Ferri – Cervical Disc Syndromes

Mar 25, 2020 admin Uncategorized 0

Cervical Disc Syndromes

  • Steven F. Defroda, M.D., M.ENG.
  • Kalpit N. Shah, M.D.

 Basic Information

Definition

Cervical disc syndromes result from a disc herniation and degenerative changes in the cervical spine. The symptoms can be categorized either as cervical radiculopathy (nerve root impingement) or as myelopathy (spinal cord impingement) if the stenosis is most significant at the neural foramen or more centrally in the spinal canal, respectively. Central cord stenosis (myelopathy) can result in both upper- and lower-extremity symptoms, while foraminal narrowing typically results in radicular symptoms.

Synonyms

Cervical myelopathy, cervical radiculopathy, cervical spondylopathy (degenerative vs. traumatic)

ICD-10CM CODES
M50.00 Cervical disc disorder with myelopathy, unspecified cervical region
M50.30 Other cervical disc degeneration, unspecified cervical region
M50.00 Cervical disc disorder with myelopathy, unspecified cervical region
M50.01 Cervical disc disorder with myelopathy, high cervical region
M50.02 Cervical disc disorder with myelopathy, mid-cervical region
M50.03 Cervical disc disorder with myelopathy, cervicothoracic region
M50.10 Cervical disc disorder with radiculopathy, unspecified cervical region
M50.11 Cervical disc disorder with radiculopathy, high cervical region
M50.12 Cervical disc disorder with radiculopathy, mid-cervical region
M50.13 Cervical disc disorder with radiculopathy, cervicothoracic region
M50.20 Other cervical disc displacement, unspecified cervical region
M50.21 Other cervical disc displacement, high cervical region
M50.22 Other cervical disc displacement, mid-cervical region
M50.23 Other cervical disc displacement, cervicothoracic region
M50.30 Other cervical disc degeneration, unspecified cervical region
M50.31 Other cervical disc degeneration, high cervical region
M50.32 Other cervical disc degeneration, mid-cervical region
M50.33 Other cervical disc degeneration, cervicothoracic region
M50.80 Other cervical disc disorders, unspecified cervical region
M50.81 Other cervical disc disorders, high cervical region
M50.82 Other cervical disc disorders, mid-cervical region
M50.83 Other cervical disc disorders, cervicothoracic region
M50.90 Cervical disc disorder, unspecified, unspecified cervical region
M50.91 Cervical disc disorder, unspecified, high cervical region
M50.92 Cervical disc disorder, unspecified, mid-cervical region
M50.93 Cervical disc disorder, unspecified, cervicothoracic region

Epidemiology & Demographics

Incidence

The incidence of cervical radiculopathy can be up to 107.3 and 64.5 per 100,000 men and women, respectively, in the U.S.

Prevalence

Up to 67% of all adults experience neck and arm pain at some point in their life.

Predominant Sex and Age

Males and females are affected equally between the ages of 30 and 60. Most commonly, cervical myelopathy is seen in patients >55 years of age.

Genetics

No definitive genetic associations have been identified.

Risk Factors

Risk factors include aging, repetitive microtrauma to the neck, and, potentially, genetic factors, although research is ongoing.

Physical Findings & Clinical Presentation

  1. •

    Neck pain, especially with extension, and limited neck range of motion. Spurling’s sign (pain on axial compression of the neck while it is extended and the head is turned to the affected side) is usually positive in the setting of foraminal stenosis.

  2. •

    Referred unilateral interscapular pain.

  3. •

    Numbness, tingling, or radiating pain in a dermatomal distribution may be secondary to nerve root impingement at the associated level (radicular symptoms).

  4. •

    Extremity or hand weakness and clumsiness, gait disturbance and spasticity in upper and lower extremities (myelopathic symptoms), abnormal reflexes: positive Hoffman’s sign, positive inverted radial reflex, and hyperactive biceps and triceps reflexes are usually seen in myelopathic patients.

Etiology

Degeneration of vertebral bodies, intervertebral disc herniations, hypertrophy of facets, uncovertebral joints, and ligamentum flavum can all lead to spinal cord and/or nerve root impingement causing cervical disc syndrome.

Diagnosis

Differential Diagnosis

  1. •

    Muscle spasms

  2. •

    Rotator cuff tendinitis/tear

  3. •

    Frozen shoulder

  4. •

    Carpal tunnel syndrome

  5. •

    Cubital tunnel syndrome

  6. •

    Radial tunnel syndrome

  7. •

    Thoracic outlet syndrome

  8. •

    Brachial neuritis or brachial plexopathy

  9. •

    Cervical spine epidural abscess

  10. •

    Malignancy (primary or metastatic) causing nerve root or spinal cord impingement

A differential diagnosis for evaluation of neck pain is described in Section II.

Workup

  1. •

    Combination of clinical diagnosis and radiologic studies (x-ray and MRI).

  2. •

    Fig. E1 is an algorithm for a workup of suspected cases.

FIG.E1 

Algorithm for suspected cervical disc syndrome.
NSAID, Nonsteroidal antiinflammatory drug; PT, physical therapy.
From Mercier LR [ed]: Practical orthopedics, ed 6, St Louis, 2004, Mosby.

Laboratory Tests

No specific labs are required; however, CBC and inflammatory markers (ESR/CRP) can be obtained if infectious cause or inflammatory conditions are suspected.

Imaging Studies

  1. •

    Plain radiographs should be obtained first to rule out traumatic causes (fracture, subluxation, dislocation, spondylolisthesis).

    1. 1.

      Usually normal in soft disc herniation or foraminal stenosis.

    2. 2.

      With chronic degenerative disc disease, loss of disc height, anterior and posterior osteophyte formation, and encroachment on the intervertebral foramen by osteophytes may be seen.

  2. •

    CT myelography or MRI is indicated in patients with neurologic symptoms that do not resolve with conservative management or when other spinal pathology is suspected.

  3. •

    Electrodiagnostic studies to confirm the diagnosis or rule out peripheral nerve disorders.

Treatment

Nonpharmacologic Therapy

  1. •

    Rest and soft or hard cervical collar can be used to immobilize the neck.

  2. •

    Local modalities such as heat and ice may help.

  3. •

    Physical therapy (Fig. E2).

  4. •

    Avoid extreme range-of-motion exercises in degenerative disc disease.

FIG.E2 

Isometric neck exercises.
A, The hand is placed against the side of the head slightly above the ear, and pressure is gradually increased while resisting with the neck muscles and keeping the head in the same position. The position is held 5 sec, relaxed, and repeated five times. B, The exercise is performed on the other side and then from the back and front (C). The exercise should be performed three to four times daily.
From Mercier LR [ed]: Practical orthopedics, ed 4, St Louis, 1995, Mosby.

Acute General Rx

  1. •

    Nonsteroidal antiinflammatory drugs or oral steroids

  2. •

    Muscle relaxants

  3. •

    Analgesics as needed

  4. •

    Epidural steroid injection for radicular pain

Chronic Rx

  1. •

    If acute modalities and nonoperative therapies fail, patients can be evaluated for surgical intervention.

  2. •

    Nerve ablation for chronic pain in patients who may not be safe for surgery.

  3. •

    Discectomy or decompression and/or fusion for symptomatic cervical discs.

Complementary and Alternative Medicine

  1. •

    Herbal antiinflammatory medications

  2. •

    Chiropractic care

  3. •

    Acupuncture

  4. •

    Deep-tissue massage

Disposition

  1. •

    Acute radiculopathy usually improves with time.

  2. •

    Myelopathy is a step-wise decline with progressive symptoms.

  3. •

    Surgical intervention is normally offered to approximately 5% of the patients.

Referral

Orthopedic or neurosurgical consultation for intractable pain or worsening neurologic deficit

Pearls & Considerations

Myelopathy from cervical spondylosis is the most common cause of acquired spastic paralysis in the adult and is usually progressive. Decisions about surgical intervention are complicated in these patients.

Comments

  1. •

    Pain relief with physical therapy is variable; any overall improvement usually parallels what would have likely occurred naturally.

  2. •

    Sometimes carpal tunnel syndrome and cervical radiculopathy occur together; this is termed double-crush syndrome, pointing to the fact that the nerve is being compressed at two separate levels. Proximal compression may decrease the ability of the nerve to tolerate a second, more distal compression.

  3. •

    Surgical intervention is indicated primarily for relief of radicular pain caused by nerve root compression or for the treatment of progressive myelopathy; it is generally not helpful when the chief complaint is neck pain alone without extremity symptoms.

  4. •

    In many cases of cervical spondylosis with myelopathy, the lower extremity symptoms are much more disabling than the neck symptoms.

Prevention

  1. No known prevention exists.

Suggested Readings

  • Buttermann G.R.: Anterior cervical discectomy and fusion outcomes over 10 years, Spine (Phila Pa 1976), June 2017:1. http://dx.doi.org/10.1097/BRS.0000000000002273

  • J.J. Wong, et al.: The course and prognostic factors of symptomatic cervical disc herniation with radiculopathy: a systematic review of the literature. Spine J. 14 (8):1781–1789 2014 10.1016/j.spinee.2014.02.032 24614255

Related Content

  1. Cervical Disc Syndrome (Patient Information)

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