Between each vertebra lies a fibrocartilagenous structure called the intervertebral disc. This disc is present 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 softer 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.
A disc herniation occurs when the outer walls of the intervertebral disc (annulus fibrosis) tear. Other terms for this are “ruptured disc,” “prolapsed disc,” or “slipped disc.” When outer annular rings tear, the gel like nucleus pulposus leaks out pressing on the structures in the area including spinal nerves. The herniation usually occurs at the posterior lateral wall where the annulus fibrosis is thinnest. disc herniations can be caused by the following:
- Degeneration or general wear-and-tear which can break down the walls of the disc.
- Repetitive bending and twisting motions especially in combination. These motions place the most stress on the outer fibrous rings.
- Discs are most susceptible to injury in the sitting or bending position as the anterior pressure on the disc pushing the contents of the disc posterior laterally toward the weak walls and spinal nerves.
- A sudden fall or trauma can result in a disc herniation.
- Repetitive stress injuries such as over head activities and heavy lifting.
- Genetic factors and poor posture may contribute to disc stress, degeneration and eventual herniation.
Symptoms of a Herniated Disc
When a disc is herniated the symptoms will depend on the location of the herniation and what structures it effects. Cervical or neck disc injuries can effect the back of the head, neck, arm, shoulder blade, to the hand. Symptoms can vary from mild or none at all if the disc is the only structure involved or:
- 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 or tingling 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. 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 inability to move 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.
Treating a Disc Herniation
Treatment of a disc herniation or injury will depend on the severity of the condition. When treating acute disc or back problems
- Rest. Avoid the activities that produce the pain (jumping, running, stairs, kneeling, squatting, etc).
- Anti-inflammatory drugs and pain medications.
- Apply ice to the neck and cervical spine to help reduce pain and associated muscle spasm. Apply it right away and then at intervals for about 20 minutes at a time. Do not apply directly to the skin.
- Instruction in correction and maintenance of good posture.
- The use of a brace or other support may be necessary to reduce stress on the disc, muscles and cervical spine.
- Physical therapy for back and disc problems must remain conservative at the beginning to avoid aggravating the condition. Your therapist should emphasize rest, reducing the inflammation and increasing the blood circulation for healing. Once the initial inflammation has been reduced, a program of stretching and strengthening will be started to restore flexibility to the joints and muscles involved, while improving strength and stability of the spine. Each program will be based on the structure causing the problem and symptoms. A program not tailored to the specific problem may aggravate symptoms
In mild cases many patients found that rest, 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 activity should be gradual to prevent a flare up of symptoms.
Moderate to Severe Cases
If the problem persists, consult with your health care provider. 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 concise diagnosis:
- X-ray to determine if there is any joint degeneration, fractures, bony malformations, arthritis, tumors or infection present.
- MRI to determine and 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 my 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 nerve damage 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 Conditions
In the case of conditions that do not respond to conservative care after 8-12 weeks 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 is getting worse
- The development or increased weakness in the upper extremity and or hand
- Increase in numbness or parasthesia in the arm
- Loss of bowel and bladder control
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
- Interlaminar Caudal Epidural Steroid Injections
- Transforaminal Epidural Injections
- Selective Nerve Root Blocks
- Endoscopic Decompression
- Endoscopic Foraminotomy
- Percutaneous Decompression
- IDET Intradiscal Eletrothermal Therapy
- Selective Endoscopic Discectomy
- Spinal Cord Stimulator
- Epidural Lysis of Adhesions