C-Spine

Cervical Disc Disease

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Cervical Disc Disease, Cervical Disc Herniation, Cervical Radiculopathy, Cervical Disc Herniation Management, Cervical Disc Disorder with Radiculopathy

  • Definitions
  1. Cervical Radiculopathy
    1. Cervical nerve root irritation or compression resulting in upper extremity pain
  • Epidemiology
  1. Incidence (U.S.)
    1. Men: 107 per 100,000/year
    2. Women: 64 per 100,000/year
  2. C5-C6 disc represents 90% of cervical disc lesions
    1. C6 nerve root impingement is most common (followed by C7 nerve root impingement)
  • Anatomy
  1. See Cervical Spine Anatomy
  2. Cervical spinal nerves C1-C7 exit about their corresponding Vertebrae
    1. In transitioning to Thoracic Spine, C8 exits below the C7 Vertebra, and above T1
    2. In contrast, all thoracic and lumbar spinal nerves exit below their corresponding Vertebrae
  3. Lateral Herniation compresses the nerve root below
    1. Example: C5-6 disc Herniation compresses C6 root
  • Pathophysiology
  • Nerve Impingement Types
  1. Acute Cervical Disc Herniation (younger patients, accounts for 22% of radiculopathy cases overall)
    1. Soft disc protrusion from nuclear Herniation
    2. Intraforaminal disc Herniation causes sensory radiculopathy (most common)
    3. Posterolateral disc Herniation causes weakness and muscle atrophy
    4. Central DIsc Herniation causes central cord compression and myelopathy (least common)
      1. May result in numbness and weakness as well as Ataxia, urine changes
  2. Chronic Cervical Disc Disease (older patients, majority of patients)
    1. See Cervical Spine Anatomy
    2. Cervical Spine degeneration associated with Osteoarthritis
    3. Spurring at uncovertebral joint (posterior foramen) compresses Sensory Nerve roots
    4. Spurring at facet joints (anterior foramen) compresses Motor Nerve roots
    5. Hard disc lesion associated with Cervical Spondylosis
  • Symptoms
  1. Neck tight or stiff
  2. Radicular Symptoms
    1. Characteristics
      1. Radicular pain (most common)
      2. Paresthesias
      3. Weakness (15% of patients)
    2. Radiation into Shoulder
    3. Radiation along Radial Nerve distribution into arm
      1. Does not often radiate below elbow
      2. Contrast with Paresthesias (distal radiation)
    4. Radiation into medial Scapula
      1. Interscapular pain is not of Shoulder origin
  3. Provocative
    1. Worse with activity
    2. Worse on awakening in Morning
    3. Worse with neck extension
    4. Worse with coughing, sneezing, or straining
  4. Associated symptoms
    1. Headaches
    2. Dysphagia
      1. Related to large anterior osteophytes
  • Signs
  1. Decreased Range of Motion
    1. Neck flexion and extension
    2. Neck lateral bending to right and left
    3. Neck rotation to right and left
  2. Neck hyperextension elicits pain
  3. Pain on palpation
    1. Localized C-Spine tenderness
    2. Trigger Point tenderness over interscapular area
  • Signs
  • Provocative Tests
  1. Vertex Compression Test (Spurling Test)
    1. Turn neck to ipsilateral side (lateral flexion and extension) and axial load
    2. Pressure against top of head reproduces arm pain (by compressing neural foramina)
    3. High Test Sensitivity and Specificity
    4. Shah (2004) Br J Neurosurg 18(5): 480-3 [PubMed]
  2. Shoulder Abduction test
    1. Patient places their palm of the affected arm on top of their head
    2. Considered a positive test if this positioning relieves radicular pain
    3. Tandeter (1997) Canadian Family Physician 43:511-2
  3. Upper limb tension test
    1. Patient supine with neutral Shoulder at side with flexed elbow and wrist
    2. Examiner places counter pressure at anterior Shoulder and abducts the Shoulder to 90 degrees
    3. Examiner extends the elbow, wrist and fingers and supinates the Forearm
    4. Patient lateral deviates the neck to either side
    5. Considered a positive test if positioning provokes the pain
    6. Nee (2012) J Orthop Sports Phys Ther 42(5):413-24
  1. Background
    1. See Motor Exam
    2. See Sensory Exam
    3. See Neuroanatomy of the Arm
    4. Diminished Deep Tendon Reflex is most common objective neurologic finding
      1. Loss of Triceps Reflex is most common
    5. Motor weakness may also be identified
  2. C3-4 Disc (C4 nerve root)
    1. Pain at lower neck or trapezius muscle
    2. Sensory change only (no motor or reflex changes)
      1. Cape distribution
      2. Includes lower neck and upper Shoulder girdle
  3. C4-5 Disc (C5 nerve root)
    1. Pain
      1. Base of neck
      2. Shoulder
      3. Anterolateral arm
    2. Numbness
      1. Deltoid
    3. Motor weakness and atrophy
      1. Deltoid muscle
      2. Biceps muscle
    4. Reflexes decreased
      1. Biceps Reflex
  4. C5-6 Disc (C6 nerve root)
    1. Pain
      1. Neck
      2. Shoulder
      3. Medial Scapula
      4. Dorsolateral arm
    2. Sensory change
      1. Dorsolateral thumb
      2. Index finger
    3. Motor weakness and atrophy
      1. Biceps muscle
      2. Extensor pollicis longus
    4. Reflexes decreased
      1. Biceps Reflex
      2. Brachioradialis Reflex
  5. C6-7 Disc (C7 nerve root)
    1. Pain same as C5-6 Disc (C6 nerve root)
    2. Sensory change
      1. Index finger
      2. Middle finger
      3. Dorsal hand
    3. Motor weakness and atrophy
      1. Triceps muscle
    4. Reflexes decreased
      1. Triceps Reflex
  1. See Overuse Syndromes of the Hand and Wrist
  2. Anterior interosseus nerve entrapment
    1. Weakness of pinch and grip, without associated pain
  3. Posterior interosseous nerve entrapment
    1. Weakness of fingers and wrist, WITH associated pain
    2. In contrast to C7 nerve root, posterior interosseous has no triceps or wrist flexion weakness
  4. Radial Nerve entrapment (Radial Tunnel)
    1. Radial Forearm pain
  5. Median Nerve entrapment (Carpal Tunnel)
    1. Paresthesias and numbness in radial 3.5 fingers
    2. In contrast to C6-7 nerve roots, Carpal Tunnel has no triceps or wrist extension weakness
  6. Ulnar Nerve entrapment (Cubital Tunnel)
    1. Flexor digitorum profundus weakness with numbness and Paresthesias in ulnar 1.5 fingers
    2. In contrast to C8-T1 nerve roots, Cubital Tunnel has no thumb IP flexion weakness
  7. Brachial plexopathy (Personage-Turner Syndrome, Neuralgic Amyotrophy)
    1. Proximal arm pain, and ultimately weakness and sensory loss due to Brachial Plexus lesion
  • Differential Diagnosis
  • Serious and less common
  1. Vascular causes
    1. Arteriovenous malformation
    2. Cardiac Chest Pain (Angina)
    3. Post-median sternotomy following thoracic surgery
  2. Spinal causes
    1. Cervical Spinal Stenosis
    2. Cervical Spondylotic Myelopathy
    3. Epidural Abscess
    4. Extremity abscess
  3. Miscellaneous causes
    1. Reflex Sympathetic Dystrophy
  4. Tumor
    1. Schwannoma
    2. Osteochondroma
    3. Pancoast Tumor
    4. Thyroid Cancer
    5. Esophageal Cancer
    6. Lymphoma
  • Evaluation
  • Red Flags (consider alternative diagnosis)
  1. Patient under age 20 years or over age 50 years
  2. Systemic disease signs or symptoms
  3. Neck rigidity without Trauma
    1. Especially if rapid onset and associated with Headache
  4. Cognitive changes
    1. Decreased ability to communicate
    2. Altered Level of Consciousness
  5. Spine instability risks (ligament laxity or Atlantoaxial Instability risks)
    1. Down Syndrome
    2. Rheumatoid Arthritis
    3. C-Spine Trauma with MRI demonstrating Ligamentous Injury
  6. Neurovascular event suspected
    1. Vertebrobasilar dissection (e.g. following Chiropractic Manipulation)
    2. Carotid Stenosis
    3. Transient Ischemic Attack symptoms
  7. Suspected infection (e.g. fever, esp. immunocompromised, IVDA)
    1. Diskitis or Epidural Abscess
    2. Osteomyelitis
    3. Tuberculosis
  8. Structural deformity
    1. Failed spinal fusion
    2. Cervical Spinal Stenosis
  9. Myelopathy symptoms
    1. Ataxia
    2. Decreased dexterity
    3. Urine urgency
    4. Hyperreflexia or Clonus
    5. Hoffman Sign
  10. Malignancy symptoms
    1. Fever
    2. Cancer history
    3. Night pain
    4. Weight loss
  • Imaging
  1. Cervical Spine XRay
    1. Typically a first-line study, but limited efficacy in radiculopathy, and low Specificity in age over 50 years
    2. Indicated in persistent symptoms >4-6 weeks, Trauma, cancer red flags
    3. Cervical Spine CT is preferred for adults with Traumatic neck injury
    4. Views
      1. Standard: Anteroposterior, Lateral (and oblique views in suspected foraminal stenosis)
      2. Trauma: Anteroposterior Open Mouth Odontoid view (in addition to standard views)
      3. Additional views to consider: Flexion and extension views
  2. Cervical Spine CT
    1. Traumatic neck injury evaluation in adults at acute emergency visit
    2. Not as useful in evaluating cervical disc or radiculopathy (without myelography)
    3. Avoid in children
      1. Consult with local experts
      2. Consider MRI Cervical Spine instead if XRay not diagnostic
  3. Cervical Spine MRI
    1. Indicated urgently for red flags (see above), progessive neurologic deficit or myelopathy, epidual abscess
    2. Indicated routinely for refractory course beyond 6 weeks of conservative therapy
    3. High rate of false positives (57% over age 64 years) and false negatives in Cervical Radiculopathy
  4. CT Cervical Spine with Myelography (requires spinal contrast injection)
    1. May offer definitive evidence where MRI is non-diagnostic in Cervical Radiculopathy
    2. Offers alternative for patients who cannot undergo MRI
  • Diagnostics
  1. Electromyography (EMG)
    1. Consider in atypical Peripheral Neuropathy and distinguishing proximal from distal cause
  • Precautions
  1. Thorough Neurologic Exam is critical to identify deficits
  2. Cervical Radiculopathy with a neurologic deficit should be addressed promptly (consult spine surgery)
    1. Cervical nerve impingement is less forgiving than lumbar nerve impingement
    2. Prolonged impingement with neurologic deficits is a risk for persistent deficits
  3. Cervical Spinal Stenosis may result in significant spinal cord injury
    1. Upper Motor Neuron effects may include hyperreflexia and Clonus
    2. Assess proprioception and balance to help exclude cord compression
  • Management
  • Acute radicular pain
  1. Start with history, examination and Cervical Spine XRay as described above
  2. Urgent Cervical Spine MRI and spine referral indications
    1. Red flags (see above)
    2. Progessive neurologic deficit
    3. Myelopathy
    4. Imaging findings demonstrate osseous destruction or instability signs
  3. Initiate conservative management
    1. Relative Rest
      1. Consider 1 week of neck immobilization such as in hard Cervical Collar (soft collar insufficient)
        1. Keeps head slightly flexed or in neutral position
        2. Kuijper (2009) BMJ 339:b3883 [PubMed]
      2. Acute disc injury (soft Cervical Disc Herniation)
        1. Allows healing of disc
      3. Chronic disc disease (hard Cervical Disc Herniation)
        1. Allows inflammation around disc to subside
    2. Local moist heat and massage
      1. Relieves tenderness and muscle pain
    3. Acute Pain Management
      1. NSAIDs
      2. Muscle relaxants (e.g. Cyclobenzaprine or Flexeril)
        1. Variable efficacy
      3. Systemic Corticosteroids
        1. Epidural Corticosteroids more likely to be of benefit (see below)
        2. May offer short-term benefit (as evaluated day 10)
          1. Ghasemi (2013) J Res Med Sci 18(suppl 1): S43-6 [PubMed]
        3. However, no longterm benefit in pain, Disability or need for surgery
          1. Goldberg (2015) JAMA 313(19):1915-23 [PubMed]
      4. Opioid Analgesics may be needed (e.g. Hydrocodone, Oxycodone)
  4. Reevaluate after 2 weeks and continue conservative therapy with precautions
    1. Diagnosis unclear
      1. Consider Nerve Conduction Studies and EMG
    2. Progressive deficit found on re-evaluation (esp. beyond 3 weeks)
      1. C-Spine MRI
      2. Refer to spine surgery for progressive deficit
    3. Symptoms fail to improve
      1. Epidural Corticosteroid Injection
        1. Interlaminar injections reduce pain at 1 week, 1 month, 6 months
          1. Pasqualucci (2007) Clin J Pain 23(7):551-7 [PubMed]
        2. Transforaminal injections reduce pain at 4 weeks
          1. Engel (2014) Pain Med 15:386-402 [PubMed]
      2. Physical therapy 3-5 times per week for 4-6 weeks
        1. See Cervical Disc Herniation Rehabilitation
        2. Starting with gentle range of motion, Stretching, massage, TENS
        3. Stretching focused on neck and chest muscles
        4. Later employ isometric strengthening and active range of motion
          1. Deep neck flexor, Shoulder retraction, Scapular muscles
        5. Provides short term relief
        6. Does not change the course of the disc disease
        7. Cheng (2015) J Phys Ther Sci 3011-18 [PubMed]
      3. Consider empiric trial of Cervical Traction
        1. If no contraindications and acute muscular pain has resolved
        2. Ideal regimen (lying traction more likely to achieve, whereas over-the-door not as likely)
          1. Position neck flexion 15-25 degrees
          2. Intermittent traction 60 seconds, followed by 20 seconds relaxed force
          3. Start with 12 pounds and increase as tolerated
        3. References
          1. Fritz (2014) J Orthop Sports Phys Ther 44(2): 45-57 [PubMed]
      4. Consider starting medication to reduce daily pain
        1. Tricyclic Antidepressant (e.g. Amitriptyline)
        2. SNRI (Venlafaxine, Duloxetine)
  5. Reevaluate after an additional 4 weeks and obtain Cervical Spine MRI for those failing to improve
    1. Positive Cervical Spine MRI
      1. Consider cervical epidural steroid injection or foraminal steroid injection
        1. Kwon (2007) Skeletal Radiol 36(5): 431-6 [PubMed]
        2. Diwan (2012) Pain Physician 15(4): E405-34 [PubMed]
      2. Consider spine surgery or neurosurgery Consultation
    2. Negative Cervical Spine MRI
      1. Consider differential diagnosis (see above)
      2. Consider rheumatologic cause
  • Management
  • General
  1. See Cervical Disc Herniation Management
  2. Conservative management indicated in most cases
    1. See Cervical Disc Herniation Rehabilitation
    2. No danger in observation (except where urgencies exist as describe above)
    3. Encourage patience
    4. Do not rush surgical intervention
  3. Surgery (5% of cases)
    1. Indications
      1. Pain and Disability intolerable
        1. Arm pain responds better than Neck Pain
      2. Major neurological deficit
    2. Procedure: affected disc replaced
      1. Bone graft
      2. Arthrodesis
    3. Results
      1. Arm pain subsides immediately after surgery
      2. Osteophytes in foramen absorbed in 9-18 months
  • Prognosis
  1. Most patients improve with conservative management (88% at 4 weeks)
  2. Recovery may require weeks to months