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

Aetiology

  • Associated with
    • heavy lifting
    • smoking

Epidemiology

  • MaleFemale 1.4:1

Anatomy

  • Seven cervical vertebrae with eight cervical nerve roots
  • Each root exits above its numbered pedicle, so C6 root exits at C5/6
  • C8 root exits at C7/T1
  • Roots run horizontally, so one disc compresses one root
  • PLL is thickest centrally, so herniation is mostly posterolateral
  • Uncovertebral joint hypertrophy narrows the foramen anteromedially
  • Commonest levels are C5/6 then C6/7

Pathology

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

Classification

BasisTypes
LocationCentral, posterolateral or foraminal
MorphologyProtrusion, extrusion or sequestration
  • Central herniation compresses the cord and causes myelopathy
  • Posterolateral and foraminal herniation compress the exiting root and cause radiculopathy
  • Soft disc herniation contrasted with hard disc from a spondylotic osteophyte bar

History

  • 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

Examination

  • 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 vertebra involving the C6 or C7 roots
      • Upper limb movements are full

Investigations

Prolapsed Cervical Disc, mri of a c6 to c7 cervical disc herniation
MRI of a C6 to C7 cervical disc herniation. Image by Anthonp, Wikimedia Commons, CC BY-SA 3.0.
  • X-ray
    • 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

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 ± discectomy

Complications

Disease

  • Persistent motor deficit from prolonged root compression
  • Myelopathy from central herniation

Surgery

  • Dysphagia after ACDF, mostly transient
  • Recurrent laryngeal nerve palsy with hoarseness
  • Pseudarthrosis, higher with multilevel fusion
  • Adjacent segment disease at about 3% per year after ACDF
  • C5 palsy after decompression

Prognosis

  • Most cervical radiculopathy improves with non-operative care over weeks to months
  • Sequestrated fragments often regress on serial MRI
  • ACDF relieves arm pain in most patients
  • Arm pain responds better to surgery than neck pain
  • Established motor deficit recovers less predictably than pain
  • Myelopathy from disc herniation does better with early decompression

Reviewed by Professor Phong Tran, Head of Orthopaedic Surgery, Western Health. Last updated 10 October 2026.