Cervical Disk Herniation Causing Cord Compression

With age, the nucleus pulposus of the disk dehydrates, placing more stress on the annulus fibrosus (outer lining). Tears in the annulus may permit a sudden herniation of the nucleus—a ruptured disc. Alternatively, chronic annular bulging or nuclear herniation may lead to the formation of extensive bony spurs (osteophytes), typically located along the anterior portion of the disk interspace or posteriorly within the nerve root foramen. Osteophytes or ruptured disks produce symptoms only if they compress the spinal cord or nerve roots against posteriorly located structures, including the posterior nerve root foramen and ligamentum flavum.

Clinical Manifestations. The first manifestation of cervical disk disease is often cervical radiculopathy, with symptoms and signs referable to compression of a cervical nerve root. Cervical and unilateral arm pain, frequently acute in onset, is a common symptom of cervical disk disease, and patients often complain also of numbness, paresthesias, or, less commonly, of weakness in the involved arm in a radicular distribution. Examination may show sensory, motor, or reflex abnormalities depending on the involved nerve roots. Gait disturbances, leg weakness, or sphincter disturbances suggest an associated compressive myelopathy.

Diagnosis. Spinal MRI is the imaging modality of choice, but CT myelography may be required in those with a normal MRI when a strong clinical suspicion of the diagnosis remains. Electrodiagnostic studies (needle electromyography to detect signs of denervation in muscles) are helpful in indicating the functional significance of any anatomic abnormalities seen on imaging studies.

Treatment. Many patients with cervical radiculopathy respond to conservative treatment, including short-term use of a soft cervical collar to immobilize the neck, mild analgesics, physical therapy, and muscle relaxants as required. A brief course of oral steroids is sometimes worthwhile. Many believe that cervical traction is also helpful, provided imaging reveals no contraindication. If symptoms persist after 4 to 6 weeks, further testing, including spinal MRI, is indicated. If imaging shows compression of the clinically appropriate nerve root, surgical therapy is often undertaken. Surgery is also often performed if patients have clinical evidence of myelopathy and imaging evidence of spinal cord compression. Some neurosurgeons strongly advocate an anterior approach, and others, a posterior approach in treatment. In skilled hands, either route leads to excellent relief of symptoms in many patients, but the evidence that surgery is beneficial is incomplete.

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