Acute Cervical Disk Herniations

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Evidence of degeneration of the nucleus pulposus and the annulus fibrosis usually antecedes cervical disk herniation. These protrusions are usually confined by the posterior longitudinal ligament but can occasionally extrude through this ligament as free fragments. Direct posterior ruptures, although infrequent, can produce progressive myelopathy, whereas the more common posterolateral herniations precipitate the symptoms and signs of an acute cervical radiculopathy. Disk prolapse is 1

12 times more common in males, occurring most often in the fourth decade. The levels of most frequent involvement are C6-C7 (C7 root), usually left sided, and C5-C6 (C6 root), usually right sided.

The symptoms of an acute cervical disk prolapse include neck pain, headache, sclerotomal referral to the shoulder and along the medial scapular border, myotome pain in the spinal root distribution to the shoulder and arm, and dermatomal sensory dysesthesias of the appropriate finger. Motor signs include fasciculations, atrophy and weakness in the myotome distribution of the spinal root, loss of deep tendon reflexes; and, with cervical myelopathy, lower extremity hyperreflexia, Babinski sign and, rarely, loss of sphincter control. Cervical hyperextension and lateral flexion to the symptomatic side can replicate the symptoms, as can a Valsalva maneuver, whereas manual cervical distraction in flexion alleviates them. A thorough and searching examination, including muscle testing, easily delineates the level of root involvement (see Tabl.ei273z1).

Electroneuromyography can be complementary in diagnosis and will exclude occult peripheral mononeuropathies and acute brachial plexopathies. Cervical spine x-ray films are often more useful in these syndromes for what they fail to reveal rather than what they demonstrate. The presence of degenerative disease may mask a soft cervical disk protrusion. In younger adults, x-ray films may be normal, failing to reveal even a large herniation. In this instance, magnetic resonance imaging is necessary for diagnosis.

Treatment consists of analgesics sufficient to control pain, a cervical soft collar and, without evidence of carotid bruits or myelopathy, a trial of intermittent cervical traction. If the symptoms and signs of acute cervical root compression fail to respond to conservative treatment or reoccur, surgery may be recommended if imaging demonstrates a prolapsed cervical disk with root compression. Indications for hospital admission include:

1. Intractable radicular pain unresponsive to treatment.

2. Progressive upper extremity weakness, especially in the C7 distribution.

3. Progressive lower extremity myelopathic signs, such as positive Babinski sign, hyperreflexia, motor weakness, and bladder or bowel dysfunction. Cervical Spondylosis and Stenosis

Cervical spondylosis is a progressive condition that can present either as a loss of cervical flexibility or as neck pain. Neck pain is due to local zygoapophyseal joint degeneration. Degenerative disk disease predisposes individuals to progressive osteoarthrosis of the cervical zygoapophyseal joints. A loss of disk height associated with annulus bulging produces cervical segment instability, excessive facet weight bearing, and incongruous joint motion during neck movement, accelerating articular degeneration. Altered mechanical stresses produce traction osteogenesis with subsequent spur formation. Spurs can encroach posteriorly on the spinal canal, producing cervical myelopathy; laterally on the intervertebral foramen, producing cervical radiculopathy; and anteriorly on the esophagus, producing dysphagia.

The combination of a congenitally narrowed spinal canal further compromised by a vertebral osteophytic bar anteriorly, and a buckling ligamentum flavum posteriorly, increases the risk of myelopathy secondary to cervical spinal stenosis as the diameter of the spinal canal is reduced to less than 12 mm. Cervical spinal stenosis can also occur in about 20 percent of patients with lumbar spinal stenosis. Selective impingement of the dorsal spinal root by an osteophyte arising from the zygoapophyseal joint can present with complaints of digital numbness or vague myalgias, which on subsequent appraisal can be related to the known myotome distribution of a spinal root. The C6 nerve root emerges between the C5 and C6 vertebrae and is the earliest and most frequent site of a degenerative disk. Since the C6 myotome encompasses most of the major proximal shoulder muscles, a complaint of bilateral shoulder pain should raise suspicion of C6 radiculopathy. Spurious osteophytes can produce Horner syndrome, vertebral-basilar symptoms, severe radicular symptoms without associated neck pain, painless upper extremity myotome weakness, and chest pain mimicking angina. Radiographic studies demonstrating typical segmental degenerative changes may in fact bear no relation to the actual spinal root level of the presenting complaint. For example, foraminal encroachment visible on x-ray views may be more severe at C5-C6, with the patient presenting with both clinical and EMG evidence of a progressive C7 radiculopathy arising from the C6-C7 level.

Localized neck pain and stiffness attributable to arthritis at the zygoapophyseal joint can be treated with cervical collar support, superficial ice massage, ultrasound, flexibility exercises, and nonsteroidal anti-inflammatory drugs. Cervical traction therapy may aggravate pain due to arthritis. For cervical radicular pain, though, intermittent cervical traction initially in the formal setting of an outpatient physical therapy facility, followed by ongoing home cervical traction, is an effective approach. Myofascial pain can often be managed with topical ice, deep kneading massage, stretching exercises, and local injections of steroids and lidocaine. The prompt recognition and correction of aggravating factors, such as emotional stress or prolonged postural neck hyperextension related to overly soft seating or to the use of bifocal glasses during reading, may in itself be curative.

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