Cervical Disc Injuries Clinical Presentation
- Author: Robert E Windsor, MD, FAAPMR, FAAEM, FAAPM; Chief Editor: Sherwin SW Ho, MD more...
Athletes with symptomatic cervical disc injuries commonly present with segmental neck pain, muscle spasm, loss of ROM, and referred pain in both radicular and nonradicular distribution. Nerve root involvement leads to radicular upper extremity pain, weakness, and sensory changes. Pain symptoms may be exacerbated with motion, lifting, and Valsalva maneuvers.
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- Information obtained from the physical examination is often of limited benefit.
- Examination generally demonstrates reduced segmental motion at involved levels.
- Pain with mobilization may or may not be present.
- ROM may or may not be present, depending on the chronicity of the condition and its severity.
- Neurologic examination is generally within the reference range. (See Cervical Radiculopathy.)
- Cervical cord neuropraxia (CCN) is a transient neurologic syndrome occurring in athletes with cervical spine injury. CCN is especially common in cervical spine injuries resulting from contact sports. The presentation can range from bilateral paresthesias in the arms to complete quadriplegia. Typical episodes can last from 15 minutes to 48 hours with complete recovery. The mechanism is thought to be due to brief compression of the spinal cord resulting in transient interruption of the spinal pathways. The incidence of cervical spinal stenosis is as high as 86% in athletes who have experienced this condition.
Cervical disc injuries are relatively common in athletes involved in both contact and noncontact sports. Information on cervical injuries has primarily been obtained from evaluation of football players; however, this information can be applied to athletes who play other high-risk sports. Sports associated with cervical injuries include football, rugby, ice hockey, wrestling, gymnastics, cheerleading, baseball (headfirst slides), and swimming (diving into shallow water).
- Injuries are often the result of axial applied forces, with secondary forces of hyperflexion, hyperextension, and rotation adding to the overall injury pattern. Cervical disc disease is most often limited to a single segment and is usually unilateral. In symptomatic athletes, nerve root compression may be the result of an extruded posterolateral disc, combined disc degeneration, osteophytes, and disc fragment extrusion. Preexisting cervical spondylosis or developmental stenosis may lead to central disc herniation resulting in long-tract neurologic findings.
- Age-related morphologic changes
- In regards to the continuum of cervical degenerative disc disease, the age-related morphologic changes also must be considered. The intervertebral disc is a hydrostatic load-bearing structure. The nucleus pulposus is a confined and well-localized fluid that exists within the annulus fibrosis. The nucleus pulposus functions in converting axial loads into tensile strain on the annular fibers and the vertebral endplates.
- During the first 20 years of life, the development of disc protrusion through the cartilaginous endplates is observed. These protrusions are known as Schmorl nodes. Degenerative changes manifest during the third through fifth decades of life, with loss of intervertebral disc height and development of osteophytes, particularly at the origins of the vertebral endplates. The facets, facet joint capsule, and ligamentum flavum hypertrophy potentially compromise the intervertebral foramen and central canal. As the discs become degenerative, the hydrostatic pressure declines.
- Because of intradiscal compressive forces, disc material has a tendency to follow the radial fissure because it is the path of least resistance. Once the radial fissure becomes complete, the disc is predisposed to herniate. Penetration through the outer annular wall defines herniation (extrusion). An extruded disc penetrating through the posterior longitudinal ligament (PLL) represents an extrusion that is noncontained. One that remains confined by the PLL is termed an extrusion contained by the PLL. Primary annular disruption initially may occur in the periphery. This is called a rim lesion. As the process continues to progress and the margins of the annulus and nucleus coalesce with infiltration of type III collagen, the gelatinous nucleus becomes replaced. The disc becomes increasingly fibrotic.[13, 14, 15, 16]
- The greatest risk for herniation occurs in the younger age group because the nuclear material in this group can still generate significant turgor, enabling it to produce a focal herniation. A severely degenerative disc lacks nuclear tissue; therefore, it cannot generate the forces needed to create a disruption. Therefore, disc herniation is rare in elderly persons. When disc herniation occurs, it is primarily in the posterolateral aspect of the disc just lateral to the margin of the posterior longitudinal ligament. This is an obvious area of compromised reinforcement.
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