Dr. Kevin Yip

Dr Kevin Yip
Orthopaedic Surgeon
MBBS(UK), FRCS(EDIN), FAM(SING), FHKCOS(ORTHO)

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Cervical Disc Herniation

Basics
Description
  • Cervical disc herniation is a condition in which retropulsion of disc material occurs, with resulting compression of the neural elements (nerve root[s] and/or spinal cord), resulting in neck pain, radiculopathy, and/or myelopathy.
  • Classification
    • Herniation is classified as acute or chronic.
    • The classification of myelopathy is based on physical function.
General Prevention
  • No good evidence exists regarding preventive measures, but smoking cessation may help decrease the chances of neck pain and radiculopathy.
  • However, nonsmoking is a predictor of positive outcome after anterior cervical decompression and fusion.
Epidemiology
  • Most common in individuals >30 years old, with a mean age of 50 years.
  • Radiculopathy rarely progresses to myelopathy.
Incidence
  • 107.3 males and 64.5 females per 100,000 population (annual age-adjusted incidence).
  • 203 per 100,000 population is the age-specific annual incidence rate for 50-54-year-olds.
Prevalence
  • Up to 2/3 of adults will have at least 1 major episode of neck pain in their lifetime .
  • Radiographic evidence of disc degeneration is seen in nearly 60% of individuals >40 years old .
Risk Factors
  • Repetitive lifting
  • Smoking
  • Overhead work
Genetics
The risk of disc herniation is higher in a person with a positive family history than in a patient without such a history.

Pathophysiology
  • The mechanical nature of neural element compression is well understood.
  • Substance P concentration is elevated in compressed nerve roots.
  • Decreased blood flow in a compressed nerve root also may play a role in pain.
Etiology
Cervical disc herniations may be traumatic or nontraumatic.
 
Associated Conditions
  • Congenital cervical stenosis
  • Ossified posterior longitudinal ligament
  • Cervical spine spondylosis
Diagnosis
Signs and Symptoms
  • Symptoms can develop acutely or insidiously.
  • The spectrum of symptoms includes neck pain, occipital pain, shoulder girdle pain, and regional upper extremity symptoms (pain, paresthesias, hypesthesia, or weakness).
  • Symptoms often are exacerbated by particular neck motions and positions.
  • Nerve root compression at a specific level may cause classic findings of motor, sensory, or reflex symptoms.
  • The Spurling test (axial loading of the neck while the head is rotated and laterally bent toward the affected side) often recreates the radicular symptoms.
  • Cervical myelopathy usually presents insidiously, with a wide variety of symptoms, including:
    • Gait deterioration (unsteadiness and falls)
    • Deterioration of manual dexterity
    • Generalized weakness
    • Bowel and bladder dysfunction
  • Patients may complain of losing balance or of jumpy legs.
  • A Babinski reflex in the lower extremities or a Hoffmann reflex in the upper extremities may be seen.
History
  • Patients may present with pain, paresthesias, and motor weakness.
  • Pain in the trapezial and scapular region may accompany radicular pain.
  • Sensory abnormalities do not necessarily follow a dermatomal pattern.
  • Pain generally worsens when the neck is tilted to the affected side (because of narrowing of the neural foramina).
  • Patients with C6 and C7 radiculopathy often complain of breast pain or anginal symptoms.
  • Myelopathic patients complain of gait abnormalities, weakness, and motor skills problems.
Physical Exam
  • Neck ROM
  • Motor examination to evaluate for weakness
  • Sensory examination
  • Reflexes
    • C5: Biceps
    • C6: Brachioradialis
    • C7: Triceps
  • Evaluate for myelopathy.
Tests
  • Spurling maneuver
  • Babinski: A positive test is indicated by extension of the great toe with noxious stimulation of the plantar surface of the toes.
  • Hoffmann reflex: Elicited by pinching the nail of the middle finger.
    • Positive Hoffmann reflex: Reflexive contraction of the thumb and index finger
    • The Hoffmann reflex is absent in a normal patient.
  • Finger escape sign: Indicated by spontaneous abduction of the small finger secondary to greater involvement of hand intrinsic muscles because of cervical myelopathy.
Lab
Electrodiagnostics, including electromyography and nerve conduction velocities, can be used as objective diagnostic tools but are recommended only for patients with inconsistencies in history, physical examination, and radiographic studies.

Imaging
  • Conventional radiographs:
    • Allow assessment of skeletal alignment and the presence of degenerative changes in disc spaces.
    • Oblique views visualize the neural foramina.
    • Flexion and extension views can be used to assess stability.
    • However, because almost 50% of all people >40 years old show degenerative changes, radiographs should be reserved for patients with acute trauma or for whom nonoperative therapy has failed.
  • CT myelography:
    • Allows accurate evaluation of the degree of neural compression from bony and soft tissues
    • Myelography, an invasive procedure, should be reserved as a tool for surgical planning.
  • MRI of the cervical spine:
    • Noninvasive
    • Involves no radiation exposure
    • Provides excellent images
    • Should be reserved for patients who do not respond to nonoperative interventions because up to 30% of people >40 years old have an asymptomatic disc bulge or foraminal stenosis .
Diagnostic Procedures/Surgery
Selective injections can be used to localize the source of pain in patients with multiple sites of neural compression and unclear findings.
 
Pathological Findings
Disc material (nucleus pulposus) herniates through the disc annulus and compresses a nerve root, causing radiculopathy, or compresses the spinal cord, causing myelopathy.
 
Differential Diagnosis
  • Intrinsic disease of the shoulder, elbow, or wrist (degenerative joint disease, impingement, rotator cuff disease, or instability)
  • Peripheral nerve entrapments (CTS, cubital tunnel, Guyon canal, TOS)
  • Neurologic disorders (brachial plexopathy, multiple sclerosis, amyotrophic lateral sclerosis, spinal cord or brain tumors)
  • Infectious discitis
  • Vertebral osteomyelitis
  • Metastatic cancer
Treatment
General Measures
  • Most patients can be treated nonsurgically with the following:
    • Rest (activity modification)
    • Medication (analgesics, NSAIDs, and muscle relaxants)
    • Intermittent mobilization (soft collar)
    • Physical therapy (exercises or traction)
  • Patients for whom a minimum of 6 weeks of nonsurgical care fails, who develop increased symptoms or neurologic deficit, or who present with a myelopathy or a progressive or severe motor deficit should be referred for possible surgical treatment.
Special Therapy
Physical Therapy
  • Cervical traction, either in therapy or at home, may help reduce radicular symptoms.
  • Initially, passive modalities may help decrease acute pain.
  • Subsequent active stretching and exercises may help patients return to normal activities.
Medication
No role for maintenance opiates
First Line
  • NSAIDs (as long as no gastrointestinal side effects are noted)
  • Enteric coated aspirin (fewer gastrointestinal side effects)
  • Acetaminophen
Second Line
  • COX-2 inhibitors (Be aware of changing side-effect profile.)
  • Cervical epidural steroids
Surgery
  • Anterior cervical discectomy and fusion or posterior laminotomy and foraminotomy can be used to treat a herniated disc that is refractory to nonoperative treatment.
    • A recent study showed that the fusion rates of 1-level anterior cervical decompression and fusion with plate fixation and with bone allograft or autograft are equal.
  • Anterior cervical decompression and fusion is the preferred surgical treatment for cervical radiculopathy when the herniation is located centrally or when kyphosis or axial neck pain is present.
  • Posterior laminotomy and foraminotomy may be performed for lateral soft disc herniation with arm pain .
  • Laminoplasty provides a good alternative to laminectomy or anterior cervical decompression and fusion for multilevel cervical spondylotic radiculopathy.
Follow-up
Disposition
Issues for Referral
  • Shoulder pathology can present with symptoms similar to those of cervical spine disease.
  • Patients with shoulder pathology must be referred to a general orthopaedic surgeon or a shoulder specialist for additional evaluation.
Prognosis
In a population-based study of cervical radiculopathy, ~90% of patients were treated satisfactorily with surgery or nonoperative procedures .
 
Complications
  • Complications of surgical treatment:
    • Infection
    • Persistence of neurologic deficit
    • New onset neurologic deficit, particularly C5 nerve root palsy
    • Worsening deficit
  • Moderate and severely myelopathic patients are likely to remain myelopathic.
  • Patients having an anterior cervical discectomy may complain of:
    • Dysphagia (usually improves over 6 months)
    • Pain from pseudarthrosis
    • Late degeneration at an adjacent disc
    • Adjacent level degeneration secondary to anterior plate impingement
    • Hoarseness secondary to injury of the recurrent laryngeal nerve
Patient Monitoring
No regular monitoring is needed.
 
Miscellaneous
Codes
ICD9-CM
  • 722.0 Displacement, intervertebral disc (with neuritis, pain, or radiculitis)
  • 722.71.1 Displacement, intervertebral disc (with myelopathy)
Patient Teaching
  • Patients should be informed that, in the absence of neurologic changes, this condition can be treated nonoperatively with fairly good results.
  • For most patients unable to attain pain relief with medications and/or steroids, surgery has excellent results.
FAQ
Q: Which provocative physical examination maneuvers can be used to help evaluate for a herniated cervical disc?
A: The Spurling test (radiculopathy), Babinski sign (myelopathy), and testing of the Hoffman reflex (myelopathy).
 
Q: Which reflexes should be evaluated at C5, C6, and C7?
A: C5, biceps; C6, brachioradialis; C7, triceps.

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