Cervical Herniated Disc: Patient History and Case
Just as in the lumbar spine, cervical spine discs can herniate and cause pain, numbness, tingling, or even spinal cord compression. Typically, patients complain of neck pain associated with pain radiating to one arm. This is termed radiculopathy (rah-dick-u-lop-ah-thee). Patients who have herniated cervical discs are younger and often more active than those with cervical stenosis. The disc herniation may be associated with a particular incident, such as a sudden jerking movement or positioning of the neck. Both operative and nonoperative methods of treatment can be effective in relieving symptoms.
The image above is a general illustration of spinal anatomy
and is not an exact replica of the cervical spine.
Presentation
Mr. D is a thirty-five year old man who has a recent onset of neck and right
arm pain. He has had neck pain for about six months, while the arm pain is more
recent. Mr. D also describes some numbness in the right hand, which he attributes
to carpal tunnel syndrome. Though he had never been diagnosed with carpal tunnel
syndrome, he seemed to have very similar symptoms as a good friend of his who
was recently diagnosed with this disorder.
He is very active, lifts weights and runs about two miles daily before working as an accountant. He does not have any other symptoms. He has no other significant medical problems. Mr. D has no bowel or bladder complaints. He has never sought medical care for his neck pain, which to him is more significant than his arm pain. The arm pain comes and goes, but is tolerable. The neck pain, on occasion, prevents him from going to work. Usually, one day off with a brief course of aspirin works to relieve the pain. Running does not seem to aggravate it and his weight lifting exercises seem to decrease the pain, temporarily. Because of the onset of arm pain, he seeks medical attention, as he feels this might be related to his neck.
Examination
His primary care doctor examines Mr. D. He has near full range of motion of
the neck with some mild tenderness along the muscles of the back of the neck.
In palpating (feeling) the back of the neck, it seems that he has some tenderness
in the midline. The doctor believes this to be in the area of the C5-6 vertebrae.
The shoulders, elbows and wrists also have good range of motion and do not appear
to have pain associated with their movement.
The neurologic examination demonstrates that Mr. D has some decreased sensitivity of his thumb and along the outer forearm. He does not exhibit any weakness or abnormal reflexes. The remainder of his examination is normal. Because of the numbness and the suggestion of carpal tunnel syndrome by the patient, the doctor orders an EMG, or an electromyography test (elec-tro-my-ah-gra-fee), of his upper extremities.
Diagnostic Tests
The EMG demonstrated what is known as cervical radiculopathy. In brief, the
EMG is a test of nerve function in the hands and arms. Based on the distribution
of nerve abnormalities, the electromyographer can determine if nerves are being
compressed in the hand, elbow, shoulder, or cervical spine. Because nerves are
continuous structures, they can also be compressed in more than one location.
Mr. D's electromyogram showed no evidence of compression of nerves within the
arm itself, but rather that the nerves were being compressed in the spine. This
is known as radiculopathy.
With the EMG results, the primary care doctor is now concerned about a correlation between Mr. D's neck pain and arm symptoms. He then orders x-rays of the neck and an MRI of the cervical spine (doctors love to exchange medical words with lay terms-thus neck means the same as cervical spine). Believing that Mr. D may have significant findings on the MRI, he sends his patient to see a spine surgeon.
Specialist Consultation
The spine surgeon examines the patient and agrees with the primary care doctor's
assessment. There is definite numbness along the thumb and outer aspect of the
right forearm. This is the area to which a particular nerve, C6, supplies sensation.
Thus, he would expect to find compression of this nerve on the MRI. Looking
over the EMG results, the electromyographer found that C6 nerve root function
was altered on the right side compared to the left, an indication that the nerve
is being compressed. The plain x-rays did not show any abnormalities and were
deemed normal. The MRI, however, was a bit more interesting. The radiologist
detected a small herniation of one of the cervical intervertebral discs. The
disc herniated on the right side and was compressing the C6 nerve root. There
was no compression of the spinal cord, and there did not appear to be any other
disc herniations.
The spine surgeon discussed the diagnosis with Mr. D. He stated that what he had was a cervical disc herniation and that this was causing his arm numbness. It has probably been developing over a period of time, and likely explains his six months of neck pain. It is understandable that the disc may have started to degenerate over time and that finally, the nucleus of the disc popped out. This was the time of onset of the arm pain.
Mr. D was a bit confused at this time. Why was the other doctor calling his problem a "radiculopathy" when he really had a herniated disc? In actuality, the surgeon explained, the cervical disc is what is causing his radiculopathy. In other words, the term radiculopathy indicates that the nerve is being pinched. This usually occurs because of a herniated disc, but can happen in other disorders.
Mr. D is now concerned about what to do about his condition. He tells the spine surgeon that he can live with the pain and numbness in the arm, and that he knows what to do for his neck ache when it flares up. Basically, the pain is tolerable. The surgeon reassures Mr. D that if he can tolerate the pain, he can continue his regular activities. If he so desired, he could start a course of physical therapy to strengthen his neck muscles and increase their flexibility, but he is probably doing a good job of it in the gym on his own. The doctor does inform him that good non-steroidal inflammatory medications are available over the counter, though therapeutic doses may vary than written on the package. Additionally, many other medications can be prescribed.
Mr. D was given another non-surgical option called an epidural (ep-e-do-ral) steroid injection. This entails an injection into the space around the spinal cord and nerve roots in the neck. It can be directed to the particular nerve root being compressed by a herniated disc. It is effective in about 60 percent of cases and, as the surgeon explained, it not an unreasonable alternative to surgery.
The surgeon does inform Mr. D of the operation that he could have done. It is called a cervical discectomy (dis-eck-toe-me) and fusion. Similar to Mrs. S's operation, it involves an incision in the front part of the neck to gain access the intervertebral disc. The disc is then removed and a piece of bone graft is placed in between the two bones. This causes the bones to fuse together into one large bone. The same risks and complications are explained to Mr. D, which include paralysis, infection, bleeding, and risk of the bone not healing. Mr. D appeared quite frightened of the procedure and immediately rejected the idea of it. In further contemplation, he asked what benefits the surgery would have. The surgeon also told Mr. D that if the herniation were located more laterally (to the side) another option would be an operation through the back of his neck. This would be a laminotomy (lamb-in-ah-toe-me, removing a small amount of bone) to gain access to the spinal nerve, moving it, and taking out only the herniated component of the disc.
The surgeon explained to Mr. D that the operation, if completely successful, would be most effective in relieving the arm pain and numbness. The relief of his neck pain would be more variable, but he would have a good chance of relieving that as well. The danger of not having the operation is minimal. In other words, what would happen if the disc herniation got worse and compressed the nerves even more? The doctor informed Mr. D that if his weakness got worse, and if he started to have other symptoms like wobbly legs and incoordination of the fingers, that he should return to the office soon. This may be an indication that the disc is protruding farther into the spinal canal and may be compressing the nerves and possibly the spinal cord. If this occurred, the doctor recommends surgery. However, he assured Mr. D this rarely, if ever, occurs.
If the arm and neck pain is tolerable and the nerve function stays the same or improves, there is no need for surgery. This is the option chosen by Mr. D. Since seeing the spine surgeon, he has been taking his medication when he experiences pain. His numbness actually improved over the next couple of months. He has remained active in his jogging and weightlifting, though the latter may not be mechanically as "friendly" to his spine as aerobic exercise.
This article is an excerpt from Dr. Stewart G. Eidelson's book, Advanced Technologies to Treat Neck and Back Pain, A Patient's Guide (March 2005).