Cervical disk herniation
Background
- Nucleus pulposus protrudes through posterior annular fibrosis
- Leads to radiculopathy (most common) or myelopathy (less common, more serious)
- Most common at C5-C6 and C6-C7 levels
- Peak incidence age 30-50
Clinical Features
- Neck/shoulder/arm pain in dermatome distribution, weakness, hyporeflexia
- Spurling test: Extend neck, ipsilaterally rotate and laterally flex, then apply axial compression
- Reproduction of radicular symptoms is a positive test (specific for nerve root compression)
- Lhermitte sign: Electric shock sensation down spine with neck flexion → suggests cord compression (midline herniation)
- Shoulder abduction test: Lifting arm above head relieves radicular symptoms → differentiates from shoulder pathology
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 |
Red Flags for Myelopathy
- Bilateral upper extremity symptoms
- Gait disturbance, balance difficulty
- Bowel/bladder dysfunction
- Upper motor neuron signs: hyperreflexia, Babinski, clonus, Hoffmann sign
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 cervical spine — gold standard; indicated if neurologic deficits, red flags for myelopathy, or symptoms >6 weeks
- X-ray if concern for fracture or instability
- EMG/NCS for chronic symptoms — usually outpatient
Management
- Radiculopathy (no myelopathy): NSAIDs, short course of oral corticosteroids (controversial), muscle relaxants, activity modification
- Avoid cervical collar (no evidence of benefit, may delay recovery)
- Most cases resolve with conservative management over 6-12 weeks
- Myelopathy: Emergent neurosurgery consult — surgical decompression typically indicated
Disposition
- Discharge isolated radiculopathy with pain management and PCP/neurosurgery follow-up
- Admit or emergent consult for progressive neurologic deficits or myelopathy
- Emergent MRI and neurosurgery consult for cauda equina-like symptoms or rapidly progressive weakness