A cervical disc prolapse is a protrusion of one of the discs in the neck. This protrusion often causes pressure on one of the nerves to the arm. Sometimes, a cervical disc prolapse may press against the spinal cord, causing symptoms potentially much more serious than those of a single pinched nerve.
What are the symptoms?
• Neck pain
• Pain in the upper limb (brachalgia)
• Weakness or numbness in upper limb
• Weakness, stiffness, tingling or numbness in lower limbs
• Pain in the back side of head starting from neck (occipital neuralgia)
• These common symptoms may come suddenly or progress over time
• Pain can come and go over time, but has tendency to recur
When to seek medical help?
• If a shooting pain is not responding to simple analgesics
• If any weakness or numbness is developing in the arm, forearm or hand
• If walking is getting difficult due to stiffness or weakness of legs
When to investigate?
• If a pain in the neck continues beyond few weeks
• If a shooting pain in the upper limb continues beyond few days or weeks depending upon severity
• If there is any weakness or numbness of limbs, upper or lower
• If pain is associated with trauma or fever
What kind of investigations?
• MRI scan is the best investigating tool to see the nerves and the disc
• X ray can give some information about bone and evidence of disc disease
• CT scan, only if MRI cannot be done
• EMG, Nerve conduction study only as an adjunct
Cervical disc disease is increasingly becoming a lifestyle disease especially among young people working in the IT sector. Obviously it is related to a bad posture associated with lack of exercise of appropriate muscles. Fortunately, a vast majority get afflicted with neck pain without any neurological deficit and if the diagnosis can be confirmed on time, the disease process can be controlled with preventive measures. The two most important measures are proper posture especially while working and regular exercise to strengthen the neck muscles. It is important to exercise when you have no pain. Pain should not be the cause to restart neck exercises. A neck collar can be used for a short period if it improves the pain. Long use of neck collar tends to waste the neck muscles and hence is to be avoided. It is never good for the patients to experiment with pain relieving medications. Popping too many pain relieving pills can cause kidney failure. Long duration of medication should always be under medical supervision.
Indications of surgery
By and large, isolated neck pain is not an indication for disc surgery. However, it may be necessary, if significant pain in the upper limbs, without any weakness or numbness, persists for more than six weeks.
• If there is weakness/numbness of upper limb especially progressive
• If MRI finding of disc prolapse at a certain level matches with the nerve deficit
Anterior cervical micro discectomy with or without fusion is the gold standard for surgery in cervical disc prolapse. Fusion with bone graft or titanium tends to decrease the incidence of neck pain. Cervical plate to fix the operated level is increasingly being used and definitely allows early return to work and avoidance of cervical collar in post-operative period. However, all the procedures lead to fusion at the operative level. We must understand that nature has allowed about 7 degree of movement at an average cervical disc.
Hence a fusion especially at multiple levels will restrict the cervical spine movement. This is being blamed on increased wear and tear changes at adjacent levels (above or below the operated level) leading to significant disc disease. This can be a serious cause for concern in young people with disc disease requiring surgical intervention. To overcome this problem, a new concept of disc replacement surgery is now being practiced. Cervical disc replacement is a newer concept and rapidly developing surgical treatment for cervical spondylotic radiculopathy/myeloradiculopathy. These patients usually experience neck pain and pain with or without weakness in upper extremities when the prolapsed disc presses the cervical nerve root/roots (radiculopathy). When the disc presses the spinal cord (myeloradiculopathy), the patient might have difficulty in walking and exhibits symptoms involving the lower extremities.
Anterior cervical microdiscectomy and fusion (ACDF) with screws, plate and cage has been a successful operative method for cervical spondylotic myeloradiculopathy caused by cervical disc prolapse. However, the widely accepted concept of accelerated degeneration of adjacent disc levels has led to the hypothesis that reconstruction of an intervertebral disc after discectomy with functional disc prosthesis would offer better benefit. ACDF can cause restricted neck movements which is avoided in disc replacement surgery.
Cervical disc replacement
Cervical disc replacement offers the same benefit of decompression and fusion while simultaneously providing full neck motion. This protects the adjacent disc levels from the abnormal tress associated with fusion by maintaining physiological motion. There are presently two artificial cervical disc replacement devices that are FDA approved: the Bryan disc and the PRESTIGE® Cervical Disc. There are many other products which are in multiple stages of commercial clinical use. Considering the cost and benefit of such devices, they must be used in young people with predominantly soft disc prolapse.
The operative technique consists of initial discectomy followed by developing a virtual plane in the intervertebral disc space that is used to position the prosthesis. Then, the vertebral end plates are prepared for placement of prosthesis. The milled vertebral end plates exactly match the geometry of implants. The tight fit of prosthesis provides immediate AP and lateral stability. Good to excellent clinical results are clearly demonstrated in literature following this procedure. The procedure provides relief from neck pain, brachialgia and also improves patient’s quality of life and functionality. It also provides clinical and radiological stability and normal range of cervical motion. To conclude, cervical disc replacement for cervical disc prolapse with myeloradiculopathy represents an exciting new technology. Cervical disc replacement provides neural decompression and stabilization like ACDF. It also provides full physiological neck motion and protects the adjacent disc degeneration.