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Displacement of a cervical intervertebral disc refers to protrusion or herniation of the disc between disc between two adjacent bones (vertebrae) of the cervical spine in the neck (vertebrae C2 through C7). Note that there is no disc between C1 and C2. Although displacement is commonly referred to as a "slipped disc," the disc does not actually "slip."
Discs between each vertebra form a cushion that absorbs shock and allows movement of the neck. The discs are composed of an inner gel-like material (nucleus pulposus) and an outer ring of tough, fibrous material (annulus fibrosus). When the disc intrudes into the spinal canal (disc displacement or herniation), it may compress the spinal cord or nerves. Pressure on the nerves where they exit the spinal canal can cause changes in sensory (touch, pinprick, temperature), motor (muscle strength), and reflex function in the areas innervated. These types of changes are collectively referred to as radiculopathy; however, disc displacement may also occur without radiculopathy. Cervical radiculopathy also may be caused by tumors, infection, or vertebral fracture. Disruption of the annulus fibrosus itself may also cause symptoms (annular disruption, distension, or tear). This can allow the nucleus pulposus to leak out of the disc, causing an intense and painful chemical inflammation (radiculitis).
The most common sites of disc displacement are between the fifth and sixth (C5-C6) or the sixth and seventh (C6-C7) cervical vertebrae. Cervical intervertebral disc displacement usually occurs as a result of age-related physiological changes leading to progressive degeneration of the cervical spine; rarely, it is the result of a single traumatic injury. Age-related changes may begin as early as the second decade in life. Disc degeneration can result in looseness (hypermobility) of the affected vertebral segment, leading to instability of the cervical spine, osteoarthritis, or both. Individuals with degenerative cervical disc disease may also have lumbar disc disease. Degenerative disc disease can result in spinal cord compression (myelopathy), but this is uncommon.
Risk: Under the age of 40, risk is greater for individuals who repeatedly are exposed to heavy lifting and vibrational stress (e.g., professional drivers, jackhammer operators), and those who engage in high impact sport (Furman). Cigarette smoking, nutrition, level of physical activity, and accidents resulting in whiplash injuries also increase risk for cervical intervertebral disc displacement. Incidence and Prevalence: About 8% of all herniated discs occur in the cervical region of the spine ("Herniated Nucleus Pulposus"). Among pain-free (asymptomatic) individuals, herniated cervical discs are observed by MRI in 10% of adults younger than 40 years and in 5% of those older than 40. Displaced cervical discs occur as often in men as in women (Furman). |
Source: Medical Disability Advisor
| History: Important items to note in the history include: information about pain (onset, location, quantity, quality, setting, aggravating and alleviating factors, associated symptoms), axial vs. peripheral pain, and history of neck injury. Disc-related pain without nerve root involvement may be vague and diffuse. Radicular pain can be dull and aching or sharp and electric; neck pain may be absent. The pain may have begun with no apparent cause, or there may be a history of injury to the neck. If cervical disc displacement of the C5-C6 disc results in radiculopathy, pain may radiate from the base of neck, along the biceps muscle and lateral forearm, and into the back of the hand, the thumb, and the first two fingers. If cervical disc displacement of the C6-C7 disc results in radiculopathy, pain or numbness may be present in the middle finger, along with shoulder pain radiating into the triceps and forearm. These individuals sometimes rest the symptomatic upper extremity on the top of their head to decrease pain. Coughing or sneezing makes the pain worse, and affected individuals may report that they are more comfortable sleeping in a reclining chair than in a bed. If treatment is not sought, individuals may notice increasing weakness in the affected limb. A history of prior or existing systemic illness should be obtained, including chronic disease (e.g., diabetes, heart disease, atherosclerosis, nervous system disorders, arthritis), infections, malignancies, or weight loss. Physical exam: Cervical intervertebral disc displacement usually limits range of motion of the neck. The exam may show that neck movement aggravates pain, particularly when bending the head backward (hyperextension) and turning the head from side to side (rotation). The manual application of cervical compression and distraction during the physical exam may help to differentiate between disc pain and pain from other causes. Pain may increase when downward pressure is applied to the top of the head (cervical compression test) and be relieved by traction (cervical distraction test). The affected vertebra may be tender to palpation. Examination should include assessment of muscle strength and changes in sensation and reflexes in the upper extremities. Lower extremities may be examined to rule out signs of myelopathy. Tests: Laboratory blood analysis may include erythrocyte sedimentation rate (ESR) to evaluate inflammation, white blood count analysis to rule out infection, rheumatoid factor, thyroid and parathyroid studies, and liver function studies. Human leukocyte antigens may be typed. Results of these tests help rule out other conditions.
Imaging studies show the extent of degenerative changes but do not give any information about function. Plain x-rays show narrowing of the disc space and bone spur (osteophyte) formation, if present, as well as possible metastatic disease, spinal deformity, and spine stability. If mechanical instability is suspected as a cause of recurrent pain, it can be documented by x-rays taken with the neck bent forward (flexion) and bent backward (hyperextension).
MRI or myelography combined with CT are considered the best ways to diagnose a herniated cervical disc. Electromyography (EMG) may distinguish nerve root compression from a peripheral nerve problem such as carpal tunnel syndrome or ulnar nerve entrapment. Nevertheless, a normal EMG does not rule out nerve root compression. As in the lumbar spine, asymptomatic herniations are frequently seen in normal volunteers. For this reason, disc herniations on imaging studies must correlate precisely with the clinical signs of nerve root deficit observed on physical examination. |
Source: Medical Disability Advisor
| Conservative therapy is the first line of treatment except in cases of severe or progressive neurologic compression. Bed rest is rarely indicated. Intermittent traction may be applied, and the individual may be taught to use intermittent traction at home.
Nonsteroidal anti-inflammatory drugs (NSAIDs) may be given to relieve pain and decrease inflammation. If pain is severe, a narcotic may be added; in some cases, an antidepressant or an anticonvulsant may be used for its analgesic effect. If anxiety and tension are prominent, sedatives may be helpful. Muscle relaxants are frequently prescribed; however, their effectiveness probably is due to their sedative action. Narcotics, sedatives, and muscle relaxants usually are used only for brief periods. Ongoing use should be weighed against the potential for addiction or abuse. Other treatments such as ice, heat, massage, and ultrasound therapy may help relieve pain.
As symptoms subside, activity is gradually increased and includes physical therapy to strengthen and mobilize the muscles of the neck and shoulder. An independent home exercise program is an essential component of any physical therapy. Good posture and frequent changes in position may help prevent fatigue and decrease pain. Preventive and maintenance measures, such as exercise, stress management, and proper body mechanics, should be continued indefinitely. If there is no improvement during the first 2 weeks, or if pain is still disabling after 6 weeks, further evaluation is necessary.
Most cases of cervical disc displacement with or without radiculopathy can be managed conservatively. However, surgery is indicated in cases where 1) pain management has failed, and the individual has intractable pain; 2) there is mechanical instability of the spine associated with disc herniation; 3) signs of neurological deficits are increasing (e.g., progressive or severe muscle weakness or severe arm pain with objective signs of nerve root compression); or 4) the disc herniation is massive and compresses the spinal cord causing bowel and/or bladder control impairment, lower extremity weakness, sensory loss, or gait disturbance.
Surgery involves removal of the protruding nucleus pulposus (discectomy). The traditional method for removal of the disc is open discectomy under general anesthesia. A portion of the vertebra that acts as a roof (lamina) over the spinal nerve is removed, creating a small window into the spine. The surgeon then removes the herniated disc material through this opening.
Microdiscectomy, also called minimally invasive spine surgery, is a newer, less invasive alternative to open surgery for certain types of disc herniation. In microdiscectomy, a special operating microscope is used to view the disc and spinal nerves through a small incision in the back. Smaller and lighter surgical instruments are used to remove herniated disc material through the small incision with minimal trauma to surrounding tissue. Many individuals who undergo microdiscectomy are discharged after overnight observation and have relief of symptoms with minimal pain. (See Discectomy entry for a more detailed discussion of surgical treatment.)
Other new techniques under development include several methods to decompress the disc centrally (chemical, enzymatic, vaporization or mechanical), directed fragmentectomy and anterior cervical interbody fusion.
Fusion of the vertebrae may be indicated when mechanical instability cannot be managed conservatively. |
Source: Medical Disability Advisor
| Most cervical disc herniations (an estimated 80% to 90%) improve with conservative treatment (Furman). With proper selection of surgical candidates, discectomy with rehabilitation has a good outcome in 80% to 90% of individuals (Furman). |
Source: Medical Disability Advisor
| Note on research and authorship The primary focus of rehabilitation for a cervical intervertebral disc displacement without myelopathy is to decrease symptoms and increase function. Although exercise may be uncomfortable initially, individuals must be instructed in the benefits of ongoing exercise in managing the symptoms.
The first goal is to decrease symptoms, primarily pain. In combination with pharmacological management, modalities such as heat and cold can be used. Immobilization with a soft collar is rarely indicated; however with significant soft tissue pain, it might be necessary for a very short period of time (up to 3 days). While managing pain, individuals can be instructed in gentle exercises (Boyce). Due to the variability in response, the treating practitioner must pay careful attention to tolerance to treatment. Initial exercises may include isometrics, stretching and/or gentle range of motion. Spinal manual therapy may reduce symptoms when combined with active treatment. Postural training should be initiated as soon as tolerated by the individual.
Once symptoms subside and range of motion is restored, the individual should progress to strengthening and stabilization exercises of the neck, shoulders and upper trunk (Ylinen). Limited treatment with cervical traction has been shown to be beneficial for neck pain when done in conjunction with exercises, although traction must be carefully administered to avoid adverse response.
The individual should also be instructed in a home exercise program to complement the supervised rehabilitation, and trained to care for and protect the neck from recurrence of symptoms. An ergonomic evaluation can prove helpful in avoiding or modifying activities and work positions that may aggravate the symptoms. Psychotherapy may be indicated to support the individual and identify associated factors that may contribute to the symptoms. A short course of cognitive pain management may be beneficial for individuals experiencing psychological distress or lack of improvement with treatment (Klaber Moffett).
For further information about management of this condition and rehabilitation outcome please refer to Jenis et al. |
| FREQUENCY OF REHABILITATION VISITS | | Nonsurgical | |
| Physical Therapist | | Up to 12 visits within 6 weeks | |
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| The table above represents a range of the usual acceptable number of visits for uncomplicated cases. It provides a framework based on the duration of tissue healing time and standard clinical practice. |
Source: Medical Disability Advisor
| Worsening of the condition may cause pressure on the spinal cord as well as on the nerve roots. Functional disturbances and/or pathological changes in the spinal cord (myelopathy) may occur as a result of the displaced disc pressing on the spinal cord. Muscular atrophy and sensory disorders may occur as the result of nerve root compression. |
Source: Medical Disability Advisor
| Individuals with displaced cervical discs usually are advised to avoid overhead lifting or postures with the neck in extension, heavy lifting, or repetitive neck twisting motions. Certain other duties that require extension of the neck (e.g., painting ceilings, stocking overhead shelves) may be unsuitable for individuals with limited range of motion of the head and neck. Individuals may require regular time off for physical therapy. Use of prescription painkillers (analgesics) can affect dexterity and alertness. Their use may require review of drug policies. |
Source: Medical Disability Advisor
| If an individual fails to recover within the expected maximum duration period, the reader may wish to consider the following questions to better understand the specifics of an individual's medical case. Regarding diagnosis:
- At what level (discs C2-C7) is the displacement?
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Has individual been exposed to vibrational stress? Heavy lifting?
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Is individual sedentary?
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Has individual had a whiplash injury?
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Does the neck pain radiate to the shoulder and down to the hand?
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Is there weakness in the extremity?
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Is individual more comfortable sleeping in a recliner?
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On physical exam is pain aggravated by neck movement?
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Is the range of motion of the neck restricted?
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Is there tenderness over the affected vertebrae with palpation?
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Have x-rays been done?
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Has individual had an MRI or CT myelogram?
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Has individual had an EMG?
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Have conditions with similar symptoms been ruled out?
Regarding treatment:
- Did individual respond favorably to conservative treatment?
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Was narcotic use necessary? Sedatives?
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Were ice, heat, massage, ultrasound therapy, and intermittent cervical traction used?
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Was surgery necessary? What type of surgery was performed (discectomy, spinal fusion)?
Regarding prognosis:
- Is individual participating in an active rehabilitation program, or is there evidence of dependence on passive therapies? Does he or she utilize a home exercise program?
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Is individual's employer able to accommodate any necessary restrictions?
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Does individual have any conditions that may affect ability to recover?
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Has individual developed myelopathy?
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Source: Medical Disability Advisor
| Boyce, R. H., and J. C. Wang. "Evaluation of Neck Pain, Radiculopathy, and Myelopathy: Imaging, Conservative Treatment, and Surgical Indications." Instructional Course Lectures 52 (2003): 489-495. National Center for Biotechnology Information. National Library of Medicine. 20 Sep. 2008 <PMID: 12690875>.Canale, S. Terry, and James H. Beatty, eds. "Cervical Disc Disease." Campbell's Operative Orthopaedics. 11th ed. Philadelphia: Mosby Elsevier, 2008. 2184-2195. Furman, Michael B., and Kirk M. Puttlitz. "Cervical Disc Disease." eMedicine. Eds. Everett C. Hills, et al. 1 Feb. 2007. Medscape. 20 Sep. 2008 <http://emedicine.com/pmr/topic25.htm>. "Herniated Nucleus Pulposus (Slipped Disk)." MedlinePlus. 12 May. 2008. National Library of Medicine. 20 Sep. 2008 <http://www.nlm.nih.gov/medlineplus/ency/article/000442.htm>. Jenis, L. G. "Cervical Radiculopathy." The Adult and Pediatric Spine. Eds. J. W. Frymoyer and S. W. Wiesel. 3rd ed. 2 vols. Philadelphia: Lippincott, Williams & Wilkins, 2004. 689-711. Klaber Moffett, J. A., et al. "Randomised Trial of a Brief Physiotherapy Intervention Compared with Usual Physiotherapy for Neck Pain Patients: Outcomes and Patients' Preference." BMJ 330 7482 (2005): 75. Ylinen, J. J., et al. "Decreased Strength and Mobility in Patients after Anterior Cervical Diskectomy Compared with Healthy Subjects." Archives of Physical and Medical Rehabilitation 84 7 (2003): 1043-1047. National Center for Biotechnology Information. National Library of Medicine. 20 Sep. 2008 <PMID: 12881832>. |
Source: Medical Disability Advisor
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