Cervical Disc Disease

Aka: Cervical Disc Disease, Cervical Disc Herniation, Cervical Radiculopathy, Cervical Disc Herniation Management

1. Epidemiology
   1. C5-C6 represents 90% of cervical disc lesions
2. Anatomy
   1. Lateral herniation compresses the nerve root below
      1. Example: C5-6 disc herniation compresses C6 root
3. Pathophysiology: Nerve Impingement Types
   1. Acute Cervical Disc Herniation (younger patients)
      1. Soft disc protrusion from nuclear herniation
   2. Chronic Cervical Disc Disease (older patients)
      1. Hard disc lesion associated with Cervical Spondylosis
4. Symptoms
   1. Neck tight or stiff
   2. Provocative
      1. Worse with activity
      2. Worse on awakening in Morning
      3. Worse with neck extension
      4. Worse with coughing, sneezing, or straining
   3. Referred pain
      1. Radiation into Shoulder
      2. Radiation along Radial Nerve distribution into arm
         1. Does not often radiate below elbow
         2. Contrast with Paresthesias (distal radiation)
      3. Radiation into medial Scapula
         1. Interscapular pain is not of Shoulder origin
   4. Associated symptoms
      1. Headaches
      2. Dysphagia
         1. Related to large anterior osteophytes
5. 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
   4. Vertex Compression Test (Spurling Test)
      1. Turn neck to ipsilateral side and axial load
      2. Pressure against top of head reproduces arm pain
   5. Sensory Exam
      1. Often not helpful
6. Signs: Motor Exam and Sensory Exam localization
   1. 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
   2. 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
   3. 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
   4. 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
7. Differential Diagnosis: Common
   1. See Neck Pain
   2. See Shoulder Pain
   3. Cervical Neck Strain
   4. Rotator Cuff Tear or Shoulder Impingement Syndrome
   5. Thoracic Outlet Syndrome
   6. Peripheral Nerve Injury (Neuropraxia)
      1. See Overuse Syndromes of the Hand and Wrist
      2. Consider nerve entrapment (e.g. Carpal Tunnel Syndrome)
      3. Herpes Zoster (Shingles)
8. Differential Diagnosis: Serious and less common
   1. Cardiac Chest Pain (Angina)
   2. Cervical Spondylotic Myelopathy
   3. Reflex Sympathetic Dystrophy
   4. Parsonage-Turner Syndrome (Neuralgic Amyotrophy)
      1. Proximal arm pain, and ultimately weakness and sensory loss due to Brachial Plexus lesion
   5. Post-median sternotomy following thoracic surgery
   6. Tumor
      1. Schwannoma
      2. Osteochondroma
      3. Pancoast Tumor
      4. Thyroid Cancer
      5. Esophageal Cancer
      6. Lymphoma
9. 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
   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)
      1. Diskitis
      2. Osteomyelitis
      3. Tuberculosis
   8. Structural deformity
      1. Failed spinal fusion
      2. Cervical Spinal Stenosis
10. Imaging
    1. Cervical Spine XRay
       1. Indicated in most cases for initial evaluation
       2. Cervical Spine CT often used instead for adults with traumatic neck injury
       3. Views
          1. Standard: Anteroposterior and Lateral
          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 disc and 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 Myopathy
       2. Indicated routinely for refractory course beyond 6 weeks of conservative therapy
    4. Myelography followed by CT C-Spine
       1. Invasive test
       2. Offers alternative for patients who cannot undergo MRI
11. 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. Myopathy
       4. XRay findings demonstrate osseous destruction or instability signs
    3. Initiate conservative management
       1. Relative Rest
          1. Consider 1 week of neck immobilization such as in soft cervical collar
             1. Keeps head slightly flexed or in neutral position
          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. No evidence to support Corticosteroid use
          4. OpioidAnalgesics 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
          1. C-Spine MRI
          2. Refer to spine surgery for progressive deficit
       3. Symptoms fail to improve
          1. Physical therapy 3-5 times per week for 4-6 weeks
             1. Starting with gentle range of motion, Stretching, massage, TENS
             2. Later employ isometric strengthening and active range of motion
             3. See Cervical Disc Herniation Rehabilitation
             4. Provides short term relief
             5. Does not change the course of the disc disease
          2. Consider empiric trial of Cervical Traction
             1. If no contraindications and acute muscular pain has resolved
          3. 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
          2. Consider spine surgery or neurosurgery consultation
       2. Negative Cervical Spine MRI
          1. Consider differential diagnosis (see above)
          2. Consider rheumatologic cause
12. 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
13. Prognosis
    1. Most patients improve with conservative management
    2. Recovery may require weeks to months
14. References
    1. Eubanks (2010) Am Fam Physician 81(1): 33-40
    2. Polston (2007) Neurol Clin 25(2): 373-85
    3. Rhee (2007) J Am Acad Orthop Surg 15(8): 486-94