Cervical Disc Disease Treatment & Management
- Author: Michael B Furman, MD, MS; Chief Editor: Dean H Hommer, MD more...
For most cervical disc disorders, studies support conservative treatment, such as the McKenzie approach and cervicothoracic stabilization programs, combined with aerobic conditioning.
The McKenzie system identifies 3 mechanical syndromes, as follows, that cause pain and compromise function:
The postural syndrome provokes pain when normal soft tissues are loaded statically at end ROM; pathology need not be present. Treatment aims to correct posture.
The dysfunction syndrome produces pain when the patient, upon attempting full movement, mechanically deforms contracted scarred soft tissue. Consequently, therapy involves stretching and remodeling of such contracted tissue.
The derangement syndrome produces intermittent pain when certain movements or postures occur. Specifically, pain may become centralized or peripheralized because of theoretical activity-dependent displacement of intradiscal material. Therapy attempts to correct derangement by promoting activity that centralizes pain.
The McKenzie theory recognizes that although patients may demonstrate similar signs and symptoms, one movement (eg, cervical extension) nevertheless may help some patients and aggravate symptoms in others. Indeed, McKenzie therapy does not use only extension-biased exercise. Consequently, treatment individualization and patient education play key roles.
Cervicothoracic stabilization limits pain, maximizes function, and prevents further injury. Such stabilization includes cervical spine flexibility, postural training, and strengthening. This program emphasizes patient responsibility through active participation.
Restoring flexibility prevents further repetitive microtrauma from poor movement patterning. Pain-free ROM is determined by placing the cervical spine in positions that produce and relieve symptoms. Initially, stabilization commences within established pain-free ROM and then progresses outside this ROM as pain diminishes. Soft tissue or joint restriction inhibiting ROM is treated quickly. Anterior and posterior neck muscles are stretched. Indeed, such spine and soft-tissue mobilization, passive ROM, self-stretching, and correct posturing collectively restore ROM.
Postural training commences with the patient, supervised by a therapist, in front of a mirror. The patient performs various transfer maneuvers while maintaining a neutral spine (i.e., correct posturing), with feedback from the mirror and the therapist. Patient goals include maintenance of neutral spine and demonstrating correct posture during daily activities.
These proprioceptive skills, implemented during strengthening exercises, facilitate stable, safe, and pain-free cervical posture during strenuous activity. Indeed, cervicothoracic stabilization requires strengthening and coordination of neck, shoulder, and scapular muscles. Cervical muscles include extensors, flexors, rectus capitis anterior, rectus capitis lateralis, longissimus cervicis, and longissimus capitis. Primary thoracic stabilizers include abdominals, lumbar paraspinal extensors, and latissimus dorsi. Scapular muscles include the middle and lower trapezius, serratus anterior, and rhomboids. Chest muscles include the pectoralis major and minor. Successful stabilization also requires the training of the lumbar spine and lower extremities, which provide a foundation for the cervicothoracic spine.
Stabilization exercises proceed systematically from simple to complex. Isometric and isotonic resistive exercises employ elastic bands, weight machines, and free weights. Such conditioning distributes forces away from the cervical spine. Exercise repetition ultimately encodes an engram that commands immediate, automatic cervicothoracic stabilization during everyday activity.
Butler's therapy techniques treat radicular symptoms by mobilizing the involved nerve. First, the therapist identifies "adverse neural tension," defined as pathologic mechanical and physiologic responses elicited from a nerve when its stretch properties and ROM are evaluated. Specifically, the therapist performs neurodynamic testing to evaluate a nerve's mechanical properties (e.g., its mobilization around neighboring intervertebral discs) and physiological characteristics (e.g., its response to ischemia, inflammation). Having tested the nerve in question, the therapist may institute treatment consisting initially of passive mobilization to provide CNS input without inciting a stress response and neurogenic massage to reduce perineural swelling. Later, the therapist progresses to active neuromobilization, because, according to Butler, recovering nervous tissue (like other connective tissue) requires movement to promote healing and restoration of optimum mechanical properties.
Butler admits that limited evidence suggests that neurodynamic mobilization improves clinical outcomes. However, he believes that optimizing tissue health and cardiovascular fitness, as well as minimizing negative beliefs and environmental factors, can be beneficial.
Functional restoration programs assist patients disabled by chronic cervical pain overcome obstacles to recovery. Such obstacles include deconditioning, secondary gain, poor motivation, and psychopathology. An occupational or physical therapist, athletic trainer, or nurse instructs the patient in cervical anatomy, biomechanics, pathology, and ergonomics. Patients employ preventive measures in order to prohibit further injury during all daily activities. These medically directed interdisciplinary programs have been successful at enabling workers' compensation patients to return to work. Furthermore, Wright and colleagues reported lower rates of recurrent injury, new surgery, and need for health care services for patients with chronic cervical pain who successfully completed functional restoration.
An intervertebral disc compressing the spinal cord can provoke myelopathy with associated weakness, hyperreflexia, and neurogenic bowel and bladder dysfunction. Radiculopathy can manifest significant upper limb weakness or numbness. Intractable axial or radicular pain may result from cervical disc disorders.
Studies indicate that cervical HNP with radiculopathy can be managed conservatively. Surgery is warranted when neurogenic bowel or bladder dysfunction, deteriorating neurologic function, or intractable radicular or discogenic neck pain exists. Specifically, cervical spine surgical outcomes are most favorable for radicular pain, spinal instability, progressive myelopathy, or upper extremity weakness.
Surgical outcomes for those patients with myelopathy have been shown to be significantly greater in regards to motor recovery if surgical intervention is performed less than 1 year since the onset of symptoms. A study by Fay et al suggested that cervical arthroplasty is about as effective in treating DDD-related cervical spondylotic myelopathy (CSM) as it is in treating DDD-related cervical radiculopathy. The study involved 151 patients with cervical DDD who underwent arthroplasty, including 72 patients with CSM and 53 with radiculopathy. The investigators found at 3-year postoperative follow-up that the clinical and radiographic outcomes in the myelopathy group were similar to those in the radiculopathy patients.
The literature has demonstrated favorable cervical spine fusion outcomes for chronic discogenic axial neck pain when the presurgical evaluation incorporated provocative cervical discography. Provocative discography identified the painful segment(s) and confirmed adjacent pain-free levels.
Fusion can increase intradiscal pressure and other stress at adjacent unfused levels, thereby accelerating postsurgical spinal degeneration.[25, 26, 27, 28, 29]
The possibility of obtaining the goals of anterior cervical decompression and fusion (ACDF) while maintaining adjacent segment motion led to the advent of total disk replacement (TDR). Currently, 3 devices for disc replacement have been approved with other trials underway. Studies have shown several advantages of TDR over ACDF, including reduction of bone graft site morbidity, adjacent segment disease, pseudarthrosis, reoperation rate, and anterior cervical plating.
For example, a literature review by Luo et al comparing TDR (889 patients) to ACDF (837 patients) found that in patients with one-level cervical DDD, TDR led to a significantly reduced rate of adjacent segment disease compared with ACDF, at 24-month postoperative follow-up.
In another report, a nonblinded, prospective, randomized, industry-sponsored outcome study with 5-year follow-up (n=209), the rate of reoperation was less following cervical TDR (2.9%) than after conventional ACDF (14.5%).
However, disc replacement is not without complications and can lead to implant failure and bone-implant interface failure. Another documented complication is heterotrophic ossification and osteolysis, which can reduce the ROM at the replacement level. To date, no one surgical technique has been found to be statistically more favorable or superior to another.[32, 23, 33, 34]
A 2009 study sought to determine which factors are predictive of patient outcome following anterior discectomy and fusion Surgical outcomes that developed over a 2-year period were examined in patients who were treated for recalcitrant single-level subaxial radiculopathy or myelopathy. The study's results indicated that important prognostic factors include whether or not a patient is gainfully employed, has normal sensory function prior to surgery, has higher preoperative disability scores, and is involved in spine-related litigation.
A systematic literature review by Wullems et al indicated that percutaneous cervical nucleoplasty is a safe and effective treatment for contained herniated discs, even at long-term follow-up. The investigators cautioned, however, that the level of evidence found in their review was only moderate.
A literature review by Hu et al indicated that in the treatment of symptomatic cervical disc disease, the outcome of cervical disc arthroplasty is better than that of anterior discectomy and fusion with regard to overall and neurologic success, Neck Disability Index results, secondary procedures, functional outcomes, patient satisfaction, degeneration of the superior adjacent segment, and serious adverse events related to implants and surgery.
See the list below:
Consultation with an internal medicine specialist is indicated when neck pain suggests an underlying systemic illness (eg, malignancy, infection, metabolic bone disease).
Consider consultation with a rheumatologist when neck pain suggests a rheumatologic condition (eg, polymyalgia rheumatica).
Consultation with a surgeon for cervical disc disorders is warranted for resulting neurogenic bowel/bladder dysfunction, deteriorating neurologic status (eg, myelopathy), segmental instability, and/or intractable radicular or discogenic pain.
See the list below:
Physical modalities should be used to reduce pain only in the acute phase. Once past the acute phase, modalities are used sparingly on an as-needed basis.
- Superficial heat modalities relax muscle and relieve soft-tissue pain.
- Conversely, deep-heating modalities (eg, ultrasonography) should be avoided in acute cervical radiculopathy, because they augment inflammation and, consequently, exacerbate radicular pain and nerve root injury.
Cervical traction may relieve radicular pain from nerve root compression. Traction does not improve soft-tissue injury pain. Hot packs, massage, and/or electrical stimulation should be applied prior to traction to relieve pain and relax muscles.
- Traction regimens include heavy weight-intermittent or light weight-continuous. The neck is flexed 15-20º (ie, not extended) during traction. In the cervical spine, approximately 10 lb of force is necessary to counter gravity and 25 lb of force is necessary to achieve separation of the posterior vertebral segments.
- Light weight-continuous home traction is cost effective and provides the patient with more autonomy.
- Pneumatic traction devices afford greater patient comfort and, consequently, increased compliance.
A soft cervical collar is recommended only for acute soft-tissue neck injuries and for short periods of time (ie, not to exceed 3-4 days' continuous use). Risks include limiting cervical ROM and losing neck strength if the collar is worn continuously for longer periods.
- When worn for radiculopathy caused by foraminal stenosis, the wide part of the collar is placed posteriorly and the thin part is placed anteriorly to promote neck flexion, discourage extension, and open the intervertebral foramina.
- Collars can be worn during certain activities, such as sleeping or driving, for longer periods.
- Although not commonly used, a Philadelphia collar can be worn at night to position the neck rigidly in flexion, thereby maintaining open foramina.
Spinal manipulation and mobilization may restore normal ROM and decrease pain; however, no clear therapeutic mechanism of action is known. Some believe that zygapophysial joint adjustment improves afferent signals from mechanoreceptors to peripheral and central nervous systems.
- Normalization of afferent impulses improves muscle tone, decreases muscle guarding, and promotes more effective local tissue metabolism. These physiologic modifications subsequently improve ROM and pain reduction.
- Studies document short-term improvement in the acutely injured patient and in those with cervicogenic headache and radiculopathy secondary to disc herniation.
- No evidence exists that manipulation confers long-term benefit, improves chronic conditions, or alters the natural course of the disorder.
Cervical epidural, spinal nerve (or root), Z-joint, and sympathetic injections serve diagnostic and therapeutic roles. These procedures can be instrumental in determining the anatomic pain generator (eg, nerve root, facet) and providing aggressive, conservative treatment.
Therapeutic cervical epidural injections treat radicular pain, although some literature has demonstrated reduced axial pain as well. (See the images below.)Right C7 cervical transforaminal epidural steroid injection demonstrating epidural and radicular spread of radiologic contrast dye.
- An anesthetic and corticosteroid mixture may be injected into the epidural space (interlaminar) or along the nerve root (transforaminal) after precise radiologic, contrast-enhanced fluoroscopic localization.
- The anesthetic can relieve sympathetically mediated pain.
- The corticosteroid provides long-term relief if pain results from an intense inflammatory component.
- Such injections provide a pain-free window of opportunity for more aggressive physical therapy.
Diagnostic selective spinal nerve or ventral ramus blocks inject a small anesthetic volume extraforaminally at a single spinal segment level (eg, C5 versus C6); consequently, they are more precise than the "gunshot" interlaminar approach in identifying the symptomatic nerve.
- Precise symptomatic nerve identification permits the physician to design a more focused treatment protocol.
- Patients record pain changes in a pain diary following the injection, to confirm diagnostic accuracy.
- A double injection paradigm previously reported in the literature for facet injections can provide information to the physician for use in determining a diagnosis of radicular pain and to help confirm the symptomatic nerve level. This paradigm identifies patients who have tested false-positive or may have a tendency to respond to a placebo, by determining whether, on separate injection days, they received short-term relief with a short-acting anesthetic (eg, lidocaine) and long-term relief with a long-acting anesthetic (eg, bupivacaine).
Adverse effects include those from anesthesia, corticosteroids, and radiologic contrast dye.
- Blood clotting parameters should be drawn prior to injection in patients with suspected bleeding diathesis. Indeed, spinal cord compression could result if bleeding occurs in the presence of relative spinal stenosis (ie, midsagittal diameter less than 12 mm) in which little room exists to accommodate an epidural hematoma.
- Nonsteroidal anti-inflammatory drugs (NSAIDs), including aspirin, should be discontinued prior to the procedure in accordance with their half-life and hematologic profile.
- Other potential risks include seizure, vertebral artery spasm, infection, temporary quadriparesis from anesthetic, and respiratory arrest.
- One study, however, suggested that selective cervical nerve blocks carry low morbidity when performed under contrast-enhanced fluoroscopic guidance.
- In any event, proper patient monitoring and emergency equipment always should be present.
Reports of serious CNS complications, including spinal cord injuries and strokes, following cervical transforaminal steroid injections have gained the attention of many practitioners. The mechanism of the injury is believed to be related to the introduction of particulate matter within the corticosteroid preparations, causing occlusion of a vessel.
- Hodges and colleagues described 2 case reports in which intrinsic spinal cord damage resulted from cervical epidural steroid injection despite fluoroscopic guidance; the patients, because of intravenous sedation, were unable to perceive and report pain and paresthesias from needle-induced spinal cord trauma during the procedure.
- Furman et al demonstrated a relatively high incidence of entering the intravascular space with transforaminal epidural steroid injections. They also showed that attempting to use a flash of blood in the needle hub to predict intravascular compromise was 97% specific but only 45.9% sensitive. This article underscored the importance of using fluoroscopy and contrast dye to ensure proper placement of the therapeutic agents. Using a flash of blood in the hub without fluoroscopy cannot reliably predict intravascular compromise.
- Brouwers et al reported a fatal case of spinal cord infarction following a cervical transforaminal steroid injection.
- Baker et al demonstrated that a radicular artery supplying the cervical spinal cord can be infiltrated by a transforaminal epidural steroid injection. In this report, prior to steroid injection for a left C6-C7, contrast was administered. Using digital subtraction technique, it was clear that a radicular artery filled with contrast; the procedure was aborted without adverse effects. This report revealed a potential access point for an injection-related spinal cord infarction.
- The potentially catastrophic complications that can follow a cervical transforaminal epidural steroid injection cannot be underestimated. While these procedures are perceived as posing less of a risk than surgery, they still carry substantial hazards. They should be performed by skilled practitioners and under fluoroscopic guidance. Baker et al further suggest the use of digital subtraction, because intravascular compromise may be missed on routine spot films.
Biologic therapies for symptomatic intervertebral discs offer a novel approach to treatment. By effectively targeting the primary pain generator (ie, the intervertebral cervical disc) clinicians may treat the source of the pain and not just the sequelae of the degenerative cascade (ie, radiculopathy or discogenic pain). These treatments may also offer alternatives to conservative or surgical measures. Because these agents can be injected with contrast-enhanced fluoroscopic guidance, they may result in reduced morbidity to the patient.
To date several biologic compounds are under clinical and laboratory investigations. These include:
Growth factors, including tumor growth factor (TGF)-beta, bone morphogenetic proteins (BMP)-2, BMP -7, BMP-14: Infusion of growth factors has been shown in animal models to cause an anabolic response with increases in disc height and proteoglycan synthesis. BMP-7 and BMP-14 are currently in phase I clinical trials.
Gene transfer: The gene encoding the growth factor or therapeutic protein would be implanted into the disc to produce the protein in situ. Preliminary results have been promising, showing increased proteoglycan synthesis when injected into human disc cells in vitro. 
Cell therapy, including autologous disc cells, articular chondrocytes, and mesenchymal stem cells: These substances can be transplanted into vertebral discs, slowing disc degeneration. Several in vivo animal studies have shown that mesenchymal stem cells slow the progression of disc degeneration as well as regenerate the matrix.  Numerous other studies have demonstrated the ability of injected cells to survive, differentiate toward disc cells, and produce matrix components, including collagen II and proteoglycans. [43, 44]
Tissue engineering: Therapeutic agents, when injected into the intervertebral disc function to alter both biochemical and biomechanical stressors. At this time, a US Food and Drug Administration (FDA)-approved trial is underway evaluating the efficacy and safety of a fibrin sealant derived from human plasma derivatives (fibrinogen and thrombin). This substance (fibrinogen and thrombin) has been shown in animal studies to inhibit nucleus pulposus fibrosis, promote recovery of proteoglycan content, and facilitate repair of the annulus. A pilot study showed reduction in pain and disability at 1 and 2 years after a single injection. [45, 46]
In the early stage of disc degeneration, protein factors such as growth factors and proteinase inhibitors may be effective. In the intermediate stage of degeneration, cell or gene therapy may be required. In the advanced stages of disc degeneration, tissue engineering approaches will be needed.
Biologic substances offer a great potential for therapy of the degenerative disc. There have been numerous studies indicating in vitro and in vivo success in rebuilding or repairing the structure of the intervertebral disc. With these rapid advancements, these interventions may soon be available in clinical practice. What remains to be answered is if these biomechanical and biochemical alterations will offer clinically relevant findings. Whether structural changes to the disc will lead to decreased pain and increased function of the patient is unclear.
Fardon DF, Milette PC. Nomenclature and classification of lumbar disc pathology. Recommendations of the Combined task Forces of the North American Spine Society, American Society of Spine Radiology, and American Society of Neuroradiology. Spine (Phila Pa 1976). 2001 Mar 1. 26(5):E93-E113. [Medline].
Carette S, Fehlings MG. Clinical practice. Cervical radiculopathy. N Engl J Med. 2005 Jul 28. 353(4):392-9. [Medline].
Tanaka Y, Kokubun S, Sato T, et al. Cervical roots as origin of pain in the neck or scapular regions. Spine. 2006 Aug 1. 31(17):E568-73. [Medline].
Baptiste DC, Fehlings MG. Pathophysiology of cervical myelopathy. Spine J. 2006 Nov-Dec. 6(6 Suppl):190S-197S. [Medline].
Denda H, Kimura S, Yamazaki A, et al. Clinical significance of cerebrospinal fluid nitric oxide concentrations in degenerative cervical and lumbar diseases. Eur Spine J. 2011 Apr. 20(4):604-11. [Medline]. [Full Text].
Fei Z, Fan C, Ngo S, Xu J, Wang J. Dynamic evaluation of cervical disc herniation using kinetic MRI. J Clin Neurosci. 2011 Feb. 18(2):232-6. [Medline].
Nam TW, Lee HS, Goh TS, Lee JS. Predictors of Motor Weakness and Delayed Recovery in Cervical Disk Herniation. J Spinal Disord Tech. 2015 Aug. 28 (7):E405-9. [Medline].
Shedid D, Benzel EC. Cervical spondylosis anatomy: pathophysiology and biomechanics. Neurosurgery. 2007 Jan. 60(1 Supp1 1):S7-13. [Medline].
Miyazaki M, Hong SW, Yoon SH, et al. Reliability of a magnetic resonance imaging-based grading system for cervical intervertebral disc degeneration. J Spinal Disord Tech. 2008 Jun. 21(4):288-92. [Medline].
Radhakrishnan K, Litchy WJ, O''Fallon WM, Kurland LT. Epidemiology of cervical radiculopathy. A population-based study from Rochester, Minnesota, 1976 through 1990. Brain. 1994 Apr. 117 ( Pt 2):325-35. [Medline].
Schoenfeld AJ, George AA, Bader JO, Caram PM Jr. Incidence and epidemiology of cervical radiculopathy in the United States military: 2000 to 2009. J Spinal Disord Tech. 2012 Feb. 25(1):17-22. [Medline].
Salemi G, Savettieri G, Meneghini F, et al. Prevalence of cervical spondylotic radiculopathy: a door-to-door survey in a Sicilian municipality. Acta Neurol Scand. 1996 Feb-Mar. 93(2-3):184-8. [Medline].
Kelley LA. In neck to neck competition are women more fragile?. Clin Orthop. 2000 Mar. (372):123-30. [Medline].
Marchiori DM, Henderson CN. A cross-sectional study correlating cervical radiographic degenerative findings to pain and disability. Spine. 1996 Dec 1. 21(23):2747-51. [Medline].
Slipman CW, Plastaras C, Patel R, et al. Provocative cervical discography symptom mapping. Spine J. 2005 Jul-Aug. 5(4):381-8. [Medline].
Yates JP, McGill SM. The effect of vibration and posture on the progression of intervertebral disc herniation. Spine (Phila Pa 1976). 2011 Mar 1. 36(5):386-92. [Medline].
Malanga GA, Landes P, Nadler SF. Provocative tests in cervical spine examination: historical basis and scientific analyses. Pain Physician. 2003 Apr. 6(2):199-205. [Medline].
Boden SD, McCowin PR, Davis DO, et al. Abnormal magnetic-resonance scans of the cervical spine in asymptomatic subjects. A prospective investigation. J Bone Joint Surg Am. 1990 Sep. 72(8):1178-84. [Medline].
Kuijper B, Tans JT, van der Kallen BF, Nollet F, Lycklama A Nijeholt GJ, de Visser M. Root compression on MRI compared with clinical findings in patients with recent onset cervical radiculopathy. J Neurol Neurosurg Psychiatry. 2011 May. 82(5):561-3. [Medline].
Shim JH, Park CK, Lee JH, Choi JW, Lee DC, Kim DH, et al. A comparison of angled sagittal MRI and conventional MRI in the diagnosis of herniated disc and stenosis in the cervical foramen. Eur Spine J. 2009 Mar 18. [Medline].
Manchikanti L, Dunbar EE, Wargo BW, Shah RV, Derby R, Cohen SP. Systematic review of cervical discography as a diagnostic test for chronic spinal pain. Pain Physician. 2009 Mar-Apr. 12(2):305-21. [Medline].
Dillingham TR, Lauder TD, Andary M, et al. Identification of cervical radiculopathies: optimizing the electromyographic screen. Am J Phys Med Rehabil. 2001 Feb. 80(2):84-91. [Medline].
Fay LY, Huang WC, Wu JC, et al. Arthroplasty for cervical spondylotic myelopathy: similar results to patients with only radiculopathy at 3 years' follow-up. J Neurosurg Spine. 2014 Sep. 21(3):400-10. [Medline].
Bhadra AK, Raman AS, Casey AT, Crawford RJ. Single-level cervical radiculopathy: clinical outcome and cost-effectiveness of four techniques of anterior cervical discectomy and fusion and disc arthroplasty. Eur Spine J. 2009 Feb. 18(2):232-7. [Medline].
Bapat MR, Chaudhary K, Sharma A, et al. Surgical approach to cervical spondylotic myelopathy on the basis of radiological patterns of compression: prospective analysis of 129 cases. Eur Spine J. 2008 Dec. 17(12):1651-63. [Medline].
Pechlivanis I, Brenke C, Scholz M, et al. Treatment of degenerative cervical disc disease with uncoforaminotomy--intermediate clinical outcome. Minim Invasive Neurosurg. 2008 Aug. 51(4):211-7. [Medline].
Yan D, Li J, Zhu H, et al. Percutaneous cervical nucleoplasty and percutaneous cervical discectomy treatments of the contained cervical disc herniation. Arch Orthop Trauma Surg. 2010 Jan 8. [Medline].
King JT Jr, Abbed KM, Gould GC, et al. Cervical spine reoperation rates and hospital resource utilization after initial surgery for degenerative cervical spine disease in 12,338 patients in Washington State. Neurosurgery. 2009 Dec. 65(6):1011-22; discussion 1022-3. [Medline].
Luo J, Gong M, Huang S, et al. Incidence of adjacent segment degeneration in cervical disc arthroplasty versus anterior cervical decompression and fusion meta-analysis of prospective studies. Arch Orthop Trauma Surg. 2015 Feb. 135(2):155-60. [Medline].
Delamarter RB, Zigler J. Five-year Reoperation Rates, Cervical Total Disc Replacement versus Fusion, Results of a Prospective Randomized Clinical Trial. Spine (Phila Pa 1976). 2012 Nov 2. [Medline].
Salari B, McAfee PC. Cervical total disk replacement: complications and avoidance. Orthop Clin North Am. 2012 Jan. 43(1):97-107, ix. [Medline].
Gebremariam L, Koes BW, Peul WC, Huisstede BM. Evaluation of treatment effectiveness for the herniated cervical disc: a systematic review. Spine (Phila Pa 1976). 2012 Jan 15. 37(2):E109-18. [Medline].
Anderson PA, Subach BR, Riew KD. Predictors of outcome after anterior cervical discectomy and fusion: a multivariate analysis. Spine. 2009 Jan 15. 34(2):161-6. [Medline].
Wullems JA, Halim W, van der Weegen W. Current evidence of percutaneous nucleoplasty for the cervical herniated disk: a systematic review. Pain Pract. 2014 Jul. 14(6):559-69. [Medline].
Hu Y, Lv G, Ren S, Johansen D. Mid- to Long-Term Outcomes of Cervical Disc Arthroplasty versus Anterior Cervical Discectomy and Fusion for Treatment of Symptomatic Cervical Disc Disease: A Systematic Review and Meta-Analysis of Eight Prospective Randomized Controlled Trials. PLoS One. 2016. 11 (2):e0149312. [Medline]. [Full Text].
Derby R, Baker R, Dreyfuss P. Cervical radicular pain: transforaminal vs. interlaminar steroid injections. ISIS Scientific Newsletter: Current Concepts-SpineLine. 2005. 5(1):16-17.
Hodges SD, Castleberg RL, Miller T, et al. Cervical epidural steroid injection with intrinsic spinal cord damage. Two case reports. Spine. 1998 Oct 1. 23(19):2137-42; discussion 2141-2. [Medline].
Furman MB, Giovanniello MT, O''Brien EM. Incidence of intravascular penetration in transforaminal cervical epidural steroid injections. Spine. 2003 Jan 1. 28(1):21-5. [Medline].
Brouwers PJ, Kottink EJ, Simon MA, et al. A cervical anterior spinal artery syndrome after diagnostic blockade of the right C6-nerve root. Pain. 2001 Apr. 91(3):397-9. [Medline].
Baker R, Dreyfuss P, Mercer S, et al. Cervical transforaminal injection of corticosteroids into a radicular artery: a possible mechanism for spinal cord injury. Pain. 2003 May. 103(1-2):211-5. [Medline].
Zhang Y, Chee A, Thonar EJ, An HS. Intervertebral disk repair by protein, gene, or cell injection: a framework for rehabilitation-focused biologics in the spine. PM R. 2011 Jun. 3(6 Suppl 1):S88-94. [Medline].
DePalma M. Biologic Treatments for Discogenic Low Back Pain. SpineLine. 2012/04. 3:19-26.
Adams F. In: Paulus Aeginata. Vol 2. London:. Sydenham Society. 1816:55-6, 193, 197.
Alejos JT, Wilder RP, Cole AJ, et al. Return to work and functional optimization programs. In: Cole AJ, Herring SA, eds. The Low Back Pain Handbook: A Practical Guide for the Primary Care Clinician. St Louis, Mo:. Mosby. 1997:149-52.
Antich PA, Sanjuan AC, Girvent FM, Simo JD. High cervical disc herniation and Brown-Sequard syndrome. A case report and review of the literature. J Bone Joint Surg Br. 1999 May. 81(3):462-3. [Medline].
Aprill C, Bogduk N. The prevalence of cervical zygapophyseal joint pain. A first approximation. Spine. 1992 Jul. 17(7):744-7. [Medline].
Aprill C, Dwyer A, Bogduk N. Cervical zygapophyseal joint pain patterns. II: A clinical evaluation. Spine. 1990 Jun. 15(6):458-61. [Medline].
Bannister G, Gargan M. Prognosis of whiplash injuries. A review of the spine. In: State of the Art Reviews. Philadelphia, Pa:. Hanley & Belfus. 1993:557-70.
Barnsley L, Lord S, Bogduk N. Comparative local anaesthetic blocks in the diagnosis of cervical zygapophysial joint pain. Pain. 1993 Oct. 55(1):99-106. [Medline].
Barnsley L, Lord S, Wallis B, Bogduk N. False-positive rates of cervical zygapophysial joint blocks. Clin J Pain. 1993 Jun. 9(2):124-30. [Medline].
Bogduk N. The clinical anatomy of the cervical dorsal rami. Spine. 1982 Jul-Aug. 7(4):319-30. [Medline].
Bogduk N, Aprill C. On the nature of neck pain, discography and cervical zygapophysial joint blocks. Pain. 1993 Aug. 54(2):213-7. [Medline].
Bogduk N, Windsor M, Inglis A. The innervation of the cervical intervertebral discs. Spine. 1988 Jan. 13(1):2-8. [Medline].
Braddom RL, Buschbacher RM, Dumitru D. Physical Medicine and Rehabilitation. 2nd ed. Philadelphia, Pa: WB Saunders; 2000:. 426-9.
Bush K, Chaudhuri R, Hillier S, Penny J. The pathomorphologic changes that accompany the resolution of cervical radiculopathy. A prospective study with repeat magnetic resonance imaging. Spine. 1997 Jan 15. 22(2):183-6; discussion 187. [Medline].
Butler D. Mobilization of the Nervous System. New York, NY: Churchill Livingstone; 1991.
Butler D. The Sensitive Nervous System. Adelaide, Australia: Noigroup Publications; 2000:. 98, 378, 383-4, 394.
Chan WC, Sze KL, Samartzis D, Leung VY, Chan D. Structure and biology of the intervertebral disk in health and disease. Orthop Clin North Am. 2011 Oct. 42(4):447-64, vii. [Medline].
Chen TY. The clinical presentation of uppermost cervical disc protrusion. Spine. 2000 Feb 15. 25(4):439-42. [Medline].
Cicala RS, Thoni K, Angel JJ. Long-term results of cervical epidural steroid injections. Clin J Pain. 1989 Jun. 5(2):143-5. [Medline].
Cloward RB. Cervical diskography. A contribution to the etiology and mechanism of neck, shoulder and arm pain. Ann Surg. 1959 Dec. 150:1052-64. [Medline].
Connor PM, Darden BV 2d. Cervical discography complications and clinical efficacy. Spine. 1993 Oct 15. 18(14):2035-8. [Medline].
Dai L. Disc degeneration and cervical instability. Correlation of magnetic resonance imaging with radiography. Spine. 1998 Aug 15. 23(16):1734-8. [Medline].
Dai L, Jia L. Central cord injury complicating acute cervical disc herniation in trauma. Spine. 2000 Feb 1. 25(3):331-5; discussion 336. [Medline].
Dan NG. A prospective randomized study of anterior single-level cervical disc operations with long-term follow-up: surgical fusion is unnecessary. Neurosurgery. 1999 Apr. 44(4):919. [Medline].
Derby R, Bogduk N, Schwarzer A. Precision percutaneous blocking procedures for localizing spinal pain. Part 1: The posterior lumbar compartment. Pain Digest. 1993. 3:89-100.
Dreyfuss P. The Texas two-step injection technique. (Personal communication).
Dumitru D, Dreyfuss P. Dermatomal/segmental somatosensory evoked potential evaluation of L5/S1 unilateral/unilevel radiculopathies. Muscle Nerve. 1996 Apr. 19(4):442-9. [Medline].
Dwyer A, Aprill C, Bogduk N. Cervical zygapophyseal joint pain patterns. I: A study in normal volunteers. Spine. 1990 Jun. 15(6):453-7. [Medline].
Ferrante FM, Wilson SP, Iacobo C, et al. Clinical classification as a predictor of therapeutic outcome after cervical epidural steroid injection. Spine. 1993 May. 18(6):730-6. [Medline].
Gajendran VK, Reuter MW, Golish SR, Hanna LS, Scuderi GJ. Is the fibronectin-aggrecan complex present in cervical disk disease?. PM R. 2011 Nov. 3(11):1030-4. [Medline].
Gore DR, Sepic SB. Anterior cervical fusion for degenerated or protruded discs. A review of one hundred forty-six patients. Spine. 1984 Oct. 9(7):667-71. [Medline].
Grant RN, McKenzie RA. Mechanical diagnosis and therapy for the cervical and thoracic spine. In: Grant R, ed. Physical Therapy of the Cervical and Thoracic Spine. New York, NY: Churchill Livingstone; 1998:. 359-77.
Grubb SA, Kelly CK. Cervical discography: clinical implications from 12 years of experience. Spine. 2000 Jun 1. 25(11):1382-9. [Medline].
Guyer RD, Collier R, Stith WJ, et al. Discitis after discography. Spine. 1988 Dec. 13(12):1352-4. [Medline].
Hamada G, Rida A. Orthopaedics and orthopaedic diseases in ancient and modern Egypt. Clin Orthop. 1972. 89:253-68. [Medline].
Heckmann JG, Lang CJ, Zobelein I, et al. Herniated cervical intervertebral discs with radiculopathy: an outcome study of conservatively or surgically treated patients. J Spinal Disord. 1999 Oct. 12(5):396-401. [Medline].
Herzog J. Use of cervical spine manipulation under anesthesia for management of cervical disk herniation, cervical radiculopathy, and associated cervicogenic headache syndrome. J Manipulative Physiol Ther. 1999 Mar-Apr. 22(3):166-70. [Medline].
Humphreys SC, Hodges SD, Patwardhan A, et al. The natural history of the cervical foramen in symptomatic and asymptomatic individuals aged 20-60 years as measured by magnetic resonance imaging. A descriptive approach. Spine. 1998 Oct 15. 23(20):2180-4. [Medline].
Jackson R. The Cervical Syndrome. Springfield, Ill: Charles C. Thomas; 1958.
Jacobs LJ, Vo N, Kang JD. Identifying inflammatory targets for biologic therapies for spine pain. PM R. 2011 Jun. 3(6 Suppl 1):S12-7. [Medline].
Jensen MV, Tuchsen F, Orhede E. Prolapsed cervical intervertebral disc in male professional drivers in Denmark, 1981-1990. A longitudinal study of hospitalizations. Spine. 1996 Oct 15. 21(20):2352-5. [Medline].
Judovich BD. Herniated cervical disc; a new form of traction therapy. Am J Surg. 1952 Dec. 84(6):646-56. [Medline].
Jull G, Bogduk N, Marsland A. The accuracy of manual diagnosis for cervical zygapophysial joint pain syndromes. Med J Aust. 1988 Mar 7. 148(5):233-6. [Medline].
Kang JD, Bohlman HH. Cervical disc herniation in a patient with congenital insensitivity to pain: a case report. Spine. 2000 Jul 1. 25(13):1726-8. [Medline].
Klein GR, Vaccaro AR, Albert TJ. Health outcome assessment before and after anterior cervical discectomy and fusion for radiculopathy: a prospective analysis. Spine. 2000 Apr 1. 25(7):801-3. [Medline].
Koakutsu T, Morozumi N, Ishii Y, et al. Anterior decompression and fusion versus laminoplasty for cervical myelopathy caused by soft disc herniation: a prospective multicenter study. J Orthop Sci. 2010 Jan. 15(1):71-8. [Medline].
Laun A, Lorenz R, Agnoli AL. Complications of cervical discography. J Neurosurg Sci. 1981 Jan-Mar. 25(1):17-20. [Medline].
Leckie S, Sowa G. Emerging technologies for degenerative disk disease: potential synergy between biochemical signaling and spinal biomechanics. PM R. 2009 May. 1(5):466-70. [Medline].
Lind B, Sihlbom H, Nordwall A, Malchau H. Normal range of motion of the cervical spine. Arch Phys Med Rehabil. 1989 Sep. 70(9):692-5. [Medline].
Lu J, Ebraheim NA, Huntoon M, Haman SP. Cervical intervertebral disc space narrowing and size of intervertebral foramina. Clin Orthop. 2000 Jan. (370):259-64. [Medline].
Maiman DJ, Kumaresan S, Yoganandan N, Pintar FA. Biomechanical effect of anterior cervical spine fusion on adjacent segments. Biomed Mater Eng. 1999. 9(1):27-38. [Medline].
Maimaris C, Barnes MR, Allen MJ. 'Whiplash injuries'' of the neck: a retrospective study. Injury. 1988 Nov. 19(6):393-6. [Medline].
McKinney LA. Early mobilisation and outcome in acute sprains of the neck. BMJ. 1989 Oct 21. 299(6706):1006-8. [Medline].
Mochida K, Komori H, Okawa A, et al. Regression of cervical disc herniation observed on magnetic resonance images. Spine. 1998 May 1. 23(9):990-5; discussion 996-7. [Medline].
Modic MT, Masaryk TJ, Ross JS. MRI of the Spine. Chicago, Ill: Year Book Medical Publishers, 1992.
Nishizawa S, Yokoyama T, Yokota N, Kaneko M. High cervical disc lesions in elderly patients--presentation and surgical approach. Acta Neurochir (Wien). 1999. 141(2):119-26. [Medline].
Norris SH, Watt I. The prognosis of neck injuries resulting from rear-end vehicle collisions. J Bone Joint Surg Br. 1983 Nov. 65(5):608-11. [Medline].
Okada E, Matsumoto M, Fujiwara H, Toyama Y. Disc degeneration of cervical spine on MRI in patients with lumbar disc herniation: comparison study with asymptomatic volunteers. Eur Spine J. 2011 Apr. 20(4):585-91. [Medline]. [Full Text].
Okada Y, Ikata T, Yamada H, et al. Magnetic resonance imaging study on the results of surgery for cervical compression myelopathy. Spine. 1993 Oct 15. 18(14):2024-9. [Medline].
Parke WW. Correlative anatomy of cervical spondylotic myelopathy. Spine. 1988 Jul. 13(7):831-7. [Medline].
Pospiech J, Stolke D, Wilke HJ, Claes LE. Intradiscal pressure recordings in the cervical spine. Neurosurgery. 1999 Feb. 44(2):379-84; discussion 384-5. [Medline].
Roeske R. The new vertebral subluxation. J Chiro. 1993. 30:19-24.
Rogers EJ, Rogers R. Pain clinic #14. Fibromyalgia and myofascial pain: either, neither, or both?. Orthop Rev. 1989 Nov. 18(11):1217-24. [Medline].
Russell EJ. Cervical disk disease. Radiology. 1990 Nov. 177(2):313-25. [Medline].
Saal JS, Saal JA, Yurth EF. Nonoperative management of herniated cervical intervertebral disc with radiculopathy. Spine. 1996 Aug 15. 21(16):1877-83. [Medline].
Sambrook PN, MacGregor AJ, Spector TD. Genetic influences on cervical and lumbar disc degeneration: a magnetic resonance imaging study in twins. Arthritis Rheum. 1999 Feb. 42(2):366-72. [Medline].
Sampath P, Bendebba M, Davis JD, Ducker TB. Outcome of patients treated for cervical myelopathy. A prospective, multicenter study with independent clinical review. Spine. 2000 Mar 15. 25(6):670-6. [Medline].
Schwarzer AC, Aprill CN, Derby R, et al. The false-positive rate of uncontrolled diagnostic blocks of the lumbar zygapophysial joints. Pain. 1994 Aug. 58(2):195-200. [Medline].
Sengupta DK, Kirollos R, Findlay GF, et al. The value of MR imaging in differentiating between hard and soft cervical disc disease: a comparison with intraoperative findings. Eur Spine J. 1999. 8(3):199-204. [Medline].
Shulman M. Treatment of neck pain with cervical epidural steroid injection. Regional Anesth. 1986. 11:92-4.
Skidmore-Roth L. In: Mosby's 2000 Nursing Drug Reference. St Louis, Mo:. Mosby. 2000.
Slipman CW, Plastaras CT, Palmitier RA, et al. Symptom provocation of fluoroscopically guided cervical nerve root stimulation. Are dynatomal maps identical to dermatomal maps?. Spine. 1998 Oct 15. 23(20):2235-42. [Medline].
Smith GW, Nichols P. The technique of cervical discography. Radiology. 1963. 68:163-5.
Smith MD, Kim SS. A herniated cervical disc resulting from discography: an unusual complication. J Spinal Disord. 1990 Dec. 3(4):392-4; discussion 395.
Sweeney T, Prentice C, Saal JA. Cervicothoracic muscular stabilizing technique. In: Physical Medicine and Rehabilitation. State of the Art Reviews. Philadelphia, Pa:. Hanley & Belfus. 1990:345.
Takae R, Matsunaga S, Origuchi N, et al. Immunolocalization of bone morphogenetic protein and its receptors in degeneration of intervertebral disc. Spine. 1999 Jul 15. 24(14):1397-401. [Medline].
Tanaka N, Fujimoto Y, An HS, et al. The anatomic relation among the nerve roots, intervertebral foramina, and intervertebral discs of the cervical spine. Spine. 2000 Feb 1. 25(3):286-91.
Taylor JR, Twomey LT. Acute injuries to cervical joints. An autopsy study of neck sprain. Spine. 1993 Jul. 18(9):1115-22.
Teresi LM, Lufkin RB, Reicher MA, et al. Asymptomatic degenerative disk disease and spondylosis of the cervical spine: MR imaging. Radiology. 1987 Jul. 164(1):83-8. [Medline].
Travell JG, Simons DG. In: Myofascial Pain and Dysfunction: The Trigger Point Manual. Baltimore, Md: Lippincott Williams & Wilkins; 1983.
Tucci SM, Hicks JE, Gross EG, et al. Cervical motion assessment: a new, simple and accurate method. Arch Phys Med Rehabil. 1986 Apr. 67(4):225-30.
Walker EA. A History of Neurological Surgery. New York, NY: Hafner Publishing; 1967.
Warfield CA, Biber MP, Crews DA, et al. Epidural steroid injection as a treatment for cervical radiculitis. Clin J Pain. 1988. 4:201-4.
White AA 3d, Southwick WO, Deponte RJ, et al. Relief of pain by anterior cervical-spine fusion for spondylosis. A report of sixty-five patients. J Bone Joint Surg [Am]. 1973 Apr. 55(3):525-34. [Medline].
White AA, Panjabi MM. In: Biomechanics of the Spine. 2nd ed. Philadelphia, Pa:. JB Lippincott. 1990.
Whitecloud TS 3d, Seago RA. Cervical discogenic syndrome. Results of operative intervention in patients with positive discography. Spine. 1987 May. 12(4):313-6. [Medline].
Wilbourn AJ, Aminoff MJ. AAEM minimonograph 32: the electrodiagnostic examination in patients with radiculopathies. American Association of Electrodiagnostic Medicine. Muscle Nerve. 1998 Dec. 21(12):1612-31. [Medline].
Williams JL, Allen MB Jr, Harkess JW. Late results of cervical discectomy and interbody fusion: some factors influencing the results. J Bone Joint Surg [Am]. 1968 Mar. 50(2):277-86. [Medline].
Wolfe F, Smythe HA, Yunus MB, et al. The American College of Rheumatology 1990 Criteria for the Classification of Fibromyalgia. Report of the Multicenter Criteria Committee. Arthritis Rheum. 1990 Feb. 33(2):160-72. [Medline].
Wu MP, Chen HH, Yen EY, et al. A potential complication of laparoscopy--the surgeon''s herniated cervical disk. J Am Assoc Gynecol Laparosc. 1999 Nov. 6(4):509-11.
Yiannikas C, Shahani BT, Young RR. Short-latency somatosensory-evoked potentials from radial, median, ulnar, and peroneal nerve stimulation in the assessment of cervical spondylosis. Comparison with conventional electromyography. Arch Neurol. 1986 Dec. 43(12):1264-71. [Medline].
Yin W, Pauza K, Olan W, Doerzbacher JF. Intradiscal injection of fibrin sealant for the treatment of symptomatic internal disc disruption: results of a prospective multicenter IDE pilot study with 6-month follow-up. Pain Medicine. 2009. 10:955.
Yunus MB, Kalyan-Raman UP, Kalyan-Raman K. Primary fibromyalgia syndrome and myofascial pain syndrome: clinical features and muscle pathology. Arch Phys Med Rehabil. 1988 Jun. 69(6):451-4.
Zhang HY, Kim YS, Cho YE. Thermatomal changes in cervical disc herniations. Yonsei Med J. 1999 Oct. 40(5):401-12. [Medline].
Zhang Y, An HS, Tannoury C, Thonar EJ, Freedman MK, Anderson DG. Biological treatment for degenerative disc disease: implications for the field of physical medicine and rehabilitation. Am J Phys Med Rehabil. 2008 Sep. 87(9):694-702. [Medline].