Medscape is available in 5 Language Editions – Choose your Edition here.


Cervical Disc Injuries

  • Author: Robert E Windsor, MD, FAAPMR, FAAEM, FAAPM; Chief Editor: Sherwin SW Ho, MD  more...
Updated: Jan 22, 2015


Acute cervical spine injury has been associated with sports such as football, gymnastics, rugby, ice hockey, and diving. Athletes with cervical disc injury may present with neck pain, radicular pain, quadriparesis, or quadriplegia secondary to myelopathy.

Cervical disc injury includes 2 entities. The more common form involves annular tears with herniation of the nucleus pulposus (ie, soft disc herniation). The second type of disc injury is an annular tear without herniation of the nucleus pulposus (ie, internal disc disruption).

When considering the term cervical disc injury, it is important to recognize the natural history of cervical degenerative disease. It is this process that may insidiously predispose one to cervical disc injury of either an acute or chronic nature. Cervical disc injuries can be treated conservatively or by surgery, depending on the clinical presentation.

Return to play is an important but controversial issue following successful treatment of cervical disc injury. No accepted universal guidelines regarding return to play exist.

This article intends to outline the etiopathology, evaluation, and treatment of cervical disc disease. Available guidelines for return to play following cervical disc injury are also presented.




United States

In a study of asymptomatic individuals younger than 40 years, the incidence of cervical disc herniation was 10%, the incidence of disc degeneration was 25%, and the incidence of foraminal stenosis was 4%.[1] In another study, the incidence of cervical focal disc protrusions in asymptomatic volunteers was 50% and of annular tears at one or more levels was 37%.[2]


Functional Anatomy

Seven cervical vertebrae articulate with one another anteriorly via the interbody joint with an intervening intervertebral disc and 2 uncovertebral joints. Laterally, they articulate via the paired posterolaterally placed zygapophyseal (facet) joints.

Each cervical vertebra forms a ring with the vertebral body anteriorly, the pedicles laterally, and the laminae posteriorly. The ring is known as the spinal or neural canal. As the vertebrae stack upon one another, the connection of the spinal foramina is known as the spinal canal. Through the spinal canal runs the spinal cord, nerve roots, vessels, and meninges (membranous covering of the spinal cord and nerve roots).

The cervical spinal nerves take origin from the spinal cord as the anterior and posterior rootlets. The posterior rootlet has a segmental brain that lies on its most lateral extent at the inner portion of the intervertebral foramen. The posterior and anterior rootlets join to form a spinal nerve, which is only approximately 2 cm long and lies within the intervertebral foramen. The spinal nerve divides into a posterior and anterior ramus at the outlet of the intervertebral foramen. The spinal nerves exit the intervertebral foramen above the numbered cervical vertebrae, and the thoracic and lumbar nerves exit the intervertebral below the numbered vertebra. Consequently, the eighth cervical nerve exits between the C7 and T1 segment

The symptoms related to pathology at each of the intervertebral disc segments have been well described and are not elaborated on in this article. Note that during dynamic range of motion (ROM), the intervertebral foramen, which houses the exiting cervical nerves, becomes very dynamic. In flexion, the intervertebral foramen enlarges in patency, and it decreases with extension. In rotation, the ipsilateral side becomes smaller, and the contralateral side becomes larger. The extreme changes of the foramina are magnified when motions are coupled with flexion and extension.

Distinctiveness of the cervical disc

The predominance of literature has addressed the lumbar spine; much of the lumbar spine literature has been extrapolated and applied to the cervical spine. Bogduk, using microdissection, systematically evaluated 59 human cadaveric intervertebral discs.[3] The orientation, location, and attachments of each strip bundle of collagen were recorded photographically and in sketches. He concluded that the cervical annular fibrosus did not consist of concentric laminae of collagen fibers, as noted in lumbar discs. Rather, the annulus forms a crescentic mass. The primary thickness is anterior and tapers laterally toward the uncinate processes. Posterolaterally, it is essentially deficient; posteriorly, it is represented by a thin layer of paramedian vertically oriented fibers. The anterior crescentic mass is likened to an interosseus ligament more so than a ring of concentric fibers surrounding the nucleus pulposus.[4]


Sport Specific Biomechanics

Cervical spine injury is commonly associated with axial loading with the neck in flexion. In flexion of the neck to 30°, the normal lordosis of the cervical spine is obliterated and axial loading of the head is dissipated through a straight spine.[5] Examples of axial loading in players include a football player striking his opponent with the crown of his helmet, an ice hockey player striking his head on the board while doing a push or check, a diver striking the ground with his head after diving in shallow water, and a gymnast accidentally landing head down while performing a somersault on a trampoline.

The effects of axial loading of the cervical spine include fracture of vertebrae, cervical disc herniations, ligament rupture, facet fracture, and dislocations. The neurologic deficits are greater in athletes with congenital spinal stenosis.[6, 7]

New guidelines in athletic sports have decreased the incidence of spinal cord injury. For example, permanent cervical quadriplegia has decreased significantly in high school and college level football, secondary to changes in the rules involving tackling. The Guidelines of NCCA Football rules committee banned spear tackling in football.[8] In 1977, The American Academy of Pediatrics published a statement banning the use of trampolines in schools because of the high incidence of quadriplegia associated with this apparatus.[9] The Canadian Committee on the prevention of spinal injury due to hockey recommends rules against boarding and crosschecking and on education to avoid spearing and impact with boards.[10] Similar guidelines for diving prohibit diving in water that is less shallow than twice one's height.[5]

Disc herniation resorption

Absorption of a cervical herniated disc has been appreciated. Mochida followed the regression of cervical disc herniation by using MRI. He noted that acutely, active resorption of herniated material occurred. The MRI findings did suggest that part of the resorbed material may have consisted of hemorrhagic substance. Mochida noted that extruded material exposed to the epidural space was resorbed more quickly than subligamentous herniation probably because of increased exposure to the immune system.[11]

Resorption of herniated disc material should not be confused with repair. Injured or degenerative disc material does not repair itself to a significant extent. In review of intervertebral segment physiology and metabolic turnover, Nachemson drew some remarkable conclusions.[12] He cited that diffusion of solutes can take place through the central portion of the endplates, as well as through the annulus fibrosus. There are also vascular contacts between the marrow spaces, the vertebral body, and the hyaline cartilaginous endplates. These vascular contacts are significantly less in discs that show advanced degenerative changes. He also cited that the area between the nucleus and annulus posteriorly is proportionally less than the area of the anterior margins, lending itself to possible nutrient deficiency and hastened fibrotic infiltration.

The surface area for diffusion is smaller posteriorly. Combining the relative diffusion limitations posteriorly and the mechanics of posterolateral disc herniation, it becomes rather apparent why a possible pattern of failure exists in this region.[12]

Contributor Information and Disclosures

Robert E Windsor, MD, FAAPMR, FAAEM, FAAPM President and Director, Georgia Pain Physicians, PC; Clinical Associate Professor, Department of Physical Medicine and Rehabilitation, Emory University School of Medicine

Robert E Windsor, MD, FAAPMR, FAAEM, FAAPM is a member of the following medical societies: American Academy of Pain Medicine, American Academy of Physical Medicine and Rehabilitation, American College of Sports Medicine, American Medical Association, International Association for the Study of Pain, Texas Medical Association

Disclosure: Nothing to disclose.


Ricardo A Nieves, MD, FAAPMR President, Colorado Spine, Pain and Sports Medicine, PC

Ricardo A Nieves, MD, FAAPMR is a member of the following medical societies: North American Spine Society, American Society of Interventional Pain Physicians, American Academy of Physical Medicine and Rehabilitation, American Association of Neuromuscular and Electrodiagnostic Medicine

Disclosure: Nothing to disclose.

Kevin P Sullivan, MD Consulting Staff, The Boston Spine Group

Kevin P Sullivan, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, North American Spine Society, International Spine Intervention Society

Disclosure: Nothing to disclose.

Frank J King, MD Clinical Instructor, Department of Physical Medicine and Rehabilitation, Georgia Pain Physicians/Emory School of Medicine

Frank J King, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, American Medical Association, Association of Academic Physiatrists

Disclosure: Nothing to disclose.

Samuel Punnamoottil Thampi, MD Attending Pain Management, Anesthesiology, North Shore Pain Service

Samuel Punnamoottil Thampi, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, North American Spine Society

Disclosure: Nothing to disclose.

Erik D Hiester, DO Fellow in Interventional Pain Management, Georgia Pain Physicians, Emory University School of Medicine

Erik D Hiester, DO is a member of the following medical societies: American Academy of Family Physicians, American Medical Association, American Osteopathic Association, American Pain Society

Disclosure: Nothing to disclose.

R Blake Windsor, MD Resident Physician, Department of Pediatrics, Boston Children's Hospital and Boston Medical Center

R Blake Windsor, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Pediatrics, Massachusetts Medical Society

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Henry T Goitz, MD Academic Chair and Associate Director, Detroit Medical Center Sports Medicine Institute; Director, Education, Research, and Injury Prevention Center; Co-Director, Orthopaedic Sports Medicine Fellowship

Henry T Goitz, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Society for Sports Medicine

Disclosure: Nothing to disclose.

Chief Editor

Sherwin SW Ho, MD Associate Professor, Department of Surgery, Section of Orthopedic Surgery and Rehabilitation Medicine, University of Chicago Division of the Biological Sciences, The Pritzker School of Medicine

Sherwin SW Ho, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, Arthroscopy Association of North America, Herodicus Society, American Orthopaedic Society for Sports Medicine

Disclosure: Received consulting fee from Biomet, Inc. for speaking and teaching; Received grant/research funds from Smith and Nephew for fellowship funding; Received grant/research funds from DJ Ortho for course funding; Received grant/research funds from Athletico Physical Therapy for course, research funding; Received royalty from Biomet, Inc. for consulting.

Additional Contributors

Janos P Ertl, MD Assistant Professor, Department of Orthopedic Surgery, Indiana University School of Medicine; Chief of Orthopedic Surgery, Wishard Hospital; Chief, Sports Medicine and Arthroscopy, Indiana University School of Medicine

Janos P Ertl, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Association, Hungarian Medical Association of America, Sierra Sacramento Valley Medical Society

Disclosure: Nothing to disclose.


The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous coauthor Dr Dennis P White to the development and writing of this article.

  1. Boden SD, McCowin PR, Davis DO, Dina TS, Mark AS, Wiesel S. 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].

  2. Ernst CW, Stadnik TW, Peeters E, Breucq C, Osteaux MJ. Prevalence of annular tears and disc herniations on MR images of the cervicalspine in symptom free volunteers. Eur J Radiol. 2005 Sep. 55(3):409-14. [Medline].

  3. Bogduk N, Tynan W, Wilson AS. The nerve supply to the human lumbar intervertebral discs. J Anat. 1981 Jan. 132(Pt 1):39-56. [Medline].

  4. Mercer S, Bogduk N. The ligaments and annulus fibrosus of human adult cervical intervertebral discs. Spine. 1999 Apr 1. 24(7):619-26; discussion 627-8. [Medline].

  5. Torg J. Epidemiology, pathomechanics, and prevention of athletic injuries to the cervical spine. The Cervical Spine. 1989. 442-463.

  6. Torg JS, Corcoran TA, Thibault LE, Pavlov H, Sennett BJ, Naranja RJ Jr, et al. Cervical cord neurapraxia: classification, pathomechanics, morbidity, and management guidelines. J Neurosurg. 1997 Dec. 87(6):843-50. [Medline].

  7. Mall NA, Buchowski J, Zebala L, Wright RW, Matava MJ. Spine and axial skeleton injuries in the national football league. Am J Sports Med. 2012 Aug. 40(8):1755-61. [Medline].

  8. National Collegiate Athletic Association. Article 2-1,2-N 1976; Rule 2, Section 24; Rule 9, Section 1. Football rule changes and modifications. 1976.

  9. American Academy of Pediatrics. Trampoline. Pediatrics. 1981. 67:438.

  10. Tator CH, Edmonds VE. National survey of spinal injuries in hockey players. Can Med Assoc J. 1984 Apr 1. 130(7):875-80. [Medline].

  11. Mochida K, Komori H, Okawa A, Muneta T, Haro H, Shinomiya K. Regression of cervical disc herniation observed on magnetic resonance images. Spine. 1998 May 1. 23(9):990-5; discussion 996-7. [Medline].

  12. Nachemson, Alf L. The lumbar spine: An orthopedic challenge. Spine. 1976. 1(1):

  13. Coventry MB, Ghormley RK, Kernahan JW. The intervertebral disc: Its microscopic anatomy and pathology. Part III: Pathologic changes in the intervertebral disc. J Bone and Joint Surg. 1945. 27:460-474.

  14. Gower WE, Pedrini V. Age-related variations in proteinpolysaccharides from human nucleus pulposus, annulus fibrosus, and costal cartilage. J Bone Joint Surg Am. 1969 Sep. 51(6):1154-62. [Medline].

  15. Lipson SJ, Muir H. Experimental intervertebral disc degeneration: morphologic and proteoglycan changes over time. Arthritis Rheum. 1981 Jan. 24(1):12-21. [Medline].

  16. Pearce RH, Grimmer BJ, Adams ME. Degeneration and the chemical composition of the human lumbar intervertebral disc. J Orthop Res. 1987. 5(2):198-205. [Medline].

  17. Torg JS, Sennett B, Pavlov H, Leventhal MR, Glasgow SG. Spear tackler's spine. An entity precluding participation in tackle football and collision activities that expose the cervical spine to axial energy inputs. Am J Sports Med. 1993 Sep-Oct. 21(5):640-9. [Medline].

  18. Nakashima H, Yukawa Y, Suda K, Yamagata M, Ueta T, Kato F. Abnormal Findings on Magnetic Resonance Images of the Cervical Spines in 1,211 Asymptomatic Subjects. Spine (Phila Pa 1976). 2015 Jan 12. [Medline].

  19. Tomasino A, Gebhard H, Parikh K, Wess C, Härtl R. Bioabsorbable instrumentation for single-level cervical degenerative disc disease: a radiological and clinical outcome study. J Neurosurg Spine. 2009 Nov. 11(5):529-37. [Medline].

  20. Phillips FM, Tzermiadianos MN, Voronov LI, Havey RM, Carandang G, Dooris A, et al. Effect of two-level total disc replacement on cervical spine kinematics. Spine (Phila Pa 1976). 2009 Oct 15. 34(22):E794-9. [Medline].

  21. Peng CW, Quirnoa M, Bendo JA, Spivak JM, Goldstein JA. Effect of intervertebral disc height on postoperative motion and clinical outcomes after Prodisc-C cervical disc replacement. Spine J. 2009 Jul. 9(7):551-5. [Medline].

  22. 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].

  23. Flynn TB. Neurologic complications of anterior cervical interbody fusion. Spine. 1982 Nov-Dec. 7(6):536-9. [Medline].

  24. Johnson JP, Filler AG, McBride DQ, Batzdorf U. Anterior cervical foraminotomy for unilateral radicular disease. Spine. 2000 Apr 15. 25(8):905-9. [Medline].

  25. Tu TH, Wu JC, Fay LY, Ko CC, Huang WC, Cheng H. Vertebral body split fracture after a single-level cervical total disc replacement. J Neurosurg Spine. 2012 Mar. 16(3):231-5. [Medline].

  26. Miyazaski K, Hirohuji E, Ono S, et al. Extensive simultaneous multisegment laminectomy and posterior decompression with posterolateral fusion. Jpn Spine Res Soc. 5:167.

  27. Pointillart V. Cervical disc prosthesis in humans: first failure. Spine. 2001 Mar 1. 26(5):E90-2. [Medline].

  28. Goffin J, Casey A, Kehr P, Liebig K, Lind B, Logroscino C. Preliminary clinical experience with the Bryan Cervical Disc Prosthesis. Neurosurgery. 2002 Sep. 51(3):840-5; discussion 845-7. [Medline].

  29. Aydin Y, Kaya RA, Can SM, Türkmenoglu O, Cavusoglu H, Ziyal IM. Minimally invasive anterior contralateral approach for the treatment of cervicaldisc herniation. Surg Neurol. 2005 Mar. 63(3):210-8; discussion 218-9. [Medline].

  30. Whang PG, Simpson AK, Rechtine G, Grauer JN. Current trends in spinal arthroplasty: an assessment of surgeon practices and attitudes regarding cervical and lumbar disk replacement. J Spinal Disord Tech. 2009 Feb. 22(1):26-33. [Medline].

  31. Buchowski JM, Anderson PA, Sekhon L, Riew KD. Cervical disc arthroplasty compared with arthrodesis for the treatment of myelopathy. Surgical technique. J Bone Joint Surg Am. 2009 Oct 1. 91 Suppl 2:223-32. [Medline].

  32. Lin CY, Kang H, Rouleau JP, Hollister SJ, Marca FL. Stress analysis of the interface between cervical vertebrae end plates and the Bryan, Prestige LP, and ProDisc-C cervical disc prostheses: an in vivo image-based finite element study. Spine (Phila Pa 1976). 2009 Jul 1. 34(15):1554-60. [Medline].

  33. Torg JS, Ramsey-Emrhein JA. Suggested management guidelines for participation in collision activities with congenital, developmental, or post-injury lesions involving the cervical spine. Med Sci Sports Exerc. 1997. 29:256-272.

  34. Cantu RC. Functional cervical spinal stenosis: a contraindication to participation in contact sports. Med Sci Sports Exerc. 1993 Mar. 25(3):316-7. [Medline].

  35. Morganti C. Recommendations for return to sports following cervical spine injuries. Sports Med. 2003. 33(8):563-73. [Medline].

  36. Cantu RC, Bailes JE, Wilberger JE Jr. Guidelines for return to contact or collision sport after a cervical spine injury. Clin Sports Med. 1998 Jan. 17(1):137-46. [Medline].

  37. Duggal N, Pickett GE, Mitsis DK, Keller JL. Early clinical and biomechanical results following cervical arthroplasty. Neurosurg Focus. 2004 Sep 15. 17(3):E9. [Medline].

  38. North American Spine Society. Orthopaedic Knowledge Update: Spine. American Academy of Orthopaedic Surgeons; 1997. 75, 97-101.

  39. Sasai K, Saito T, Ohnari H, Yamamoto T, Kasuya T, Wakabayashi E, et al. Microsurgical posterior herniotomy with en bloc laminoplasty: alternative methodfor treating cervical disc herniation. J Spinal Disord Tech. 2005 Apr. 18(2):171-7. [Medline].

All material on this website is protected by copyright, Copyright © 1994-2016 by WebMD LLC. This website also contains material copyrighted by 3rd parties.