Ilse P.

Torres
Orthopaedics

Is a spine condition of the cervical segment that

occurs when the gel-like center of a disc (nucleus
pulposus) ruptures through a weak area in the tough
outer wall (annulus fibrosus).

Spine is made of 24 movable bone

called vertebrae.
There are 7 cervical vertebrae
numbered C1-C7

Gel like Tissue between each vertebra

fibro cartilaginous cushions
serve as the spine's shock absorbing system
protect the vertebrae, brain, and other
structures
The discs allow some vertebral motion
extension and flexion.

The disc is made up of 3 structures the

(1) Nucleus pulposus, gelatinous center
(2) Annulus Fibrosus. Its job is to contain the
nucleus
(3) Vertebral end plates that attach the disc
to the vertebrae

Herniated disc can occur when there is enough pressure

from the vertebrae above and below
This can force some or all of the nucleus pulposus
through a weakened or torn part of the annulus fibrosus.

Disc Degeneration: chemical changes associated with

aging causes discs to weaken, but without a
herniation.

The form or position of the disc changes with some

slight impingement into the spinal canal. Also called a
bulge or protrusion.

The gel-like nucleus pulposus breaks through the tirelike wall (annulus fibrosus) but remains within the
disc.

The nucleus pulposus breaks through the annulus

fibrosus and lies outside the disc in the spinal canal
(HNP).

Injury
Improper lifting
Aging
Spontaneous

Symptoms of a herniated disc can vary

depending on the location of the herniation
and the types of soft tissue that become
involved.
They can range from little or no pain if the disc
is the only tissue injured, to severe and
unrelenting neck that will radiate into the
regions served by affected nerve roots that
are irritated or impinged by the herniated
material

The two most common levels in the cervical

spine to herniate are the C5 - C6 level (cervical 5
and cervical 6) and the C6 -C7 level. The next
most common is the C4 - C5 level, and rarely the
C7 - T1 level may herniate.
Rarely, the herniated disc may put pressure on
the spinal cord,causing problems in the leg.

Include dull or sharp pain in the neck or between the shoulder, pain
that radiates down the arm to the hand or fingers, or numbness or
tingling in the shoulder or arm. Certain positions or movements of
the neck can intensify the pain.
Weakness in the arm muscles may accompany the dull pain in some
cases

C4 - C5 (C5 nerve root) - Can cause weakness in the deltoid muscle in the
upper arm. Does not usually cause numbness or tingling. Can cause
shoulder pain.
C5 - C6 (C6 nerve root) - Can cause weakness in the biceps (muscles in the
front of the upper arms) and wrist extensor muscles. Numbness and
tingling along with pain can radiate to the thumb side of the hand. This is
one of the most common levels for a cervical disc herniation to occur.
C6 - C7 (C7 nerve root) - Can cause weakness in the triceps (muscles in the
back of the upper arm and extending to the forearm) and the finger
extensor muscles. Numbness and tingling along with pain can radiate
down the triceps and into the middle finger. This is also one of the most
common levels for a cervical disc herniation
C7 - T1 (C8 nerve root) - Can cause weakness with handgrip. Numbness
and tingling and pain can radiate down the arm to the little finger side of
hand.

C4 - C5 (C5 nerve root) - Can cause weakness in the deltoid muscle in the
upper arm. Does not usually cause numbness or tingling. Can cause
shoulder pain.
C5 - C6 (C6 nerve root) - Can cause weakness in the biceps (muscles in
the front of the upper arms) and wrist extensor muscles. Numbness and
tingling along with pain can radiate to the thumb side of the hand. This is
one of the most common levels for a cervical disc herniation to occur.
C6 - C7 (C7 nerve root) - Can cause weakness in the triceps (muscles in
the back of the upper arm and extending to the forearm) and the finger
extensor muscles. Numbness and tingling along with pain can radiate
down the triceps and into the middle finger. This is also one of the most
common levels for a cervical disc herniation
C7 - T1 (C8 nerve root) - Can cause weakness with handgrip. Numbness
and tingling and pain can radiate down the arm to the little finger side of
hand.

X-ray
CT Scan
MRI
Electromyography (EMG) &Nerve
Conduction Velocity (NCV)

Plain cervical spine radiographs evaluate chronic degenerative changes, metastatic

disease,infection, spinal deformity, and stability. But cant show herniation.

CT scan delineates cervical spine fracture and is used extensively in trauma cases.
Occasionally a CT scan with a myelogram may also be ordered, as it is more
sensitive and can diagnose even subtle cases of nerve root pinching.

The single best test to diagnose a herniated

disc is aMRI (Magnetic Resonance Imaging)
scan.
A MRI scan can image any nerve root pinching
caused by a herniated cervical disk.

An EMG is an electrical test that is done by

stimulating specific nerves and inserting needles
into various muscles in the arms or legs that may
be affected from a pinched nerve. If the muscles
have lost their normal innervation, there will be
spontaneous electrical activity.
These test can detect nerve damage and muscle
weakness

Brachial Neuritis
Cervikal Myofascial
Pain
Cervikal Spondylosis
Cervikal Sprain and
Strain
Complex Regional Pain
Syndromes
Fibromyalgia
Neoplastic Brachial
Plexopathy
Osteoarthritis
Osteoporosis (Primary

and Secondary)
Paget Disease
Psoriatic Arthritis
Radiation-Induced
Brachial Plexopathy
Rheumatoid Arthritis
Rotator Cuff Disease
Scheuermann Disease
Thoracic Outlet
Syndrome
Traumatic Brachial
Plexopathy

Nonsurgical
- Self care : Rest and restrict activity
- Medication
- Physical theraphy and exercise
- Bracing
- Cervical traction

Surgical

Conservative non surgical treatment is the

first step to recovery. Most cases of cervical
pain do not require surgery and are treated
using non-surgical methods.
*Resolve in 4 to 6 weeks.

NSAID, such as aspirin, naproxen, ibuprofen, etc

used to reduce inflammatory and relieve pain.
Analgesic, such as Acetaminophen can relieve
pain but dont have the anti-inflammatory effect
of NSAIDs.
Muscle relaxant such as methocarbamol may be
prescribed to control muscle spasm.
Steroid may be prescribed to reduce swelling and
inflammation of the nerves. Taken orally in
tapering dosage over a-five day period
Steroid injection into the area of your herniated
disc may performed if the pain is severe.

NSAID, such as aspirin, naproxen, ibuprofen, etc

used to reduce inflammatory and relieve pain.
Analgesic, such as Acetaminophen can relieve
pain but dont have the anti-inflammatory effect
of NSAIDs.
Muscle relaxant such as methocarbamol may be
prescribed to control muscle spasm.
Steroid may be prescribed to reduce swelling and
inflammation of the nerves. Taken orally in
tapering dosage over a-five day period
Steroid injection into the area of your herniated
disc may performed if the pain is severe.

NSAID, such as aspirin, naproxen, ibuprofen, etc

used to reduce inflammatory and relieve pain.
Analgesic, such as Acetaminophen can relieve
pain but dont have the anti-inflammatory effect
of NSAIDs.
Muscle relaxant such as methocarbamol may be
prescribed to control muscle spasm.
Steroid may be prescribed to reduce swelling and
inflammation of the nerves. Taken orally in
tapering dosage over a-five day period
Steroid injection into the area of your herniated
disc may performed if the pain is severe.

NSAID, such as aspirin, naproxen, ibuprofen, etc

used to reduce inflammatory and relieve pain.
Analgesic, such as Acetaminophen can relieve
pain but dont have the anti-inflammatory effect
of NSAIDs.
Muscle relaxant such as methocarbamol may be
presribed to control muscle spasm.
Steroid may be prescribed to reduce swelling and
inflammation of the nerves. Taken orally in
tapering dosage over a-five day period
Steroid injection into the area of your herniated
disc may performed if the pain is severe.

NSAID, such as aspirin, naproxen, ibuprofen, etc

used to reduce inflammatory and relieve pain.
Analgesic, such as Acetaminophen can relieve
pain but dont have the anti-inflammatory effect
of NSAIDs.
Muscle relaxant such as methocarbamol may be
presribed to control muscle spasm.
Steroid may be prescribed to reduce swelling and
inflammation of the nerves. Taken orally in
tapering dosage over a-five day period
Steroid injection into the area of your herniated
disc may performed if the pain is severe.

Mckenzie exercises can be used to help

reduce the pain in the arm.

In the initial period a physical therapist may

also opt to use modalities, such as heat/ice or
ultrasound, to help reduce muscle spasm.

For patient whose pain doesnt improve with the

nonsurgical treatment, surgery may be necessary.
The goal of surgery is to remove the portion of disc
that is pushing on the nerve.
Surgical procedure to remove the disc called
Discectomy

 Anterior Cervical Discectomy and Fusion

(ACDF)
Artificial disc replacement
Minimally invasive microendoscopic
discectomy
Posterior Cervical Discectomy

Protrusion ( contained or subligamentous

herniation )
Extrusion ( non-contained or
transligamentous herniation )
Sequestration ( freek fragment )

The gold standard for imaging of the

herniated lumbar disc is magnetic resonance
imaging

Central region
Paracentral region or
lateral recess
Intraforaminal zone or
subarticular zone
Extraforaminal zone

The most common sites for a herniated lumbar disc are L4-5
and L5-S1, resulting in back pain and pain radiating down the
posterior and lateral leg, to below the knee

Back pain caused by a herniated lumbar disc is

exacerbated by sitting and bending; conversely,
the pain of lumbar muscular strain is aggravated
by standing and twisting movements.

Mechanical deformation of the nerve root

Biochemical activity if the disc tissue on the
nerve root

Surgery Vs conservative treatment

Same results with respect to over-all-long term
improvement.
Advantage of surgery: if indicated:-faster pain relief
and back to work.
Exception: severe pain with
radiculopathy,progressive neurological deficit,
development of cauda equina syndrome.

Conservative treatment for up to 2 months. If

there is no improvement in symptoms and
signs, surgery should then be considered
without further conservative treatment
options.

Inflamed discs can cause referred leg pain

without neural compression by irritating the
sinu-vertebral nerve
Mild disc degeneration can result in quite severe
pain- because of inflammatory chemicals in the
disc space- not seen on MRI scans
Analgesic Discography- a new technique offers
a simple way to confirm the relevant disc as the
pain generator
Interbody fusion can then be used to treat the
problem definitively.