Cervical Discogenic Pain Syndrome

Cervical intervertebral disc disease accounts for 36% of all spinal intervertebral disc disease, second only to lumbar disc disease, which accounts for 62% of all spinal intervertebral disc disease. Cervical problems tend to be less debilitating than lumbar problems, and they do not cause individuals to miss work as often as lumbar spine problems do.[1, 2]

One of 5 visits to an orthopedic practice is for cervical discogenic pain (CDP), with C5-6 and C6-7 accounting for approximately 75% of visits. C7 is the most common nerve root involved.[3] Cervical discogenic pain syndrome (CDPS) presents with proximal symptoms first, and, later, it can progress to brachialgia.

For excellent patient education resources, visit eMedicineHealth's First Aid and Injuries Center. Also, see eMedicineHealth's patient education articles Shoulder and Neck Pain and Neck Strain.

Frequency

United States

Cervical intervertebral disc disease accounts for 36% of all spinal intervertebral disc disease. This condition is somewhat more common in women. Although acute attacks may start at a very young age with episodes of acute torticollis or "wry neck," the incidence peaks when persons are aged 45-50 years (see image below).

Of all sports-related injuries, 2-3% are spinal injuries and the majority of these happened during unsupervised activities such as football, soccer, wrestling, diving, surfing, skiing and sandlot games.[4] The majority of the available literature, however, is found for football and this group is the most likely to sustain cervical trauma.

Statistical estimates of the incidence of cervical injury for football players varies ranging from 1 quadriplegic injury per 7,000 to 1 injury per 58,000.[5] Another review reported that since 1977, there has been an annual incidence of fewer than 10 cases of permanent injury to the cervical spinal cord among football players.[6] In 1976, the National Collegiate Athletic Association football rules committee disallowed the technique of spear tackling or the technique of using the helmet to butt or ram an opponent. This resulted in a remarkable decrease in the incidence of catastrophic neck injuries over the next 9 years.[7]

The cervical spine permits a wide range of motion (ROM) of the head in relation to the trunk. A degree of stability and flexibility is required to control the motion and dissipate the forces applied to the spine. Great differences in anatomy and function exist between the occiput-C1, the C1-2 (upper complex), and C3-C7 (lower complex) levels. Eight motion segments occur between the occiput and T1. No disc exists between C1 and C2; therefore, the first intervertebral disc is between C2 and C3.

The intervertebral disc consists of an outer annulus fibrosus and an inner nucleus pulposus. The intervertebral disc is thicker anteriorly, contributing to the normal cervical lordosis. The C6-7 disc is the thickest disc of the cervical spine. The nucleus pulposus and the inner one half of the annulus fibrosus are avascular and receive nutrition through diffusion, compression, dehydration, and imbibition of fluids.[8]

The annulus fibrosus, particularly the outer one third, has been found to be innervated by the sinuvertebral nerve and the vertebral nerve. The sinuvertebral nerve arises from the ventral ramus (somatic root), whereas the vertebral nerve (autonomic root) is derived primarily from the sympathetic nervous system. However, the vertebral nerve has connections with the cervical ventral rami, which suggests the possibility of the vertebral nerve also conveying somatic afferents from the disc.[9, 10, 11]

The nociceptors and mechanoreceptors in the annulus fibrosus mediate pain transmission from structural disruption of the intervertebral disc itself or from the chemically mediated inflammatory effect of phospholipase A2.[10, 12] Pacinian corpuscles and Golgi tendon organs present in the posterolateral region of the outer one third of the annulus transmit proprioceptive information from the intervertebral disc.[8, 12, 13, 14, 15]

The adult cervical disc has a crescentic shape anteriorly, with the apex of the crescent at the uncovertebral joints on each side. The posterior annulus has multiple vertical fissures allowing for a very degenerative appearance during discography and on gross examination. In addition, the nucleus of the cervical disc tends to be poorly centralized when compared with the lumbar disc. In the lumbar disc, the nucleus tends to be well localized in the center of the disc, and the posterior annulus tends to remain relatively intact when compared with the cervical disc. Annular fissures in the lumbar disc tend to be circumferential and/or radial in nature.

Biomechanics is the study of the changes in the anatomic structures occurring during body movements. The movements of the cervical spine include flexion and extension in the sagittal plane, lateral flexion in the coronal plane, and rotation in the horizontal plane. Lateral flexion and rotation occur as coupled movements. Other movements of the cervical spine include protrusion (ie, the head is moved as far forward as possible with the neck outstretched and maintaining forward-facing position) and retraction (ie, the head is moved as far backward as possible and maintaining a forward-facing position).

Fifty percent of rotation of the cervical spine occurs in the upper cervical complex with the atlas rotating ipsilaterally around the odontoid. Protrusion causes upper cervical spine extension and lower cervical spine flexion, whereas retraction causes upper cervical spine flexion and lower cervical spine extension. At the occiput-C1 and C1-2 levels, ROM is greater with the protruded and retracted position than with full-length flexion and full-length extension positions.[16] See the image below.

The annular fibers are made up of collagenous lamellae with alternating directions of inclination oriented 35° from the horizontal. The annulus is more susceptible to injury with rotation and translation movements due to resistance offered only by the lamella oriented in the direction of movement. In the cervical spine, as in the lumbar spine, the intervertebral disc dissipates the transmission of compressive loads throughout the ROM by slowing the rate at which these forces are transmitted through the spine. By diverting the load via temporarily stretching the annular fibers, the disc protects the vertebra from taking the entire load at once.

In asymmetric loading, the nucleus pulposus migrates toward the area with less load. Thus, in flexion movements of the cervical spine, anterior offset loading of the intervertebral disc occurs, in which the nucleus pulposus moves posteriorly and the posterior annular wall is stretched. In addition, the cervical lordosis reduces, the vertebral canal lengthens, and the intervertebral foramina open.[2]

In extension movements of the cervical spine, posterior offset loading of the intervertebral disc occurs, in which the nucleus moves anteriorly and the anterior annular wall is stretched. Shortening of the vertebral canal and closing of the intervertebral foramen also occur.[2] In lateral flexion and rotation (coupling movement) of the cervical spine, there is offset loading of the intervertebral disc on the side of flexion and rotation, with nuclear material moving to the opposite side (site of the convexity), and the posterolateral annular wall is stretched.[2]

The intervertebral foramina house the exiting cervical nerves. The largest cervical spine foramen is at the C2-3 level, and the smallest foramen is at the C6-7 level.[17] The cervical foramina become very dynamic during cervical spine ROM. The intervertebral foramina enlarge with flexion and decrease with extension. In rotation, the ipsilateral side becomes smaller, and the contralateral side enlarges. The extreme changes of the foramina occur with coupled movements (ie, flexion-rotation and extension-rotation-lateral flexion).[18]

In addition to the above biomechanical concerns, cervical spinal stenosis has been evaluated with regard to catastrophic cervical sports injuries. The Torg/Pavlov ratio (measured by dividing the sagittal diameter of the spinal canal by the sagittal diameter of the vertebral body) when less than 0.8 was thought to subject the football player to high risk of cervical cord injury due to suspected cervical stenosis (see image below). However, subsequent studies found that this ratio may be erroneously low in players that have wide vertebral bodies. A study by Cantu suggested that functional stenosis as documented by myelogram or magnetic resonance imaging (MRI) may be a more appropriate measure of stenosis.[6]

Classification of athletic cervical spine injuries

A review by Bailes and Maroon classified athletes with cervical injuries into 3 types[4] :

• Type I injuries were those that caused permanent spinal cord damage, including conditions such as anterior cord syndrome, Brown-Sequard syndrome, central cord syndrome, and mixed incomplete syndrome.

• Type II injuries were classified as those that occur transiently after athletic trauma with normal neurologic examination and normal radiologic evaluation. Type II injuries included spinal concussion neurapraxia, and "burning hands" syndrome. The burning hands syndrome was described as suspected injury to the spinothalamic and corticospinal tracts, resulting in arm and hand weakness with burning dysesthesias.[19] This is distinct from the burner or stinger injury that is a common cervical injury in football players and is thought to be due to traction on the upper trunk of the brachial plexus. In this condition, athletes typically have a burning, dysesthetic pain that begins in the shoulder region and radiates unilaterally into the arm and hand, with C5-C6 distribution numbness or weakness.

• Type III injuries were classified in athletes with only radiologic abnormalities but without neurologic deficit. These included congenital spinal stenosis, acquired spinal stenosis, herniated cervical disc, an unstable fracture, fracture/dislocation, ligamentous injury, and spear-tackler’s spine. Spear tackler’s spine was described by Torg et al described athletes that were at high risk for quadriplegic injury. These athletes had developmental cervical canal stenosis, reversal of the cervical lordosis, preexisting posttraumatic cervical radiographic abnormalities, and documentation of using spear-tackling techniques.

Obtaining an accurate history is essential when evaluating patients with neck pain.

• Identifying specific red flags that are indicators of potentially serious spinal or nonspinal pathology or conditions that may interfere with treatment is extremely important. The absence of red flags diminishes the need for special studies during the first 4 weeks of symptoms, a time in which spontaneous recovery is common. Serious spinal and nonspinal conditions associated with red flags include the following:

  • Cancer/malignancy

  • Infection

  • Trauma with possible underlying fracture

  • Osteoporosis with possible underlying fracture

  • Conditions associated with spine instability (eg, rheumatoid arthritis, Down syndrome)

  • Significant or progressive neurologic deficit (eg, profound muscle weakness and/or reflex loss, bowel and/or bladder incontinence or retention)

  • Vertebral basilar artery insufficiency

  • Pregnancy

• Obtain an accurate description of the characterization of the pain, including location, onset, duration, frequency, description, distribution, and aggravating and relieving factors.

  • Differentiating between referred and radicular pain is important. Referred pain is more diffuse, whereas radicular pain is more specifically along the course of a dermatome.

  • Patients with disc degeneration could have chronic low-grade pain that is periodically exacerbated for several weeks.

  • Cervical discogenic pain may be localized pain, referred pain, or radicular pain.

  • Mechanical pain can be constant or intermittent, whereas chemical pain is more likely to be constant.

  • Cervicogenic pain is usually worse in positions that involve prolonged sitting, especially in sitting positions with a protruded head posture or prolonged flexion. Bending positions also provoke cervicogenic pain. Frequent changes of position provide relief. However, in cases of severe acute pain, a still position may be most comfortable. Pain worse upon awakening is probably related to using an unsuitable pillow or having adopted an inappropriate posture while sleeping.[2, 20]

  • In 1959, Ralph B. Cloward, MD, published referral patterns of the cervical spine discs using cervical discography.[21]

    • He found that stimulating the anterolateral aspect of the cervical discs produced pain at the ipsilateral scapula. Stimulation in the midline of the anterior aspect of the disc produced pain between the shoulders in the middle of the back. Cloward described that pain from the C6-7 disc was felt in the inferior angle of the scapula. Pain from the C5-6 disc was felt in the center of the medial scapular border. Pain from C4-5 disc was experienced in the region of the spine and superior angle. Pain from the C3-4 disc was referred to the C7 spinous process and the posterior border of the trapezius muscle.

    • Cloward also found that when stimulating patients with posterolateral disc protrusions, the referral patterns were found to be more intense than when stimulating the anterior aspect of the disc and were found to spread from the vertebral border of the scapula out to the shoulder and upper arm as far as the elbow. Midline posterior disc protrusions were found to refer pain to a confined area overlying the fifth cervical to the second thoracic spinous processes near the midline, with upper discs more cephalad and lower discs more caudad. When extensive disc rupture and degeneration were present, a combination of the posterolateral and midline posterior referral patterns was found.[21]

• Risk factors for malignancy include age older than 50 years, history of cancer, unexplained weight loss, pain with bed rest, and failure to improve with conservative therapy.[22, 23]

• Ask questions related to potential infection (eg, history of recent surgery, including dental surgery; history of fever or chills; history of intravenous drug abuse)[23]

• Obtain information regarding the patient's past medical history, including previous neck pain, surgeries, trauma, motor vehicle accidents, and work-related or sports-related injuries.

• Obtain information regarding a history of alcohol, tobacco, or drug use or abuse; osteoporosis; rheumatologic conditions; diabetes; or other conditions associated with neuropathy (eg, vitamin deficiencies, thyroid disease).

• Obtain information regarding previous diagnostic studies and treatment interventions.

The initial evaluation of cervical spine injuries starts with the basic history and physical examination done on the field. Following this initial evaluation, a more comprehensive evaluation may include plain radiographs; serial examinations; neurologic or orthopaedic consultation; and computed tomography (CT) scanning, MRI, or CT myelogram, or dynamic studies.

See the list below:

• Physical examination of the patient with cervical discogenic pain includes the assessment for neurologic deficits suggestive of myelopathy.

  • While assessing the patient, look for altered balance, stooped and wide-base gait, weakness, decreased sensation of the upper extremities, lower motor neuron findings in the upper extremities, and upper motor neuron findings in the lower extremities.

  • Patients with a herniated nucleus pulposus (HNP) without radiculopathy can present with limited ROM and referred pain, which may be elicited with the cervical compression test (see image below). Patients with an HNP with radiculopathy may present with limited ROM and radicular pain, dermatomal sensory loss, diminished strength in a myotomal distribution, and loss of muscle stretch reflexes.

    Axial computed tomography scan of cervical herniated nucleus pulposus.

  • Manual muscle testing has greater specificity than either reflex or sensory changes.[17, 24] The Spurling test can elicit radicular pain and is performed by having the patient actively extend the neck, laterally flex, and rotate toward the side of the pain. Then, careful downward compression is applied on the head. The Spurling test is helpful in the diagnosis of cervical radiculopathy, because of its high specificity. However, its absence does not preclude the diagnosis of radiculopathy because of its low sensitivity.[17]

• The Lhermitte test is performed by flexing the neck with the patient in the sitting position. This test may produce an electriclike sensation down the spine and occasionally the extremities. This electriclike sensation has been reported in patients with cervical spondylosis, cervical myelopathy, cervical cord involvement secondary to tumor, and multiple sclerosis.[17]

• Another helpful clinical sign is pain relief upon arm abduction in cases of a ruptured cervical disc. No changes in pain occur with arm position when the disease process is spondylosis with foraminal stenosis.[25]

• The neck compression test (Spurling test), axial manual traction, and the shoulder abduction test have high specificity but low sensitivity for the diagnosis of root compression in cervical disc disease. Despite the low sensitivity, these tests are valuable in the clinical examination of a patient with neck and arm pain.[26]

• The Arm Squeeze Test may be used to differentiate shoulder pain caused by cervical nerve root compression from that caused by shoulder disease.[27] The test involves squeezing the middle third of the upper arm; if pain is elicited from this maneuver, the etiology of the should pain may be cervical in origin.[27]

See the list below:

• Degenerative changes

  • Degenerative changes appear early in the lower cervical spine, with the most severe changes occurring at the C5-6 and C6-7 levels. According to Kramer, this is due to the mechanical influence on the cervical intervertebral discs by the extensive movement carried out in the cervical spine in relation to the rigid thoracic spine.[3] Therefore, the comparative loading per squared centimeter by the head on the cervical discs exceeds that of the thoracic and lumbar spine.[3] Cervical spine degenerative changes appear first in the intervertebral discs during the third, fourth, and fifth decades of life.

  • Degenerative disc changes are appreciated by loss of intervertebral disc height and osteophyte development at the origins of the vertebral endplates. These changes lead to loss of shock-absorbing capacity, resulting in abnormal force transmission and increased load to the zygapophyseal joints. Therefore, cervical zygapophyseal joint degenerative changes commonly follow intervertebral disc degeneration.[2, 3] The combination of decreased intervertebral disc space and facet joint degeneration with hypertrophy causes narrowing of the intervertebral foramina, with potential compression of the exiting nerves and associated radicular symptoms.

  • Creep is the further detectable movement that occurs after maximal ROM is attained and a constant force is continued on a collagenous structure.[28] Creep is believed to be due to gradual rearrangement of collagen fibers, proteoglycans, and water content in the ligament or capsule being stressed. As the water content of the nucleus pulposus decreases with disc degeneration and aging, the ability to imbibe water and distribute compressive loads also decreases,[29] resulting in increased creep under compression, which can cause incompetence of the annulus. Hickey and Hukins reported that if ligaments were stretched more than 4% of their resting length, irreversible damage would follow.[30]

  • As disc degeneration continues, the distinction between the margins of the nucleus and annulus becomes obscured. The negatively charged proteoglycan side chains decrease with subsequent loss of their imbibing capabilities. During this process, the overall collagen content within the disc increases. Primary annular disruption initially may occur in the periphery and is referred to as 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 and the disc essentially becomes fibrotic.[31, 32, 33, 34]

• Predisposing and precipitating factors for cervical discogenic pain syndrome (CDPS)

  • Predisposing and precipitating factors for cervical discogenic pain syndrome (CDPS) include prolonged sitting with poor posture (eg, protruded head posture), frequent of flexion, sudden unexpected movements, and trauma.

  • Harms-Ringdahl was able to provoke pain in individuals who were asymptomatic by maintaining a protruded sitting posture.[35] All subjects in the study reported neck pain within 2-15 minutes.

  • Static loading with poor sitting or lying postures eventually lead to problems within the cervical spine. Poor posture can also enhance or perpetuate an already existing cervical pain from trauma or whiplash injury.

  • Kramer reported that most patients in his practice developed pain for no apparent reason.[3]

  • Frequent flexion of the cervical spine is another predisposing factor in the production of symptoms from the cervical spine.

  • Sudden unexpected movements, particularly those that involve lateral flexion and rotation of the head and neck with the neck in a protruded position, can cause or precipitate neck pain. Trauma to the cervical spine is commonly seen as a result of whiplash forces occurring during significant motor vehicle accidents or in sports-related cervical spine injuries.

See the list below:

• Laboratory studies typically are not indicated in the diagnosis of cervical discogenic pain syndrome.

See the list below:

• Radiographs of the cervical spine primarily are indicated in cases in which significant trauma is involved (eg, motor vehicle accident, sport injuries) and in cases in which the history and physical examination suggest the possibility of a fracture or instability. See the images below.

  Lateral cervical spine plain radiograph illustrating the Torg/Pavlov ratio.

  Lateral view of a C2 fracture dislocation.

  See the list below:

  • An oblique view is necessary to evaluate for fracture of the pars interarticularis and facet joint arthropathy. If spondylolisthesis is found and is believed to be symptomatic, flexion/extension lateral views are helpful to evaluate for instability.

  • In cervical discogenic pain syndrome (CDPS), radiographic findings can be normal or can show decreased intervertebral space and associated facet joint and/or vertebral body degenerative changes. Radiographic findings commonly show degenerative changes in persons older than 55 years. Little correlation exists between symptomatic and asymptomatic individuals and structural changes on roentgenographic examinations.[2, 17, 36]

  • In 1987, Deyo recommended radiographic studies be obtained in the following circumstances[37] :

    • Patients older than 50 years

    • History of significant trauma (fracture risk)

    • Neuromotor deficits (to rule out spondylolisthesis or tumor)

    • Unexplained weight loss (to rule out malignancy)

    • Drug or alcohol abuse (risk factors for osteomyelitis, osteoporosis, and trauma)

    • History of cancer (to rule out metastasis)

    • Use of corticosteroids (increased risk of infections and osteoporosis)

    • Fever (potential sign of osteomyelitis or epidural abscess)

    • Failure to improve with conservative therapy

    • Medicolegal cases involved in litigation

• CT scanning provides high-quality osseous detail and spatial resolution.

  • CT scanning is a valuable adjunct in evaluating patients with extensive bony degenerative changes and suspected stenosis or bony pathology not identified by plain radiographic films.

  • CT scan also is an alternative to evaluate for disc herniations in patients in which MRI is contraindicated. See the image below.

    Axial computed tomography scan of cervical herniated nucleus pulposus.

  • When combined with discography, axial CT scanning surpasses MRI in detecting annular fissures.[38]

  • CT scanning with myelography is helpful in evaluating patients with extradural compression of the neural elements from bone or disc material.[39, 40]

• MRI is the study of choice in patients with suspected degenerative discogenic disease. See the images below.

  T1-weighted magnetic resonance image of a cervical disk herniation.

  T2-weighted magnetic resonance image of a cervical disk herniation.

  See the list below:

  • MRI is a sensitive diagnostic modality that offers multiplanar imaging capability and excellent soft-tissue and spatial resolution without ionic radiation. MRI also provides physiologic information regarding the water content of the disc.[41]

  • Schellhas et al studied subjects who were asymptomatic and those who experienced pain.[42] The investigators concluded that significant disc annular tears often escape MRI detection and that MRI cannot reliably identify the source or sources of cervical discogenic pain syndrome (CDPS).

  • MRI abnormalities are common in patients who are asymptomatic and must therefore be corroborated with physical examination findings in making the diagnosis of cervical discogenic pain syndrome (CDPS).

  • Matsumoto et al completed a study of 497 patients who were asymptomatic.[43] In this study, cervical MRI revealed that the frequency of degenerative changes increases as age increases. Disc degeneration was the most common observation. In men and women in their 20s, 17% of men and 12% of women showed disc degeneration; in individuals than 60 years, 86% of men and 89% of women showed disc degeneration.[43] Posterior disc protrusion with demonstrable compression of the spinal cord was found in 7.6% of subjects, mostly those older than 50 years.[43]

See the list below:

• Cervical discography

  • Cervical discography is an important adjunct in the evaluation of the patient with cervical discogenic pain syndrome (CDPS), particularly when other diagnostic studies fail to detect any abnormalities in a patient with subjective symptoms of cervical discogenic pain.[42, 44]

  • Manchikanti et al performed a systematic review of the cervical discography literature.[45] The investigators found that cervical discography plays a significant role in selecting surgical candidates and improving outcomes, despite concerns regarding the false-positive rate, lack of standardization, and assorted potential confounding factors. Manchikanti et al concluded that cervical discography performed according to the International Association for the Study of Pain (IASP) criteria may be a useful tool for evaluating chronic cervical pain, without disc herniation or radiculitis. "Based on a modified Agency for Healthcare Research and Quality (AHRQ) accuracy evaluation and US Preventive Services Task Force (USPSTF) level of evidence criteria, this systematic review indicates the strength of evidence as level II-2 for diagnostic accuracy of cervical discography."[45]

  • Cervical discography is also useful in the evaluation of patients with multiple degenerative disc findings or various levels of disc herniations in which surgery is contemplated.[46]

  • The most important part of the cervical discography evaluation is the provocation/analgesia response, because it will differentiate symptomatic from nonsymptomatic discs. In a study published by Osler, a series of patients with positive cervical analgesic discography followed by anterior cervical fusion with or without discectomy resulted in 81% excellent or good results.[47] Osler concluded that analgesic discography is the most effective test for location of the lesion in the painful disc syndrome.[47, 48]

• Electromyography (EMG)

  • EMG is performed primarily by specialists in neurology or physical medicine and rehabilitation as an extension of the history and physical examination of patients with suspected cervical radiculopathy.

  • Prevalence studies of cervical radiculopathies demonstrate that 2 age peaks exist, one in the 60s and 70s and one in the 20s. Cervical radiculopathy in the older age group almost always is caused by a combination of osteophytic spurs and disc protrusion compressing an exiting nerve root, and cervical radiculopathy in the younger age group tends to be caused by a typical type of disc herniation.

  • EMG is a physiologic test not necessary in the initial evaluation of patients with new symptoms unless it is being utilized as a baseline for worker's compensation or to assess personal injuries to rule out a preexisting injury.

  • Wait approximately 3 weeks after the onset of symptoms to perform an EMG. Delaying the study for 3 weeks ensures accurate detection of positive waves and fibrillation potentials.[17, 49]

  • EMG can also be useful by assisting in the determination of the approach to epidural injections, selective nerve root blocks, and/or surgery. EMG is valuable in identifying other possible concomitant neurologic conditions, such as entrapment neuropathies, peripheral neuropathies, brachial plexopathies, myopathies, and motor neuron diseases.

• Sensory-evoked potentials are useful in evaluating patients with cervical myelopathy.[50]

Rehabilitation Program

Treatment for cervical discogenic pain depends on the clinical presentation and other concomitant medical conditions that can interfere or limit certain interventions. Many cervical disc herniations can be managed successfully with aggressive nonsurgical treatment. Conservative nonsurgical treatment includes use of medications, such as nonsteroidal anti-inflammatory drugs (NSAIDs), a short course of steroids on a tapering dose, nonnarcotic analgesics, or short-term narcotic analgesics; partial rest; and instructions on proper posture, proper body mechanics, and a home exercise program.[51, 52]

Physical Therapy

For patients with cervical discogenic pain with or without radiculopathy, physical therapy should be focused on educating the patient about proper posture, proper body mechanics, and how to implement a specific exercise program. The exercise program should be supervised initially to assure proper technique and performance of the exercises.

The McKenzie method of mechanical evaluation and treatment of the cervical spine involves establishing a baseline ROM with single cervical spine motion in each direction, a baseline level of pain, and a baseline of more distal or peripheral symptoms, as well as identifying patterns of movements or positions that decrease symptoms and improve the segmental motion. At times, it is necessary to add force by a mobilization or manipulation to attain end range of movement in the already identified direction of preference.[2, 53, 54, 55]

After obtaining a baseline of ROM and symptoms, test repetitive motion of the cervical spine to the end range of each direction by frequently assessing the changes in the initial symptoms and ROM with repetitive end range movement.[2] If symptoms worsen as a result of repetitive movements in a particular direction, that particular movement should be stopped immediately.[2]

If symptoms and/or ROM improve upon a specific direction of motion (ie, retraction) and no symptoms peripheralize, a direction of preference is established. This direction of preference is used in a specific rehabilitative exercise program.[2, 53, 54, 55]

At times, patients with radicular symptoms can experience the phenomenon of centralization. McKenzie described centralization as the phenomenon whereby as a result of the performance of certain repeated movements or the adoption of certain positions, radiating symptoms originating from the spine and referred distally are caused to move proximally toward the midline of the spine.[2, 53, 54, 55] Centralization is the hallmark sign that a correct movement or position is being performed, whereas peripheralization is a contraindication to further movements in that direction.[2, 53, 54, 55]

Surgical Intervention

Surgical intervention for cervical discogenic pain syndrome (CDPS) is commonly considered in cervical radiculopathy or myelopathy with persistent radicular pain, motor weakness, progressive neurologic deficits, or evidence of cord compression with no response to appropriate conservative treatment.

Anterior cervical discectomy (ACD) using an operating microscope is a safe and effective approach for patients with soft disc herniations.[56, 57, 58, 59] Anterior cervical discectomy with interbody fusion (ACDF) is preferred for patients with advanced spondylosis. A single-level surgery is preferred to multiple levels.[56, 57, 59] Studies report successful outcomes for pain relief, patient satisfaction, and increased function in persons with neck pain in the absence of radicular symptoms that have been managed with anterior cervical discectomy and fusion.[58, 60]

The surgical treatment of cervical degenerative disc disease should be considered only after an adequate trial of conservative treatment has failed.[61] Multiple studies report of patients with herniated cervical intervertebral discs and cervical radiculopathy who experience successful response to nonoperative treatment interventions.[17, 62, 63, 64, 65] Furthermore, studies document the regression of cervical disc herniations accompanying the resolution of cervical radiculopathy.[66, 67, 68]

Other Treatment

At times, patients with cervical discogenic pain syndrome (CDPS) require image-guided interventional procedures to control their pain and facilitate their participation in physical therapy.[17, 65] Cervical epidural injections are commonly used with successful results in patients with cervical radiculopathy.[17, 62, 69, 70, 71] Use of fluoroscopic-guided selective nerve root blocks can be an effective alternative approach for cervical epidural steroid injections in patients with atraumatic cervical spondylotic radicular pain.[72, 70]

Rehabilitation Program

Physical Therapy

This phase of rehabilitation for cervical discogenic pain syndrome (CDPS) focuses on soft-tissue overload and biomechanical dysfunction. The 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.

Rehabilitation Program

Physical Therapy

The final phase of rehabilitation for cervical discogenic pain syndrome (CDPS) requires functional, pain-free cervical ROM and proper spinal and shoulder girdle mechanics. Sport-appropriate flexibility, strength, and skills are necessary before return to play. Sport-specific activities should be reviewed to ensure correct techniques, especially in contact and collision sports.

Oral NSAIDs can help decrease pain and inflammation. Various oral NSAIDs can be used, and no single NSAID holds a clear distinction as the drug of choice. The choice of NSAID is largely a matter of convenience (how frequently doses must be taken to achieve adequate analgesic and anti-inflammatory effects) and cost.

Class Summary

NSAIDs have analgesic, antiinflammatory, and antipyretic activities. The mechanism of action of these agents is not known, but NSAIDs may inhibit cyclooxygenase 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, which is considered to be an 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 the lowest dose of celecoxib for each patient.

Ibuprofen (Motrin, Advil)

For pain, DOC for patients with mild to moderate pain. Inhibits inflammatory reactions and pain by decreasing prostaglandin synthesis.

Return to play following treatment for cervical discogenic pain syndrome (CDPS) is an individualized process. No specific time frame exists for a particular injury. A review of the literature by Morganti revealed that there was agreement with regard to the general requirements for return to play.[7] These included full and painless ROM, normal strength, a stable vertebral column, and adequate space for the neurolgic structures.

Players with compromise of C1-C2, acute fractures, residual neurologic deficit, spinal cord edema or deformity, acute disc herniation, or painful range of motion of the neck should not play collision sports.[7] Certainly, playing with improper technique such as spear-tackling, diving in unknown depths, diving while intoxicated, using a trampoline without a spotter, and checking from behind in hockey should be avoided.

Complications of surgical intervention include bleeding, infection, nerve damage, chronic dural leak, and scar-tissue formation surrounding or compressing nervous tissue. Fortunately, these complications do not happen often, but when they do, they may, alone or in combination, cause the patient to be in a worse condition than before having had surgery.

Injury prevention is accomplished best through good coaching, proper techniques of sport-specific activity, adequate preparticipation training, and appropriate safety measures, including proper protective equipment and adherence to the rules of the game.

Inform patients that the natural history of an acute radiculopathy suggests that most patients recover within several weeks to months and that surgery is generally not necessary. Educate patients with cervical discogenic pain syndrome (CDPS) regarding home program activities, which may be performed on a routine basis to help strengthen their spine and associated muscle groups, which may help prevent injury in the future.