Diagnosis
History
Important items to note in the history include: information about pain (onset, location, quantity, quality, setting, aggravating and alleviating factors, associated symptoms), axial vs. peripheral pain, and history of neck injury. Disc-related pain without nerve root involvement may be vague and diffuse. Radicular pain can be dull and aching or sharp and electric; neck pain may be absent. The pain may have begun with no apparent cause, or there may be a history of injury to the neck. If cervical disc displacement of the C5-C6 disc results in radiculopathy, pain may radiate from the base of neck, along the biceps muscle and lateral forearm, and into the back of the hand, the thumb, and the first two fingers. If cervical disc displacement of the C6-C7 disc results in radiculopathy, pain or numbness may be present in the middle finger, along with shoulder pain radiating into the triceps and forearm. These individuals sometimes rest the symptomatic upper extremity on the top of their head to decrease pain. Coughing or sneezing makes the pain worse, and affected individuals may report that they are more comfortable sleeping in a reclining chair than in a bed. If treatment is not sought, individuals may notice increasing weakness in the affected limb. A history of prior or existing systemic illness should be obtained, including chronic disease (e.g., diabetes, heart disease, atherosclerosis, nervous system disorders, arthritis), infections, malignancies, or weight loss.
Physical Exam
Cervical intervertebral disc displacement usually limits range of motion of the neck. The exam may show that neck movement aggravates pain, particularly when bending the head backward (hyperextension) and turning the head from side to side (rotation). The manual application of cervical compression and distraction during the physical exam may help to differentiate between disc pain and pain from other causes. Pain may increase when downward pressure is applied to the top of the head (cervical compression test) and be relieved by traction (cervical distraction test). The affected vertebra may be tender to palpation. Examination should include assessment of muscle strength and changes in sensation and reflexes in the upper extremities. Lower extremities may be examined to rule out signs of myelopathy.
Tests
Laboratory blood analysis may include erythrocyte sedimentation rate (ESR) to evaluate inflammation, white blood count analysis to rule out infection, rheumatoid factor, thyroid and parathyroid studies, and liver function studies. Human leukocyte antigens may be typed. Results of these tests help rule out other conditions.
Imaging studies show the extent of degenerative changes but do not give any information about function. Plain x-rays show narrowing of the disc space and bone spur (osteophyte) formation, if present, as well as possible metastatic disease, spinal deformity, and spine stability. If mechanical instability is suspected as a cause of recurrent pain, it can be documented by x-rays taken with the neck bent forward (flexion) and bent backward (hyperextension).
Magnetic resonance imaging (MRI) or myelography combined with computed tomography (CT) are considered the best ways to diagnose a herniated cervical disc. Electromyography (EMG) may distinguish nerve root compression from a peripheral nerve problem such as carpal tunnel syndrome or ulnar nerve entrapment. Nevertheless, a normal EMG does not rule out nerve root compression. As in the lumbar spine, asymptomatic herniations are frequently seen in normal volunteers. For this reason, disc herniations on imaging studies must correlate precisely with the clinical signs of nerve root deficit observed on physical examination.
Treatment
Conservative therapy is the first line of treatment except in cases of severe or progressive neurologic compression. Bed rest is rarely indicated. Intermittent traction may be applied, and the individual may be taught to use intermittent traction at home.
Nonsteroidal anti-inflammatory drugs (NSAIDs) may be given to relieve pain and decrease inflammation. If pain is severe, a narcotic may be added; in some cases, an antidepressant or an anticonvulsant may be used for its analgesic effect. If anxiety and tension are prominent, sedatives may be helpful. Muscle relaxants are frequently prescribed; however, their effectiveness probably is due to their sedative action. Narcotics, sedatives, and muscle relaxants usually are used only for brief periods. Ongoing use should be weighed against the potential for addiction or abuse. Other treatments such as ice, heat, massage, and ultrasound therapy may help relieve pain.
As symptoms subside, activity is gradually increased and includes physical therapy to strengthen and mobilize the muscles of the neck and shoulder. An independent home exercise program is an essential component of any physical therapy. Good posture and frequent changes in position may help prevent fatigue and decrease pain. Preventive and maintenance measures, such as exercise, stress management, and proper body mechanics, should be continued indefinitely. If there is no improvement during the first 2 weeks, or if pain is still disabling after 6 weeks, further evaluation is necessary.
Most cases of cervical disc displacement with or without radiculopathy can be managed conservatively. However, surgery is indicated in cases where 1) pain management has failed, and the individual has intractable pain; 2) there is mechanical instability of the spine associated with disc herniation; 3) signs of neurological deficits are increasing (e.g., progressive or severe muscle weakness or severe arm pain with objective signs of nerve root compression); or 4) the disc herniation is massive and compresses the spinal cord causing bowel and/or bladder control impairment, lower extremity weakness, sensory loss, or gait disturbance.
Surgery involves removal of the protruding nucleus pulposus (discectomy). The traditional method for removal of the disc is open discectomy under general anesthesia. A portion of the vertebra that acts as a roof (lamina) over the spinal nerve is removed, creating a small window into the spine. The surgeon then removes the herniated disc material through this opening.
Microdiscectomy, also called minimally invasive spine surgery, is a newer, less invasive alternative to open surgery for certain types of disc herniation. In microdiscectomy, a special operating microscope is used to view the disc and spinal nerves through a small incision in the back. Smaller and lighter surgical instruments are used to remove herniated disc material through the small incision with minimal trauma to surrounding tissue. Many individuals who undergo microdiscectomy are discharged after overnight observation and have relief of symptoms with minimal pain.
Other new techniques under development include several methods to decompress the disc centrally (chemical, enzymatic, vaporization or mechanical), directed fragmentectomy and anterior cervical interbody fusion.
Fusion of the vertebrae may be indicated when mechanical instability cannot be managed conservatively.
See the original guideline document for information on prognosis and differential diagnoses.
Rehabilitation
The primary focus of rehabilitation for a cervical intervertebral disc displacement without myelopathy is to decrease symptoms and increase function. Although exercise may be uncomfortable initially, individuals must be instructed in the benefits of ongoing exercise in managing the symptoms.
The first goal is to decrease symptoms, primarily pain. In combination with pharmacological management, modalities such as heat and cold can be used. Immobilization with a soft collar is rarely indicated; however, with significant soft tissue pain, it might be necessary for a very short period of time (up to 3 days). While managing pain, individuals can be instructed in gentle exercises. Due to the variability in response, the treating practitioner must pay careful attention to tolerance to treatment. Initial exercises may include isometrics, stretching and/or gentle range of motion. Spinal manual therapy may reduce symptoms when combined with active treatment. Postural training should be initiated as soon as tolerated by the individual.
Once symptoms subside and range of motion is restored, the individual should progress to strengthening and stabilization exercises of the neck, shoulders and upper trunk. Limited treatment with cervical traction has been shown to be beneficial for neck pain when done in conjunction with exercises, although traction must be carefully administered to avoid adverse response.
The individual should also be instructed in a home exercise program to complement the supervised rehabilitation, and trained to care for and protect the neck from recurrence of symptoms. An ergonomic evaluation can prove helpful in avoiding or modifying activities and work positions that may aggravate the symptoms. Psychotherapy may be indicated to support the individual and identify associated factors that may contribute to the symptoms. A short course of cognitive pain management may be beneficial for individuals experiencing psychological distress or lack of improvement with treatment.
Frequency of Rehabilitation Visits
| Nonsurgical |
Physical Therapist |
Up to 12 visits within 6 weeks |
Rehabilitation Disclaimer: The table above represents a range of the usual acceptable number of visits for uncomplicated cases. It provides a framework based on the duration of tissue healing time and standard clinical practice.
See the original guideline document for information about comorbid conditions, complications, and factors influencing duration.
Length of Disability
Duration depends on severity of symptoms, length of time the condition has persisted, and response to treatment. Persistent radicular pain from a cervical disc herniation even without myelopathy may not be compatible with heavy work. Disc displacement without radiculopathy may improve rapidly with appropriate management. The only absolute restriction following a cervical discectomy without fusion for individuals with no history of prior spine surgery is no repetitive heavy overhead lifting. Nevertheless, permanent disability may follow a discectomy with or without spinal fusion. This usually is due to persistent neuropathic radicular pain rather than persistent limitation in neck motion or arm weakness. In rare cases, individuals with severe arm muscle weakness are not able to resume heavy or very heavy work.
Surgical Treatment, Cervical Discectomy with or without Fusion (One Level)
| Duration in Days |
| Job Class |
Minimum |
Optimum |
Maximum |
| Sedentary Work |
7 |
21 |
42 |
| Light Work |
21 |
42 |
56 |
| Medium Work |
42 |
56 |
84 |
| Heavy Work |
56 |
84 |
112 |
| Very Heavy Work |
70 |
91 |
140 |
Medical Treatment, Cervical Disc Displacement
| Duration in Days |
| Job Class |
Minimum |
Optimum |
Maximum |
| Sedentary Work |
0 |
7 |
21 |
| Light Work |
0 |
14 |
28 |
| Medium Work |
0 |
21 |
42 |
| Heavy Work |
0 |
49 |
84 |
| Very Heavy Work |
0 |
56 |
90 |
Return to Work (Restrictions/Accommodations)
Individuals with displaced cervical discs usually are advised to avoid overhead lifting or postures with the neck in extension, heavy lifting, or repetitive neck twisting motions. Certain other duties that require extension of the neck (e.g., painting ceilings, stocking overhead shelves) may be unsuitable for individuals with limited range of motion of the head and neck. Individuals may require regular time off for physical therapy. Use of prescription painkillers (analgesics) can affect dexterity and alertness. Their use may require review of drug policies.
Failure to Recover
If an individual fails to recover within the maximum duration expectancy period, the reader may wish to reference the following questions to assist in better understanding the specifics of an individual's medical case.
Regarding Diagnosis
- At what level (discs C2-C7) is the displacement?
- Has individual been exposed to vibrational stress? Heavy lifting?
- Is individual sedentary?
- Has individual had a whiplash injury?
- Does the neck pain radiate to the shoulder and down to the hand?
- Is there weakness in the extremity?
- Is individual more comfortable sleeping in a recliner?
- On physical exam is pain aggravated by neck movement?
- Is the range of motion of the neck restricted?
- Is there tenderness over the affected vertebrae with palpation?
- Have x-rays been done?
- Has individual had an MRI or CT myelogram?
- Has individual had an EMG?
- Have conditions with similar symptoms been ruled out?
Regarding Treatment
- Did individual respond favorably to conservative treatment?
- Was narcotic use necessary? Sedatives?
- Were ice, heat, massage, ultrasound therapy, and intermittent cervical traction used?
- Was surgery necessary? What type of surgery was performed (discectomy, spinal fusion)?
Regarding Prognosis
- Is individual participating in an active rehabilitation program, or is there evidence of dependence on passive therapies? Does he or she utilize a home exercise program?
- Is individual's employer able to accommodate any necessary restrictions?
- Does individual have any conditions that may affect ability to recover?
- Has individual developed myelopathy?
