Cervical Herniated Disc
Background & Etiology
Intervertebral Disc - An intervertebral disc is a fibrocartilaginous structure found between the bodies of vertebra. These discs are located between each pair of vertebra in the spine except for those at the first and second cervical level (called atlas and axis).
The disc is similar to a jelly donut. It has a series of outer fibrous rings (annulus fibrosis) surrounding a gelatinous center (nucleus pulposus). The outer annular rings are thinnest posterior and lateral; most disc herniations occur at this location due to the weakness of the disc wall. The disc functions as a cushion, allows for movement, and serves as a cartilaginous joint between adjacent vertebrae.
Inflammation, damage or degeneration of a disc can cause a range of symptoms, which vary based on the severity of the problem. Disc pathology may produce a loss of neck motion, neck pain, pain that radiates into the arm and hand, numbness, tingling, upper extremity (arm) weakness and associated muscle spasm or some combination of these symptoms. The cervical levels with the highest rate of disc degeneration and herniation are the fifth and sixth (C5-C6,) and sixth and seventh (C6-C7) levels.
Degenerative disc disease
Anular tear of the disc
A disc herniation occurs when the outer walls of the intervertebral disc are torn. Other terms for this condition are ruptured disc, prolapsed disc, or slipped disc. When the outer annular rings are torn the central gel-like nucleus pulposus can push out and place pressure on the other structures in the area. The herniation usually occurs at the posterior lateral wall where the annulus fibrosis is thinnest. Unfortunately, this is where the nerves of the spine exit and track distally into the body. The larger the tear, and the further the nucleus pushes out into the surrounding area, the more severe the symptoms.
- Degeneration or general wear and tear, which can break down the walls of the disc.
- Repetitive bending and twisting motions especially in combination. This motion places the most stress on the outer fibrous rings (annulus fibrosis).
- Discs are most susceptible to injury in the sitting or bending position as the pressure on the disc is displaced to the front (anteriorly) pushing the contents of the disc posterior laterally toward the thinner and weaker annulus fibrosis.
- Sudden fall or trauma like a motor vehicle accident.
- Repetitive stress injuries like those from over the head motions and heavy lifting.
- Genetic factors may contribute to the likelihood of intervertebral disc disease.
- Smokers are more susceptible to disc herniation and degeneration.
When a disc is herniated the symptoms will depend on the location of the herniation and what soft tissue structures are affected. Cervical or neck disc injuries can effect the back of the head, neck, arm, shoulder blade and the hand. Symptoms can vary from none at all to very mild if the disc is the only structure involved, or can be more severe. Other symptoms can include:
- Pain in the neck or radicular to the arm and down to the hand if the disc presses on the nerve root.
- Sensory changes such as numbness, tingling, or paraesthesia if the nerve is compromised.
- Weakness, muscle atrophy or wasting in the arm or hand may occur if the motor portion of the nerve is effected by the disc’s condition. In severe cases paralysis may occur.
- Diminished reflexes in the upper extremity.
- Muscle spasm and changes in posture in response to the injury.
- Loss of motion including difficulty moving the head and neck.
- Sitting for extended periods of time may produce neck and arm pain.
- A patient with a herniation may be symptom free if the disc does not press on a sensitive soft tissue structure.
Treatment of Disc Herniation
Treatment of a disc herniation or injury will depend on the severity of the condition. When treating acute disc or back problems it is important treatment recommendations can include:
- Rest: avoid the activities that produce the pain.
- Medication to reduce inflammation (anti-inflammatory and pain medication).
- Ice: apply ice to the neck and cervical spine to help reduce pain and associated muscle spasm. Apply ice right away and then at intervals for about 20 minutes at a time. Do not apply directly to the skin.
- Physical Therapy
- An exercise regiment designed specifically to address the cause of the symptoms.
- Instruction to correct and maintain good posture.
- Bracing or the use of supports may be necessary to reduce stress on the disc, muscles and lumbar spine.
Mild: In mild cases, rest, ice and medication may be enough to reduce the pain. Many patients will do well with this regiment. Once the pain is reduced, physical therapy is recommended to develop a series of postural correction, stretching and stabilization exercises to prevent reoccurrence of the injury. Return to activity should be gradual to prevent a flare up of symptoms.
Moderate to Severe: If the problem persists, consulting with your health care provider should be the next step. Your physician will perform a thorough evaluation to determine the possible cause of your symptoms, the structures involved, the severity of the condition and the best course of treatment.
In addition to performing a thorough examination your physician may order the following tests to make a more precise diagnosis:
- X-ray to determine if there is any joint degeneration, fractures, bony malformations, arthritis, tumors or infections present.
- MRI to determine any soft tissue involvement, including visualization of the discs, spinal cord and nerve roots.
- CT scans which can give a cross section view of the spinal structures.
- EMG, which is used to determine nerve involvement or damage.
Your physician may recommend several medication options individually or in combination to reduce the pain, inflammation and muscle spasm that may be associated with disc injuries.
- Over the counter medications for mild to moderate pain.
- If over the counter medications are not effective your physician may recommend stronger, prescription pain medication.
- Anti-inflammatory drugs or prescription NSAIDS (non-steroidal anti-inflammatory drugs) to reduce inflammation following acute injury.
- Muscle relaxers to reduce acute muscle spasm.
- Prescription nerve pain medication designed specifically to reduce nerve damage and pain.
- Injections such as facet injections, nerve blocks or epidural injections. These may involve the injection of corticosteroids to a specific structure to reduce local inflammation.
Severe or non-responsive disc condition
In the case of conditions that do not respond to conservative care after 8-12 weeks, surgery may be necessary. If you continue to experience some of the following symptoms, your doctor may recommend you for a surgical procedure:
- Increase in radiating or radicular pain from the neck to the arm.
- Pain or nerve damage that gets worse.
- The development of increased weakness in the upper extremity and/or the hand.
- An increase in numbness or paraesthesia in the arm.
- Loss of bowel and bladder control.
The most common disc related surgery is a discectomy in which the disc is removed through an incision. In the cervical spine a discectomy can be performed either anteriorly (front) or posteriorly (back). In some cases a fusion may be indicated. The majority of patients receiving a discectomy do well following a course of physical therapy.
Physical Therapists are professionals, educated and trained to administer interventions. As defined by The Guide to Physical Therapist Practice, interventions are the skilled and purposeful use of physical therapy methods and techniques to produce changes consistent with the diagnosis, prognosis and the patient or client’s goals.
- Your physical therapist will perform a thorough evaluation to assess and determine the following:
- Spinal examination: the patient is put through a series of movements and tests to determine the most probable cause of the back condition.
- Strength: resisted testing is performed to determine if there is associated weakness or strength imbalances.
- Flexibility: tight muscles can contribute to poor mechanics and weakness creating imbalances and making one more susceptible to disc and back injuries.
- Posture Analysis, ADL’s and technique: a physical therapist will discuss and observe the activity that may have started the problem. Examination of dynamic and static postures that may have caused or contributed to your current back problem. A review of your current activities at home and work that may or may not be causing or prolonging your present condition.
Physical therapy for back and disc problems must remain conservative at the onset to avoid aggravating the condition. Emphasis will be on rest, reducing the inflammation and increasing the blood circulation for healing. Once the initial inflammation has been reduced, a program of postural re-education, stretching and strengthening will be initiated to restore flexibility to the joints and muscles involved while improving stability of the spine. Each program design will be based on the structure causing the problem and symptoms. A program not tailored to the specific problem may aggravate symptoms.
Physical Therapy Interventions
Common Physical Therapy interventions in the treatment of Cervical Spine Disc Herniation include:
- Manual Therapeutic Technique (MTT): hands on care including soft tissue massage, stretching and joint mobilization by a physical therapist to improve alignment, mobility and range of motion of the cervical spine. Use of mobilization techniques also helps to modulate pain.
- Therapeutic Exercises (TE) including stretching and strengthening exercises to regain range of motion and strengthen muscles of the cervical spine and shoulder girdle to support, stabilize and decrease the stresses place on the disc and neck.
- Neuromuscular Reeducation (NMR) to improve posture, restore stability, retrain the patient in proper sleeping, sitting and body mechanics to protect the injured disc and spine.
- Modalities including the use of ultrasound, electrical stimulation, ice, cold laser, traction and others to decrease pain and inflammation of the spinal structures.
- Home programs including strengthening, stretching and stabilization exercises and instructions to help in the performance of daily tasks and progress to the next functional level.
Most cervical disc problems improve without surgery and return to normal function. Duration of treatment can range from 4 to 12 weeks depending on the severity of the symptoms. Patients need to continue with a regiment of stretching, strengthening and stabilization exercises. Use of postural awareness, body mechanics and being cognizant of the do’s and don’ts for having a healthy neck are necessary for a good long-term prognosis. Remember, “once you have a neck problem, you have a neck problem” goes a long way to preventing further injury.