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

Basis	Types
Location	Central, posterolateral or foraminal
Morphology	Protrusion, 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 reduced 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

• 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

Guidelines and Consensus

• CR Classification Delphi 2022. Classification requires radicular arm pain worse than neck pain, with paraesthesia, numbness, weakness or altered reflex, and concordant MRI nerve root compression.

Reviewed by Professor Phong Tran, Head of Orthopaedic Surgery, Western Health. Last updated 19 October 2026.