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, Soft Cervical Disc Protrusion, Hard Cervical Disc Lesion

  • 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 (22% of radiculopathy cases overall)
    1. Acute, sudden onset of radiculopathy in younger patients
    2. Acute disc rupture leads to immediate radiculopathy
    3. Mechanism: Soft disc protrusion from nuclear Herniation
      1. Cervical compression
      2. Axial loading
      3. Hyperflexion
    4. Intraforaminal disc Herniation causes sensory radiculopathy (most common)
    5. Posterolateral disc Herniation causes weakness and muscle atrophy
      1. Annulus fibrosus weakest posterolaterally
      2. Posterior longitudinal ligament also weak
    6. 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 (majority of patients)
    1. Gradual, progressive onset in older patients
    2. See Cervical Spine Anatomy
    3. See Spondylosis
    4. Mechanism: Cervical Spine degeneration associated with Osteoarthritis
    5. Hard disc lesion associated with Cervical Spondylosis
      1. Spurring at uncovertebral joint (posterior foramen) compresses Sensory Nerve roots
      2. Spurring at facet joints (anterior foramen) compresses Motor Nerve roots
  • Symptoms
  1. See Neck Pain
  2. Neck tight or stiff
  3. 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
  4. Provocative
    1. Worse with activity
    2. Worse on awakening in Morning
    3. Worse with neck extension
    4. Worse with coughing, sneezing, or straining
  5. Associated symptoms
    1. Headaches
    2. Dysphagia
      1. Related to large anterior osteophytes
  • Signs
  1. See Neck Exam in Cervical Disc Disease
  2. General
    1. Decreased Neck 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 disc-related pain
    3. Pain on palpation
      1. Localized C-Spine tenderness
      2. Trigger Point tenderness over interscapular area
  3. Cervical Disc Provocative Test
    1. Vertex Compression Test (Spurling Test)
    2. Shoulder Abduction Relief Sign
    3. Upper limb Tension Test
  4. Cervical Radicular Pain Localization
    1. Localize involved cervical disc level (C4 to T1)
  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)
  • 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 with atypical symptoms suggestive of non-radicular Peripheral Neuropathy
      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
  • Management
  • Return to Sports Participation
  1. Requirements to return to Contact Sports
    1. Healed anterior or lateral disc Herniation
    2. Discectomy and interbody solid fusion
      1. Lateral or central Herniation
      2. Neurologically intact
      3. Painless Range of Motion
  2. Relative Contraindications to Contact Sports
    1. Residual facet instability
  3. Absolute contraindications to Contact Sports
    1. Acute Central DIsc Herniations
    2. Neurologic deficit
    3. Pain or limited range of motion
    4. Spinal stenosis
  • Complications
  1. See Cervical Spinal Stenosis
  2. Cervical Spondylotic Myelopathy
    1. Results from hard disc lesion, Cervical Spondylosis (chronic) with gradual onset in patients over age 50 years
    2. Pressure of posterior osteophytes at anterior cord results in combined nerve root and cord symptoms
      1. Cervical Radiculopathy
      2. Gait difficulty
      3. Leg weakness and spasticity
  • Prognosis
  1. Most patients improve with conservative management (88% at 4 weeks)
  2. Recovery may require weeks to months
  • Resources