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Wheeless' Textbook of Orthopaedics

Cervical Disc Herniation



- See:
      - Cervical Spondylosis:
      - SCIWORA Syndrome

- Discussion:
    - are most frequent at C 6-7 level but also occur at C 5-6 & to a lesser extent at C4-5 & other levels;
    - in relatively younger persons soft disk protrussion is more common than hard disk protrussion;
    - differential diagnosis:
    - types of herniation:
          - intraforaminal herniation:
                - most common type:
                - cause predominately sensory changes;
          - posterolateral type:
                - occurs near near entrance zone of foramen;
                - causes predominately motor changes;
          - central type:
                - if disc herniation occurs more to the midline (ie posterior herniation), then it compresses spinal cord in addition to, or instead 
                       of the nerve root;
                - results in cervical myelopathy:

- Symptoms:
    - neck pain from nerve root compression;
    - pain radiating into ipsilateral upper extremity w/ paresthesias, numbness, or weakness;
    - pain & paresthesias may be intensified by neck movement, especially by extension or by lateral flexion to side of herniation, & by 
          coughing or straining;


- Exam:
    - see: cervical radiculopathy and myelopathy
    - limitation of neck extension
    - downward head compression increases pt's radicular pain & paresthesias, especially if neck is flexed to side of involvment;
    - shoulder abduction relief test:
          - significant relief of arm pain with shoulder abduction;
          - this sign is more likely to be present w/ soft disc herniation, whereas, the test is likely to be negative with radiculopathy caused by 
                 spondylosis (osteophyte compression);
    - spurling's Sign:
          - mechanical stress, such as excessive vertebral motion, may exacerbate symptoms;
          - the provocation of the patient's arm pain with induced narrowing of the neuroforamen
          - gentle neck hyperextension with the head tilted toward the affected side will narrow the size of the neuroforamin and may exacerbate 
                 the symptoms or produce radiculopathy;
                 - ipsilateral rotation of the neck will also increase radiculopathy;
     - downward head compression increases the patient's radicular pain and paresthesias, especially if the neck is flexed to the side of 
             involvment;
          - provocation of pt's arm pain w/ induced narrowing of neuroforamen
          - oblique cervical extension augments root compression & increases symptoms;
    - lower motor neuron dysf(x) (muscle weakness & hypotonia, reduction of deep tendon reflexes) at level of cord compression;
    - upper motor neuron dysfunction (spasticity, clonus, increased deep tendon reflexes, Babinski's sign, reduction of sensation) below level;
          - loss of erection, bladder, & bowel f(x) may occur;

- MRI:  


- Treatment:
    - surgery is usually performed by a posterior approach thru a hemi-laminectomy or by an anterior approach to approach the intervebral disc;
           - anterior approach:
                 - anterior approach tends to be more popular with orthopaedic surgeons and is especially indicated for central or peri-central 
                        disc herniation;
                 - decompression is usually followed by arthrodesis;
           - posterior approach:
                 - posterior decompression is a smaller operation that takes less time and does not require a bone graft;
                 - posterior decompression is most indicated for far-lateral disc herniation



Surgical management of cervical soft disc herniation. A comparison between the anterior and posterior approach.



Original Text by Clifford R. Wheeless, III, MD.

Last updated by Data Trace Staff on Wednesday, December 21, 2011 4:26 pm