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Cervical Disc Herniations

What is a Cervical Disc Herniation?

Disc herniations are also called “slipped discs” or “ruptured discs”. When a patient has a disc herniation, the outer ring of the disc (annulus fibrosus) ruptures and allows some of the softer inner core material (nucleus pulposus) to escape. An analogy would be a tube of toothpaste which was stepped on where the cap comes off and some of the toothpaste leaks out.

What is the difference between a Disc Bulge, a Disc Protrusion, a Disc Herniation and a Disc Fragment?

It is often thought that any change in the disc beyond a normal and healthy appearance is a disc herniation. In reality there are several different changes in the shape of the disc which can occur, each with their own name and description.

  1. Disc bulge:

A “disc bulge” is a change in the shape of the disc where the outer shell (annulus fibrosus) is weakened and allows a change in the shape to happen. The outer shell of the disc is only weakened to the point where it allows the pressure from the inner core to change its shape, but will not allow material to actually push all the way through and herniate. To qualify as a “bulged disc”, the change in the disc or bulging has to consist of more than 50% of the circumference of the disc when looking at it from the top down (cross-section). An analogy would be a hamburger which is too big for its bun and bulges over the sides of the bun. Disc bulges are often part of the normal aging process of the spine and may not be part of a specific spine disease.

      2. Disc Protrusion

A “disc protrusion” is a change in the shape of the disc where the outer shell is weak in a smaller, more confined area. This weakness is more profound than that seen in a “disc bulge” and allows that part of the disc to push out significantly more. In a “disc protrusion”, some of the core material (nucleus) will push very hard against the weakened area and its material will be part of the protrusion, but it does not leak out through the outer shell (annulus) of the disc. The outer shell, though weakened is still intact.

      3. Disc Herniation

A “disc herniation” goes beyond what happens in a “disc bulge” or a “disc protrusion”. To qualify as a true herniation, core material (nucleus pulposus) of the disc must have escaped from the main part of the core. Sometimes, a small amount of the disc’s outer shell (annulus fibrosus) still remains, coating this material, while at other times the core material is completely outside the outer shell.

      4. Disc Fragment

A “disc fragment” (disc sequestration” is a condition where a “disc herniation” has pushed a piece of the disc’s core completely outside of the disc’s outer shell. This piece, called a “fragment” is no longer connected to the rest of the disc and is now by itself.

Who is most likely to get a Cervical Disc Herniation?

A true disc herniation is most common in younger adults aged 35-45, but can occur at any age. The rarest cases occur in children.

Studies have found that cervical disc herniations are present in 5% of the population under the age of 40 who have no symptoms. Over the age of 40 this number doubles to 10%. This shows that only a small percentage of the public actually has symptoms from a disc herniation. It is not known why only some patients get symptoms while many do not.

Which discs in the neck are most likely to herniate?

The most common spinal levels for discs to herniate are at the C5/6 and C6/7 disc levels in the neck.

Which part of the disc is most likely to herniate?

The most common area for a herniation is on the sides of the back of the disc (posterior-lateral), where the disc’s outer shell (annulus fibrosus) is thinnest. Next to this part of the disc we have a spinal nerve on each side. When a disc herniates in this location, a spinal nerve can be affected. Depending on how much disc material herniates, a spinal nerve can either be irritated and inflamed or actually compressed.

Why do disc herniations happen?

Disc herniations happen for a variety of reasons. A common situation is a whiplash injury from a car accident or sports accident. In other patients it is the final result of many small injuries which happen over time.

Disc herniations can also have a genetic component, i.e. can run in families. Sometimes one of the genes in charge of making a certain disc protein can be defective, leaving the disc weakened from birth.

In all of these situation, the outer shell of the disc (annulus fibrosus) weakens and allowsthe softer core of the disc (nucleus pulposus) to push through. After the core material pushes through it can cause pressure or irritation of the spinal cord or spinal nerves which are located just outside the disc.

What symptoms do patients with disc herniations have?

The pain from a disc herniation can be felt in different ways, depending on where the disc herniated and how much material herniated.

Pain can be felt from the neck or shoulder down the arm and even into the hand

Sometimes patients feel numbness or tingling as well. In cases of severe compression of the spinal nerves, true weakness in an arm or even the legs can be felt.

In other patients, the herniation does not affect the nerve itself, but inflames the outer shell (Annulus Fibrosus) of the disc or some of the structures next to it. This may result primarily in neck pain, which is often sharp, deep pain which radiates up and down the spine. This pain is often felt in the back of the neck, between the shoulder blades and can travel to the shoulders and head. Spasms of the back muscles are very common in this situation.

Unlike other pain syndromes where the pain may vary during the day, pain from disc herniation is often very steady and annoying.

Here again are some of the common symptoms of cervical disc herniations:

  1. Neck pain radiating into the arm or hand
  2. Numbness and tingling in the arm or hand
  3. Weakness in the arm or hand
  4. Neck stiffness
  5. Pain with neck movement
  6. Pain between the shoulder blades
  7. Pain and spasm in the neck muscles

How do spine specialists make the diagnosis of a Cervical Disc Herniation?

Spine specialists use information from the patient history, the physical examination and special spine tests to make the diagnosis.

  1. History

The patient history often points to a disc herniation. A patient’s description of an accident followed by neck or arm pain is very common. Some patients have a history of prior disc herniations and can pinpoint that the current problem is “just like when I herniated it before”.

Often questions are asked about sensation and strength in the arms. When the disc herniation is causing compression of a spinal nerve we may lose the ability to feel or move the arm. This can be a significant warning sign that the spinal nerve is severely compressed.

The spine specialists may also ask specific questions about your bowel and bladder function. The reason for that is the fact that very large disc herniations can affect the spinal cord. When these structures are compressed, we often have difficulties emptying our bladder and cannot control our bowels. This is rarely the case. However when it is, surgery may have to be performed urgently.

      2. Examination

Here are some common examination techniques performed by spine specialists for disc herniations in the neck:

  1. Palpation (touching and pushing on the spine)
  2. Sensation Testing (csn)
  3. Strength Testing (csn)
  4. Reflex Testing (csn)
  5. Valsalva Test
  6. Spurling’s Test
  7. Compression Test
  8. Distraction Test
  9. Hoffman’s Test
  10. Lhermitte’s Sign

 

      3. Imaging

The following images are often used to diagnose a disc herniation:

  1. X-Ray

A basic X-Ray of the spine cannot show the disc itself, but it shows the space between the vertebrae where the disc is located. The height of each disc can be seen. This can help to make a general judgment of the spine anatomy.

       2. MRI

MRI technology is the most advanced tool to actually see a disc herniation. The images created by the MRI will show the discs, the spinal nerves and the spinal cord in detail. It can also show any compression of the spinal cord and spinal nerves by the disc herniation.

      3. CT Myelogram

This study is sometimes used if other imaging studies cannot show a disc herniation, yet the spine specialist is suspecting one. For instance when a patient has had metal inserted in the spine at the time of a previous surgery, the MRI images may be less than optimal in that area. A myelogram may help in this situation to show the spinal cord and spinal nerves.

       4. Electromyogram/Nerve Conduction Study (EMG/NCS)

An Electromyogram and Nerve Conduction Study can help evaluate the function of nerves in our arms or legs for patients which might be irritated or compressed from a disc herniation. These studies can often verify which nerve is affected by the herniation, and how healthy the nerve is. It can also tell if the nerve is recovering from the compression. Sometimes this will help with the decision for surgery.

       5. Cervical Discogram

A discogram is a study where a spine specialist injects medication into a disc to help make a diagnosis. A disc may look suspicious for a herniation or degeneration on an MRI study, however that may not be enough to prove that it is the source of the pain. A discogram can get more information from the disc, such as whether a particular disc is painful as well as the overall health of the disc.

What treatment do spine specialists offer for Cervical Disc Herniations?

Most disc herniations will heal with time and do not require surgery. In fact, only 5% of all disc herniation will require an operation. Over 90% of patients with a disc herniation will improve in the first 6 weeks. However, patients may have significant pain during this time and can benefit from non-surgical care.

 

  1. Non-Surgical Care

A. Alternative Health Care

Alternative Health Care options such as Massage Therapy, Acupuncture, Meditation Exercises and Herbal Remedies can help with the symptoms from a Disc Herniation in the neck.

B. Chiropractic Care

Chiropractic care including spine manipulation can help with the symptoms from some disc herniations in the neck. However, it may be dangerous to perform spine manipulation for very large disc herniations, specifically those which place pressure on the spinal cord. In this scenario it may be best to offer non-manipulation treatments.

C. Spine Exercises

Spine exercises can help maintain muscle mass, tone and conditioning for this condition. Patients often guard the muscles due to pain or fear of pain. This can quickly lead to loss of muscle mass and function.

D. Physical Therapy (PT)

PT can help disc herniations in the neck through a variety of means. This includes exercises, change in spine posture, and conditioning of certain muscles at risk for atrophy (loss of muscle bulk due to nerve damage). Physical therapists can also explain in detail what activities to avoid and which are best for a disc herniation.

They also use modalities such as ultrasound and muscle stimulation to help with muscle spasms.

E. Self Help Devices

Certain Self Help Devices such as Neck Braces and Neck Pillows can help with the symptoms from this condition. Neck braces can be useful to prevent certain neck movements which exacerbate the pain.

F. Medications

Below are the most common groups of medications used for disc herniations. They can be used alone or in combination depending on the severity of the symptoms and the doctor’s advice.

 

  1. Non-steroid Anti-inflammatory Drugs (NSAIDS)

This group of medications which includes Ibuprofen (Advil, Motrin) and Naproxen Sodium (Aleve, Naprosyn) amongst many others can have some benefit for disc herniations. However, higher doses are typically needed which may be difficult to tolerate.

      2. Steroids

Steroid type anti-inflammatories can be very helpful especially for nerve pain in the arm. They are usually just used for the short term due their potential side effects.

      3. Muscle Relaxants

Muscle relaxants are helpful when neck spasms are present. They may be able to interrupt the cycle of spasticity.

      4. Pain Killers

Narcotic pain medications are usually reserved for severe pain or pain not relieved by the medications above. They should be used for the short term to avoid complications.

      5. Nerve Pain Medications

These medications can be very helpful for nerve pain from a compressed spinal nerve.

      6. Antidepressants

These medications can help with nerve pain and the depression some patients suffer from severe or chronic pain.

     7. Rest

Taking time off from activities which stress the spine is important. For instance, if work exposes a patient to overhead lifting, work restrictions may have to be placed. Staying in bed for longer periods of time has not been shown to help the symptoms from disc herniations. Typically it is recommended to do activities as tolerated except for lifting, running, excessive bending and twisting of the neck, and high-impact activities.

      8. Tabaco Cessation

Smoking reduces the amount of oxygen available to tissues. In the presence of a disc herniation, oxygen is needed to assist in healing from the inflammation resulting from the herniation. Nicotine may also interfere with the disc’s nutrition. In addition, nicotine appears to cause some sensitivity to pain.

      9. Injections

a. Trigger Point Injections/Muscle Blocks

Sometimes a muscle which is in severe spasm can be helped by an injection with medications such as steroids or local anesthetics for relief.

 b. Cervical Epidural Injections

Epidural injections can deliver medication such as steroids and local anesthetics directly to the disc and a spinal nerve. This can help significantly to reduce the inflammation and pain from a disc herniation.

Injections such as Cervical Interlaminar Epidural Steroid Injections, Cervical Transforaminal Epidural Steroid Injections, and Cervical Nerve Root Blocks are some examples of commonly performed injections for Disc Herniations in the neck.

 

2. Surgical Care

Surgical care for cervical disc herniations is usually reserved for patients who do not get better after non-surgical care for 6-12 weeks and have significant symptoms. Statistically, only 5% of patients with disc herniations undergo surgery. Exceptions are patients who have signs of severe spinal cord or spinal nerve compression, who may need urgent surgery to avoid permanent nerve damage.

Here are some of the spine surgeries commonly performed for Cervical Disc Herniations:

 

  1. Minimally Invasive Surgery
    1. Cervical Percutaneous Discectomy
    2. Anterior Cervical Endoscopic Microdiscectomy
    3. Cervical Endoscopic Laminotomy and Discectomy

 

      2. Open Surgery

                 1. Anterior Cervical Decompression and Fusion (ACDF)

                 2. Cervical Artificial Disc Replacement (C-ADR)

                 3. Cervical Laminotomy and Discectomy