What is Cervical Disc Herniation?
The spine, or vertebral column, is a key part of the body made up of individual bones called vertebrae and discs that sit between each vertebra. Running from the base of the skull to the tailbone, the spine is divided into different sections: the neck (cervical), mid-back (thoracic), lower back (lumbar), and the tailbone area (sacral). The spine is responsible for protecting our spinal cord and nerves, providing support to the body, and allowing us to bend and move.
The discs between each vertebra are like cushions and help protect our spine from the stress and strain of everyday movements, such as walking or lifting.
In the neck, or cervical area, there are seven vertebrae, numbered C1 to C7. The first one, C1, connects to the base of the skull, and the last one, C7, connects to the thoracic or mid-back area of the spine. Vertebrae C3 to C6 are similar in structure, having a body, an arch, and seven processes, which are parts of the vertebra that allow vessels to pass through. The arch itself is made up of two parts, the pedicles, which are bone projections from the body of the vertebra, and the lamina, or bone segments which form the majority of the arch, encircling the spinal canal, where the spinal cord is located.
However, the first two vertebrae (C1 and C2) and the last one (C7) are different. C1, called the “atlas,” connects with the skull and is unique because it does not have a body – it fuses with C2, or the “axis.” The axis has a unique feature, a process called the odontoid (dens), that sticks upwards and connects with C1. The last vertebra, C7, is distinct because it does not have certain vessels running through it and has a long part of bone sticking out, which is why it’s known as the “vertebra prominens.”
Although there are seven cervical vertebrae, there are actually eight pairs of cervical nerves, numbered C1 to C8. Each pair of nerves comes out from the spinal cord above the vertebra it is named after, except for the C8 nerves, which come out below the C7 vertebra. If a disc in the cervical region were to move out of place, known as a herniation, it could press on these nerves or the spinal cord, causing pain and other symptoms.
What Causes Cervical Disc Herniation?
Your spine is made up of building blocks called vertebrae, and in between each of these is a cushion known as an intervertebral disc. This disc is made of three parts: a core in the middle (nucleus pulposus), a tough ring on the outside (annulus fibrosus), and a top and bottom layer (endplates) that connect the disc to the vertebrae above and below it.
A disc herniation is when some or all of the disc’s core sticks out through the tough ring. This can happen all of a sudden or over a longer period of time.
Long-term or “chronic” herniations typically develop as part of the normal aging process. This happens when the disc starts to wear out and lose its moisture. Often, symptoms from these types of herniations start slowly and may not be as intense.
On the other hand, short-term or “acute” herniations usually occur due to an injury, causing the disc’s core to push through a break in the tough outer ring. This type of herniation will generally lead to sudden and more intense symptoms compared to chronic herniations.
Risk Factors and Frequency for Cervical Disc Herniation
Cervical disc herniation, an issue related to the neck’s spinal discs, is more common as people age. It is most often seen in people from their thirties to fifties. The majority of these cases, over 60%, occur in females. However, it can occur in both men and women. Particularly, those between the ages of 51 and 60 are the most likely to get diagnosed.
Signs and Symptoms of Cervical Disc Herniation
Cervical disc herniations often develop between the C5-C6 and C6-C7 vertebral bodies of the spinal cord. This typically results in symptoms showing at the C6 and C7 levels. Symptoms usually include neck pain that extends to one side of the arm, often accompanied by tingling or numbness of the skin. Understanding past treatments, what can make the symptoms better or worse, and when the symptoms began, is essential for diagnosing.
In investigating neck pain, it’s crucial to watch out for red flags, which could indicate more serious underlying conditions such as infections, cancer, or various inflammatory diseases. These warning signs are:
- Fever, chills
- Night sweats
- Unexplained weight loss
- History of inflammatory arthritis, cancer, systemic infection, tuberculosis, HIV, immunosuppression, or drug use
- Constant pain
- Tenderness over a vertebra of the spine
- Swollen lymph nodes in the neck
Determining the patient’s range of motion can help assess the pain’s intensity and the level of degeneration. A thorough neurological examination is necessary to evaluate any sensory disturbances, muscle weakness, and reflex abnormalities. It is also crucial to check for signs of spinal cord dysfunction.
Understanding specific symptoms related to each nerve affected by disc herniation can also assist in the diagnosis. For example:
- The C2 Nerve can cause eye or ear pain, headache
- C3, C4 Nerve can result in neck and shoulder discomfort, tenderness, and muscle spasms
- C5 Nerve symptoms include neck, shoulder, and scapula pain, tingling of the lateral arm, and issues with shoulder and elbow movements
- C6 Nerve could cause neck, shoulder, and scapula pain, tingling down the forearm and hand, and difficulties with elbow and wrist movements
- C7 Nerve could result in neck and shoulder pain, tingling in the posterior forearm and third digit, and movement impediments with elbow extension and wrist flexion
- C8 Nerve may cause neck and shoulder pain, tingling of the medial forearm and hand, and issues with fingers and thumbs movement
- T1 Nerve can cause neck and shoulder pain, tingling of the medial forearm and fingers difficulties
Different tests can help pinpoint the source of the pain. The Spurling test, Hoffman test, and Lhermitte sign are examples of diagnostic techniques used to identify problems like acute radiculopathy or spinal cord compression and myelopathy.
Testing for Cervical Disc Herniation
Most people who suffer from a sudden spinal injury or bulging or ruptured spinal disc will feel better within the first month, and generally, no treatment is needed. Because of this, doctors usually do not suggest any imaging tests such as X-rays or scans during this period, since the results wouldn’t typically change how the patient is treated initially. However, if there’s reason to suspect a severe condition, or if there are signs of nerve damage, imaging tests might be recommended.
If symptoms don’t improve after four to six weeks with non-invasive treatments, like rest, ice, heat, and over-the-counter pain medications, additional tests may be needed. People who show serious warning signs or symptoms may also need to get certain laboratory tests. This might include:
1. Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) tests: These can tell your doctor if there’s inflammation in your body, which can be a sign of conditions like rheumatoid arthritis, polymyalgia rheumatica, and other joint diseases. They can also indicate if an infection is present.
2. Complete blood count (CBC): This test is often used when an infection or cancer is suspected. It gives information about different types of cells in your blood.
X-rays are usually the first imaging test doctors use because they are easy to do at most clinics and doctor’s offices. X-rays can help evaluate the overall shape of the spine and detect any age-related changes or signs of wear-and-tear arthritis. If the X-ray shows a broken bone, a CT scan or MRI is required for the next steps.
CT scans are the best tests to examine the bones of the spine. They can also show calcified (hardened) bulging or ruptured discs or any infection or tumor that could be causing bone loss. For patients who cannot have an MRI, a CT myelogram, which uses dye and X-rays, can be used to visualize a bulging or ruptured disc.
MRI is the preferred imaging test and it’s especially sensitive for spotting a bulging or ruptured disc, as it is excellent at showing soft tissues and nerves.
Electrodiagnostic testing, such as electromyography and nerve conduction studies, can be an option for some patients. These tests are especially helpful when symptoms or imaging test results are unclear, or to rule out nerve damage limited to one area. However, these tests can only catch a pinched nerve in the neck in about half to three-fourths of patients.
Treatment Options for Cervical Disc Herniation
Acute cervical radiculopathies, which happen when a herniated disc puts pressure on the nerves in your neck, are usually treated without the need for surgery. Most patients with this condition (about 75% to 90%) improve with non-surgical treatments.
We can look after this condition in a few different ways:
Neck Brace: For those with severe neck pain, using a neck brace for a short time (about a week) can help during the initial inflammation or swelling period.
Traction: This therapy involves applying a small amount of force to your neck, which can help relieve pressure on the affected nerves and improve symptoms. This typically involves 15 to 20-minute sessions with a small weight pulling at a specific angle.
Medications: Non-steroidal anti-inflammatory drugs (NSAIDs) are commonly used, though there’s no concrete evidence of their effectiveness in treating this specific problem. These can be beneficial for some people. They might include COX-1 or COX-2 inhibitors, which mainly differ in the side effects they produce. Steroids, like prednisone, can also be used for a short time in severe cases. We usually avoid opioids, as there’s no evidence to support their use and they have more side effects. If muscle spasms are big problem, a muscle relaxant can be used for a short period. Antidepressants and anticonvulsants have also been used to treat nerve pain.
Physical Therapy: After resting and immobilizing the neck for a while, physical therapy can be helpful. This includes activities such as stretching, strengthening exercises, cold and hot treatment, ultrasound therapy, and electrical stimulation. While there’s no firm evidence that shows these techniques to be better than a placebo, they aren’t harmful and may help, so they’re recommended unless your symptoms are related to damage in the spinal cord.
Neck Manipulation: There’s limited evidence suggesting that manipulating the neck can help temporarily with neck pain and headaches related to the neck. But it’s important to note that there are risks with this approach, including potential nerve or spinal cord injuries or worsening of your current symptoms, though these are rare.
When surgery becomes necessary, alternatives like spinal steroid injections or neuropathic pain treatments can be considered. Spinal steroid injections involve injecting medication around the inflamed nerve to reduce swelling and pain, usually done under radiologic guidance. If you’re not suitable for surgical intervention, neuropathic pain treatment options, such as spinal cord stimulation devices and intrathecal pain pumps can be considered. These devices can be inserted with minimal invasion and can effectively manage the pain from disc herniations.
For those who require surgery, this generally includes those with severe or progressing nerve-related issues and significant pain unresponsive to non-surgical treatments. There are multiple surgical techniques depend on the specifics of the condition. The usual treatment is an anterior cervical discectomy with fusion, which involves removing the problem area and performing a fusion to prevent future pressure on the nerves. A technique called a posterior laminoforaminotomy can be used for patients with herniations at the front side of their neck. Total disk replacement is another, more recent technique, but it’s use is still being explored.
What else can Cervical Disc Herniation be?
When trying to diagnose a certain medical condition, doctors look at several other possible conditions that can present with similar symptoms. They consider the likelihood of various conditions, such as:
- Brachial plexus injury (an injury to the network of nerves connected to the spinal cord)
- Degenerative cervical spondylosis (wear-and-tear changes in the spine)
- Muscle strain (common injury that involves a torn muscle or tendon)
- Parsonage-Turner syndrome (a rare neurological disorder that causes severe shoulder pain)
- Peripheral nerve entrapment (a condition that causes numbness, pain, or tingling due to a nerve being compressed)
- Tendinopathies of the shoulder (conditions that stem from the overuse or strain of the shoulder)
What to expect with Cervical Disc Herniation
The pain, limited movement, and nerve pain (radiculopathy) that come from a slipped disc usually get better on their own within six weeks for most patients. This improvement happens because the body either breaks down or absorbs the slipped disc material. It could also be due to the disc material losing water content or the swelling around the disc going down, resulting in less pain and returning to normal function.
However, in about one third of people experiencing these conditions, symptoms persist even with non-surgical treatments. If the symptoms continue for more than six weeks, there’s less likelihood that they’ll get better without surgery.
Possible Complications When Diagnosed with Cervical Disc Herniation
: Side effects from steroid injections are usually not severe and occur in roughly 3% to 35% of cases. However, there can be more serious complications such as:
- Nerve injury
- Infection
- Blood accumulation in the spine (Epidural hematoma)
- Infection in the spine (Epidural abscess)
- Damage to the spinal cord’s blood supply (Spinal cord infarction)
There can also be complications from surgical procedures, like:
- Infection
- Injury to the throat and tongue nerves (Recurrent laryngeal, superior laryngeal and hypoglossal nerve injuries)
- Injury to the food pipe (Esophageal injury)
- Injury to the spine/backbone and neck arteries (Vertebral and carotid injuries)
- Difficulty swallowing (Dysphagia)
- Eye drooping and other symptoms (Horner syndrome)
- Non-healing spine fractures (Pseudoarthrosis)
- Degeneration in the spine segment near the surgery (Adjacent segment degeneration)
Preventing Cervical Disc Herniation
Having the right educational tools is very important for doctors, patients, and the general public. They help everyone understand how to keep us healthy and recover faster when we are sick. There are plenty of resources that we can refer to. These include organizations like the American Academy of Orthopedic Surgeons and the American Academy of Physical Medicine and Rehabilitations. They offer valuable information for the best medical care results.
