Cervical Herniated Discs

What is a Cervical Herniated Disc?

Arm pain from a cervical herniated disc is one of the more common cervical spine conditions treated by the spine specialists at United Spine & Joint. It usually develops in the 30 - 50 year old age group. Although a cervical herniated disc may originate from some sort of trauma or injury to the cervical spine, the symptoms, including arm pain, commonly start spontaneously. If you are interested in treatment options for your herniated disc, please contact us to determine what option is best for you, what your insurance will cover and any additional surgery costs.

The arm pain from a cervical herniated disc results because the herniated disc material “pinches” or presses on a cervical nerve, causing pain to radiate along the nerve pathway down the arm. Along with the arm pain, numbness and tingling can be present down the arm and into the fingertips. Muscle weakness may also be present due to a cervical herniated disc.

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.

The nerve that is affected by the cervical disc herniation is the one exiting the spine at that level, so at the C5-C6 level it is the C6 nerve root that is affected.

Symptoms of a Cervical Herniated Disc

A cervical herniated disc will typically cause pain patterns and neurological deficits as follows:

• 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.

It is important to note that the above list comprises typical pain patterns associated with a cervical disc herniation, but they are not absolute. Some people are simply wired differently than others, and therefore their arm pain and other symptoms will be different.

Since there is not a lot of disc material between the vertebral bodies in the cervical spine, the discs are usually not very large. However, the space available for the nerves is also not that great, which means that even a small cervical disc herniation may impinge on the nerve and cause significant pain. The arm pain is usually most severe as the nerve first becomes pinched.

Treatments for a Cervical Herniated Disc

The majority of the time, the arm pain from a cervical herniated disc can be controlled with medication, and conservative (non-surgical) treatments alone are enough to resolve the condition.

Once the arm pain does start to improve it is unlikely to return, although it may take longer for the weakness and numbness/tingling to improve. If the arm pain gets better it is acceptable to continue with conservative treatment, as there really is no literature that supports the theory that surgery for cervical disc herniation helps the nerve root heal quicker.

All treatments for a cervical herniated disc are essentially designed to help resolve the arm pain, and usually the weakness and numbness/tingling will resolve with time.

After the initial exam, special diagnostic imaging tests may be required to better diagnose a cervical herniated disc.

MRI Scan to Identify a Cervical Herniated Disc

The single best test to diagnose a herniated disc is a MRI (Magnetic Resonance Imaging) scan. A MRI scan can image any nerve root pinching caused by a herniated cervical disk.

CT Scan with Myelogram to Identify a Cervical Disc Herniation

An MRI is the best first test, although 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.

Although a CT scan with myelogram is more sensitive it is also a slightly invasive test, as the myelogram dye must be injected into the spinal canal as part of the procedure. Because of the injection, a CT scan with myelogram is not usually the first test ordered.

Plain CT scans (without myelogram) are for the most part not useful for the diagnosis of a herniated cervical disc.

EMG to Identify Other Conditions Causing Pain

Occasionally, an EMG (Electromyography) may also be requested. 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.

An EMG can also help rule out other nerve entrapment syndromes that can give one arm pain, such as carpal tunnel syndrome, brachial plexitis, ulnar nerve entrapment, thoracic outlet syndrome, among other conditions.

Additional Conservative Treatment Options for a Cervical Herniated Disc

In addition to anti-inflammatory medications, there are a number of non-surgical treatment options that can help alleviate the pain from a cervical herniated disk, such as:

• Physical therapy and exercise. Just as in the lumbar spine, 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.
   
• Cervical traction. Traction on the head can help reduce pressure over the nerve root. It does not work for everyone but is easy to do, and if effective the patient can use a home traction device for pain from a cervical herniated disc.
   
• Chiropractic manipulation. Gentle manipulation can help reduce the joint dysfunction that may be an added component of the pain. High velocity manipulations should be avoided as they can make the pain worse, or worsen any neurological damage.
   
• Osteopathic medicine. Osteopathic manipulation and special techniques to restore normal joint motion can be helpful in reducing pain from a cervical herniated disc.
   
•  Activity modification. Some types of activities may tend to exacerbate the herniated disc pain and it is reasonable to avoid these activities to keep from irritating the nerve root. Such activities may include heavy lifting (over 50 pounds), activities that can cause increased vibration and compression to the cervical spine (boating, snowmobile riding, running, etc.), and overhead activities that require prolonged neck extension and/or rotation.
   
• Bracing. In some instances a cervical collar or brace may be recommended to help provide some rest for the cervical spine.
   
• Medications. In addition to the anti-inflammatory medications mentioned above, narcotic agents (pain killers) might be used on a temporary basis to help reduce the pain and discomfort from a cervical herniated disc. Also, muscle relaxants or certain anti-depressants may help reduce the nerve-type pain (neuropathic pain) and help restore normal sleep patterns.
   
• Injections. Epidural steroid injections or selective nerve root blocks can be helpful to reduce inflammation in cases of severe pain from a cervical herniated disc, and can be very effective if accompanied by a comprehensive rehabilitation program that may involve a number of the above conservative treatments.

Spine Surgery for Cervical Herniated Disc

Most episodes of arm pain due to a cervical herniated disc will resolve over a period of weeks to a couple of months. However, if the pain lasts longer than 6 to 12 weeks, or if the pain and disability is severe, spine surgery may be a reasonable option.

Spine surgery for a cervical herniated disc is generally very reliable and can be done with a minimal amount of postoperative pain (unwanted aftereffects).

With the experienced spine surgeons like those at United Spine & Joint, the back surgery should carry a low risk of failure or complications. The success rate for back surgery for a cervical herniated disc is about 95 to 98% in terms of providing relief of arm pain.

The spine surgery for a cervical herniated disc can be done a number of different ways:

• Anterior cervical discectomy and spine fusion. This is by far the most commonly preferred method among spine surgeons for most cervical herniated discs. In this surgery, the disc is removed through a small one-inch incision in the front of the neck. After removing the disc, the disc space itself is fused. A plate can be added in front of the graft for added stability and possibly a better fusion rate.
   
• Anterior discectomy without spine fusion. This is basically the same procedure as above except after removing the disc the space is left open and no bone is added to get a fusion. The disc space will still often fuse even without a bone graft but the healing seems to be longer and when and if it does heal, it tends to heal in a deformed position.
   
• Posterior cervical discectomy. This is similar to a posterior (from the back) lumbar discectomy, and for discs that occur laterally out in the neural foramen (the “tunnel” that the nerve travels through to exit the spinal canal) it is often a reasonable approach. However, it is technically more difficult than an anterior approach because there are a lot of veins in this area that can result in a lot of bleeding, and the bleeding limits visualization during the surgery. This approach also necessitates more manipulation to the spinal cord.

Potential Risks and Complications of Spine Surgery for a Cervical Herniated Disc

Although any major surgery has possible risks and complications, with an experienced spine surgeon serious complications from cervical disc surgery should be rare.

Possible complications from spine surgery for a herniated disc include:

• Damage to either the trachea/esophagus or one of the major blood vessels in the anterior spine (front of the neck). This should happen in less than 1 in 1,000 cases.
   
• In about 1% of cases, retraction on the nerve to the voice box (recurrent laryngeal nerve) can cause hoarseness. The hoarseness usually resolves in two to three months.
   
• Fusion rates run about 95%. Occasionally, there may be a postoperative nonunion that requires a re-fusion. Without a cervical plate there is a possibility (less than 1%) that the anterior bone graft will displace.
   
• With either the anterior or posterior approach there is a 1 in 10,000 chance that there would be either nerve root or spinal cord damage.
   
• Infection or cerebrospinal fluid leak happens less than 1% of the time.

Postoperative Care Following Spine Surgery for a Cervical Herniated Disc

For anterior surgery, there usually is not a great deal of postoperative pain. The surgery is done through a small incision in the front of the neck, and the spine can be accessed in between tissue planes that do not require cutting. This type of surgery usually can be done either outpatient (going home the same day as surgery) or with one overnight stay in the hospital.

The pain in the arm usually goes away fairly quickly, although it may take weeks to months for the arm weakness and numbness to subside. It is not uncommon to have some neck pain for a while.

Postoperatively, most spine surgeons prescribe a neck brace, although the type of brace and length of usage is variable. Also, most spine surgeons will ask their patients to limit their activities postoperatively, although the amount of restrictions and the length of time tend to vary. Ask your spine surgeon before the surgery what his or her usual protocol is regarding postoperative care.