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.
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. [20, 21, 22]
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. [23] 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. [24] 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. [25, 26]
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. [27] 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. [28] However, a larger study with 60 patients showed clinical success rates at 6 months and 1 year after implantation of 86% and 90%, respectively. [29]
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. [30]
Recent studies
Whang et al surveyed 113 orthopedic and neurosurgical spine surgeons about their current practices and opinions regarding cervical and lumbar total disc arthroplasty (TDA) as alternatives to arthrodesis for treatment of degenerative spinal disorders. The responses showed that more surgeons had performed lumbar TDA (42%) than cervical TDA (30%). However, according to the survey, 81% said that compared with their feelings a year ago, they were now more likely to perform cervical TDA. Regarding lumbar TDA, 64% indicated that they were now less likely to perform lumbar TDA as compared to a year ago. The reasons most frequently mentioned for not performing both cervical and lumbar TDA were concerns about long-term outcomes and perceived difficulties with regard to financial compensation by insurance companies. Many of the surgeons were also concerned about revision of lumbar TDAs. [31]
Buchowski et al performed a cross-sectional analysis of 2 large, prospective, randomized multicenter trials (ie, Prestige ST Trial and Bryan Trial) to evaluate the efficacy of cervical disc arthroplasty for the treatment of myelopathy. A total of 199 patients were included in the study, with 106 undergoing arthroplasty and 93 undergoing arthrodesis. All patients showed improvement in postoperative neurologic status and gait function. At 24 months after surgery, 90% of the Prestige group patients in the arthroplasty group and 81% in the arthrodesis group had improvement in, or maintenance of, neurological status. Of the Bryan group patients, 90% in the arthroplasty group and 77% in the arthrodesis group had improvement in, or maintenance of, neurologic status. [32]
Lin et al analyzed segmental motion and bone-implant interface stresses at C5-C6 levels with Bryan, Prestige LP, and ProDisc-C cervical disc prostheses, using an image-based finite element modeling technique, to better understand the mechanisms of subsidence and how the load transfer pattern of each disc affects segmental motion. They found that the Bryan disc recovered the highest range of motion (4.75º ) because of the high elastic nucleus, therefore imposing the lowest stresses superior to C6. The ProDisc-C and Prestige LP discs caused high stress concentrations around their central fins or teeth and therefore, according to the authors, may initiate bone absorption. The authors added that analysis of Prestige LP disc may indicate possible subsidence posteriorly, caused by the rear-positioned metal-to-metal joint. [33]
Lin et al also noted in the study that the rigidity of the cores, or nuclei, of the Prestige LP and ProDisc-C guarantee initial maintenance of disc height but that high contact stress occurs at the bone-end plate interface if improperly placed or undersized. In addition,they noted that the anchorage designs may increase subsidence. The Bryan disc, they described, creates larger displacement during motion, with more variation in disc height, which may increase the load sharing of facet and/or uncovertebral joints, as compared with more rigid artificial discs. [33]
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.
