Anatomy & Background
Between each vertebra lies a fibrocartilagenous structure called the intervertebral disc. This disc can be found at all levels of the cervical spine except for the first and second vertebra (atlas and axis). The disc is comprised of a series of outer fibrous rings (annulus fibrosis) and a soft center (nucleus pulposus). The walls of the disc are thinnest and weakest posterior laterally where the spinal nerves exit the spinal column. The disc serves as a joint between the vertebra, functions as a cushion and allows movement between the vertebra.
Inflammation, damage or degeneration of a disc may produce loss of neck motion, pain radiating to the arm, numbness and weakness. The cervical fifth and sixth C5-C6 and cervical sixth and seventh C6-C7 levels have the highest rate of disc degeneration and herniation.
Degenerative Disc Disease
Degenerative Disc disease is the progressive and gradual wear-and-tear of the intervertebral disc. This degeneration affects the outer annulus fibrosis and nucleus pulposus. As the disc wears there is loss of disc height and an increased likelihood of the development of bulging and herniated discs. Degeneration of the disc is normal as we age, but can be accelerated as a result of trauma, repetitive strain or injury, as well as musculo-skeletal imbalances like scoliosis. Disc degeneration itself may not be a problem, but the associated conditions that may develop as it progresses can be symptomatic and debilitating.
Stages of Disc Degeneration
The progression of disc degeneration can be classified in the following phases:
- The annular rings of the disc begin to tear and irritation of the facet joints at the corresponding spinal level may occur.
- There is the beginning loss of joint mobility, localized neck pain, muscle spasms, and a loss of movement especially extension or backward motions.
- A loss of disc fluid with dehydration and disc narrowing. The facet joints and capsule may develop laxity, resulting in instability.
- A patient will present with pain, sharp catching, giving way, a shift in spinal alignment and loss of motion.
- The body reacts to the instability of the spine by laying down bone in the form of osteophytes in an attempt to stabilize the spine. This increase in bone formation can result in Stenosis.
- Back pain will usually decrease, but still remain present in a less severe form. Individuals may develop stenotic-like symptoms.
Causes of Cervical Degenerative Discs
- Aging is the most common cause of disc degeneration. As the body ages, the discs start to loose fluid and dehydrate. The discs start to narrow and lose their height, compromising their ability to absorb shock and stress.
- The outer fibrous annular rings may begin to crack and tear, weakening the disc walls.
- Individuals who smoke, are obese, or are involved in activities that require heavy labor are more likely to develop disc degeneration.
- A sudden fall or similar trauma to the spine or an individual disc may begin the degenerative processes.
- A disc herniation may be a part of, or initiate the stages of disc degeneration.
- Unlike muscles, there is minimal blood supply to the discs, so they lack the ability to repair themselves.
Conditions of the intervertebral disc that can develop as a result of disc degeneration include bulging disc, herniated disc, prolapsed disc, degenerative disc disease, annular tear of the disc, ruptured disc and slipped disc.
The symptoms associated with degenerative disc disease of the neck or cervical spine will depend on the location and structures that are affected. Cervical disc degeneration can affect the back of the head, neck, arm, shoulder blade, and may extend into the hand.
- Many patients with DDD (degenerative disc disease) do not exhibit symptoms.
- Chronic pain in the neck, extending into the shoulders with or without radiation to the arm and down to the hand if the disc presses on the nerve root.
- Sensory changes such as numbness or tingling, if the nerve is compromised.
- If the portion of the nerve responsible for motor function is effected by disc disease, muscle weakness, atrophy or wasting in the arm or hand may occur. In severe cases, paralysis may occur.
- Diminished reflexes in the upper extremity.
- Muscle spasms and changes in posture in the neck and shoulder area.
- Loss of motion, with decreased ability to move the head and neck when turning, looking overhead, and bending to the side.
- Sitting for extended periods of time may produce neck and arm pain.
- Difficulty with lifting and over-the-head activities.
- In later stages, spinal Stenosis may develop. This requires surgical intervention if symptoms are bad enough. Weakness, loss of coordination and abnormal reflex response may occur if the spinal cord is affected.
Treating Degenerative Disc Disease
Treatment of cervical degenerative disc disease or injury will depend on the severity of the condition. When treating acute back problems:
- Rest. Avoid the activities that produce the pain (bending, lifting, twisting, turning, bending backwards, etc).
- Anti-inflammatory drugs and other pain medications.
- Apply ice in acute cases to the cervical spine to help reduce pain and associated muscle spasms. Apply it right away and then at intervals for about 20 minutes at a time. Do not apply directly to the skin.
- Moist heat may be helpful to reduce pain and improve any feelings of stiffness.
- An exercise regiment designed specifically to address the cause of the symptoms associated with the degenerative disc disease and improve joint mobility, spinal alignment, posture, and range of motion.
- A cervical collar or the use of other supports may be necessary to reduce stress on the facet joints, muscles and head and neck.
- Steroidal medication to reduce inflammation in moderate to severe conditions.
- Epidural injections directly to the involved disc may be indicated.
- Physical therapy to reduce inflammation, restore joint function, improve motion, and help the return of full function.
In mild cases rest many patients found that ice and medication were enough to reduce the pain Once the pain is reduced, physical therapy is recommended to develop a series of postural correction, stretching and stabilization exercises to prevent re-occurrence of the injury. Return to the activity that caused the injury should be gradual to prevent a flare up of symptoms.
Moderate to Severe Cases
If the problem persists, consult with your health care provider next. Your physician should 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 concise diagnosis:
- X-ray to determine if there is any joint degeneration, fractures, bony malformations, arthritis, tumors or infection 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.
Medications to consider
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.
- Narcotics, if over the counter medications are not effective your physician may prescribe stronger pain medication.
- Anti-inflammatory drugs or prescription NSAIDS to reduce inflammation following acute injury.
- Muscle relaxers to reduce acute muscle spasm.
- Nerve pain medication by prescription, designed specifically to reduce pain from nerve damage.
- Injections like facet injections, nerve blocks or an epidural. These may involve the injection of corticosteroids to a specific structure to reduce local inflammation.
Severe or Non-responsive Degenerative Disc Conditions
In the case of conditions that do not respond to conservative care , surgery may be indicated. If you continue to experience some of the following symptoms:
- Increase in radiating or radicular pain from the neck to the arm.
- Pain or nerve damage that gets worse.
- The development of, or an increase in weakness in the upper extremity or hand.
- Increase in numbness or parasthesia in the arm.
Injections like facet injections, nerve blocks or an epidural. These may involve the injection of corticosteroids to a specific structure to reduce local inflammation.
- Caudal Epidural Injections
- Facet Joint Injections
- Interlaminar Caudal Epidural Steroid Injections
- Transforaminal Epidural Injections
- Selective Nerve Root Blocks
- Medial Branch Blocks
- Endoscopic Decompression
- Endoscopic Foraminotomy
- Percutaneous Decompression
- IDET Intradiscal Eletrothermal Therapy
- Selective Endoscopic Discectomy
- Spinal Cord Stimulator
- Radiofrequency Ablation
- Epidural Lysis of Adhesions