Cervical Disc Herniations

Cervical disc herniation is a common cause of neck pain with radiation to the shoulder blade and arm. Frequently associated symptoms include tingling (paresthesia) and numbness in the arm, hand and fingers. Occasionally weakness is also present although this is usually subtle. Neck pain usually predates the onset of shoulder and arm pain and with the onset of arm pain neck pain is frequently diminished. Pain in the shoulder and arm is the usual reason patients seek the assistance of an orthopedic spine surgeon.

An appropriately trained and experienced physician can usually make the diagnosis of a cervical disc herniation on the basis of history and physical examination alone. Initial treatment can begin without diagnostic testing and usually includes the use of analgesic medications and frequently a short course of oral corticosteroid (Medrol Dose Pack) medication. For patients whose symptoms are refractory to treatment over a 4-6 week period diagnostic testing is appropriate. It should be noted that chiropractic and physical therapy are ineffective and frequently aggravating treatments in patients with “pinched nerve” symptoms. Diagnostic testing includes basic neck x-rays and MRI imaging. EMG/nerve conduction tests are frequently recommended by primary care physicians and neurologists but are costly and rarely provide information that is useful in guiding treatment.

Once the diagnosis of cervical disc herniation is confirmed by imaging treatment recommendations frequently include 1-3 cervical epidural cortisone injections. The goal of this treatment is to reduce nerve pain in the arm and shoulder in order to allow the condition to improve with time. Approximately 70% of patients who receive epidural injections will experience at least a temporary response. If symptoms resolve, no further treatment may be necessary. If response is temporary or does not occur after 1-2 injections, further injections are not appropriate. There is no research evidence to support the routine provision of 3 epidural injections or more than three injections in the course of 1 year. For patients whose symptomatic relief is temporary or inadequate consideration of surgery is appropriate.

Surgical treatment for cervical disc herniation is appropriate for patients with neck and arm pain of greater than 6-8 weeks of non-surgical care and in those whose symptoms are non-responsive and intolerable or have progressive weakness. Traditional surgical treatment includes removal of the herniated disc with a fusion of the disc space (ACDF). Recently presented research (North American Spine Society 2011) has confirmed that the results of cervical disc replacement are superior to ACDF in the short and intermediate term (up to 8 year follow-up) with regard to rate of pain relief, neurologic recovery, complication and reoperation rate, and overall patient satisfaction. Cervical Disc Replacement ( arthroplasty ) has also been shown to be significantly more cost effective than ACDF. It is important to note that not all patients with cervical disc herniations are candidates for disc replacement. The appropriate procedure can only be identified by an appropriately trained and experienced surgeon. Both ACDF and Cervical Disc Replacement can usually be performed on an outpatient basis with very low complication rates and high patient satisfaction.