Herniated disc HWSIn the area of the cervical spine, neck pain occurs with a herniated disc and radiating pain in the arm. Surgical treatment is necessary if there is severe pain that does not improve with conservative treatment or if neurological deficits occur.
In addition to pain, there may also be a loss of nerve function. This manifests itself in the form of a numbness or tingling sensation. If there is even a loss of motor function due to the prere of the herniated disc on the nerve root, paralysis symptoms develop, which usually do not improve on their own. Much less frequently (in about ten percent of cases), a herniated disc occurs in the cervical spine (cervical disc herniation, herniated disc of the cervical spine). Surgical treatment is necessary if there is severe pain that does not improve with conservative treatment or if there are neurological deficits. In the case of certain failure symptoms such as z.B. Impairment of standing. If you are going to be operated on, immediate surgical treatment is required.
– Herniated disc cervical spine – Symptoms – Therapy – Imaging diagnostics
How a herniated disc in the cervical spine occurs ?
Herniated disc of the cervical spine
Herniated discs in the cervical spine occur less frequently than herniated discs in the lumbar spine. Unlike in the lumbar spine, the spinal cord (myelon) lies directly behind the intervertebral discs in the cervical spine. When there is a problem with the cervical spine, pain is felt primarily in the neck, shoulders and back of the head. Because the nerve roots for the arms are located in this area of the spinal column, the pain often radiates into the arms along the affected and compressed nerve root.. Many patients tend to adopt a protective posture due to the discomfort, which additionally stiffens the neck. Sensory disturbances and an unpleasant tingling or numbness in the hands and arms can also occur with a herniated disc of the cervical spine. Some sufferers even feel the effects in their legs. Prere on the spinal cord does not necessarily cause severe pain. Nevertheless, the damage to the nerve fibers can cause slowly progressive disorders with walking problems. Spastic muscle spasms develop – myelopathy. In case of corresponding symptoms, imaging is performed, preferably magnetic resonance imaging (MRI). A CT scan may also be sufficient at first to show grosser changes.
The decisive factor for treatment in the case of a proven herniated disc is that the symptoms complained of correspond to the height in the cervical spine in question. Herniated discs are common in the heights HWK 5/6 and 6/7. If there are no neurological deficits, the pain is not extreme and the size of the herniated disc does not force immediate action, conservative therapy can be tried. This includes medication with anti-inflammatory drugs (non-steroidal anti-inflammatory drugs) in combination with light physiotherapy and/or hot air treatment. CT-guided pain therapy can also be attempted, including on the cervical spine.
What to do in case of longer existing complaints ?
If the pain persists for a longer period of time (4-6 weeks), neurological deficits and a correspondingly high level of suffering on the part of the affected patient, surgical treatment should be performed. This can be performed via two possible access routes. Either via an anterior (ventral) approach – the ventral discectomy with installation of a placeholder (cage, made of plastic with titanium reinforcement) in place of the removed disc, or via a posterior (dorsal) approach – the dorsal foraminotomy (operation according to Frykholm). Here, too, the chance of success of being pain-free afterwards, or at least of achieving a decisive relief, is about 80-90%. A new prolapse at the operated height, if the operation was performed from the front (ventral), cannot occur if the intervertebral disc is completely removed (due to the operation).
Symptoms – Herniated disc of the cervical spine
Of course, symptoms vary from person to person and from case to case. Sometimes even from day to day. Here are some typical symptoms of cervical disc herniation described.
Pain can be intensified when the arm is held downwards. With relief or holding the arm above the head, there is a decrease in pain. This is typical for a herniated disc in the cervical spine. Over years it comes again and again. More and more often to tension of the neck muscles. The pain may move upward, there is a headache at the back of the head, which can sometimes even move to the forehead. If the pain moves downwards, patients complain of tension in the thoracic spine. As the symptoms increase, tension in the shoulder girdle then frequently occurs. Sometimes a feeling of dizziness occurs, especially when changing position. As rarer symptoms, some patients complain of ringing in the ears, pulling pain in the lower jaw or numbness in the back of the head. Often it is reported that the neck and the head are not free and that it feels as if a fist is sitting in the neck and pulling everything together.
The arm pain
Fresh herniated discs and osteochondrotic, bony edge spikes (bone growths that develop as a support reaction due to the instability of the affected cervical segment and constrict the nerve canal) lead to irritation of the brachial plexus (nerve plexus that is formed by the union of the individual nerve roots and supplies the arm) due to compression of the nerve root. This manifests as pain radiating from the neck to the shoulder, arm and hand (Schuter arm syndrome). In the case of an acute incident, this symptomatology occurs abruptly. The most common symptom is a probing and pulling, bright pain. In osteochondrosis, the pain develops slowly and tends to be felt more dull and deep. The patient may rest the shoulder joint due to the pain on movement, which may result in painful restriction of shoulder joint movement. This pain can be the original. Causative cervical root irritation syndrome masking.
Nerve paralysis
The neurological irritation or failure symptoms are relatively typical. In a process of the upper cervical spine (cervical spine, up to and including the vertebral bodies C 3/4, migraine-like pain develops, pulling from the upper cervical spine into the back of the head to the forehead (unilaterally or bilaterally, depending on the localization). At the level of C 4/5, nerve root C5 is affected. This can lead to shoulder pain, sensory disturbances in the area of the delta muscle (shoulder-upper arm muscle) and partial paralysis of the muscles (lifting of the arm in the shoulder joint is difficult or impossible). The C6 nerve root is affected in processes at the C 5/6 level. The pain extends from the neck-shoulder area over the inside of the arm to the thumb. If the C6 nerve root is damaged, sensory disturbances may occur at dermatome C6 (sensitive supply area of the C6 nerve root: inner side of the upper and lower arm up to the thumb and index finger) and signs of paralysis as well as atrophy of the characteristic muscle (biceps brachii muscle – arm flexor: bending of the lower arm is difficult). Musculus triceps brachii – arm extensor muscle on the back of the upper arm – is the identification muscle of the C7 nerve root. In case of a process at the level of C 6/7, this nerve root is affected. Pain and sensory disturbances occur in the index, middle and ring fingers and in the middle of the back of the hand and forearm. Nerve root C8 is affected in processes at the level C7/Th1. Pain and sensory disturbances are found on the outer side of the forearm up to the little finger. Vegetative syndromes of the herniated disc in the cervical spine: Pain can lead to an increase in sympathetic activity with increased vasomotor excitability of the vessels. The result can be a circulatory disorder of the arm and hand. However, fibers of the sympathetic nervous system can also be irritated by direct nerve root irritation. Best known examples are migraine cervical, unclear vertigo and ear complaints, such as hypotension and ringing in the ears.
Emergency
Spinal cord compression syndrome: Unlike lumbar disc herniation, cervical disc herniation or chronic changes in the cervical spine with dorsal osteophytes (bony marginal spines) can result in direct compression of the myelon (spinal cord) and/or affect blood flow to the spinal cord (cervical myelopathy). This manifests as acute or slowly developing paraplegia of varying severity. Continue reading here for symptoms and complaints of the cervical spine
Therapy options for a herniated disc of the cervical spine
The intervertebral disc is not only a shock absorber between the vertebrae, but also has an important stabilizing role in the cervical spine area. Therefore, stability in the affected cervical spine segment is considerably more at risk than in the lumbar spine segment if the intervertebral disc is damaged.
Three goals are to be achieved by surgery:
– The compression of the nerve root with typical arm pain should be eliminated. – The compression of the spinal cord due to the prolapse should be relieved. – The normal width of the spinal canal is thus restored.
If the joint function of the affected vertebrae is destroyed (with the typical neck- shoulder- headache), the motion segment must be stiffened. However, this does not result in any noticeable restriction of mobility. As with any operation on the nervous system, the procedure is performed under microscopic magnification.
There are three surgical treatment options. Which of the three operations is used is decided individually according to the imaging and the complaints and age of the patient:
1. ventral discectomy with implantation of a cage (placeholder)
The removed intervertebral disc is replaced by an implant to achieve fusion (spondylodesis, stiffening). We use different titanium implants resp. Plastic implants. They are well suited as spacers because they are hollow in the middle, allowing the bones to grow together not only laterally but also in the middle. Since, in contrast to surgery for lumbar disc herniation, the entire disc is removed and replaced by an implant, there can be no recurrence of the herniation at the operated level.
2. Dorsal foraminotomy (operation according to Frykholm)
This method of surgery is used when the herniated disc does not affect the spinal cord, but only a nerve root is constricted in its bony canal, far from the edge of the disc. This canal can then be widened. The nerve root can then be given the space it needs. In the prone position, also under general anesthesia, the neck muscles are detached from the cervical spine on one side and the intervertebral hole is reamed on the side of the prolapse. The intraforaminal prolapse is removed with special grasping forceps. This method does not remove the dorsal bony edge spike. No spondylodesis is performed. Stabilization of the affected segment is therefore absent. A recurrence at the operated level is possible, since the disc is not completely removed. 3. ventral discectomy. Implantation of a disc prosthesis. ventral discectomy and implantation of a disc prosthesis. An artificial disc is a prosthesis implanted between two vertebral bodies to replace the natural disc and to maintain mobility in the treated vertebral segment. The goal of such an operation is to remove all parts of the damaged disc (discectomy), to reduce the prere on the nerves and/or the spinal cord (decompression), and to restore spinal stability and alignment after removal of the disc. In principle, the disc prosthesis is intended to maintain mobility in the operated segment, d.h. preserve where the disc is herniated. Thus, the so-called connection degeneration of the segments above and below is reduced. This in turn means that mainly patients with an otherwise inconspicuous cervical spine and usually only a single-segment problem can benefit from implantation of the disc prosthesis. The indication will ultimately be reviewed and can be made by your treating neurosurgeon.
In acute cases, the treatment of pain has priority. The point of attack is the building up cycle of pain → muscle tension → pain intensification. Suitable is a range of pain-. Anti-inflammatory drugs. Medication can be administered in the form of tablets, suppositories, injections or infusions. Local infiltrations can be helpful for localized pain or joint pain. Through careful stretching treatment, z.B. With a Glisson sling, temporary prere relief of the intervertebral disc can be achieved under certain circumstances in the acute phase. An improvement of the blood circulation of the neck muscles by heat application. Short-wave radiation can bring relief. Physiotherapeutic exercises loosen the musculature. Can counteract frozen shoulder. Manual therapy is contraindicated in the case of a herniated disc with neurological deficits. Temporary immobilization of the cervical spine with a cervical collar may be necessary in the acute phase. Which measure is necessary in each individual case must be decided by the experienced practitioner depending on the symptoms and symptoms.
Imaging diagnostics
MRI is the examination method of first choice for clarifying a disease of the cervical spine. It has largely eclipsed other examination methods in recent years. In very special cases and when it is not possible to perform an MRI examination (pacemaker or claustrophobia), other examination methods such as CT, cervical myelography, myelo-CT and discography are used.