AUTHOR AND EDITOR INFORMATION

Section 1 of 9  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• References

INTRODUCTION

Section 2 of 9  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• References

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

Section 3 of 9  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• References

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.

DIFFERENTIALS

Section 4 of 9  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• References

Other Problems to be Considered

Cervical spine acute bony injuries

WORKUP

Section 5 of 9  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• References

Lab Studies

• Laboratory studies typically are not indicated in the diagnosis of cervical discogenic pain syndrome.

Imaging Studies

• Radiographs of the cervical spine primarily are indicated in cases in which significant trauma is involved (eg, motor vehicle accident, sport injuries) and in cases in which the history and physical examination suggest the possibility of a fracture or instability.
• • An oblique view is necessary to evaluate for fracture of the pars interarticularis and facet joint arthropathy. If spondylolisthesis is found and is believed to be symptomatic, flexion/extension lateral views are helpful to evaluate for instability.

  • Radiographic findings commonly show degenerative changes in persons older than 55 years. Little correlation exists between symptomatic and asymptomatic individuals and structural changes on roentgenographic examinations (Ellenberg, 1994; Gore, 1986; McKenzie, 1990). In cervical discogenic pain, radiographic findings can be normal or can show decreased intervertebral space and associated facet joint and/or vertebral body degenerative changes.

  • In 1987, Deyo recommended radiographic studies be obtained in the following circumstances:
    • Patients older than 50 years

    • History of significant trauma (fracture risk)

    • Neuromotor deficits (to rule out spondylolisthesis or tumor)

    • Unexplained weight loss (to rule out malignancy)

    • Drug or alcohol abuse (risk factors for osteomyelitis, osteoporosis, and trauma)

    • History of cancer (to rule out metastasis)

    • Use of corticosteroids (increased risk of infections and osteoporosis)

    • Fever (potential sign of osteomyelitis or epidural abscess)

    • Failure to improve with conservative therapy

    • Medicolegal cases involved in litigation

• CT scan provides high-quality osseous detail and spatial resolution.
• • CT scan is a valuable adjunct in evaluating patients with extensive bony degenerative changes and suspected stenosis or bony pathology not identified by plain radiographic films.

  • CT scan also is an alternative to evaluate for disc herniations in patients in which MRI is contraindicated.

  • When combined with discography, axial CT scan surpasses MRI in detecting annular fissures (Yu, 1988).

  • CT scan with myelography is helpful in evaluating patients with extradural compression of the neural elements from bone or disc material (Karnaze, 1988; Modicc, 1986).

• MRI is the study of choice in patients with suspected degenerative discogenic disease.
• • MRI is a sensitive diagnostic modality that offers multiplanar imaging capability and excellent soft tissue and spatial resolution without ionic radiation. MRI also provides physiologic information regarding the water content of the disc (Kramer, 1991).

  • Schellhas et al studied subjects who were asymptomatic and those who experienced pain. They concluded that significant disc annular tears often escape MRI detection and that MRI cannot reliably identify the source or sources of cervical discogenic pain (Schellhas, 1996).

  • MRI abnormalities are common in patients who are asymptomatic.

  • Matsumoto et al completed a study of 497 patients who were asymptomatic. In this study, cervical MRI revealed that the frequency of degenerative changes increases as age increases. Disc degeneration was the most common observation. In men and women in their 20s, 17% and 12% showed disc degeneration, respectively; in men and women older than 60 years, 86% and 89% showed disc degeneration, respectively. Posterior disc protrusion with demonstrable compression of the spinal cord was found in 7.6% of subjects, mostly those older than 50 years (Matsumoto, 1998).

Other Tests

• Cervical discography
• • Cervical discography is an important adjunct in the evaluation of the patient with cervical discogenic pain, particularly when other diagnostic studies fail to detect any abnormalities in a patient with subjective symptoms of cervical discogenic pain (Schellhas, 1996; Parfenchuck, 1994).

  • Cervical discography also is useful in the evaluation of patients with multiple degenerative disc findings or various levels of disc herniations in which surgery is contemplated (Sienberock, 1993).

  • The most important part of the cervical discography evaluation is the provocation/analgesia response since it will differentiate symptomatic from nonsymptomatic discs. In a study published by Osler in 1987, he reported a series of patients with positive cervical analgesic discography followed by anterior cervical fusion with or without discectomy, resulting in 81% excellent or good results. He concluded that analgesic discography is the most effective test for location of the lesion in the painful disc syndrome (Osler, 1987; Roth, 1976).

• Electromyography
• • Electromyography (EMG) is performed primarily by specialists in neurology or physical medicine and rehabilitation as an extension of the history and physical examination of patients with suspected cervical radiculopathy.

  • EMG is a physiologic test not necessary in the initial evaluation of patients with new symptoms unless it is being utilized as a baseline for worker's compensation or to assess personal injuries to rule out a preexisting injury.

  • Wait approximately 3 weeks after the onset of symptoms to perform an EMG. Delaying the study for 3 weeks ensures accurate detection of positive waves and fibrillation potentials (Ellenberg, 1994; Wilbourn, 1988).

  • EMG also can be useful by assisting in the determination of the approach to epidural injections, selective nerve root blocks, and/or surgery. EMG is valuable in identifying other possible concomitant neurologic conditions, such as entrapment neuropathies, peripheral neuropathies, brachial plexopathies, myopathies, and motor neuron diseases.

• Sensory-evoked potentials are useful in evaluating patients with cervical myelopathy (Dvorak, 1998).

TREATMENT

Section 6 of 9  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• References

Acute Phase

Rehabilitation Program

Physical Therapy

For patients with cervical discogenic pain with or without radiculopathy, physical therapy should be focused on educating the patient about proper posture, proper body mechanics, and how to implement a specific exercise program. The exercise program should be supervised initially to assure proper technique and performance of the exercises. The McKenzie method of mechanical evaluation and treatment of the spine involves identifying patterns of movements or positions that decrease symptoms and improve the segmental motion. The centralization and direction of preference were previously described (see Physical). At times, it is necessary to add force by a mobilization or manipulation to attain end range of movement in the already identified direction of preference (Donelson and Aprill, 1997; Donelson and McKenzie, 1997; Donelson, 1990; McKenzie, 1990).

Surgical Intervention

Surgical intervention for cervical discogenic pain commonly is considered in cervical radiculopathy or myelopathy with persistent radicular pain, motor weakness, progressive neurologic deficits, or evidence of cord compression with no response to appropriate conservative treatment. Anterior cervical discectomy (ACD) using an operating microscope is a safe and effective approach for patients with soft disc herniations (Benini, 1982; Martins, 1976; Palit, 1999; Yamamoto, 1991). Anterior cervical discectomy with interbody fusion (ACDF) is preferred for patients with advanced spondylosis. A single level surgery is preferred to multiple levels (Benini, 1982; Matsumoto, 1998; Yamamoto, 1991). Studies report successful outcomes for pain relief, patient satisfaction, and increased function in persons with neck pain in the absence of radicular symptoms managed with anterior cervical discectomy and fusion (Green, 1977; Palit, 1999).

The surgical treatment of cervical degenerative disc disease should be considered only after an adequate trial of conservative treatment has failed (Heller, 1996). Multiple studies report of patients with herniated cervical intervertebral disc and cervical radiculopathy who undergo successful response to nonoperative treatment interventions (Bush, 1996; Ellenberg, 1994; Honet, 1976; Rubin, 1960; Saal, 1996). Furthermore, studies document the regression of cervical disc herniations accompanying the resolution of cervical radiculopathy (Bush, 1997; Maigne, 1994; Mochida, 1998).

Other Treatment

Treatment for cervical discogenic pain depends on the clinical presentation and other concomitant medical conditions that can interfere or limit certain interventions. Many cervical disc herniations can be managed successfully with aggressive nonsurgical treatment. Conservative nonsurgical treatment includes use of medications, such as nonsteroidal anti-inflammatory drugs (NSAIDs), a short course of steroids on a tapering dose, nonnarcotic analgesics, or short-term narcotic analgesics; partial rest; and instructions on proper posture, proper body mechanics, and a home exercise program.

At times, patients require image-guided interventional procedures to control their pain and facilitate their participation in physical therapy (Ellenberg, 1994; Saal, 1996). Cervical epidural injections commonly are used with successful results in patients with cervical radiculopathy (Ellenberg, 1994; Bush, 1996; Schulman, 1986). Use of fluoroscopic-guided selective nerve root blocks can be an alternative effective approach for cervical epidural steroid injections in patients with atraumatic cervical spondylotic radicular pain (Slipman, 2000).

Recovery Phase

Rehabilitation Program

Physical Therapy

This phase of rehabilitation focuses on soft tissue overload and biomechanical dysfunction. Goals of this phase are to eliminate pain, normalize spinal mechanics, and improve neuromuscular control of the injured cervical spine. Restoration of the resting muscle length and full, pain-free, cervical ROM are necessary. Strengthening exercises start in simple planes and progress to complex muscle patterns.

Maintenance Phase

Rehabilitation Program

Physical Therapy

The final phase of rehabilitation requires functional, pain-free cervical ROM and proper spinal and shoulder girdle mechanics. Sport appropriate flexibility, strength, and skills are necessary prior to return to play. Sport-specific activities should be reviewed to ensure correct techniques, especially in contact and collision sports.

MEDICATION

Section 7 of 9  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• References

Oral NSAIDs can help decrease pain and inflammation. Various oral NSAIDs can be used, and no single NSAID holds a clear distinction as the drug of choice. Choice of NSAID is largely a matter of convenience (how frequently doses must be taken to achieve adequate analgesic and anti-inflammatory effects) and cost.

Drug Category: Nonsteroidal anti-inflammatory drugs (NSAIDs)

Have analgesic, antiinflammatory, and antipyretic activities. Their mechanism of action is not known but may inhibit cyclo-oxygenase activity and prostaglandin synthesis. Other mechanisms may exist as well, such as inhibition of leukotriene synthesis, lysosomal enzyme release, lipoxygenase activity, neutrophil aggregation, and various cell membrane functions.

FOLLOW-UP

Section 8 of 9  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• References

Return to Play

Return to play is an individualized process. No specific time frame exists for a particular injury. Safe return to play is allowed after the appropriate sport-specific rehabilitation program is completed and the athlete demonstrates full pain-free ROM and proper neutral spine posture with sport-specific activities.

Complications

Complications of surgical intervention include bleeding, infection, nerve damage, chronic dural leak, and scar tissue formation surrounding or compressing nervous tissue. Fortunately, these complications do not happen often, but when they do, they may, alone or in combination, cause the patient to be in worse condition than prior to having surgery.

Prevention

Injury prevention is accomplished best through good coaching, proper techniques of sport-specific activity, adequate preparticipation training, and appropriate safety measures, including proper protective equipment and adherence to the rules of the game.

Education

Inform patients that the natural history of an acute radiculopathy suggests that most patients recover within several weeks to months and that surgery is generally not necessary. Educate patients regarding home program activities, which may be performed on a routine basis to help strengthen their spine and associated muscle groups, which may help prevent injury in the future.

For excellent patient education resources, visit eMedicine's Back, Ribs, Neck, and Head Center. Also, see eMedicine's patient education articles Shoulder and Neck Pain and Neck Strain.

REFERENCES

Section 9 of 9

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• References

• Bagduk N, Twomey LT. Clinical Anatomy of the Lumbar Spine. 2^nd ed. New York, NY: Churchill Livingston; 1991.
• Beatty RM, Fowler FD, Hanson EJ Jr. The abducted arm as a sign of ruptured cervical disc. Neurosurgery. Nov 1987;21(5):731-2. [Medline].
• Benini A, Krayenbühl H, Brüderl R. Anterior cervical discectomy without fusion. Microsurgical technique. Acta Neurochir (Wien). 1982;61(1-3):105-10. [Medline].
• Bogduk N, Tynan W, Wilson AS. The nerve supply to the human lumbar intervertebral discs. J Anat. Jan 1981;132(Pt 1):39-56. [Medline].
• Bogduk N, Windsor M, Inglis A. The innervation of the cervical intervertebral discs. Spine. Jan 1988;13(1):2-8. [Medline].
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Article Last Updated: Dec 17, 2004