Cervical disc herniation — degeneration and prolapse beyond the boundaries of the intervertebral space of the cervical intervertebral disc. Clinically manifests pain in the upper arm and arm radiating into the fingers, weakness and hypesthesia of the arm, vertebral artery syndrome. It is diagnosed mainly by the results of MRI of the cervical spine. Conservative therapy consists of anti-inflammatory and muscle relaxant drugs, corticosteroid blockades, kinesiotherapy, physiotherapy, massage, therapeutic traction. Surgical treatment usually consists of removing the affected disc and stabilizing the spine.
General information
Cervical disc herniation is quite common. In terms of prevalence, it ranks second after lumbar disc herniation. Most often, hernias are formed in the discs between the fifth and sixth, between the sixth and seventh cervical vertebrae. More rarely — between the fourth and fifth, extremely rarely between the seventh cervical and first thoracic vertebrae. Given the prevalence of cervical disc herniation, the relatively young age of the patients (on average 30-50 years), the risk of severe vascular complications, this pathology remains an urgent problem of clinical neurology, vertebrology and orthopedics.
The discs of the cervical spine have a smaller diameter than the thoracic and lumbar, therefore, hernias in this department are smaller. However, a narrower spinal canal and a reduced space for the roots to exit from the spinal cord cause the occurrence of clinical symptoms even with a small protrusion of the disc. A feature of the cervical spine is the passage from two sides along the vertebral bodies of the vertebral arteries. In this regard, intervertebral hernia is manifested not only by neurological, but also by vascular disorders.
Causes
The formation of an intervertebral hernia is associated with degenerative processes occurring in the disc, as a result of which it loses elasticity. Chronic injury with increased load on the cervical spine or acute spinal injury (spinal contusion, subluxation of the cervical vertebra) leads to the formation of cracks in the fibrous ring of the disc, the exit of part of the disc beyond the intervertebral space, and in the future — to the prolapse of the pulpous nucleus.
Degenerative changes in cervical disc herniation are usually associated with osteochondrosis, but may be caused by cervical spondylosis, spinal spondyloarthrosis, spinal tuberculosis, inadequate load on the cervical spine with spinal abnormalities (Klippel-Feil syndrome, wedge-shaped vertebra, Atlanta assimilation), posture disorders, cervical-thoracic scoliosis, obesity. Various dysmetabolic processes in the body that occur in diabetes mellitus, alcoholism, smoking, and genetically determined metabolic diseases are factors contributing to disc degeneration.
Clinical symptoms of cervical disc herniation are caused by compression of the spinal root, spinal cord substance, vertebral artery. In the first two cases, neurological symptoms occur (pain, motor deficits and sensory disorders), in the third — vertebral artery syndrome. The latter can cause repeated transient ischemic attacks (TIA), chronic cerebral ischemia in the vertebrobasilar basin with the formation of dyscirculatory encephalopathy.
Symptoms
At the initial stages of cervical disc herniation, its main manifestations are pain and spinal syndromes associated with irritation of the spinal root at the level of hernia formation. Initially, the pain syndrome may have a periodic character, provoked by turns and tilts of the head. Then the pain is transformed into a constant, it increases with head movements. It is localized in the neck, shoulder and arm from the side of the formed hernia, accompanied by paresthesia and numbness of the hand. With movements in the cervical region, so-called “lumbago” is possible – acute pain going from the neck to the fingers of the hand.
Pain impulses cause the reflex development of muscle-tonic changes that make up the spinal syndrome. The resulting increase in the tone of the paravertebral muscles of the cervical spine and other neck muscles leads to limited mobility and aggravates the course of the pain syndrome. Tonic contraction of the muscles on the side of the lesion causes the appearance of reflex torticollis.
Over time, compression of the herniated nerve fibers of the spinal root leads to disruption of nerve impulses along them — a root radiculopathy. There is weakness in the arm, accompanied by a decrease in muscle tone (sluggish monoparesis). Paresthesia is replaced by a significant decrease or complete loss of pain and other types of sensitivity in the area of innervation of the compressed root.
A further increase in the size of a cervical disc herniation entails compression not only of the spine, but also of the spinal cord with the development of discogenic myelopathy. Compression of the vertebral artery is manifested by dizziness, headache, vestibular ataxia, transient visual disturbances (photopsias, scotomas, decreased visual acuity), tinnitus and mild hearing loss, vegetative disorders, the occurrence of fainting with a sharp turn of the head, drop attacks, TIA.
Intervertebral hernia of the cervical region, depending on the level of location, may have a variable clinical picture. With a herniated disc C4-C5, pain in the shoulder and weakness of the muscles of the upper arm prevail. With a hernia of the C5-C6 level, weakness is noted in the biceps and extensors, numbness and paresthesia in the thumb of the hand are characteristic. Hernia C6-C7 is accompanied by a decrease in muscle strength in the triceps and extensors of the fingers, pain running along the back of the hand to the tip of the middle finger. Hernia C7-T1 is manifested by weakness when the hand is clenched into a fist, pain and paresthesia radiate into the little finger.
Diagnostics
At the initial stages (disc protrusion), if there is only pain and spinal syndromes in the clinic, it is difficult for the doctor to suspect the formation of a cervical disc herniation. In such cases, an X-ray of the spine is usually performed, which can reveal signs of osteochondrosis, spondyloarthrosis, and other pathological changes in the bone structures of the spinal column. A cervical disc herniation can be visualized using an MRI or CT scan of the spine. The indication for their implementation is the presence of muscle weakness in the arm or the clinic of the vertebral artery syndrome. Previously, contrast myelography was used in such cases. Currently, MRI of the spine is a safer and more informative diagnostic method. MRI is better than CT allows you to visualize the soft tissue structures of the spine, gives more complete information about the size of the hernia and the degree of narrowing of the spinal canal.
Electrophysiological studies (EMG, ENG, ENMG) make it possible to identify the neural nature of the lesion and determine its level. To assess the condition of the vertebral artery, REG with functional tests, duplex scanning or ultrasound of the vertebral arteries is performed. Differential diagnosis is carried out with brachial plexitis, shoulder periarthrosis, cervical plexitis, cervical myositis, infectious myelopathy at the cervical level.
Treatment
Conservative therapy of a cervical disc herniation and recovery after its surgical treatment can be carried out by the joint efforts of a neurologist, orthopedist, vertebrologist, chiropractor, masseur, kinesiotherapist. In the acute pain period, anti-inflammatory drugs (ibuprofen, ketorolac, nimesulide, meloxicam, etc.), local administration of corticosteroids (hydrocortisone, diprospane), muscle relaxants (tolperisone hydrochloride) are prescribed. From the first days, neurometabolic pharmaceuticals are used, primarily vitamins of group B. The use of electrophoresis, UHF, magnetotherapy and phonophoresis contributes to the relief of pain syndrome and the reduction of inflammation.
In order to reduce the pressure on the affected intervertebral disc, it is possible to use soft manual therapy or traction therapy. Traction of the cervical spine is carried out using a Glisson loop in a sitting position. The use of techniques of myofascial massage and reflexotherapy helps to reduce the intensity of the muscular-tonic syndrome. In case of vertebral artery syndrome, vascular (pentoxifylline, vinpocetine) and nootropic (piracetam, pyritinol) agents are additionally prescribed.
At the beginning of the disease, it is necessary to ensure the rest of the cervical spine. For this purpose, the wearing of a Trench collar is widely used. However, it is fraught with the rapid development of atrophy of the neck muscles, while the main guarantee of recovery and prevention of further progression of the disease is the creation of a powerful muscular corset that holds the anatomical structures of the cervical spine in a normal position. This task is solved with the help of kinesiotherapy, which includes performing individually selected exercise therapy exercises and classes on special simulators under the supervision of a physical therapy doctor or a kinesiologist.
Surgical treatment of a cervical disc herniation should be carried out according to strict indications and with extreme caution. The reason for the operation may be the development of a significant neurological deficit that does not decrease against the background of conservative therapy, pronounced narrowing of the spinal canal, compression of the vertebral artery, leading to ischemia of brain tissue. Surgical treatment, as a rule, involves radical removal of a hernia (discectomy or microdiscectomy), supplemented by spine-fixing operations (intervertebral fixation with cages, interbody fusion, etc.). Minimally invasive interventions (puncture laser vaporization, endoscopic microdiscectomy, intradiscal electrothermal therapy) can be used only with small hernia sizes, when conservative methods of treatment are also effective in most cases.
