What is a cervical disc injury?
Cervical is the medical term for neck. A cervical "disc injury," or neck injury refers to a disruption of annular fibers of the disc and movement of disc material. Annular disruption is accompanied by an inflammatory reaction capable of producing symptoms. Significant annular disruption can lead to disc bulging or herniation, resulting in compression of nerve roots. Most complaints of tingling, numbness, and pain in the arm rare thought to be caused from a combination of mechanical and chemical factors (1). Ensuing symptoms may include pain, paresthesia, numbness, or weakness.
What causes a cervical disc injury?
Disc injuries are rarely the result of a single traumatic event, but rather, a continuum of problems, beginning with repetitive disc sprain, leading to herniation, ending in degeneration. The normal age-related loss of the normal disc height along with with repetitive stressors like compressive loading, sheer stress, and vibration weaken the disc's annular fibers. This process eventually leads to annular disruption (2). Constant neck motion and awkward postures combined with compressive loading allow for herniations to become more prominent. Only the outermost fibers have a nerve supply, so early disruption may not cause any pain at all. In fact, asymptomatic "protrusions" are present in up to 63% of males over the age of 40 (4). Asymptomatic "herniations" are present in 10% of adults under 40, and 5% of adults over 40 (5). Ninety percent of symptomatic disc herniations occur at C5-6 or C6-7. (8,16)
Cervical disc injuries is the second most common cause of cervical radiculopathy (pain into the shoulder, upper back, and arms) behind degenerative stenosis (11,12). Cervical disc herniations are most likely to affect adults below the age of 55, with a peak incidence in the fourth decade (13,62). Cervical disc herniations are slightly more common in males (13,62). Activities that are thought to predispose patients to cervical disc problems include repetitive stressful workstation postures (i.e. maintaining a prolonged forward head posture), repetitive cervical flexion, improper sleep postures, trauma, frequent heavy lifting, cigarette smoking, and driving or operating vibrating equipment- including motor vehicles (13,14,62).
What are the symptoms of a cervical disc injury?
Symptoms may arise from inflammation in the area, mechanical compression of a nerve, or both (15). Cervical (neck) discogenic pain often begins with simply symptoms in the neck and then progresses into pain in the shoulder, arm, and hands (16). Cervical disc injuries without mechanical compression may produce neck pain that can radiate (or move) into the head, neck, shoulders. Neck pain may be worse with prolonged sitting with poor posture or prolonged neck forward bending. Arm pain may be the predominant symptom in cases of a cervical disc injury (12). Patients may note an increase in pain in their arm when coughing or sneezing and find relief by elevating their arm above their head (2).
Do I need x-rays or other imaging?
A radicular complaint in the upper extremity may suggest the need for radiographic workup. Plain film radiographs of cervical disc injuries are often "normal," but may show concurrent degenerative change, particularly in older patients. Joint degenerative changes can cause narrowing of the intervertebral foramen (IVF) and is visualized on the oblique films. Symptoms often arise from a combination of disc bulging and spondylolytic bony encroachment, i.e. “disc/ osteophyte complex” or “hard disc”.
MRI is a sensitive modality for detection of cervical disc injury and provides additional information concerning the hydration status of the dis (25). However, MRI can yields false positives, and the true origin of the patient’s complaints may not always arise from the imaged disc lesion (5). Direct displacement of a nerve root or fluid within the nerve root are generally associated with symptomatology but are not always present.
What are the bet treatment options for a cervical disc injury?
Treatment Goals:
The goal of conservative management should be to reduce pain and inflammation, decrease mechanical compression, and improve functional stability. Conservative management of cervical disc herniation with radiculopathy has been shown to result in regression of herniated material with subsequent reduction in local and radicular complaints (22,30-33). The relatively avascular anatomy (lack of blood flow) of the disc may prolong recovery times.
Treatment options:
The judicious application of spinal manipulation has been shown to be safe, appropriate, and effective for the management of cervical disc herniation and/or radiculopathy (35-50,65,66). One study of 50 patients undergoing HVLA manipulation at the level of cervical disc herniation demonstrated significant improvement after two weeks of care with none worsening and 85.7% reporting significant improvement at three months (40). Another study of 104 MRI-confirmed disc herniations demonstrated that patients treated with chiropractic spinal manipulation were significantly more likely to report relevant “improvement” compared to those treated with cervical nerve root injection blocks (65). Alternatives to HVLA manipulation include Grade 3-4 mobilization, instrument-assisted adjusting, and cervical flexion distraction. Cervical spine manual traction is a beneficial modality for cervical disc lesion and has been shown to help decompress, rehydrate, and promote recovery (8,56-60). The use of ice, electrical stimulation, or ultrasound may provide benefit.
Restoration of normal flexibility and mobility allows for a more balanced distribution of forces away from the injured segment. Stretching and myofascial release techniques may be necessary for the paracervical region, including the suboccipital, posterior cervical, SCM, levator, and trapezius muscles. Implementation of IASTM procedures may help release myofascial adhesions in chronic cases. Cautious application of upper extremity nerve flossing may help mobilize and de-sensitize the irritated nerves.
Therapeutic Exercise:
Stabilization programs should focus on coordinating cervical, thoracic, and shoulder girdle movement and correct for biomechanical deficits including weakness in the deep neck flexors, upper crossed syndrome, or paradoxical breathing. Patients should be counseled on proper workstation and sleep postures and should avoid activities that involve axial loading of the cervical spine, like headstands, carrying objects on the head, and diving into water.
Other options:
NSAIDs may help relieve inflammation. Medical co-management of acute cases with short-term tapering oral steroids is a potent anti-inflammatory adjunct. Recalcitrant cases may require pain management and/or neurosurgical consult. Cervical epidural injections or selective nerve root blocks may be helpful. (64) The addition of spinal manipulation post-epidural injection has been shown to improve outcomes. (61) Surgical alternatives, including discectomy, or discectomy with fusion, should be considered only after a failed trial of conservative therapy, or in the presence of progressive neurologic deficit (22).
At Creekside Chiropractic & Performance Center, we are highly trained to treat each of these conditions. We are the only inter-disciplinary clinic providing services to Sheboygan, Sheboygan Falls, Plymouth, and Oostburg including chiropractic, manual therapy, myofascial release, ART (Active Release Technique), massage therapy, acupuncture, physiotherapy, rehabilitative exercise, nutritional counseling, personal training, and golf performance training under one roof. Utilizing these different services, we can help patients and clients reach the best outcomes and the best versions of themselves. Voted Best Chiropractor in Sheboygan by the Sheboygan Press.
Evidence Based-Patient Centered-Outcome Focused
Sources:
1. Saal JA. Natural history and nonoperative treatment of lumbar disc herniation. Spine. 1996 Dec;21(24 Suppl):2S-9S. Link
2. Yeung JT, Johnson JI, Karim AS. Cervical disc herniation presenting with neck pain and contralateral symptoms: a case report. Journal of medical case reports. 2012 Dec;6(1):166. Link
3. Tampier C, Drake JD, Callaghan JP, McGill SM. Progressive disc herniation: an investigation of the mechanism using radiologic, histochemical, and microscopic dissection techniques on a porcine model. Spine. 2007 Dec 1;32(25):2869-74. Link
4. Healy JF, Healy BB, Wong WH, Olson EM. Cervical and lumbar MRI in asymptomatic older male lifelong athletes: frequency of degenerative findings. Journal of computer assisted tomography. 1996 Jan 1;20(1):107-12. Link
5. Tanaka Y, Kokubun S, Sato T, Ozawa H. Cervical roots as origin of pain in the neck or scapular regions. Spine. 2006 Aug 1;31(17):E568-73. Link
6. Bogduk N, Twomey LT. Clinical Anatomy of the Lumbar Spine. 2nd ed. New York, NY: Churchill Livingston; 1991.
7. Byrne TN, Benzel E, Waxman SG. Diseases of the Spine and Spinal Cord. Oxford University Press, 2000, p126.
8. Constantoyannis C, Konstantinou D, Kourtopoulos H, Papadakis N. Intermittent cervical traction for cervical radiculopathy caused by large-volume herniated disks. Journal of manipulative and physiological therapeutics. 2002 Mar 1;25(3):188-92. Link
9. Oliver J., Middleditch A. Functional anatomy of the spine. Oxford: Butterworth-Hienemann, Ltd., Reed International Books, 1991.
10. David F. Fardon, MD Nomenclature and Classification of Lumbar Disc Pathology SPINE Volume 26, Number 5, pp E93–E113
11. Radhakrishnan K, Litchy WJ, O'Fallon WM, Kurland LT. Epidemiology of cervical radiculopathy: a population-based study from Rochester, Minnesota, 1976 through 1990. Brain. 1994 Apr 1;117(2):325-35. Link
12. Murphy DR. Herniated disc with radiculopathy following cervical manipulation: nonsurgical management. The Spine Journal. 2006 Jul 1;6(4):459-63. Link
13. Kelsey JL, Githens PB, Walter SD, Southwick WO, Weil U, Holford TR, Ostfeld AM, Calogero JA, O'connor T. An epidemiological study of acute prolapsed cervical intervertebral disc. The Journal of bone and joint surgery. American volume. 1984 Jul;66(6):907-14. Link
14. Harms-Ringdahl K. On assessment of shoulder exercise and load-elicited pain in the cervical spine. Biomechanical analysis of load--EMG--methodological studies of pain provoked by extreme position. Scandinavian journal of rehabilitation medicine. Supplement. 1986;14:1-40. Link
15. Wainner RS, Fritz JM, Irrgang JJ, Boninger ML, Delitto A, Allison S. Reliability and diagnostic accuracy of the clinical examination and patient self-report measures for cervical radiculopathy. Spine. 2003 Jan 1;28(1):52-62. Link
16. Kramer J. Intervertebral Disk Diseases. Causes, Diagnosis, Treatment and Prophylaxis. George Thieme Verlag, Stuttgart Year Book, Medical Publishers Inc; 1981.
17. Grubb SA, Kelly CK. Cervical Discography:: Clinical Implications From 12 Years of Experience. Spine. 2000 Jun 1;25(11):1382-9. Link
18. Cloward RB. Cervical diskography: a contribution to the etiology and mechanism of neck, shoulder and arm pain. Annals of Surgery. 1959 Dec;150(6):1052. Link
19. Viikari-Juntura E, Porras M, Laasonen EM. Validity of clinical tests in the diagnosis of root compression in cervical disc disease. Spine. 1989 Mar;14(3):253-7. Link
20. Liebenson C. Functional reactivation for neck pain patients. Journal of bodywork and movement therapies. 2002 Jan 1;6(1):59-66. Link
21. Liebenson C. Self-treatment of Mid-thoracic Dysfunction: a Key Link in the Body Axis. Part I: Overview and Assessment. J of Bodywork and Movement Therapy 2001, 5:90-98
23. Ellenberg MR, Honet JC, Treanor WJ. Cervical radiculopathy. Arch Phys Med Rehabil. Mar 1994;75(3):342-52.
24. Deyo RA, ed. Occupational Back Pain. Spine: State of the Art Reviews. Vol 2. Philadelphia, Pa: Hanley and Belfus; 1987.
25. Kramer J, Rivera CA, Kleefield J. Degenerative disorders of the cervical spine. Rheum Dis Clin North Am. Aug 1991;17(3):741-55.
26. Matsumoto M, Fujimura Y, Suzuki N, Nishi Y, Nakamura M, Yabe Y, Shiga H. MRI of cervical intervertebral discs in asymptomatic subjects. The Journal of bone and joint surgery. British volume. 1998 Jan;80(1):19-24. Link
27. Yu SW, Sether LA, Ho PS, Wagner M, Haughton VM. Tears of the anulus fibrosus: correlation between MR and pathologic findings in cadavers. American Journal of Neuroradiology. 1988 Mar 1;9(2):367-70. Link
28. Karnaze MG, Gado MH, Sartor KJ, Hodges 3rd FJ. Comparison of MR and CT myelography in imaging the cervical and thoracic spine. American Journal of Roentgenology. 1988 Feb 1;150(2):397-403. Link
29. Modic MT, Masaryk TJ, Mulopulos GP, Bundschuh C, Han JS, Bohlman H. Cervical radiculopathy: prospective evaluation with surface coil MR imaging, CT with metrizamide, and metrizamide myelography. Radiology. 1986 Dec;161(3):753-9. Link
30. Manchikanti L, Abdi S, Atluri S, Benyamin RM, Boswell MV, Buenaventura RM, Bryce DA, Burks PA, Caraway DL, Calodney AK, Cash KA. An update of comprehensive evidence-based guidelines for interventional techniques in chronic spinal pain. Part II: guidance and recommendations. Pain physician. 2013 Apr;16(2 Suppl):S49-283. Link
31. Bush K, Hillier S. Outcome of cervical radiculopathy treated with periradicular/epidural corticosteroid injections: a prospective study with independent clinical review. Eur Spine J. 1996;5(5):319-25.
33. BenEliyahu DJ. Magnetic resonance imaging and clinical follow-up: study of 27 patients receiving chiropractic care for cervical and lumbar disc herniations. J Manipulative Physiol Ther. 1996;19(9):597–606.
34. Croft AC. Appropriateness of cervical spine manipulation in disc herniation: a survey of practitioners. Chiropractic Technique. 1996;8:178-81.
35. Heckmann JG, Lang CJ, Zöbelein I, Laumer R, Druschky A, Neundörfer B. Herniated cervical intervertebral discs with radiculopathy: an outcome study of conservatively or surgically treated patients. Journal of spinal disorders. 1999 Oct;12(5):396-401. Link
35. Senstad O, Leboeuf-Yde C, Borchgrevink C. Frequency and characteristics of side effects of spinal manipulative therapy. Spine. 1997 Feb 15;22(4):435-40. Link
36. Saal JS, Saal JA, Yurth EF. Nonoperative management of herniated cervical intervertebral disc with radiculopathy. Spine. 1996 Aug 15;21(16):1877-83. Link
37. BenEliyahu DJ. Disc herniations of the cervical spine. AJCM. 1989;2(3):93-100.
38. Murphy DR, Hurwitz EL, Gregory A, Clary R. A nonsurgical approach to the management of patients with cervical radiculopathy: a prospective observational cohort study. Journal of manipulative and physiological therapeutics. 2006 May 1;29(4):279-87. Link
39. BenEliyahu DJ. Chiropractic management and manipulative therapy for MRI documented cervical disk herniation. Journal of manipulative and physiological therapeutics. 1994;17(3):177-85. Link
40. Peterson CK, Schmid C, Leemann S, Anklin B, Humphreys BK. Outcomes from magnetic resonance imaging–confirmed symptomatic cervical disk herniation patients treated with high-velocity, low-amplitude spinal manipulative therapy: a prospective cohort study with 3-month follow-up. Journal of manipulative and physiological therapeutics. 2013 Oct 1;36(8):461-7. Link
41.Murphy DR, Hurwitz EL, Gregory A, Clary R. A nonsurgical approach to the management of patients with cervical radiculopathy: a prospective observational cohort study. Journal of manipulative and physiological therapeutics. 2006 May 1;29(4):279-87. Link
42. Eriksen K. Management of cervical disc herniation with upper cervical chiropractic care. Journal of manipulative and physiological therapeutics. 1998 Jan;21(1):51-6. Link
43. Brouillette DL, Gurske DT. Chiropractic treatment of cervical radiculopathy caused by a herniated cervical disc. Journal of manipulative and physiological therapeutics. 1994 Feb;17(2):119-23. Link
44. David BenEliyahu Conservative Nonoperative Treatment of the Cervical Soft Disc Herniation Dynamic Chiropractic – April 8, 1994, Vol. 12, Issue 08
45. BenEliyahu DJ. Efficacy of chiropractic manipulation of treatment of cervical disc herniation. Proceedings of the 1991 FCER Conference/ICSM.
46. Tibbles AC, Cassidy JC. Cervical Disc Herniation JCCA, 36(1):17-21, 1992.
47. Siciliano MA, Bernard TA. Reduction of a confirmed C5/6 disc herniation. Journal of Chiropractic Res. and Clin Invest, 8(1):17, 1991.
48. Hughes BL. Management of cervical disk syndrome utilizing manipulation under anesthesia. Journal of manipulative and physiological therapeutics. 1993;16(3):174-81. Link
49. ICA Best Practices & Practice Guidelines, Chapter 4: Risk of Chiropractic Care. Link
50. Bergman T, Peterson D, Lawrence D. Chiropractic Technique Principles and Procedures. Churchill Livingstone, New York, 1993.
52. J Can Chiropr Assoc. 2007 March; 51(1): 19–22.
53. Haldeman S. Principles and Practice of Chiropractic. Appleton and Lange, San Mateo, 1992.
54. Haldeman S. Contraindication and complications (Chapter 12) in: Guidelines for Chiropractic Quality Assurance and Practice Parameters.
56. Sowa GA, Agarwal S. Motion exerts a protective effect on intervertebral discs. American Journal of Physical Medicine & Rehabilitation. 2006 Mar 1;85(3):246-7. Link
57. Guehring T, Omlor GW, Lorenz H, Engelleiter K, Richter W, Carstens C, Kroeber M. Disc distraction shows evidence of regenerative potential in degenerated intervertebral discs as evaluated by protein expression, magnetic resonance imaging, and messenger ribonucleic acid expression analysis. Spine. 2006 Jul 1;31(15):1658-65. Link
58. Browder DA, Erhard RE, Piva SR. Intermittent cervical traction and thoracic manipulation for management of mild cervical compressive myelopathy attributed to cervical herniated disc: a case series. Journal of Orthopaedic & Sports Physical Therapy. 2004 Nov;34(11):701-12. Link
59. Chung TS, Lee YJ, Kang SW, Park CJ, Kang WS, Shim YW. Reducibility of cervical disk herniation: evaluation at MR imaging during cervical traction with a nonmagnetic traction device. Radiology. 2002 Dec;225(3):895-900. Link
60. Moeti P, Marchetti G. Clinical outcome from mechanical intermittent cervical traction for the treatment of cervical radiculopathy: a case series. Journal of Orthopaedic & Sports Physical Therapy. 2001 Apr;31(4):207-13. Link
61. Dougherty P, Bajwa S, Burke J, Dishman JD. Spinal manipulation postepidural injection for lumbar and cervical radiculopathy: a retrospective case series. Journal of manipulative and physiological therapeutics. 2004 Sep 1;27(7):449-56. Link
62. DeLisa JA, Gans BM, Walsh NE, editors. Physical medicine and rehabilitation: principles and practice. Lippincott Williams & Wilkins; 2005. Link
63. Bussières AE, Taylor JA, Peterson C. Diagnostic imaging practice guidelines for musculoskeletal complaints in adults—an evidence-based approach—part 3: spinal disorders. J Manipulative Physiol Ther. 2008;31(1):33–88.
64. [Manchikanti L, Abdi S, Atluri S, Benyamin RM, Boswell MV, Buenaventura RM, Bryce DA, Burks PA, Caraway DL, Calodney AK, Cash KA. An update of comprehensive evidence-based guidelines for interventional techniques in chronic spinal pain. Part II: guidance and recommendations. Pain physician. 2013 Apr;16(2 Suppl):S49-283. Link
65. Peterson, C.K., Pfirrmann, C.W., Hodler, J., Leemann, S., Schmid, C., Anklin, B. and Humphreys, B.K., 2016. Symptomatic, Magnetic Resonance Imaging–Confirmed Cervical Disk Herniation Patients: A Comparative-Effectiveness Prospective Observational Study of 2 Age-and Sex-Matched Cohorts Treated With Either Imaging-Guided Indirect Cervical Nerve Root Injections or Spinal Manipulative Therapy. Journal of manipulative and physiological therapeutics, 39(3), pp.210-217. Link
66. Thoomes EJ. Effectiveness of manual therapy for cervical radiculopathy, a review. Chiropractic & Manual Therapies. 2016 Dec;24(1):45. Link
67. Gao K, Zhang J, Lai J, Liu W, Lyu H, Wu Y, Lin Z, Cao Y. Correlation between cervical lordosis and cervical disc herniation in young patients with neck pain. Medicine. 2019 Aug;98(31). Link