Cervical herniated disc disorder refers to acute injury or degenerative changes (wear and tear changes from aging) to the intervertebral discs that causes the disc contents (aka. nucleus pulposus) to be bulged out and displaced outside of the normal disc space.  The bulging typically occurs in the direction toward the back or slightly oblique to the sides.  When the bulging of disc is toward the back and in the middle, the spinal cord can be compressed.  Patients can develop acute spinal cord injury in those cases.  In more chronic processes such as degenerative disc disease, the injury to the spinal cord is more subtle and patients develop progressive spinal cord dysfunctions, as known as myelopathy.  On the other hand, disc herniations often occur toward the back and to the side of the spinal cord.  The gutters along both sides of the spinal cord are also known as neuroforamina (nerve opening).  These openings are the exiting zone of nerve roots away from the spinal cord.  Disc herniation toward these openings causes mechanical pressure on the nerves, impingement of the nerves, and the symptoms known as cervical radiculopathy (nerve dysfunction). 

Causes:

The most common cause of a cervical herniated disc is degenerative spine disease.  This is a wear and tear process that all individuals experienced with aging.  Gradual weakening of the ligaments and exterior of the disc spaces allows the disc contents to bulge or expel out of the normal disc space.  The most common disc levels at risk in the neck are C5-6 and C6-7, where there are higher forces distributed in these levels from neck movements.

Symptoms:

Cervical herniated disc can cause neck pain alone.  Often times, there is spinal cord or nerve root compression because of the herniated disc.  When the spinal cord is compressed significantly, patients can develop spinal cord dysfunction symptoms, which is also known as cervical myelopathy.  Symptoms of myelopathy are more diffuse and affect both sides of the body.  They can include weakness of all 4 extremities, numbness or paresthesia (pins and needle sensation), difficulty with fine motor activities of the hand, and difficulty with walking. Many patients with acute cervical herniated discs present with symptoms of nerve root compression (aka. cervical radiculopathy).  Cervical radiculopathy is often associated with neck pain that radiates into the arms and hands.  The symptoms typically involve only one side, and they are often isolated to the distribution(s) of the nerve root(s) compressed.  Weakness and loss of sensation can occur with compression of the nerve root(s).  Occasionally, patients can present with both cervical myelopathy and radiculopathy symptoms. 

Diagnostic test:

MRI is the test of choice for detection of cervical herniated disc.  It allows detailed visualization of the herniated disc and its relationship with the bone, spinal cord, and nerves.  Occasionally, MRI cannot be completed because of a pacemaker or spinal cord stimulator.  In those cases, a CT myelogram is the next best test to assess the degree of spinal cord compression and spinal canal narrowing.  In addition to radiographic studies, electromyography and nerve conduction velocity (EMG/NCV) tests are useful to determine which nerve is affected.  This test is not always needed, but in cases when the clinical presentation is not consistent with the MRI findings, EMG/NCV can help to determine which nerves are behaving abnormally and rule other possibilities of pain, weakness, or sensory loss.

Treatment:

The initial treatment of cervical herniated disc is conservative or medical therapy. Conservative therapy can include rest, medications, physical therapy, epidural steroid injection, nerve block injections, chiropractic treatments, or alternative medicine treatments.  Many patients will respond to conservative therapy and not require any surgical treatment. 

Surgery is reserved for patients with weakness, severe sensory loss, spinal cord dysfunction (myelopathy), severe pain, or those that failed conservative treatment. The goal of surgery is to relieve the compression from the spinal cord and/or spinal nerves.  The most common procedure for cervical herniated disc is anterior discectomy and fusion.  This procedure allows for direct visualization and removal of the herniated disc and complete decompression of spinal cord and nerve root.  The procedure is most often performed in conjunction with a fusion of the involved segment.  This procedure has been performed for over 50 years with excellent results.  Patients generally go home the same day or morning after following the procedure, and it is one of the most gratifying procedures in all spine surgery.  In recent years, artificial discs have been approved for clinical use in the United States.  In patients with single level diseases, artificial disc can be placed in the cervical spine to retain motion and to prevent some potential long-term problems with fusion.  Although long-term results of artificial disc placement are not comparable to those of fusions, early results are extremely encouraging. 

Other than anterior discectomy with fusion or artificial disc placement, in certain cases, minimally invasive keyhole discectomy can be performed from the back of the neck.  The procedure is performed through an approximately ½ inch incision and patients generally go home the day of the surgery with this procedure.  The main advantage of the procedure is to avoid the potential complications associated with an anterior procedure and to avoid the need for a fusion at the time of surgery.

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