Cervical Disc Hernia

The cervical part of our spine (the neck) is composed of seven vertebrae and has the highest capability of moving. Disc and facet joints allow vertebrae to move and allow us to bend or turn our neck and back. The discs are comprised of a strong connective tissue and function as a pad or shock absorber between the vertebrae.

A herniated disc of the neck called ‘Cervical Disc Hernia’ occurs when the content of discs between the vertebrae is displaced towards where spinal cord or nerve roots are. Cervical disc hernia often results in pain in the neck, pain that radiates down the arm and numbness of the arm which is called radiculopathy, accompanied by changes in sense, motor functions and reflexes. In approximately one fourth of the patients can develop myelopathy with structural changes in spinal cord. This presents with findings of spinal cord damages such as weakness of legs and arms, loss of sensation, and difficulty in walking.

Diagnosis

The diagnosis of cervical disc hernia involves a detailed examination of the patient. Magnetic resonance imagining is commonly used as a noninvasive and sensitive method to diagnose cervical disc hernia. An electrophysiological examination (EMG) can be used to support the diagnosis and for differential diagnosis in patients with radiculopathy.

Treatment

Cervical disc hernia has usually a good course. The patients should primarily receive a conservative therapy. Conservative therapy involves resting, neck bracing, analgesics and muscle relaxants as well as physical therapy exercises. A transforaminal steroid injection can be useful in some patients to relax the nerve roots. Surgical treatment should be considered for patients with severe neurological signs such as loss of sensation and movement and patients with myelopathic symptoms in particular, and who did not gain any benefits from a conservative therapy. The purpose of the surgery is to remove the part of the disc compressing on the nerve. After removal of the disc causing compression, fusion of vertebrae (connection) is a commonly used procedure.
Another treatment option offered by our center is disc prosthesis which is preferred to conserve the movements in young patients in particular.

Cervical Degenerative Diseases

Cervical movement is performed by discs and joints between the vertebrae. Degeneration of cervical spine starts in the intervertebral discs, resulting in secondary changes to other adjacent joints. This process in the spine is defined as ‘spondylosis’. Cervical spondylosis generally occurs between the most moving cervical vertebrae (C4-5, C5-6, C6-7) and in middle-aged or elderly people. This disease is the most common cause of progressive spinal cord and nerve root compression. Restriction of neck movements, pain or neurological damages (radiculopathy or myelopathy) can occur.

Small bony growths called osteophytes occur around spinal canal and nerve root canal in spondylosis. Osteophythic extensions alone can be symptomatic and cause narrowing of spinal canal. It can cause narrowing of diameter of spinal canal when located in the midline or cause root compression by extending into where the roots arise. Loss of movement develops between the vertebrae involved at advanced stages which results in loading an abnormal stress on adjacent spinal segments. As a result of this interaction degenerative changes occur involving multiple levels such as spondylosis or stenosis. A cervical spine with spondylosis is more exposed to traumatic impacts and can cause major injuries even with minor traumas.

The factors causing cervical disc diseases can include ageing, overloading and trauma, long-term working in abnormal posture, genetic causes, smoking, vascular diseases and diabetes, or chronic rheumatic diseases. Cervical spondylosis results in pain in the neck, shoulders and arms by compressing nerve roots. The pain can radiate from the arm into the palm by specific distribution of the nerve root under compression. If cervical disc hernia compresses the spinal cord, problems with walking, spasticity (increased muscle tone) and urinary incontinence can occur.

Diagnosis

The diagnosis of patients with cervical spondylosis involves a detailed physical examination including a neurological examination. The bony changes to spine can be viewed by radiography and computerized tomography (CT). Magnetic resonance (MRI) imaging is particularly useful to demonstrate the compression on the nerves. With EMG, the levels of complaints can be determined especially in preoperative planning.

Treatment

Initial treatment is usually conservative; patient education, cervical bracing, physical therapy exercises, and nonsteroid anti-inflammatory drugs are the most common treatment methods. The use of neck bracing can reduce cervical movements and relieve the compression. Physical therapy exercises will help strengthening the muscles and increasing in movement range. Injection is another treatment option, can be used to soothe the complaints for a certain period of time.

If the complaints of the patient persist, or if neurological findings are found or aggravated despite conservative treatment, a surgical intervention will be considered. The surgical intervention to be performed depends on the pathology causing the current state of the patient. The most commonly used surgical approaches are anterior (from the front) and posterior (from the back).

Anterior approach: Cervical vertebrae are accessed by entering from the front of the neck. The herniated disc between the vertebrae and the bony spurs causing compression on the spinal cord are removed. This is called corpectomy. The resulting space can be supported by an implant or bones from the patient or artificial bone grafts.

Posterior approach: It is based on removal of posterior membranes of vertebrae (laminectomy) and relief of spinal cord canal. It is performed for stenosis of spinal canal along one or more levels. If required, posterior fixation would be performed with titanium screws to maintain the stability of spine after removal of back membranes.

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