What is a Cervical Disc Herniation?
Between each bone of the spine there is a disc referred to as a spinal disc. The discs are jelly-like structures that facilitate motion & act as shock absorbers in the spine. Over time cervical discs can degenerate & give rise to disc bulges or disc herniations (slipped discs) that can give rise to neck pain. When these discs bulge sufficiently they can give rise to compression of nerve roots; this compression of a nerve root is referred to as radiculopathy. Slipped discs can occur anywhere in the spine but are most common at in the lower back or the neck.
Woods & Hilibrand (2015) state that ‘cervical radiculopathy is a relatively common neurological disorder resulting from nerve root dysfunction, which is often due to mechanical compression; however, inflammatory cytokines released from damaged intervertebral discs can also result in neck pain symptoms.’
Although compression of the nerve may be a driver of the symptoms it is also important to understand that there may be an inflammatory component to the condition as alluded to above. Because the discs of the spine have no blood circulation internally, it is thought that when a disc herniation occurs, the exposure of the disc material to the blood may induce a vigorous inflammatory response & that this may give rise to symptoms of neck pain & radiculopathy.
What are the Symptoms of a Disc Bulge in the Neck?
The cervical nerve roots exit the spine & travel down the arm to the hands. For this reason, a cervical disc herniation in the neck can give rise to pins & needles, numbness or tingling in the hands also referred to as radiculopathy. The patient may also experience weakness of the muscles of the arm & hand. In many cases, patients will report a higher intensity of arm pain and milder neck pain
Depending on the spinal segment undergoing a disc herniation, different nerve roots will be compressed & thus varying patterns of weakness or sensory changes may occur in the upper limb. Compression of these nerve roots will diminish nerve messages supplying the muscles therefore giving rise to weakness on muscle strength testing. Diminished reflexes in the upper limb is a strong indicator of a disc herniation. An orthopaedic test known as the Spurling Test when positive is also a strong indicator that a disc issue is present.
Patients will often report difficulty lifting items or performing normal daily activities such as opening lids. The pain can be worse when performing activities like ironing and eased when walking, especially with the hands in the pockets.
How is a disc bulge in the Neck Diagnosed?
Diagnosis of a disc herniation in the neck will often be based on patient symptoms reported during examination. If the patient wishes, an MRI scan may be warranted to confirm the diagnosis. MRI scans show soft-tissue & disc material more clearly than an x-ray and therefore an MRI is routinely used for diagnois of a disc herniation.
In most cases, MRI scans are not required as it does not impact greatly on the physiotherapist or chiropractor management of the condition. The findings of the MRI must correlate with the patient’s symptoms as disc degeneration, disc prolapses and degeneration viewed on images are part of everyday life and may not necessarily be of relevance to your presenting condition.
Special orthopaedic tests such as the Spurling’s test and testing of reflexes of the upper limb, when abnormal, are strong indicators of a disc bulge.
How do I know if I need Surgery on my Neck?
Patients presenting to physiotherapists or chiropractors often look for their opinions on whether surgery is adviseable or not. Research published in the Spine Journal (2013) compared the effectiveness of surgery alone versus physiotherapy for patients suffering with cervical disc herniations (Gwendolen, J. 2013). This randomised controlled trial (a randomised controlled trial is the highest ranking form of research) demonstrated that surgery plus physiotherapy results in a shorter term improvement in symptoms when compared with physiotherapy alone; however, in the longer term (two years), the outcomes become very similar.
Participants reported neck pain symptoms of between 8 weeks and 5 years. The authors recommend a comprehensive physiotherapy programme should be trialled before surgery in patients with cervical disc herniations with associated sensory changes in the arm.
This research is similar to studies of disc herniations of the lower back where, altough a short-term reduction may occur, longer term outcomes are no better for patients who decide to opt for surgery instead of conservative (non-surgical) options such as physiotherapy or chiropractor treatment. It is difficult to weigh up the potential benefits of this short-term gain when the risks & costs associated with surgery are analysed.
In my experience, most patients are confused when it comes to making a decision regarding whether to go for surgery or not. Most feel that they have no option but to go the surgical route if this is what they have been advised to do. They seem to be under the impression that if they are to avoid surgery then they will get worse or never recover fully; however, the recovery process is rarely as clear-cut as that & every individuals response will differ.
Often, a wait & see approach is warranted where the patient undergoes a physiotherapy programme of manual therapy & specific exercises over several weeks to months prior to making a decision regarding surgery. Research by Boyles et al. (2011) reported that a consensus exists within the literature that using manual therapy techniques in conjunction with therapeutic exercise is effective with regard to increasing function, as well as range of motion, while decreasing levels of pain and disability.
According to Woods & Hilibrand (2015) “in the absence of myelopathy or significant muscle weakness all patients should be treated conservatively for at least 6 weeks. For patients who are persistently symptomatic despite conservative treatment, or those who have a significant functional deficit surgical treatment is appropriate. Surgical options include anterior cervical decompression and fusion, cervical disk arthroplasty, and posterior foraminotomy.”
Should I undergo Physiotherapy after Surgery for a Cervical Disc Herniation?
The old approach after several surgical procedures such as those involving the knee or shoulder was to rest & avoid exercise or physiotherapy. The research is now very clear that undergoing an intensive physiotherapy programme is hugely important both pre and post-operatively in optimising recovery by restoring normal muscle strength & function. The research alluded to above (Gwendolen, J. 2013) is unique in that it compares surgery alone versus surgery with a follow-up physiotherapy programme in those who have had neck surgery. Once again, the benefit of physiotherapy is evident. Logic would suggest that the same physiological processes involving muscle wasting & deconditioning will take place irrespective of the body part involved & therefore rehabilitation is of equal importance to any surgical procedure applied to the joints.
Does Physiotherapy Help with a Cervical Disc Herniation?
Manual therapy is the use of hands-on treatments such as joint mobilisation or soft tissue techniques to relieve neck pain. According to a thorough review of the literature (systematic review), there is a general consensus that using manual therapy techniques in conjunction with physiotherapist guided exercise rehabilitation is effective in increasing function, as well as range of motion, while decreasing levels of pain and disability (Boyles et al. 2011).
Oftentimes, patients will ask my opinion on various techniques utilised to minimise nerve root pressure such as those involving traction of the neck. Langevin et al. (2015) found a definite improvement in symptoms in those undergoing manual therapy in conjunction with exercise. The authors reported that techniques applied to increase the size of the intervertebral foramen, that is the space between two adjacent bones where the nerve root exits the spine, were not any more effective than treatment techniques which were not specifically targeting this goal.
Does Chiropractic Manipulation Help with a Disc Bulge in the Neck?
Miller & Giles (2005) performed a randomised controlled trial comparing the effectiveness of spinal manipulation, medication & acupuncture in the treatment of chronic spinal pain. The largest group whose symptoms were eradicated most quickly came from the manipulation group (27.3%), followed by acupuncture (9.4%), and medication (5%). The authors found that spinal manipulation was ‘the only treatment modality of the assessed regimens that provides broad and significant long-term benefit.
Cervical (neck) radiculopathy arises due to compression of a nerve root in the neck. The nerves from the neck travel down to the shoulder, arm & hands. As a result patients can report pain or pins & needles in the neck, shoulder blade or arm. It may also give rise to weakness and decreased reflexes
Research from Langevin et al. (2016) showed that cervical & thoracic mobilisations, as well as physiotherapist guided home exercise program resulted in highly favourable outcomes in pain & disability. Manual techniques specifically targeted at increasing the size of the spinal canal & decreasing the pressure on the nerve root did not provide any additional benefits.
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References:
- Gwendolen, J. (2013). Treatment of cervical radiculopathy: a prospective, randomized study comparing surgery plus physiotherapy with physiotherapy alone with a 2-year follow- up. Spine; 20:1715-1722.
Reference: http://www.medscape.com/viewarticle/81106 - Boyles et al. (2011). Effectiveness of manual physical therapy in the treatment of cervical radiculopathy: a systematic review. The Journal of Manual & Manipulative Therapy; 19(3): 135-42. Reference: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3143012/
- Nikolaidis I, et al. Cochrane Database Syst Rev. 2010. CD001466. 2. Hermansen A, et al. Spine. 2011;36:919–925.
Reference: http://dx.doi.org/10.1016/j.jphys.2014.05.010 - Engguist et al. (2015). Factors affecting the outcome of surgical versus nonsurgical treatment of cervical radiculopathy – a randomized, controlled study. Spine; Jul 17.
Reference: http://www.ncbi.nlm.nih.gov/pubmed/26192721 - Woods and Hillabrand (2015). Cervical radiculopathy: epidemiology, etiology, diagnosis, and treatment. Journal of Spinal Disord Tech; Jun; 28(5): E251-9.
Reference: http://www.ncbi.nlm.nih.gov/pubmed/25985461 - Langevin et al. (2015). Comparison of 2 manual therapy and exercise protocols for cervical radiculopathy: a randomized clinical trial evaluating short-term effects. J Orthop Sports Phys Ther. Jan; 45(1): 4-17.
Reference: http://www.ncbi.nlm.nih.gov/pubmed/25420010 - Miller & Giles (2005). Long-term follow-up of a randomized controlled clinical trial assessing the efficacy of medication, acupuncture, and spinal manipulation for chronic mechanical spinal pain syndromes. J Manipulative Physiol Ther; 28:3-11.
Reference: http://www.ncbi.nlm.nih.gov/pubmed/15726029 - Langevin et al. (2016). Comparison of 2 manual therapy and exercise protocols for cervical radiculopathy: a randomized clinical trial evaluating short-term effects. J Orthop Sports Phys Ther 45 (2016).
Reference: http://www.ncbi.nlm.nih.gov/pubmed/25420010
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