eMedicine Specialties > Physical Medicine and Rehabilitation > Cervical Spine Disorders

Cervical Disc Disease: Differential Diagnoses & Workup

Author: Michael B Furman, MD, MS, Physiatrist, Interventional Spine Care Specialist, Electrodiagnostics, Orthopedic and Spine Specialists
Coauthor(s): Jeremy Simon, MD, Attending Physician, Department of Physical Medicine, The Rothman Institute; Kirk M Puttlitz, MD, Consulting Staff, Pain Management and Physical Medicine, Arizona Neurological Institute; Frank John English Falco, MD, Physiatrist, MidAtlantic Spine
Contributor Information and Disclosures

Updated: Apr 6, 2009

Differential Diagnoses

Brachial Neuritis
Paget Disease
Cancer and Rehabilitation
Psoriatic Arthritis
Cervical Myofascial Pain
Radiation-Induced Brachial Plexopathy
Cervical Spondylosis
Rheumatoid Arthritis
Cervical Sprain and Strain
Rotator Cuff Disease
Complex Regional Pain Syndromes
Scheuermann Disease
Fibromyalgia
Thoracic Outlet Syndrome
Neoplastic Brachial Plexopathy
Traumatic Brachial Plexopathy
Osteoarthritis
Osteoporosis (Primary)
Osteoporosis (Secondary)

Other Problems to Be Considered

Mechanical etiologies

Cervical stenosis
Cervical zygapophyseal (facet) arthropathy

Infectious etiologies

Discitis
Epidural, subdural, or intradural abscess

Metabolic etiologies

Osteomalacia
Parathyroid disease

Rheumatologic etiologies

Polymyalgia rheumatica
Ankylosing spondylitis
Reiter syndrome
Enteropathic arthritis
Diffuse idiopathic skeletal hyperostosis

Workup

Laboratory Studies

  • Consider performing rheumatologic workup to evaluate for possible rheumatoid arthritis, ankylosing spondylitis, Reiter syndrome, and polymyalgia rheumatica. These tests include the following:
    • Rheumatoid factor (elevated in rheumatoid arthritis)
    • HLA-B27 (positive in ankylosing spondylitis)
    • Erythrocyte sedimentation rate (elevated in polymyalgia rheumatica)
  • Consider performing infection workup to evaluate for possible discitis, epidural abscess, and vertebral osteomyelitis, including the following tests:
    • White blood cell count with differential (elevated with a left shift in bacterial infection)
    • Blood cultures (positive for the infecting organism)
    • Erythrocyte sedimentation rate (elevated in infection, but may be a nonspecific finding)

Imaging Studies

  • Imaging studies evaluate anatomy, rather than function, and are prone to false positive and negative results. For example, Boden et al's cervical MR study cites abnormalities in nearly 20% of asymptomatic subjects.10 Consequently, results of imaging studies must be interpreted within the context of each clinical case.
  • Plain radiographs
    • Plain cervical spine radiographs are used to evaluate chronic degenerative changes, metastatic disease, infection, spinal deformity, and stability.
    • Cervical spine trauma films use 7 views, including anteroposterior (AP), lateral, bilateral oblique, open-mouth, flexion, and extension.
      • Flexion-extension views identify subluxations or cervical spine instability.
      • Open-mouth views evaluate the odontoid process and C1-C2 stability.
      • AP views identify tumors, osteophytes, and fractures.
      • Lateral views assess stability and spondylosis (ie, spurring, disc space narrowing).
      • Oblique views reveal DDD, as well as foraminal encroachment by uncovertebral or Z-joint osteophytes.
  • Computed tomography (CT) scanning (See image below and Image 8.)
    • CT scans delineate cervical spine fracture and are used extensively in trauma cases.
    • Helical or spiral CT scanning generates an infinite number of images after data acquisition, providing more information for detailed fracture evaluation than does conventional CT scanning.
Postdiscography axial computed tomography (CT) sc...

Postdiscography axial computed tomography (CT) scan demonstrating right posterolateral subligamentous protrusion.

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Postdiscography axial computed tomography (CT) sc...

Postdiscography axial computed tomography (CT) scan demonstrating right posterolateral subligamentous protrusion.

  • CT myelography
    • A myelogram followed by a CT scan may be obtained prior to cervical decompressive spinal cord or nerve root surgery.
    • This study evaluates the spinal canal, its relationship to the spinal cord, and nerve root impingement from disc, spur, or foraminal encroachment.
    • CT myelography, still the criterion standard, remains superior to MRI in detecting lateral and foraminal encroachment, despite greater expense and morbidity. Consequently, CT myelography is not the initial imaging study to evaluate cervical spine and is reserved for complicated cases.
  • MRI remains the imaging modality of choice to evaluate cervical HNP, due to its low morbidity.5,11
    • Advantages include soft-tissue definition (eg, cervical discs, spinal cord), cerebrospinal fluid visualization, noninvasiveness, and lack of patient radiation exposure. (See images below and Images 2-3.)
    • Newer MRI pulse sequences and higher field magnets provide faster and more detailed imaging.
    • Unfortunately, some sequences (eg, spin echo) depict pathology larger than actual size and obscure other abnormalities. Other disadvantages include expense, inability of claustrophobic patients to tolerate the procedure, dependence on patient cooperation to minimize artifact, high false-positive rate, and insensitivity compared with CT scanning in evaluating bony structures.
    • Furthermore, MRI appears inferior in differentiating cervical disc prolapse (ie, soft cervical disc) from spondylitic osteophytic compression (ie, hard cervical disc).
    • Contraindications to MRI include patients with embedded metallic objects, such as pacemakers, surgical clips, spinal cord stimulators, or prosthetic heart valves that may be dislodged by MRI magnets.
Axial magnetic resonance imaging (MRI) scan (C3-C...

Axial magnetic resonance imaging (MRI) scan (C3-C4) demonstrating left-sided posterolateral protrusion of the nucleus pulposus with compression of the cerebrospinal fluid.

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Axial magnetic resonance imaging (MRI) scan (C3-C...

Axial magnetic resonance imaging (MRI) scan (C3-C4) demonstrating left-sided posterolateral protrusion of the nucleus pulposus with compression of the cerebrospinal fluid.


Sagittal magnetic resonance imaging (MRI) scan de...

Sagittal magnetic resonance imaging (MRI) scan demonstrating cervical intervertebral disc protrusions at C3-C4 and C7-T1.

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Sagittal magnetic resonance imaging (MRI) scan de...

Sagittal magnetic resonance imaging (MRI) scan demonstrating cervical intervertebral disc protrusions at C3-C4 and C7-T1.

  • Provocative cervical discography has been controversial since its introduction in 1957 by Smith. (See images below and Images 6-7.)
    • This imaging procedure involves sterile-technique placement of spinal needles into cervical intervertebral discs.
    • At least 2 different techniques exist for performing this procedure.
      • The paravertebral technique uses digital palpation to retract vital soft-tissue structures (eg, trachea, carotid artery, esophagus).
      • The oblique approach obviates the need for digital palpation. After spinal needles are placed within the center of the nucleus pulposus, contrast is injected to determine internal disc architecture and any pain response provoked.
    • Provocative discography is the only procedure that can determine whether a disc serves as the pain generator.
    • Discomfort and invasiveness render this procedure less desirable than cervical MRI, which provides much of the anatomical information that provocative discography does.
    • Provocative cervical discography identifies symptomatic disc(s), assisting in evaluation of patients with inconclusive diagnostic tests and presurgical fusion planning.
    • Contraindications to provocative discography include large disc herniation and midsagittal spinal canal diameter of less than 12 mm.
    • Complications include discitis, epidural abscess, quadriplegia, stroke, pneumothorax, nerve injury, and spinal cord injury. The reported rate of cervical discitis is 0.37%.
    • Discography should be performed at all accessible cervical levels, given the high frequency of multilevel symptomatic cervical discs.
    • Provocative discography may identify poor surgical candidates, thereby improving fusion outcomes.
Cervical discography. Anteroposterior fluoroscopi...

Cervical discography. Anteroposterior fluoroscopic image.

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Cervical discography. Anteroposterior fluoroscopi...

Cervical discography. Anteroposterior fluoroscopic image.


Cervical discography. Lateral fluoroscopic image.

Cervical discography. Lateral fluoroscopic image.

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Cervical discography. Lateral fluoroscopic image.

Cervical discography. Lateral fluoroscopic image.


Other Tests

  • Electrodiagnostic studies continue to be standard for evaluating neurologic function of the cervical spine.
    • Advantages of these tests include limited expense and low morbidity.
    • Nerve conduction studies (NCSs) and electromyography (EMG) studies provide physiologic assessment of cervical nerve root and peripheral nerve function.
      • Needle EMG can detect acute, subacute, and chronic radicular features if motor nerve fiber pathology exists.
      • A diagnosis of radiculopathy is apparent when needle EMG reveals abnormal spontaneous potentials and/or certain changes in motor unit action potentials, in 2 or more muscles innervated by the same nerve root but by different peripheral nerves. Ideally, EMG abnormalities also should be demonstrated in the paraspinal muscles to confirm the diagnosis of radiculopathy.
      • A compound motor action potential amplitude drop of 50% or more indicates significant axonal loss. This assessment is made via NCS of motor axons.
      • NCS/EMG is especially helpful in differentiating cervical radiculopathy from confounding neuropathic conditions (eg, ulnar nerve entrapment, carpal tunnel syndrome, peripheral neuropathy, plexopathy).
      • Unfortunately, cervical radiculopathies involving exclusively sensory axons (ie, without involvement of motor axons) rarely are detected by electrodiagnostic studies, which is a shortcoming of this diagnostic modality. In addition, routine motor NCSs do not evaluate the C6 and C7 nerve roots, which are most commonly involved, or the levels above.
      • Unlike needle EMG (which involves intramuscular evaluation and is a well-accepted diagnostic test), surface EMG generally is not considered to have an accepted role in the diagnosis of radiculopathy.
  • Somatosensory evoked potentials (SEPs) evaluate sensory conduction peripherally and centrally.
    • Lower limb SEPs involving tibial and peroneal nerves, which assess spinal cord conduction, are more sensitive in diagnosing myelopathy than are upper limb median and ulnar SEPs.
    • Dermatomal evoked potentials have been used to detect cervical radiculopathy but are of questionable value.

More on Cervical Disc Disease

Overview: Cervical Disc Disease
Differential Diagnoses & Workup: Cervical Disc Disease
Treatment & Medication: Cervical Disc Disease
Follow-up: Cervical Disc Disease
Multimedia: Cervical Disc Disease
References
Further Reading
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Keywords

cervical disc disease, spine, cervical spine, herniated disc, spinal stenosis, back surgery, degenerative disc disease, disc disease, radiculopathy, cervical spondylosis, disc herniation, back disc, cervical disc, disc surgery, spinal disc, disc pain, disk disease, degenerative spine, cervical disk, herniated discs, spine disc, nucleus pulposus, degenerative disk disease, cervical spinal stenosis, cervical spine surgery, annular tear, DDD, disc degeneration, disc extrusion, disc herniation, disc protrusion, disc sequestration, discogenic pain, herniated nucleus pulposus, HNP, inflammatory radiculopathy, internal disc disruption, IDD, intervertebral disc herniation, radicular pain, radiculitis, degenerative annular tears, cervical radiculopathy, nerve root injury, disc stenosis, myofascial pain, cervical disc disorder, central cord syndrome, CCS, spondylosis, neck pain, shoulder pain, Brown-Séquard syndrome, chemical radiculitis, vertebral sclerosis, osteophytic formation, whiplash, dynatome, Spurling maneuver, abduction sign, repetitive cervical stress, cervical flexion injury, cervical rotation injury

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Contributor Information and Disclosures

Author

Michael B Furman, MD, MS, Physiatrist, Interventional Spine Care Specialist, Electrodiagnostics, Orthopedic and Spine Specialists
Michael B Furman, MD, MS is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, American Association of Neuromuscular and Electrodiagnostic Medicine, American Medical Association, International Spine Intervention Society, North American Spine Society, Pennsylvania Medical Society, and Physiatric Association of Spine, Sports and Occupational Rehabilitation
Disclosure: pfizer Honoraria Speaking and teaching

Coauthor(s)

Jeremy Simon, MD, Attending Physician, Department of Physical Medicine, The Rothman Institute
Jeremy Simon, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, International Spine Intervention Society, North American Spine Society, and Physiatric Association of Spine, Sports and Occupational Rehabilitation
Disclosure: Nothing to disclose.

Kirk M Puttlitz, MD, Consulting Staff, Pain Management and Physical Medicine, Arizona Neurological Institute
Kirk M Puttlitz, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation and Phi Beta Kappa
Disclosure: Nothing to disclose.

Frank John English Falco, MD, Physiatrist, MidAtlantic Spine
Frank John English Falco, MD is a member of the following medical societies: American Academy of Pain Medicine, American Academy of Physical Medicine and Rehabilitation, American Association of Neuromuscular and Electrodiagnostic Medicine, American Medical Association, American Society of Regional Anesthesia and Pain Medicine, Association of Academic Physiatrists, and Physiatric Association of Spine, Sports and Occupational Rehabilitation
Disclosure: St. Jude's Medical Consulting fee Speaking and teaching

Medical Editor

Everett C Hills, MD, MS, Medical Director, Penn State Hershey Rehabilitation Hospital, Assistant Professor of Orthopaedics and Rehabilitation, Assistant Professor of Neurology, Penn State Milton S. Hershey Medical Center and Penn State University College of Medicine
Everett C Hills, MD, MS is a member of the following medical societies: American Academy of Disability Evaluating Physicians, American Academy of Physical Medicine and Rehabilitation, American College of Physician Executives, American Congress of Rehabilitation Medicine, American Medical Association, American Society of Neurorehabilitation, Association of Academic Physiatrists, and Pennsylvania Medical Society
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Patrick M Foye, MD, FAAPMR, FAAEM, Associate Professor of Physical Medicine and Rehabilitation, Co-Director of Musculoskeletal Fellowship, Co-Director of Back Pain Clinic, Director of Coccyx Pain Service (Tailbone Pain Service: www.TailboneDoctor.com), University of Medicine and Dentistry of New Jersey, New Jersey Medical School
Patrick M Foye, MD, FAAPMR, FAAEM is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, American Association of Neuromuscular and Electrodiagnostic Medicine, Association of Academic Physiatrists, and International Spine Intervention Society
Disclosure: Nothing to disclose.

CME Editor

Kelly L Allen, MD, Regional Medical Director, IMX-Medical Management Services
Disclosure: Nothing to disclose.

Chief Editor

Consuelo T Lorenzo, MD, Consulting Staff, Department of Physical Medicine and Rehabilitation, Alegent Health Care, Immanuel Rehabilitation Center
Consuelo T Lorenzo, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation
Disclosure: Nothing to disclose.

 
 
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