eMedicine Specialties > Sports Medicine > Spine
Cervical Disc Injuries: Treatment & Medication
Updated: Apr 6, 2006
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
Treatment
Acute Phase
Rehabilitation Program
Physical Therapy
Physical therapy emphasizes segmental mobilization, postural training, and reconditioning.
Surgical Intervention
Surgery is indicated in acute cervical disc herniation causing central cord syndrome and in cervical disc herniations refractory to conservative measures. Studies have shown that an anterior discectomy with fusion is the recommended procedure for central or anterolateral soft disc herniation, while a posterior laminotomy-foraminotomy may be considered when technical limitations for anterior access exist (eg, short thick neck) or when the patient has had prior surgery at the same level (Herkowitz, 1990).
Other Treatment
Translaminar cervical epidural injections can decrease the inflammation secondary to acute disc herniation and help the patient to tolerate physical therapy.
Recovery Phase
Rehabilitation Program
Physical Therapy
This phase of rehabilitation focuses on soft tissue overload and biomechanical dysfunction. Goals of this phase are to eliminate pain, normalize spinal mechanics, and improve neuromuscular control of the injured cervical spine. Restoration of the resting muscle length and full, pain-free, cervical ROM are necessary. Strengthening exercises start in simple planes and progress to complex muscle patterns.
Surgical Intervention
Surgical treatment for cervical disc herniation is needed in only a very small percentage of athletes. This includes those with any evidence of a cervical myelopathy or progressive neurologic deficits and those in whom conservative treatment has failed for a period of 3 months. Radiographically confirmed evidence of cervical disc disease should be available before performing this surgery. The common surgical procedures for cervical disc injuries include (1) anterior decompression and fusion (ADCF), (2) laminectomy, laminotomy-facetectomy, and (3) laminoplasty.
Anterior decompression and fusion
A herniated disc in the neck is commonly approached anteriorly. Both lateral and central discs can be removed through this approach. Other indications include progressive neurologic deficit and unremitting pain.
The results from cervical discectomy have shown an approximately 95% chance of good-to-excellent relief from the radiating arm pain (Gore, 1984). Numbness in the upper extremity generally improves. Weakness in the affected arm may require some physical therapy to maximize recovery. Three to 6 months following surgery, the patient may resume full, unrestricted activities.
Complications from this surgery are very rare. The most common complications following anterior decompression and fusion are transient sore throat, hoarseness, and difficulty swallowing. Other complications include failure of bony fusion, which occurs in 5-8% of patients. Pseudarthrosis is commonly related to the number of levels fused. When it occurs, half of the patients have no symptoms from it and nothing further is required. No correlation exists between radiologic appearance of pseudarthrosis alone and the clinical outcome. Careful considerations must be made before reoperating. For the 50% of patients who do develop neck pain as a result of the failure of fusion, additional surgery may be required to obtain a solid fusion of the disc and to alleviate the neck pain.
Permanent spinal cord injury is the most dreaded complication and occurs at a rate of 1 in 1000 (Flynn, 1982). The infection rate is less than 1 in 100. Other rare complications include recurrent injury to the laryngeal nerve, laceration of vertebral and carotid vessels, and injury to the trachea or esophagus.
Laminectomy
A cervical laminectomy is a procedure designed to resect the lamina on one or both sides to increase the axial space available for the spinal cord. The procedure is typically indicated for spinal stenosis. The indication in the context of cervical disc disease is when more than 3 levels of disc degeneration with anterior spinal cord compression are present. Single-level cervical disc herniation is ideally managed from the anterior approach. The complications of the posterior approach include instability leading to kyphosis, recalcitrant myofascial pain, and occipital headaches.
Postlaminectomy kyphosis requires revision surgery. If preexistent kyphosis is present, an anterior approach is favorable because in a patient with kyphosis, laminectomy may accelerate kyphosis. As an alternative to laminectomy, a foraminotomy can be used to remove a single-level unilateral lateral disc herniation. This involves removal of 50% of the facet joint on one side. This procedure is effective when radicular arm pain is greater than axial neck pain. Foraminotomy can also be performed anteriorly and has a success rate of 91% in relieving radicular pain (Johnson, 2000).
Laminaplasty
Kyphotic deformity is a well-known complication of laminectomy. This prompted a group of Japanese surgeons to preserve the posterior wall of the spinal canal while decompressing the spinal canal using a Z-plasty technique for the lamina. The variant of the procedure uses a hinge door for the lamina. Laminaplasty is commonly indicated for multilevel spondylotic myelopathy. Comparative studies with laminectomy have shown that patients with laminaplasty have superior functional recovery in spondylotic myelopathy (Miyazaski, 1994). The incidence of spinal cord injury with laminaplasty is approximately 10 times lower than that of laminectomy. Nerve root injury is commonly seen in about 11% of the surgeries. This complication is unique to laminaplasty, and the suggested etiology is traction on the nerve root with posterior migration of the spinal cord.
Recent advances in surgical intervention
Spinal fusion at the cervical disc produces a painless, stable spinal segment at the cost of mobility. In the field of cervical disc prostheses, research is focusing on how to maintain both stability and mobility at the spinal segment. However, only a few studies have been performed and the results have been variable. A study by Pointillart showed that a cervical disc prosthesis failed to achieve the intended mobility in 8 of 10 patients and that pain developed in the other 2 patients in whom mobility persisted (Pointillart, 2001). However, a larger more recent study with 60 patients showed clinical success rates at 6 months and 1 year after implantation of 86% and 90%, respectively (Goffi, 2003).
Other recent surgical interventions include microsurgical posterior herniotomy with en bloc laminoplasty and a minimally invasive anterior contralateral approach for the treatment of cervical disc herniation (Aydin, 2005).
Maintenance Phase
Rehabilitation Program
Physical Therapy
The final phase of rehabilitation requires functional, nonpainful, cervical ROM and proper spinal and shoulder girdle mechanics. Sport appropriate flexibility, strength, and skills are necessary prior to return to play. Sport-specific activities should be reviewed to ensure correct techniques, especially in contact and collision sports.
Medication
Oral nonsteroidal anti-inflammatory drugs (NSAIDs) can help decrease pain and inflammation. Various oral NSAIDs can be used, and none of these holds a clear distinction as the drug of choice. The choice of NSAIDs is largely a matter of convenience (how frequently doses must be taken to achieve adequate analgesic and anti-inflammatory effects) and cost.
Nonsteroidal anti-inflammatory drugs
Have analgesic, anti-inflammatory, and antipyretic activities. Their mechanism of action is not known, but they may inhibit cyclo-oxygenase activity and prostaglandin synthesis. Other mechanisms may exist as well, such as inhibition of leukotriene synthesis, lysosomal enzyme release, lipoxygenase activity, neutrophil aggregation, and various cell membrane functions.
Celecoxib (Celebrex)
For arthritis. Inhibits primarily COX-2. COX-2 is considered an inducible isoenzyme, induced by pain and inflammatory stimuli. Inhibition of COX-1 may contribute to NSAID GI toxicity. At therapeutic concentrations, COX-1 isoenzyme is not inhibited; thus, GI toxicity may be decreased. Seek lowest dose of celecoxib for each patient.
Adult
200 mg/d PO qd; alternatively, 100 mg PO bid
Pediatric
Not established
NSAIDs may increase retention of sodium and fluid and may raise blood pressure with ACE inhibitors and diuretics; NSAIDs may especially increase risk of bleeding (eg, gastrointestinal) among individuals who drink alcohol or who are already taking aspirin, corticosteroids, heparin, and warfarin; to minimize risks of adverse effects, patients should avoid taking multiple NSAIDs concurrently; special caution is needed in any patient on anticoagulants or systemic corticosteroids, as well as in any patient with a bleeding disorder or significant alcohol use; coadministration with fluconazole may cause increase in celecoxib plasma concentrations because of inhibition of celecoxib metabolism; coadministration of celecoxib with rifampin may decrease celecoxib plasma concentrations
Documented hypersensitivity; hypersensitivity to ibuprofen or other NSAIDs; aspirin/NSAID-induced asthma
Pregnancy
B - Usually safe but benefits must outweigh the risks.
Precautions
Caution with any history of GI bleed, hypertension, or CHF; caution in elderly patients; most NSAIDs are considered Class D (unsafe) during third trimester of pregnancy; avoid use during third trimester of pregnancy due to potential risk of effecting closure of the ductus arteriosus; may cause fluid retention and peripheral edema; caution in compromised cardiac function, hypertension, and conditions predisposing to fluid retention; severe heart failure and hyponatremia may occur because celecoxib may deteriorate circulatory hemodynamics; NSAIDs may mask usual signs of infection; caution in the presence of existing controlled infections; evaluate symptoms and signs suggesting liver dysfunction
Ibuprofen (Motrin, Ibuprin)
DOC for patients with mild to moderate pain. Inhibits inflammatory reactions and pain by decreasing prostaglandin synthesis.
Adult
200-400 mg PO q4-6h while symptoms persist; not to exceed 3.2 g/d
Pediatric
<6 months: Not established
6 months to 12 years: 4-10 mg/kg/dose PO tid/qid
>12 years: Administer as in adults
Coadministration with aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; may increase PT when taking anticoagulants (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently
Documented hypersensitivity; peptic ulcer disease; recent GI bleeding or perforation; renal insufficiency; high risk of bleeding
Pregnancy
B - Usually safe but benefits must outweigh the risks.
Precautions
Category D in third trimester of pregnancy; caution in congestive heart failure, hypertension, and decreased renal and hepatic function; caution in anticoagulation abnormalities or during anticoagulant therapy
Ketoprofen (Orudis, Oruvail, Actron)
For relief of mild to moderate pain and inflammation. Small dosages initially are indicated in small and elderly patients and in those with renal or liver disease. Doses over 75 mg do not increase therapeutic effects. Administer high doses with caution, and closely observe patient for response.
Adult
25-50 mg PO q6-8h prn; not to exceed 300 mg/d
Pediatric
<3 months: Not established
3 months to 12 years: 0.1-1 mg/kg PO q6-8h
>12 years: Administer as in adults
Coadministration with aspirin increases risk of inducing serious NSAID-related side effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; may increase PT when taking anticoagulants (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently
Documented hypersensitivity
Pregnancy
B - Usually safe but benefits must outweigh the risks.
Precautions
Category D in third trimester of pregnancy; caution in congestive heart failure, hypertension, and decreased renal and hepatic function; caution in coagulation abnormalities or during anticoagulant therapy
Naproxen (Naprosyn, Naprelan, Aleve, Anaprox)
For relief of mild to moderate pain. Inhibits inflammatory reactions and pain by decreasing activity of cyclo-oxygenase, which results in a decrease of prostaglandin synthesis.
Adult
500 mg PO followed by 250 mg q6-8h; not to exceed 1.25 g/d
Pediatric
<2 years: Not established
>2 years: 2.5 mg/kg/dose PO; not to exceed 10 mg/kg/d
Coadministration with aspirin increases risk of inducing serious NSAID-related side effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; may increase PT when taking anticoagulants (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently
Documented hypersensitivity; peptic ulcer disease; recent GI bleeding or perforation; renal insufficiency
Pregnancy
B - Usually safe but benefits must outweigh the risks.
Precautions
Category D in third trimester of pregnancy; acute renal insufficiency, interstitial nephritis, hyperkalemia, hyponatremia, and renal papillary necrosis may occur; patients with preexisting renal disease or compromised renal perfusion risk acute renal failure; leukopenia occurs rarely, is transient, and usually returns to normal during therapy; persistent leukopenia, granulocytopenia, or thrombocytopenia warrants further evaluation and may require discontinuation of drug
More on Cervical Disc Injuries |
| Overview: Cervical Disc Injuries |
| Differential Diagnoses & Workup: Cervical Disc Injuries |
 Treatment & Medication: Cervical Disc Injuries |
| Follow-up: Cervical Disc Injuries |
| References |
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References
American Academy of Pediatrics. Trampoline. Pediatrics. 1981;67:438.
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. Mar 2005;63(3):210-8; discussion 218-9. [Medline].
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. Sep 1990;72(8):1178-84. [Medline].
Bogduk N, Tynan W, Wilson AS. The nerve supply to the human lumbar intervertebral discs. J Anat. Jan 1981;132(Pt 1):39-56. [Medline].
Cantu RC. Functional cervical spinal stenosis: a contraindication to participation in contact sports. Med Sci Sports Exerc. Mar 1993;25(3):316-7. [Medline].
Cantu RC, Bailes JE, Wilberger JE Jr. Guidelines for return to contact or collision sport after a cervical spine injury. Clin Sports Med. Jan 1998;17(1):137-46. [Medline].
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.
Duggal N, Pickett GE, Mitsis DK, Keller JL. Early clinical and biomechanical results following cervical arthroplasty. Neurosurg Focus. Sep 15 2004;17(3):E9. [Medline].
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. Sep 2005;55(3):409-14. [Medline].
Flynn TB. Neurologic complications of anterior cervical interbody fusion. Spine. Nov-Dec 1982;7(6):536-9. [Medline].
Goffin J, Casey A, Kehr P, Liebig K, Lind B, Logroscino C. Preliminary clinical experience with the Bryan Cervical Disc Prosthesis. Neurosurgery. Sep 2002;51(3):840-5; discussion 845-7. [Medline].
Gore DR, Sepic SB. Anterior cervical fusion for degenerated or protruded discs. A review of one hundred forty-six patients. Spine. Oct 1984;9(7):667-71. [Medline].
Gower WE, Pedrini V. Age-related variations in proteinpolysaccharides from human nucleus pulposus, annulus fibrosus, and costal cartilage. J Bone Joint Surg Am. Sep 1969;51(6):1154-62. [Medline].
Johnson JP, Filler AG, McBride DQ, Batzdorf U. Anterior cervical foraminotomy for unilateral radicular disease. Spine. Apr 15 2000;25(8):905-9. [Medline].
Lipson SJ, Muir H. Experimental intervertebral disc degeneration: morphologic and proteoglycan changes over time. Arthritis Rheum. Jan 1981;24(1):12-21. [Medline].
Mercer S, Bogduk N. The ligaments and annulus fibrosus of human adult cervical intervertebral discs. Spine. Apr 1 1999;24(7):619-26; discussion 627-8. [Medline].
Miyazaski K, Hirohuji E, Ono S, et al. Extensive simultaneous multisegment laminectomy and posterior decompression with posterolateral fusion. Jpn Spine Res Soc. 5:167.
Mochida K, Komori H, Okawa A, Muneta T, Haro H, Shinomiya K. Regression of cervical disc herniation observed on magnetic resonance images. Spine. May 1 1998;23(9):990-5; discussion 996-7. [Medline].
Morganti C. Recommendations for return to sports following cervical spine injuries. Sports Med. 2003;33(8):563-73. [Medline].
Nachemson, Alf L. The lumbar spine: An orthopedic challenge. Spine. 1976;1(1).
National Collegiate Athletic Association. Article 2-1,2-N 1976; Rule 2, Section 24; Rule 9, Section 1. In: Football rule changes and modifications. 1976.
North American Spine Society. Orthopaedic Knowledge Update: Spine. American Academy of Orthopaedic Surgeons; 1997:75, 97-101.
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].
Pointillart V. Cervical disc prosthesis in humans: first failure. Spine. Mar 1 2001;26(5):E90-2. [Medline].
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. Apr 2005;18(2):171-7. [Medline].
Tator CH, Edmonds VE. National survey of spinal injuries in hockey players. Can Med Assoc J. Apr 1 1984;130(7):875-80. [Medline].
Torg J. Epidemiology, pathomechanics, and prevention of athletic injuries to the cervical spine. In: The Cervical Spine. 1989:442-463.
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. Dec 1997;87(6):843-50. [Medline].
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.
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. Sep-Oct 1993;21(5):640-9. [Medline].
Further Reading
Keywords
acute cervical spine injury, annular tear with herniation of the nucleus pulposus, annular tear without herniation of the nucleus pulposus, cervical degenerative disease
