Cervical Disc Injuries

Etiology

Degenerative disc disease or acute disc herniation most commonly cervical disc injury. Degeneration of the disc occurs from a loss of water content leads to a decreased range of motion with susceptibility to facet joint disease. [1][2][3] Traumatic injuries caused by contact sports and automobile accidents which increase the risk of disc herniation.

Epidemiology

Neck pain affects up to 15% of the population in the United States with cervical disc disease. In other words, 84 out of 100,000 people have neck pain. Cervical disc injuries due to disc herniation affect people in their thirties to forties due to disc herniation, and degenerative disc disease affects people older than 50 years of age.[4]

History and Physical

The chief complaint of patients with cervical disc injury is neck pain with or without radiation to arm and fingers. Practitioners should obtain a thorough pain history that includes the severity, onset, duration, and characteristic of the pain. Other important information includes relieving, aggravating, and associated factors. Other symptomology includes muscle spasm, a decrease in mobility, and associated numbness or radicular pain.

A detailed physical examination of sensory and motor neurological examination should be performed. The doctor should assess the range of motion (ROM). The severity of pain, spasms, or degeneration affects flexion, extension, right and left rotation, and lateral flexion.

Evaluation

X-ray

Plain radiography is an initial and inexpensive method of evaluating the cervical spine for an osseous injury. In chronic disc degeneration, decreased disc height and osteophytes can be seen.  There is a higher incidence of cervical cord injury demonstrated with the use of plain radiographs in the assessment of cervical spine stenosis. The Torg ratio is the sagittal canal/vertebral body ratio measured on cervical spine lateral radiographs. The normal value is 1.0. A ratio of 0.8 and below has been considered indicative of cervical spinal stenosis.

MRI

Magnetic resonance imaging is the best modality to assess cord compression and disc herniation. T2 weighted views are preferred. Findings include decreased disc height, reduced signal intensity, and spondylotic osteophytes.

Other Studies

Patients with equivocal studies may opt for a discography when conservative measures fail. Electrophysiological studies can be performed to evaluate and elucidate the nerve roots affected by injured cervical disc.[5][6]

Treatment / Management

In the acute phase, management consists of pain relief, physical therapy, and surgery. [6][7][8](A1)

Non-Surgical

Pain relief is used to decrease the level of inflammation, allowing for physical therapy which includes segmental mobilization. Goals of therapy are to decrease pain, improve range of motion, strengthen muscles, and improve spinal biomechanics. Initial modes of pain relief are oral anti-inflammatory agents, as well as epidural injections. Depending on the severity of pain and the extent of pathology, medial bundle branch blocks or rhizotomies may be performed.

Surgical

When conservative management fails, surgery is indicated for acute disc herniation which causes central cord syndrome. Several techniques have been described based on pathology. Anterior discectomy with fusion is the recommended procedure for anterolateral or central soft disc herniation, while a posterior laminoplasty or laminectomy may be considered when technical limitations for anterior access exist or when the patient has had prior surgery at the same level.

Surgical intervention is indicated for patients who have had six weeks to three months of conservative management of disc herniation or degenerative disc disease. Associated worsening myelopathy or neuropraxia are also indications for surgery.

Several surgical procedures can be performed. These procedures are total disc replacement, anterior cervical discectomy and fusion (ACDF), laminectomy, or laminoplasty. Indications for total disc replacement surgery include symptomatic, spontaneous/degenerative, or traumatic herniated cervical nucleus pulposus with or without radiculopathy, and cervical degenerative disc disease without posterior column instability. Indications for anterior cervical discectomy and fusion surgery included cervical spondylosis, stenosis herniated discs, degenerative disc disease with instability and facet arthritis, tropism, or facetogenic pain.

Brief Surgical Techniques

Total Disc Replacement (TDR) and Anterior Cervical Discectomy and Fusion (ACDF)

Surgical exposure of the desired vertebral level is achieved through an anterior cervical incision. Subcutaneous dissection is performed to allow for adequate mobilization to tissue incision. The discectomy is performed with pituitary rongeurs, curette, and a burr drill to remove affected disc. The posterior longitudinal ligament can be left in situ depending on the severity of herniation. The center of the disc is identified. A keel is made using the burr after which the disc is removed and disc replacement performed. A similar surgical method is used for anterior cervical discectomy and fusion, the difference is the type of implant, which can be an interbody cage with an anterior cervical plate or a standalone cage. Although complications are rare, patients experience dysphagia, hoarseness, and transient sore throat. Adjacent segment disease or pseudoarthrosis can occur depending on severity and number of levels operated. The majority of patients get symptomatic relief and can resume full activity after six months.

Laminectomy

Cervical laminectomy removes the lamina on one or both sides to increase the axial space available for the spinal cord. Clinically indicated for spinal stenosis or cervical disc disease involving more than three levels of disc degeneration with anterior spinal cord compression. Single-level cervical disc herniation is usually managed with the anterior approach. The complications of the posterior approach include instability resulting in kyphosis, recalcitrant myofascial pain, and occipital headaches.

Laminoplasty

The kyphotic deformity is a well-known complication of laminectomy. To preserve the posterior wall of the spinal canal while decompressing the spinal canal a Z-plasty technique for the lamina was developed. The variant of the procedure uses a hinged door for the lamina. Laminoplasty is commonly indicated for multilevel spondylotic myelopathy. Nerve root injury is seen in about 11% of the surgeries. This complication is unique to laminoplasty, and the suggested etiology is traction on the nerve root with the posterior migration of the spinal cord.

Differential Diagnosis

• Cervical discogenic pain syndrome

• Cervical facet syndrome

• Cervical radiculopathy

• Cervical spine sprain

• Rehabilitation for osteoarthritis

• Rehabilitation for Paget disease

• Rheumatoid arthritis

• Rotator cuff disease

• Thoracic outlet syndrome

• Traumatic brachial plexopathy