eMedicine Specialties > Sports Medicine > Spine

Cervical Discogenic Pain Syndrome

Robert E Windsor, MD, FAAPMR, FAAEM, FAAPM, President and Director, Georgia Pain Physicians PC; Clinical Associate Professor, Department of Physical Medicine and Rehabilitation, Emory University
Ricardo A Nieves, MD, Medical Director of Rehabilitation Medicine Unit, Carlsbad Medical Center; Kevin P Sullivan, MD, Consulting Staff, The Boston Spine Group; Erik D Hiester, DO, Fellow in Interventional Pain Management, Emory Medical School/Georgia Pain Physicians
Contributor Information and Disclosures

Updated: Dec 17, 2004

Introduction

Background

Cervical intervertebral disc disease accounts for 36% of all spinal intervertebral disc disease, second only to lumbar disc disease, which accounts for 62% of all spinal intervertebral disc disease. Cervical problems tend to be less debilitating than lumbar problems, and they do not cause individuals to miss work as often as lumbar spine problems do (Hult, 1954; McKenzie, 1990). One of 5 visits to an orthopedic practice is for cervical discogenic pain, with C5-6 and C6-7 accounting for approximately 75% of visits. C7 is the most common nerve root involved (Kramer, 1981). Cervical discogenic pain presents with proximal symptoms first, and, later, it can progress to brachialgia.

In sports, the most common mechanism involved in cervical spine injuries appears to be axial loading with the neck in slight flexion. Because the cervical lordosis is reversed, the cervical spine muscles are at a mechanical disadvantage and cannot efficiently dissipate the forces to the cervical spine. Therefore, forces are transmitted directly to the bones, ligaments, and discs rather than to the muscles, resulting in potential fractures, dislocations, disc herniations, disc degeneration, and ligament sprains. These types of injuries most commonly are seen with sports such as soccer, football, wrestling, ice hockey, diving, rugby, and trampolining (Cloward, 1959; Laprade, 1995; Majors, 1997; Tator, 1991; Tator, 1997; Taylor, 1991; Torg, 1991; Wu, 1985).

The incidence of catastrophic football injuries resulting in tetraplegia has shown a gradual reduction throughout the years. This reduction in incidence is attributed to sports medicine programs and a comprehensive injury tracking system that allows insights into the epidemiology of these injuries. Future prevention strategies can involve enforcing rules, implementing high coaching standards, and educating players about the dangers of high-risk and illegal contact and about axial impact. Also, increased shock absorption of contact surfaces might help in reducing severe spinal cord injuries in impact sports (Laprade, 1995; Tator, 1997).

Frequency

United States

Cervical intervertebral disc disease accounts for 36% of all spinal intervertebral disc disease. This condition is somewhat more common in women. Although acute attacks may start at a very young age with episodes of acute torticollis or "wry neck," the incidence peaks when persons are aged 45-50 years.

Prevalence studies of cervical radiculopathies demonstrate that 2 age peaks exist, one in the 60s and 70s and one in the 20s. Cervical radiculopathy in the older age group almost always is caused by a combination of osteophytic spurs and disc protrusion compressing an exiting nerve root, and cervical radiculopathy in the younger age group tends to be caused by a typical type of disc herniation.

Functional Anatomy

The cervical spine permits a wide range of motion (ROM) of the head in relation to the trunk. A degree of stability and flexibility is required to control the motion and dissipate the forces applied to the spine. Great differences in anatomy and function exist between the occiput-C1, the C1-2 (upper complex), and C3 through C7 (lower complex). Eight motion segments occur between the occiput and T1. No disc exists between C1 and C2; therefore, the first intervertebral disc is between C2 and C3.

The intervertebral disc consists of an outer annulus fibrosus and an inner nucleus pulposus. The intervertebral disc is thicker anteriorly, contributing to the normal cervical lordosis. The C6-7 disc is the thickest disc of the cervical spine. The nucleus pulposus and the inner one half of the annulus fibrosus are avascular and receive nutrition through diffusion, compression, dehydration, and imbibition of fluids (Bogduk, 1991).

The annulus fibrosus, particularly the outer third, has been found to be innervated by the sinuvertebral nerve and the vertebral nerve. The sinuvertebral nerve arises from the ventral ramus (somatic root), whereas the vertebral nerve (autonomic root) is derived primarily from the sympathetic nervous system. However, the vertebral nerve has connections with the cervical ventral rami, which suggests the possibility of the vertebral nerve also conveying somatic afferents from the disc (Bogduk, 1981; Bogduk, 1988; Malinsky, 1959).

The nociceptors and mechanoreceptors in the annulus fibrosus mediate pain transmission from structural disruption of the intervertebral disc itself or from the chemically mediated inflammatory effect of phospholipase A2 (Bogduk, 1988; Mendel, 1992). Pacinian corpuscles and Golgi tendon organs present in the posterolateral region of the outer one third of the annulus transmit proprioceptive information from the intervertebral disc (Bogduk, 1991; Mendel, 1992; Panjabi, 1993; Franson, 1992; Saal, 1990).

The adult cervical disc has a crescentic shape anteriorly, with the apex of the crescent at the uncovertebral joints on each side. The posterior annulus has multiple vertical fissures allowing for a very degenerative appearance during discography and on gross examination. In addition, the nucleus of the cervical disc tends to be poorly centralized when compared to the lumbar disc. In the lumbar disc, the nucleus tends to be well localized in the center of the disc, and the posterior annulus tends to remain relatively intact when compared to the cervical disc. Annular fissures in the lumbar disc tend to be circumferential and/or radial in nature.

Sport Specific Biomechanics

Biomechanics is the study of the changes in the anatomical structures occurring during body movements. The movements of the cervical spine include flexion and extension in the sagittal plane, lateral flexion in the coronal plane, and rotation in the horizontal plane. Lateral flexion and rotation occur as coupled movements. Other movements of the cervical spine include protrusion (ie, the head is moved as far forward as possible with the neck outstretched and maintaining forward-facing position) and retraction (ie, the head is moved as far backward as possible and maintaining a forward-facing position).

Fifty percent of rotation of the cervical spine occurs in the upper cervical complex with the atlas rotating ipsilaterally around the odontoid. Protrusion causes upper cervical spine extension and lower cervical spine flexion, while retraction causes upper cervical spine flexion and lower cervical spine extension. At the occiput-C1 and C1-2 levels, ROM is greater with the protruded and retracted position than with full-length flexion and full-length extension positions (Ordway, 1999).

The annular fibers are made up of collagenous lamellae with alternating directions of inclination oriented 35° from the horizontal. The annulus is more susceptible to injury with rotation and translation movements due to resistance offered only by the lamella oriented in the direction of movement. In the cervical spine, as in the lumbar spine, the intervertebral disc dissipates the transmission of compressive loads throughout the ROM by slowing the rate at which these forces are transmitted through the spine. By diverting the load via temporarily stretching the annular fibers, the disc protects the vertebra from taking the entire load at once.

In asymmetric loading, the nucleus pulposus migrates toward the area with less load. Thus, in flexion movements of the cervical spine, anterior offset loading of the intervertebral disc occurs, in which the nucleus pulposus moves posteriorly and the posterior annular wall is stretched. In addition, the cervical lordosis reduces, the vertebral canal lengthens, and the intervertebral foramina open (McKenzie, 1990).

In extension movements of the cervical spine, posterior offset loading of the intervertebral disc occurs, in which the nucleus moves anteriorly and the anterior annular wall is stretched. Shortening of the vertebral canal and closing of the intervertebral foramen also occur (McKenzie, 1990). In lateral flexion and rotation (coupling movement) of the cervical spine, there is offset loading of the intervertebral disc on the side of flexion and rotation, with nuclear material moving to the opposite side (site of the convexity), and the posterolateral annular wall is stretched (McKenzie, 1990).

The intervertebral foramina house the exiting cervical nerves. The largest cervical spine foramen is at the C2-3 level, and the smallest foramen is at the C6-7 level (Ellenberg, 1994). The cervical foramina become very dynamic during cervical spine ROM. The intervertebral foramina enlarge with flexion and decrease with extension. In rotation, the ipsilateral side becomes smaller, and the contralateral side enlarges. The extreme changes of the foramina occur with coupled movements, ie, flexion-rotation and extension-rotation-lateral flexion (White, 1991).

Clinical

History

Obtaining an accurate history is essential when evaluating patients with neck pain.

  • Identifying specific red flags that are indicators of potentially serious spinal or nonspinal pathology or conditions that may interfere with treatment is extremely important. The absence of red flags diminishes the need for special studies during the first 4 weeks of symptoms, a time in which spontaneous recovery is common. Serious spinal and nonspinal conditions associated with red flags include the following:
    • Cancer/malignancy
    • Infection
    • Trauma with possible underlying fracture
    • Osteoporosis with possible underlying fracture
    • Conditions associated with spine instability (eg, rheumatoid arthritis, Down syndrome)
    • Significant or progressive neurologic deficit (eg, profound muscle weakness and/or reflex loss, bowel and/or bladder incontinence or retention)
    • Vertebral basilar artery insufficiency
    • Pregnancy
  • Obtain an accurate description of the characterization of the pain, including location, onset, duration, frequency, description, distribution, and aggravating and relieving factors.
    • Differentiating between referred and radicular pain is important. Referred pain is more diffuse, whereas radicular pain is more specifically along the course of a dermatome.
    • Patients with disc degeneration could have chronic low-grade pain that is periodically exacerbated for several weeks.
    • Cervical discogenic pain may be localized pain, referred pain, or radicular pain.
    • Mechanical pain can be constant or intermittent, while chemical pain is more likely to be constant.
    • Cervicogenic pain usually is worse in positions that involve prolonged sitting, especially in sitting positions with protruded head posture or prolonged flexion. Bending positions also provoke cervicogenic pain. Frequent changes of position provide relief. However, in cases of severe acute pain, a still position may be most comfortable. Pain worse upon awakening probably is related to using unsuitable pillow or having adopted an inappropriate posture while sleeping (McKenzie, 1990; Lavin, 1997).
    • In 1959, Ralph B. Cloward, MD, published referral patterns of the cervical spine discs using cervical discography.
      • He found that stimulating the anterolateral aspect of the discs produced pain at the ipsilateral scapula. Stimulation in the midline of the anterior aspect of the disc produced pain between the shoulders in the middle of the back. He described that pain from the C6-7 disc was felt in the inferior angle of the scapula. Pain from the C5-6 disc was felt in the center of the medial scapular border. Pain from C4-5 disc was experienced in the region of the spine and superior angle. Pain from the C3-4 disc was referred to the C7 spinous process and the posterior border of the trapezius muscle.
      • Cloward found that when stimulating patients with posterolateral disc protrusions, the referral patterns were found to be more intense than when stimulating the anterior aspect of the disc and were found to spread from the vertebral border of the scapula out to the shoulder and upper arm as far as the elbow. Midline posterior disc protrusions were found to refer pain to a confined area overlying the fifth cervical to the second thoracic spinous processes near the midline with upper discs more cephalad and lower discs more caudad. When extensive disc rupture and degeneration were present, a combination of the posterolateral and midline posterior referral patterns was found. (Cloward, 1959)
  • Risk factors for malignancy include age older than 50 years, history of cancer, unexplained weight loss, pain with bed rest, and failure to improve with conservative therapy (Deyo, 1988; Deyo, 1992).
  • Ask questions related to potential infection (eg, history of recent surgery, including dental surgery; history of fever or chills; history of intravenous drug abuse) (Deyo, 1992).
  • Obtain information regarding the patient's past medical history, including previous neck pain, surgeries, trauma, motor vehicle accidents, and work-related or sports-related injuries.
  • Obtain information regarding history of alcohol, tobacco, or drug use or abuse; osteoporosis; rheumatologic conditions; diabetes; or other conditions associated with neuropathy (eg, vitamin deficiencies, thyroid disease).
  • Obtain information regarding previous diagnostic studies and treatment interventions.

Physical

  • Physical examination of the patient with cervical discogenic pain includes the assessment for neurologic deficits suggestive of myelopathy.
    • While assessing the patient, look for altered balance, stooped and wide-base gait, weakness, decreased sensation of the upper extremities, lower motor neuron findings in the upper extremities, and upper motor neuron findings in the lower extremities.
    • Patients with a herniated nucleus pulposus (HNP) without radiculopathy can present with limited ROM and referred pain, which may be elicited with the cervical compression test. Patients with a HNP with radiculopathy may present with limited ROM and radicular pain, dermatomal sensory loss, diminished strength in a myotomal distribution, and loss of muscle stretch reflexes.
    • Manual muscle testing has greater specificity than either reflex or sensory changes (Ellenberg, 1994; Yoss, 1957). The Spurling test can elicit radicular pain and is performed by having the patient actively extend the neck, laterally flex, and rotate toward the side of the pain. Then, careful downward compression is applied on the head. The Spurling test is helpful in the diagnosis of cervical radiculopathy because of its high specificity. However, its absence does not preclude the diagnosis of radiculopathy because of its low sensitivity (Ellenberg, 1994).
  • The McKenzie model for mechanical evaluation of the cervical spine involves establishing a baseline ROM with single cervical spine motion in each direction, a baseline level of pain, and a baseline of more distal or peripheral symptoms.
    • After obtaining a baseline of ROM and symptoms, test repetitive motion of the cervical spine to end range of each direction by frequently assessing the changes in the initial symptoms and ROM with repetitive end range movements (McKenzie, 1990). If symptoms worsen as a result of repetitive movements in a particular direction, that particular movement should be stopped immediately (McKenzie, 1990).
    • If symptoms and/or ROM improve upon a specific direction of motion (ie, retraction) and no symptoms peripheralize, a direction of preference is established. This direction of preference is used in a specific rehabilitative exercise program (Donelson and Aprill, 1997; Donelson and McKenzie, 1997; Donelson, 1990; McKenzie, 1990).
    • At times, patients with radicular symptoms can experience the phenomenon of centralization. McKenzie describes centralization as the phenomenon whereby as a result of the performance of certain repeated movements or the adoption of certain positions, radiating symptoms originating from the spine and referred distally are caused to move proximally towards the midline of the spine (Donelson and Aprill, 1997; Donelson and McKenzie, 1997; Donelson, 1990; McKenzie, 1990). Centralization is the hallmark sign that a correct movement or position is being performed, while peripheralization is a contraindication to further movements in that direction (Donelson and Aprill, 1997; Donelson and McKenzie, 1997; Donelson, 1990; McKenzie, 1990).
  • The Lhermitte test is performed by flexing the neck with the patient in the sitting position. This test may produce an electriclike sensation down the spine and occasionally the extremities. This electriclike sensation has been reported in patients with cervical spondylosis, cervical myelopathy, cervical cord involvement secondary to tumor, and multiple sclerosis (Ellenberg, 1994).
  • Another helpful clinical sign is pain relief upon arm abduction in cases of a ruptured cervical disc. No changes in pain occur with arm position when the disease process is spondylosis with foraminal stenosis (Beatty, 1987).
  • The neck compression test (Spurling test), axial manual traction, and the shoulder abduction test have high specificity but low sensitivity for the diagnosis of root compression in cervical disc disease. Despite the low sensitivity, these tests are valuable in the clinical examination of a patient with neck and arm pain (Viikari-Junctura, 1989).

Causes

  • Degenerative changes
    • Degenerative changes appear early in the lower cervical spine, with the most severe changes occurring at the C5-6 and C6-7 levels. According to Kramer, this is due to the mechanical influence on the cervical intervertebral discs by the extensive movement carried out in the cervical spine in relation to the rigid thoracic spine. Therefore, the comparative loading per squared centimeter by the head on the cervical discs exceeds that of the thoracic and lumbar spine (Kramer, 1981). Cervical spine degenerative changes appear first in the intervertebral discs during the third, fourth, and fifth decades of life.
    • Degenerative changes are appreciated by loss of intervertebral disc height and osteophyte development at the origins of the vertebral endplates. These changes lead to loss of shock-absorbing capacity, resulting in abnormal force transmission and increased load to the zygapophyseal joints. Therefore, cervical zygapophyseal joint degenerative changes commonly follow intervertebral disc degeneration (Kramer, 1981; McKenzie, 1990). The combination of decreased intervertebral disc space and facet joint degeneration with hypertrophy causes narrowing of the intervertebral foramina with potential compression of the exiting nerves and associated radicular symptoms.
    • Creep is the further detectable movement that occurs after maximal ROM is attained and a constant force is continued on a collagenous structure (Twomey, 1982).
    • Creep is believed to be due to gradual rearrangement of collagen fibers, proteoglycans, and water content in the ligament or capsule being stressed. As the water content of the nucleus pulposus decreases with disc degeneration and aging, the ability to imbibe water and distribute compressive loads also decreases (Handa, 1997). This results in increased creep under compression, which can cause incompetence of the annulus. Hickey and Hukins reported that if ligaments were stretched more than 4% of their resting length, irreversible damage would follow (Hickey, 1980).
    • As disc degeneration continues, the distinction between the margins of the nucleus and annulus becomes obscured. The negatively charged proteoglycan side chains decrease with subsequent loss of their imbibing capabilities. During this process, the overall collagen content within the disc increases. Primary annular disruption initially may occur in the periphery and is referred to as a rim lesion. As the process continues to progress and the margins of the annulus and nucleus coalesce with infiltration of type III collagen, the gelatinous nucleus becomes replaced and the disc essentially becomes fibrotic (Coventry, 1945; Gower, 1969; Lipson, 1981; Pearce, 1987).
  • The most common cause of cervical radiculopathy is a herniated disc followed by cervical spondylosis (Ellenberg, 1994). The most common cervical disc herniation is at the C6-7 level, with C7 radiculopathy found to be the most common (Ellenberg, 1994; Heiskari, 1986; Honet, 1976; Odom, 1958; Yoss, 1957). Cervical disc herniations have commonly been divided into soft disc or hard disc herniations. The soft disc herniation is a bulging, ruptured, or extruded nucleus pulposus. The hard disc herniation is referred to as an intraforaminal spur from the uncovertebral or facet joint or as disc hardening, thickening, or calcification resulting in a medial ridge formation (Ellenberg, 1994; Odom, 1958; Schmidek, 1986). Hard disc herniations commonly are related to cervical spondylosis with or without radiculopathy (Ellenberg, 1994; Schmidek, 1986).
  • Predisposing and precipitating factors
    • Predisposing and precipitating factors for cervical discogenic pain include prolonged sitting with poor posture (eg, protruded head posture), frequent of flexion, sudden unexpected movements, and trauma.
    • Harms-Ringdahl was able to provoke pain in individuals who were asymptomatic by maintaining a protruded sitting posture. All subjects in the study reported neck pain within 2-15 minutes (Harms-Ringdahl, 1986).
    • Static loading with poor sitting or lying postures eventually lead to problems within the cervical spine. Poor posture also can enhance or perpetuate an already existing cervical pain from trauma or whiplash injury.
    • Kramer reports that most patients in his practice developed pain for no apparent reason (Kramer, 1981).
    • Frequent flexion of the cervical spine is another predisposing factor in the production of symptoms from the cervical spine.
    • Sudden unexpected movements, particularly those that involve lateral flexion and rotation of the head and neck with the neck in a protruded position, can cause or precipitate neck pain. Trauma to the cervical spine commonly is seen as a result of whiplash forces occurring during significant motor vehicle accidents or in sports-related cervical spine injuries.

Contents

Overview: Cervical Discogenic Pain Syndrome
Differential Diagnoses & Workup: Cervical Discogenic Pain Syndrome
Treatment & Medication: Cervical Discogenic Pain Syndrome
Follow-up: Cervical Discogenic Pain Syndrome
[ CLOSE WINDOW ]

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Further Reading

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Keywords

cervical degenerative disc disease, cervical spondylosis, cervical radiculopathy, cervical myelopathy, cervicogenic pain, cervical disc disease, cervical disc syndrome, cervical disc herniation, cervical intervertebral disc disease

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Contributor Information and Disclosures

Author

Robert E Windsor, MD, FAAPMR, FAAEM, FAAPM, President and Director, Georgia Pain Physicians PC; Clinical Associate Professor, Department of Physical Medicine and Rehabilitation, Emory University
Robert E Windsor, MD is a member of the following medical societies: American Academy of Pain Medicine, American Academy of Physical Medicine and Rehabilitation, American College of Sports Medicine, American Medical Association, International Association for the Study of Pain, Physiatric Association for Spine, Sports and Occupational Rehabilitation, and Texas Medical Association
Disclosure: Nothing to disclose

Coauthor

Ricardo A Nieves, MD, Medical Director of Rehabilitation Medicine Unit, Carlsbad Medical Center
Ricardo A Nieves, MD is a member of the following medical societies: American Academy of Disability Evaluating Physicians, American Academy of Pain Medicine, American Academy of Physical Medicine and Rehabilitation, and American Association of Neuromuscular and Electrodiagnostic Medicine
Disclosure: Nothing pertinent to anything I have done for EMedicine

Kevin P Sullivan, MD, Consulting Staff, The Boston Spine Group
Kevin P Sullivan, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, American College of Sports Medicine, Association of Academic Physiatrists, and Physiatric Association for Spine, Sports and Occupational Rehabilitation
Disclosure: Nothing to disclose

Erik D Hiester, DO, Fellow in Interventional Pain Management, Emory Medical School/Georgia Pain Physicians
Erik D Hiester, DO is a member of the following medical societies: American Academy of Family Physicians, American Medical Association, American Osteopathic Association, and American Pain Society
Disclosure: Nothing to disclose

Medical Editor

Janos P Ertl, MD, Clinical Assistant Professor, Department of Orthopedic Surgery, University of California at Davis; Director of Amputee Clinic, Chief of Orthopedic Trauma, Kaiser Hospital
Janos P Ertl, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, Hungarian Medical Association of America, Orthopaedic Trauma Association, and Sierra Sacramento Valley Medical Society
Disclosure: Nothing to disclose

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose

Managing Editor

Russell D White, MD, Professor of Medicine, Department of Community and Family Medicine, University of Missouri-Kansas City School of Medicine, Truman Medical Center Lakewood
Disclosure: Nothing to disclose

CME Editor

Jon Whitehurst, MD, Consulting Staff, Rockford Orthopedic Associates
Disclosure: Nothing to disclose

Chief Editor

Sherwin SW Ho, MD, Associate Professor, Department of Surgery, Section of Orthopedic Surgery and Rehabilitation, University of Chicago
Sherwin SW Ho, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Society for Sports Medicine, and Arthroscopy Association of North America
Disclosure: Nothing to disclose

 
 
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