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Prolapsed Cervical Disc

Definition

  • Prolapsed disc material may press on the dura resulting in neck pain & stiffness or the nerve root causing pain & paraesthesia in one or both arms

Incidence

  • MaleFemale 1.4:1

Aetiology

  • Associated with
    • heavy lifting
    • smoking

Clinically

  • Pain
    • Onset usually not related to severe strain & often occurs on stretching upon waking
    • often radiates to the scapular region & sometimes the occiput
    • Radicular pain (brachialgia) to one (rarely both) arms in the distribution of innervation of involved segment

Nerve roots in order of effect = C7, C6, C5, C8

    • C7 - Triceps
      • Dorsal forearm pain
      • Medial scapular pain
      • Tip of index finger numbness
      • Absent triceps jerk
    • C6 - Biceps compartment pain
      • Biceps weakness
      • Tip of thumb ↓ sensation
      • Depressed biceps jerk
    • C5
      • Short history because of noticeable reduction in shoulder abduction
      • Severe effects
      • Obvious signs & disability
    • C8 - Scapular pain
      • Medial brachial / axillary radiation
      • Severe impact on hand function
      • Similar to an ulnar nerve lesion
  • Look
    • Torticollis - neck may be tilted
  • Palpation
    • tender spots are palpated in the cervical musculature (trapezius & scapular region)
  • Movements
    • Some movements are restricted & painful but at least one movement is full & painless in all but the most severe cases
    • May be weakness of muscle groups innervated by the affected root
  • Special tests
    • Foraminal compression test
      • often positive & abduction / external rotation of the arm without changing neck position relieves the pain (hand behind the head)
  • Note
    • commonest level is above or below the sixth cervical vertebrae involving the C6 or C7 roots
      • Upper limb movements are full

Investigations

  • XRay
    • Loss of normal cervical lordosis
    • Disc space is often narrowed
  • CT
    • gives variable image quality
  • Myelography
    • rarely used now
  • MRI
    • gold standard

Differential Diagnosis

  • Cervical rib syndrome involving C8/T1 roots
  • Carpal tunnel syndrome where neck movements are painless
  • Supraspinatus tendon lesions or other shoulder pathology
  • Tumours of the cervical spine or region may present with radicular symptoms
  • Cervical spine infection
  • Neuralgic Amyotrophy where pain is sudden & severe with multiple levels involved

Pathogenesis

  • Degenerate or traumatic tear of the annular fibres allowing prolapse of the intervertebral disc material

Treatment

  • Nonoperative
    • Rest, analgesics & anti-inflammatories (80 - 90% resolve!)
    • Occasional role for oral steroids
    • A soft cervical collar may be useful in the short term to improve comfort
  • Cervical traction
    • may also provide relief of symptoms & provide comfort while the condition resolves (should not exceed 10lbs which is the approximate weight of the head)
  • Operative
    • Decompression
      • If symptoms severe & refractory operative decompression may be indicated
    • anterior approach with subsequent stabilisation of the cervical spine
    • bone graft ± internal fixation
    • foraminectomy ± diskectomy
Webpage Last Modified: 18 February, 2010