Cervical disk herniation

Background

• Nucleus pulposus protrudes through posterior annular fibrosis
  • Leads to radiculopathy or less commonly myelopathy

Clinical Features

• Neck/shoulder/arm pain in dermatome distribution, weakness, hyporeflexia

Cervical Exam by Level

Radiculopathy	Motor Deficit	Sensory Deficit	Diminished Reflex
C4	Levator Scapulae & Shoulder elevation
C5	Deltoid & Biceps		Biceps
C6	Brachioradialis & Wrist extension	Thumb Paresthesia	Brachioradialis
C7	Triceps & Wrist flexion	Index/Middle/Ring Paresthesia	Triceps
C8	Index/Middle distal phlnx flexion	Small Finger Paresthesia

• Spurling test
  • Flex neck forward, ipsilaterally rotate, and ipsilaterally tilt
  • Reproduction of radicular symptoms is positive test
  • Specific for nerve root compression
• Lhermitte's sign positive suggests cord compression from midline herniation
• Shoulder abduction test - lifting arm above head relieves symptoms; differentiates radiculopathy from shoulder pathology

Differential Diagnosis

Neck pain

• Musculoskeletal
• Torticollis
• Dystonic reaction
• Cervical spondylosis
• Cervical stenosis
• Cancer
• Epidural abscess
• Vertebral osteomyelitis
• Transverse myelitis
• Temporal arteritis
• Epidural hematoma (anticoagulation, hemophilia)
• Cervical disk herniation
• Blunt neck trauma
• Anterior horn disease
• Cervical fractures and dislocations
• Cervical radiculopathy

Evaluation

• MRI required for definitive diagnosis; indicated if neurologic signs

Disposition

• In consultation with Neurosurg, admit if progression of neurologic signs

See Also

• Neck pain

References

Orthobullets