead to pain relief and functional restoration.
About one-third of patients will experience persistent symptoms despite non-operative treatment. If symptoms persist for more than six weeks, it is less likely that they will improve with surgical intervention.
Complications
Steroid injections can cause mild complications that range from 3% to 35% in most cases. You may also experience more severe complications such as:
- Nerve injury
- Infection
- Hematoma epidural
- Epidural abscess
- Infarction of the spinal cord
The following complications can result from a surgical procedure:
- Infection
- Recurrent hypoglossal, superior, and laryngeal nerve injuries
- Esophageal injury
- Vertebral, carotid and vertebral injuries
- Dysphagia
- Horner syndrome
- Pseudoarthrosis
- Adjacent segment degeneration
