Contents
Definition
- The result of displacement of the nucleus pulposus of the intervertebral disc, which may impinge the dural sheath of the nerves as they exit the neural foramen or directly compressing the spinal cord contained within the spinal canal 1
- Pain may be intermittent, or constant based on location of herniation and size of mass affecting nerve root
Causes
- As a result of degeneration of the intervertebral disc / natural aging of disc2
- Trauma/injury3
- As a result of fall, whiplash, head injury, violence
- Typically gives more sudden onset of more severe symptoms when compared to chronic herniation
- High energy external force resulting in extreme hyperflexion or hyperextension of the cervical vertebra can lead to injury
Occurrence
- Typical age of occurrence is between the ages of 35-604
- Usually does not occur before the age of 30
- If symptoms of this are present in such young individuals’ further investigation should be made to uncover if a more severe disorder or cause is present
- Peak is between 50-54 years of age
- Cervical herniation by descending order of occurrence:56
- C6 (66%)
- C7 (62%)
- C5 (38%)
- C4 (22%)
- C8 (15%)
- C3 (7,4%)
- T1 (4,9%)
- C2 (1,5%)
- Usually does not occur before the age of 30
Localization
- Pressure compressing the dural sheaths of the associated nerve root affected as a result of disc herniation of the intervertebral disc
Development
- A root affection or posterolateral displacement may either be primary/acute or secondary/chronic
- Chronic = discrete attacks
- Suddenly as a result of a trauma
- In discrete attacks there may be neck pain and pain in trapezius and scapular area which is then reaches spontaneous relief, and this process may sometimes repeat itself several times
- Normally when a disc herniation occurs, there is usually a protrusion of the disc preceding this period, it is very uncommon for pain to first appear in the arm
- If pain shifts from the scapular area towards the arm, then this may indicate a herniation of the disc has occurred
- This will put pressure towards the dural investment of the nerve root of the level below the respective level of the herniation
- See cervical herniated disc document for more information
- It is important to ask the patient if there has been any period of pain in the neck before pain appears in the arm, which may indicate a herniation
- Pain usually develops in the following order
- Neck pain
- Trapezius/scapular pain
- Arm pain
- Root pain and remission should occur within 3-4 months after the moment of the herniation
- Muscles strength should return in 3-6 months after pain is terminated
- If root pain does not disappear within 6 months, further investigation should be made as if a more serious cause is present
- The symptoms of disc herniation are usually experienced in the following order in regards to time of onset
- Pain
- Pins and needles
- Numbness
- Weakness
- Numbness
- Pins and needles
- Pain
Indications
- Arm pain which preceded by trapezius and or scapular pain, which again was preceded by neck pain
- The patterns may vary between each patient, but this is typical presentation
- Night pain
- Patient has a tendency to elevate arm to widen the intervertebral foramen affected to relieve some of the tension felt
- Pins and needles felt in the head/neck/arm/hand location indicates respective level affected
- After some time pins and needles are changed to numbness
- Pain that appears suddenly together with twinges and pain during movement of the head may indicate a sudden displacement of a discal fragment in the neck
- Coughing or sneezing causes pain in the trapezius/scapular area, this can both happen with a protrusion or a herniation
By level:
C3
- Very rare occurrence
- Pain
- Lateral aspect of neck
- Pins and needles or numbness felt at
- The lower part of ear
- The posterior part of the cheek
- Temporal region
- Lateral aspect of neck towards the chin
- Weakness not detected
- Loss of sensation of skin may be present in lateral aspect of neck but is unusual
C4
- Very rare occurrence
- Pain
- Lower part of neck towards the shoulder
- Pins and needles not felt
- Loss of sensation of skin along:
- Spina scapula
- Mid-deltoid
- Clavicula
- Weakness not detected
C5
- Pain
- Lateral aspect of arm towards the thumb
- Pins and needles not felt
- Loss of sensation of skin not affected
- Weakness detected in testing of
- Supraspinatus
- Infraspinatus
- Deltoid
- Brachialis and biceps brachii
C6
- Pain
- Along anterior aspect of arm
- Pins and needles felt in the thumb and index fingers
- Loss of sensation of the skin may be present at tips of thumb and index fingers
- Weakness detected in testing of
- Brachialis and biceps brachii
- Supinator brevis
- Extensor carpi radialis
- Biceps reflex test is weak or absent
C7
- Pain
- Along the posterior aspect of arm towards the 2-4th fingers
- On rare occasions pain can be felt at anterior and upper part of chest
- Pins and needles felt in the index, middle and ring fingers
- Loss of sensation of the skin at the dorsal aspect of the index and middle finger
- Weakness detected in testing of
- Triceps brachii – extension elbow
- Flexor carpi radialis – flexion wrist
- In severe cases – latissimus dorsi – adduction
- In severe cases wasting of
- Middle portion of pectoralis major
C8
- Pain
- Inferior aspect of scapula
- Ulnar aspect hand
- 3-5th fingers
- Pins and needles felt in the middle, ring and little fingers
- Loss of sensation of the skin at the little finger
- Weakness detected in testing of
- Extensors of the thumb
- Extensor carpi ulnaris
- Flexor carpi ulnaris
- Adductor pollicis
- Common extensors of the fingers
- Abductor indicis
T1
- Very rare occurrence
- Pain
- Pectoral area and scapula
- Ulnar aspect of lower arm
- Pins and needles felt at the ulnar aspect of the hand
- Loss of sensation of the skin felt at the ulnar aspect of the hand
- Weakness not detected
Observation
- The head might be held in lateral flexed position, often away from the painful side
- The arm on the affected side is often kept still as to avoid provocation of pain, sometimes also covered by the opposite hand
- The patient may request a half-lying position as lying flat will often provoke more pain
Examination
- The cervical examination depends on which state or stage the herniation is in, it’s position and size may give different symptoms, so each patient may present different symptoms and signs
- This means not all symptoms are not necessarily present in each case, but the symptoms are relevant to which affect it is having on the structure it is giving pressure towards
- Neck movements may influence pain in the arm or pins and needles, but not necessarily
- Resistance testing of the arm affecting the involved nerve roots is important, but may be difficult to sense, therefore it should be carefully compared with the non-affected arm
- Neck examination may range from limitation and pain to no limitation varying on each individual case
C5
- Weakness detected in testing of
- Supraspinatus
- Infraspinatus
- Deltoid
- Brachialis and biceps brachii
C6
- Loss of sensation of the skin may be present at tips of thumb and index fingers
- Weakness detected in testing of
- Brachialis and biceps brachii
- Supinator brevis
- Extensor carpi radialis
- Biceps reflex test is weak or absent
C7
- Loss of sensation of the skin at the dorsal aspect of the index and middle finger
- Weakness detected in testing of
- Triceps brachii – extension elbow
- Flexor carpi radialis – flexion wrist
- In severe cases – latissimus dorsi – adduction
- In severe cases wasting of
- Middle portion of pectoralis major
C8
- Loss of sensation of the skin at the little finger
- Weakness detected in testing of
- Extensors of the thumb
- Extensor carpi ulnaris
- Flexor carpi ulnaris
- Adductor pollicis
- Common extensors of the fingers
- Abductor indicis
T1
- Loss of sensation of the skin felt at the ulnar aspect of the hand
Considerations
- Consider the following factors if they could be provocative or causative of the problem
- Activities in daily life
- Hobbies
- Sports
- Posture