Cervical disc

Prolapse/Herniation
Dr Syed Maroof Ali
Cervical Disc Herniation
• Important applied anatomy in herniated cervical disc (HCD):
• In the cervical region, the nerve root exits above the pedicle of its
like-numbered vertebra (opposite to the situation in the lumbar spine,
due to the fact that there are 8 cervical nerve roots and only 7
cervical vertebrae)
• As each nerve root exits through its neural foramen, it passes in close
relation to the undersurface of the like-numbered pedicle
• The intervertebral disc space is located close to the inferior portion of
the pedicle (unlike the lumbar region)
Cervical nerve root syndromes (cervical
radiculopathy)
• An HCD usually impinges on the nerve exiting from the neural
foramen
• At the level of the herniation (e.g. a C6–7 HCD usually causes C7
radiculopathy).
• This gives rise to the characteristic cervical nerve root syndromes
• C4 radiculopathy is not common, and may produce non-radiating axial
neck pain.
• Left C6 radiculopathy (e.g. from C5–6 HCD) occasionally presents with
pain simulating an MI (pseudo-angina).
• C8 and T1 nerve root involvement may produce a partial Horner
syndrome.
• The most common scenario for patients with herniated cervical disc is
that the symptoms were present upon awakening in the morning,
without identifiable trauma or stress.
Cervical myelopathy and SCI due to cervical
disc herniation
• Acute cord compression presenting with myelopathy or spinal cord
injury (SCI) (including complete SCI and incomplete syndromes,
especially central cord syndrome and sometimes Brown-Séquard
syndrome is well described in association with traumatic cervical disc
herniation.
• Less commonly, these findings may occur in non-traumatic cervical
disc herniation.
Differential diagnosis: Radiculopathy, upper
extremity (cervical)
• primary shoulder pathology: characteristically, pain is aggravated by
active and/or passive shoulder movement. In general, shoulder
pathology does not produce pain referred to the neck
• rotator cuff tear
• bicipital tendonitis: tenderness over biceps tendon
• subacromial bursitis: there may be tenderness over the AC joint
• adhesive capsulitis
• impingement syndrome: the “empty can test” is usually positive (each arm
held out in front,30° lateral to straight forward, thumbs pointing down, as in
emptying out a soda can. Examiner pushes down on the patient’s hands while
the patient resists. Test is positive if it reproduces pain)
Differential diagnosis: Radiculopathy, upper
extremity (cervical)
• Shoulder pain is very common in polymyalgia rheumatica, typically
worsens with movement
• interscapular pain: a common location for referred pain with cervical
radiculopathy, may also occur with cholecystitis or some shoulder
pathologies
• MI: some cases of cervical radiculopathy (especially left C6) may present
with symptoms that are suggestive of an acute myocardial infarction
• complex regional pain syndrome AKA reflex sympathetic dystrophy: may
be difficult to distinguish from cervical radiculopathy. Stellate ganglion
blocks may help.
Differential diagnosis: Neck pain(cervical
pain)
• Axial neck-pain without radicular features
• cervical spondylosis (including facet arthritis)
• cervical sprain: including whiplash associated disorder
• fracture of the cervical spine: with upper cervical spine fractures (e.g. odontoid), patients
characteristically hold their head in their hands, especially when going from recumbent to upright
position
• traumatic
• pathologic (tumor invasion, rheumatoid arthritis)
• occipital neuralgia
• herniated cervical disc:
• lateral herniated disc: if symptomatic, tends to produce more radicular symptoms in the UE than actual neck
pain
• central disc herniation: if symptomatic, tends to produce myelopathy, does not produce any neck pain
whatsoever in many cases
Differential diagnosis: Neck pain(cervical
pain)
• Abnormalities of the cranio-cervical junction:
• Chiari 1 malformation
• Atlantoaxial subluxation
• fibromyalgia: idiopathic chronic pain syndrome characterized by
widespread non-articular musculoskeletal pain, nodularity, and stiffness
without pathologic inflammation. Possible link to neuroendocrine
dysfunction. Afflicts 2% of the population, female:male ratio is 7:1. No
diagnostic laboratory study. May be associated with psychiatric illness
and multiple non-specific somatic complaints including malaise, fatigue,
impaired sleep, GI complaints, and cognitive impairment
Differential diagnosis: Neck pain(cervical
pain)
• Eagle’s syndrome: elongation of the styloid process. Surgical resection can
ameliorate the pain.
• Two variants:
• typical variant: history of tonsillectomy. Pharyngeal pain, dysphagia, and otalgia
• second variant: AKA carotid artery-styloid process syndrome. Carotidynia radiating into
ipsilateral eye and vertex
• Crystal deposition diseases: gout, pseudogout, hydroxyapatite (HA), or calcium
pyrophosphate dihydrate (CPPD) crystal deposition diseases. May appear as a
crown-like density encompassing the odontoid process (crowned-dens
syndrome) representing calcifications in the transverse ligament, seen best on
cervical CT. May be treated with a short course of prednisolone (e.g.15 mg/d)
followed by NSAIDs
Physical exam for cervical disc herniation
• Evaluation for radiculopathy
• Lower motor neuron findings
• weakness usually in one myotome group on one side
• muscle bulk and tone: atrophy and fasciculations may be present
• Sensation: with nerve root compression, sensory loss will follow a
dermatomal pattern and will be in the same nerve root distribution as
the weakness
• Muscle stretch reflexes
• Mechanical signs: reproduction of radicular symptoms with axial loading
of the head
Physical exam for cervical disc herniation
• Evidence of spinal cord involvement (myelopathy)
• Upper motor neuron findings, usually in the lower extremities
• Weakness may occur without atrophy or fasciculations
• Spasticity: poor control of the legs when walking, scissoring of the legs
• Sensation: any loss below the level of involvement will follow spinal cord patterns
• Complete loss
• Brown-Séquard pattern: unilateral loss of pinprick with contralateral vibratory and position
sense loss
• Central cord syndrome: suspended sensory loss in upper extremities, less impaired
below
• Pathologic reflexes: Hoffmann’s reflex, Babinski sign, ankle clonus
Signs useful in evaluating cervical
radiculopathy
• Almost all herniated cervical discs cause painful limitation of neck
motion.
• Neck extension usually aggravates pain when cervical disc disease is
present (a minority of patients instead exhibit pain with flexion).
• Some patients find relief in elevating the arm and cupping the back or
the top of the head with the hand (abduction relief sign).
• Lhermitte’s sign (electrical shock-like sensation radiating down the
spine) may be present
Miscellaneous
• The following tests were found to be specific, but not particularly
sensitive in detecting cervical root compression
• Spurling’s sign: radicular pain reproduced when the examiner exerts
downward pressure on vertex while tilting head towards symptomatic
side (sometimes adding neck extension). Causes narrowing of the
intervertebral foramen and possibly increases disc bulge. Used as a
“mechanical sign” analogous to SLR for lumbar disc herniation
Miscellaneous
• Axial manual traction: 10–15 kg of axial traction is applied to a supine
patient with radicular symptoms (pull up on patient’s mandible and
occiput). The reduction or disappearance of radicular symptoms is a
positive finding.
• Shoulder abduction test: a sitting patient with radicular symptoms lifts
their hand above their head. The reduction or disappearance of
radicular symptoms is a positive finding. Moderately sensitive, fairly
specific.
Radiologic evaluation
• MRI
• The study of choice for initial evaluation for herniated cervical disc (HCD)
and for imaging the spinal cord.
• Protocol:
• Sagittal T1WI
• Multiple echo cardiac gated sagittal images (Tr = 1560, Te = 25, 4th echo)
• GRASS image: axial partial flip-angle fast scan (Tr = 25, Te = 13, angle =
8°). Dark material adjacent to disc space is bone, disc is higher signal, CSF
and flowing blood are high signal.
Radiologic evaluation
• CT and myelogram/CT
• Indications: when MRI cannot be done or when more bony detail than
what MRI provides is required. Evaluates for ossification of the
posterior longitudinal ligament (OPLL) when suspected.
• Plain CT: is usually good at C5–6, is variable at C6–7 (due to artifact
from patient’s shoulders, depending on body habitus), and is usually
poor at C7–1.
• Myelogram/CT (water soluble intrathecal contrast): invasive, on rare
occasions requires overnight hospitalization. Accuracy is ≈ 98% for
cervical disc disease.
Electrodiagnostics (EMG and NCV)
• Compression may occur at the level of the dorsal (pre-ganglionic)
sensory root (which, if occurs alone, produces a sensory-only
radiculopathy) and/or at the ventral (motor) root.
• When motor exam is normal, EMG is unlikely to show abnormality.
• The AANEM practice parameter for cervical radiculopathy reports
sensitivity of 50–71% for the needle EMG examination and correlation
between positive needle EMG and radiologic findings of 65–85%.
Treatment
• Over 90% of patients with acute cervical radiculopathy due to cervical
disc herniation can improve without surgery, and regression of an
extruded cervical disc has been demonstrated radiographically by CT
and MRI.
• The recovery period may be made more tolerable by adequate pain
medication, anti-inflammatory medication (NSAIDs or short-course
tapering steroids) and intermittent cervical traction (e.g. gradually
escalating up to 10–15 lbs for 10–15 minutes, 2–3 × daily).
Treatment
• Surgery is indicated for those that fail to improve or those with
progressive neurologic deficit while undergoing non-surgical
management.
• Management of myelopathy/central cord syndrome associated with
acute cervical disc herniation is controversial, since the natural history
is favorable in most cases. However, some patients have poor
recovery and experience permanent deficits even with emergency
surgery.
Conservative management
• Modalities include:
• Physical therapy, which may also include cervical traction
• interventional pain management
• trigger point injections
• facet blocks
• epidural steroid injection: not used as often and with lumbar spine
Surgery
• Surgical options
• anterior cervical discectomy:
• without any prosthesis or fusion: rarely used today
• combined with interbody fusion: the most common approach
• without anterior cervical plating
• with anterior cervical plating or with zero profile
• with artificial disc AKA cervical disc arthroplasty
• posterior approaches
• cervical laminectomy: not typically used for a herniated cervical disc, more common for cervical
spinal stenosis, OPLL
• without posterior fusion
• with lateral mass fusion
• keyhole laminotomy: sometimes permits removal of disc fragment
Thank you