Cervical Disc Herniation FAQ’s

The pinched nerves are usually caused due to inflammation of the nerve roots near the spinal cord where they exit. The inflammation, once improved, causes relief in the pinched nerve. This improvement in inflammation can be caused rest, anti-inflammatory medication, steroid medications or cortisone shot. Occasionally the cause of inflammation may be persistent compression over the nerve, which may not get better with all form of conservative management.

Cervical disk herniation is a technical term, while cervical disk encroachment is a layman term to almost the similar diseases. Both means that there is pressure of cervical disk onto the spinal nerves or the spinal cord which may or may not cause symptoms.

In normal individuals, pushups are usually not bad for any cervical disk, but in patients who have cervical disk disease or who have weakness along the back of the cervical disk, pushups may cause increased herniation which may or may not cause pressure on the spinal cord or spinal nerves, leading to problems.

All cervical disk patients should be first treated with noninvasive methods, like medications, rest and physical therapy. If the patient fails all noninvasive options or if they develop worsening pain, neurological deficit, problems with balance, bowel or bladder, these patients will need medical attention and may need invasive procedures on their cervical spine.

Majority of the patients of cervical disk herniation get better within four to six weeks. In patients who do not get better in that period, they may need medical attention and a possible need for surgical intervention.

Nonsurgical options for treatment of a cervical disk disease are medications, physical therapy, rest, use of cervical collar. Cervical traction has not shown much help or effect on these patients, though it may be beneficial in some patients.

Most of the patients with cervical disk herniation do not need surgical treatment. They should be initially treated with rest, medications, cervical collar, physical therapy. Patients who are not relieved with these measures, as well as patients who develop worsening neurological deficit or weakness or involvement of balance or gait or bowel or bladder may need surgical treatment.

Most of the patients do not need a collar after surgery. There may be occasional patients who may need collar just for rest or pain relief.

Whiplash injury may cause herniated disk. Most of the whiplash injury patients present with neck pain or pain along the midline. Those patients who develop herniated disk because of whiplash injury may develop tingling, numbness with or without weakness into either of the upper extremity.

There are multiple therapies available to deal with pain. The most commonly involved are using of anti-inflammatory medications, including Aleve, Advil, Tylenol, or prescription strength anti-inflammatory medications. If patients are not improved with this, patients can be given narcotic medications, though they have higher side effects than anti-inflammatory medications.

There are certain other pain modalities which can be used in these patients, especially in chronic pain patients, which may involve stimulator or other invasive procedures. Pain can also be managed by steroid injection to the nerve root or epidural injection to the cervical spine but must be done by physicians who are well trained in these specific modalities.

If the surgery is delayed enough to let damages happen due to nerve compression, there may be irreversible damage especially after patient starts developing neurological deficit in the form of weakness or involvement of bowel or bladder or gait imbalance.

Patients pain can be caused by multiple structures in the cervical spine, including bone, spinal cord, nerve routes, the covering of the spinal cord and the nerve routes, the blood vessels, the muscles around the spine etc. The presentation of the patient, Physical examination findings as done by physician, as well as, findings of special investigations in viewing x-ray and MRI help in knowing the origin of the pain and hence plan the treatment.

Most of the patients with cervical disk disease and subsequent pain can be treated with conservative means and do not require MRI. Patients who fail conservative measures, as well as patients who develop worsening neurological deficit or weakness or involvement of bowel or bladder or gait may require MRI. Patients usually need to see a physician before an MRI can be done.

Patients with spine problem need to undergo special investigations to confirm the diagnosis. The initial form of imaging is an x-ray, which shows bones only. After the x-ray is done, and if patient needs, then an MRI is performed, which help to know the anatomy about the spinal cord and spinal nerves and to understand as to where the problem lies. Occasionally physician may ask patient to undergo CAT scan in which a bony anatomy is better delineated.

Certain patients, especially who have contraindication to MRI, may need to undergo a CAT scan. Occasionally a dye can be put along the spinal cord and a CAT scan can be done. This procedure is called CT myelography.

Depending on the complexity of the surgery, most of the patients will have pain in the surgical site for five to seven days. This pain is gradually improving, and patients are asked to take pain medications for the same. Even after a week, there is some residual pain which takes four to six weeks to completely resolve.

Most of the patient do not need to wear a brace or collar after the surgery. Even if a neck collar or a back brace is needed, it may be discarded soon depending on the recovery of the patient.

There is a rare chance of injury to the nerve roots as well as spinal cord while doing a spine surgery. With advancement and use of magnification and refined instruments, the risk of causing nerve damage and paralysis are rare.

Occasionally patients may need further surgeries. These surgeries may be required due to failure of the fusion or failure of the initial procedure or failure of the implants. Occasionally after many years, some patients may develop degenerative disease on the nearby areas. These patients, if symptomatic enough, may need surgical intervention.

If the patient has a superficial infection, few days of antibiotics will help heal these infections. Occasionally patient may develop deep infection. In these patients may need IV antibiotics for a longer period. If despite all efforts or in patients with rapid deterioration due to infection, surgery may be needed to help clean off the infection.

General anesthesia is a preferred mode of anesthesia for cervical spine surgery. In this anesthesia, a tube is placed through the windpipe of the patient to control the respiration while the patient is operated upon.

Occasionally patients will have pressure on the spinal cord from the back. These patients need the pressure to be relieved from the back and in such cases, cervical laminectomy needs to be performed. Most of the time, the cervical laminectomy is also accompanied by placement of screws and rod to make the spine stable and fuse in an appropriate position.

Minimal invasive surgery does not remove enough bone to make the neck unstable. If a fusion surgery is performed, then removal of disc as well as bone may lead to instability and these patients usually need placement of a support in the form of a cage with plate and screws.

Most healthy patients have more than 90th percent chance of bone growing back leading to good result with fusion. This healing of bone can be suboptimal in patients with systemic diseases like diabetes, or in patients who continue to smoke after the surgery.

While doing fusion surgeries, the adjoining areas of the two vertebrae are cleaned, so that a healing process can be activated. In minimal invasive surgery, a small amount of bone is removed to make a window to reach the nerve root and the disc, to remove the discectomy. The amount of bone removed is not enough to cause any instability because of the loss of bone.

Spondylolisthesis or slipping of one vertebra over the other are usually taken care by the surgery if it fails to give relief with conservative means. It is not necessary to get them 100% reduced, but the most important part is to relieve the neural elements of all the pressure, which is caused either by the bony vertebrate or the disc and prepare the vertebrae for fusion.

In case of lumbar spine, spondylolisthesis need not to be reduced fully 100%, especially if the patient has a high grade listhesis, it is not desirable to reduce it completely. An important part of surgery is to clean the pressure of the spinal and nerve roots and prepare a healthy environment for bones to fuse.

For patients undergoing fusion surgery, it is highly desirable that they quit smoking. Smoking is detrimental for bone healing and hence the fusion. Smokers are at a higher risk of nonunion, that means non-healing of the fusion mass, and these patients may need revision surgery. If the patient is not able to quit smoking, it is at least highly desirable for them to quit for three months. Use of the nicotine patch in place of smoking has the same detrimental effect as smoking itself.

Patients with one or two level cervical spine fusion can get back to sports after they are completely healed, recovered and rehabilitated from the surgery. Patients who have undergone more than two level fusion or surgery on upper cervical spine are not recommended to go back to contact sports. In circumstances when the patient undergoes minimal invasive discectomy procedures and no fusion is done, these patients are allowed to go back to sports when they are fully healed and rehabilitated.

The screws, plates, and rods put into the spine, either from the front or the back, are placed very deep, and it is highly unusual for the patients to feel the metal through their skin. The metal is covered with multiple layers of thick tissue, and thus the metal is usually not amiable to be felt even with deep pressure over the skin.

Patients are asked to follow up regularly with the spine surgeon after a certain period of time. In the interim, patients may need to contact their surgeon if there are unusual changes to their postoperative recovery, which include discharge from the wound, worsening of pain, which is not relieved with pain medications, worsening of neurological deficits, occurrence of new neurological deficit, occurrence or worsening of tingling and numbness, involvement of bowel or bladder.

If the patient suffers chest pain, shortness of breath, any stroke-like symptoms, or paralysis, sudden onset of severe pain or in the calves or in the belly, these patients should contact the emergency room or call 911 as soon as possible.

Life after a single or two level cervical disc fusion is usually as normal as it was before the surgery. Occasionally, these patients may have some limitation of movement and occasional neck pain. Regarding its recommendation for a 26-year-old, it depends on the presentation as well as findings on examination and investigations like x-ray, MRI, and CT. The surgeon should try to keep the disc intact as much possible as it can be, but if the patient has failed all conservative means, and there are no other options, then these patients may undergo anterior cervical discectomy and fusion.

A patient with neck pain with tingling, numbness, with or without weakness, but with peripheral pain going down the arms who have failed all conservative means are usual patients for surgery. All such patients should be tried with conservative means except if there is neurological deficit or worsening neurological involvement, severely worsening pain, involvement of bowel or bladder, or balance. These patients may need urgent or emergent surgery to halt the neurological deficit or progression and help in recovery.

Cervical spine fusion at one level decreases the mobility of the cervical spine by approximately 10%. Under usual circumstances this is not of much consequence. There may be a subtle increased mobility on the adjoining levels to compensate. There also may be decreased mobility because of stiffness of the muscles around it, but this can be regained over time naturally, with or without physical therapy.

Spine surgery, especially fusion, will decrease the mobility of the spine depending on the level it has been done to. Surgeries like disc replacement tend to cause decreased worsening of mobility as compared to fusion surgeries due to its quality of preserving the joint mobility.

Cervical fusion is a surgery in which two adjoining spine vertebrae are prepared to undergo fusion by removal of the intervening disc and preparation of the bone ends so as to decrease the mobility of that segment. The surgery is usually performed to stabilize the segment as a part of removing the pressure over the neural elements.

Cervical spine fusion can be performed routinely from the front of the neck or the back of the neck. The type of surgery needed depends on the type of problem the patient is having. The decision as to go from the front or the back of the neck is taken by the spine surgeon after discussion with the patient with regards to the type of problem the patient has and how it can be relieved.

In the more common spine fusion in which it is done from the front of the neck, almost all of the disc is removed between the two vertebrates so as to create a good environment for spine fusion.

There are few patients who are good candidates for cervical discectomy which is done from the back of the neck, but most of the patients are not a good candidate for such a surgery, in which case we must go from the front of the neck to remove the disc and do what is called Cervical Fusion Surgery. When duly performed, both procedures can give good results in appropriate patients.

Rarely patients may have failure from a spine fusion surgery, which may present in the form of persisting pain in the neck or in the arms or worsening of the symptoms. In these cases, further investigations are done, so a to find the cause of the symptoms as well as failure if there is any. If the symptoms are not relieved by conservative measures, or the symptoms are progressively worsening, these patients may need surgery, which may be a revision or may be an augmentation of the previous surgery. A decision as to what type of surgery is done is taken after discussion with the patient.

Occasionally the patient is not able to fuse over a period, then the metal may fatigue due to mobility at the fusion site and may fracture. Some of these patients may go on to fuse after the metal breaks, while other may need a revision surgery.

Common complications of a cervical spine surgery are bleeding, temporary or permanent neurological deficits, rarely infection, leak of cerebral spinal fluid, injury to the windpipe, food pipe, or the major vessels in the neck, damage to nerves/spinal cord causing deterioration of neurological symptoms, blindness, and other complications related to the anesthesia.

Implants put into cervical spine usually do not need removal unless they are causing problems, or the patient needs to undergo a revision surgery. The implants are not removed for cosmetic purposes.

There is a small chance that surgery by fusion may not help the patient. This may happen if the fusion fails or if the patient has pain due to symptoms other than what the fusion has been done for. Exacerbation needs to be re-investigated to find the cause of pain. Occasionally, the patient may start having issues at a different level after being relieved at the symptomatic level after surgery. In such a case, the patients need to be managed for a different level accordingly.

Usually patients are pain free or with minimal pain at six months post cervical fusion. If the patient still has some pain, they should consult their spine surgeon. Occasionally there may be nonunion, that means the bones are not able to fuse, which may be causing the residual pain. Certain investigations like X-rays or maybe CT scan may be needed to confirm the finding. Rarely, the patient may have infection that may cause some of the symptoms and need to be investigated and treated.

Spine fusions usually take a very predictable course and are completely fused by three to five months. If fusion has not been successful, then the patient will have symptoms in the form of neck pain or pain going down the arms with or without tingling and numbness. The patient should follow up with their spine surgeon who will do specific investigations in the form of X-rays and CT scans to confirm their findings.

If the symptoms of the patient are not relieved by conservative means, then a surgery is needed. Surgery can in most cases relieve the patient completely of all the symptoms including pain, tingling, and numbness. Occasionally, severe symptoms like weakness or involvement of bowel or bladder or balance may not be completely corrected even after a successful surgery.

Most of the patients can walk away on the day of surgery. They can take care of their activities of daily living within the first week. The pain improves gradually and is better by three to four weeks. Patients in desk-type jobs can be back to work in four to six weeks, and those in heavy jobs may take longer. A fusion usually takes about three to five months to heal completely.

After one to two level spine fusions surgery or after total disc replacement of the cervical spine, the patient is usually back to his normal life as before the problem started in about three to five months. Many of our patients do not have any complaints after that period. A few patients may have occasional off and on pain, which is usually relieved by use of anti-inflammatory medications.

Usually patients are in their follow up with their spine surgeon at one month follow up, and on x-ray, the surgeon may inform him about loosening of the screw. Most of the times, if the patient has no symptoms, these patients are treated conservatively without any surgical intervention, and they go on to uncomplicated fusion over time. If the patient has symptoms that seem to be coming out of the loose screw or if there is movement of the spine because of loosening of plate or fracture, the patient may need revision surgery.

The answer to this question is found after a detailed discussion between the surgeon and the patient. The patient should discuss regards to different options with the surgeon and come to an informed decision. If a patient failed all forms of conservative management, is having worsening of symptom or if there is presence of weakness or bowel or bladder involvement or gait issues, then surgery may be the best answer at that time.

Vertebrate have disc in between them, which keeps them mobile and helps in movement. If the disc is diseased and is causing symptoms, then a decision of fusion may be done, in which case physically the disc is removed, and the bone tags are repaired to cause union. A spacer can also be put between the two vertebrates to keep the gap intact while fusion happens. There are multiple form of bone or other products that can be used to maintain the space as well to promote the fusion between the two vertebrates.

Surgery is usually not the first step for patients presenting with radiating pain, neck pain, tingling or numbness. Patients who present with rapid deterioration of neurological symptoms, like weakness, bowel or bladder involvement, or gait problems, may be a candidate for urgent or emergent surgeries. In all the other cases, patients need to be treated conservatively with medications with or without physical therapy and other modalities. Only when the patient has failed all these modalities, are they a candidate for surgical intervention.

Surgery is needed when the patient has failed all forms of conservative management with no relief in the pain over a period of four to six weeks or more. The patient may need an earlier surgery, which may occasionally be urgent or emergent also in case they are having weakness in muscles or involvement of bowel or bladder or gait problems.

If the patient has developed neurological involvement in the form of weakness, bowel or bladder involvement or gait problems, there may be a residual neurological deficit even after the surgery. Though surgery helps in removing the pressure from the compressed nerves of the spinal cord, but the recovery of nerves happens by a natural process in which body heals by itself. The presence of chronic disease may also hamper such a healing process.

Cervical Disc Disease can present in multiple ways. It can be most commonly presented as radiating pain or/and tingling and numbness going down the arms, with or without neck pain. If there’s weakness going down the arms, then the symptoms are taken to be serious. Occasionally, the patient may have an electric shock-like sensation going down the arms or legs. Sometimes balance of walking may be involved or patient may have what is called quadriparesis, in which all the four extremities or limbs are involved. Patient may have decreased control of what is bowel and bladder.

Cervical Disc Disease is mostly treated with medicine with or without physical therapy. Occasionally, when patient symptoms are not relieved with alternative means he may need to undergo invasive procedure which may include injection, a form of minimal invasive procedures or open surgeries, in the form of discectomy and fusion.

Physical therapists can be very helpful in treating Cervical Disc Disease pain. They can help in decreasing the neck pain as well as an improvement in the radiating pain, tingling and numbness of the arms. In case patient has weakness, or improper balance, or involvement of bowel or bladder they should seek immediate medical attention for timely management of the problem.

The cervical disc pain should be initially treated like pain in any other part of the body like hip joint or knee joint. If the pain is not improved or is associated with weakness or loss of bowel or bladder control or imbalance, then patient should seek immediate medical attention.

Usually prescription pain killers are given for acute pain and, in such cases, the addiction potential is very low. It’s only if they are being used without medical supervision that the patient may become addict to the pain killers. Strict medical supervision is always needed while taking these pain medications.

There is no cervical disc at the junction of the skull with C-1 or between C-1 or C-2. The first cervical disc is at the level of C-2 and C-3 and this disc is mostly involved in cases of injuries like motor vehicle accidents. Injury to the C 2-3 disc can have grave consequences and should be treated under strict supervision of a spine surgeon. Most of these cases will need surgical intervention or immobilization. In some cases, these injuries can cause long lasting neurological deficit. Other discs below C-2 and C-3 usually present in similar way with radiating pain down the arms along with tingling and numbness. Occasionally the disc at C2-3 and C4 may cause partial paralysis of the diaphragm leading to shortness of breath and possible respiratory failure.

Cervical disc herniation can cause shortness of breath if the nerve supplying the diaphragm is involved which may be possible in higher disc herniations. These patients may develop respiratory failure and may need respiratory support in the form of a ventilator. These patients should be managed in hospital setting in care of a spine surgeon along with a team of physician and other support staff.

Herniated cervical disc is a common problem and is usually self-limiting in 90% of the cases. Occasionally, the disc herniation may cause worsening pain which is not relieved by conservative means, or it may also cause weakness, or involvement of bowel or bladder, or balance problems, in which case medical attention is needed and patient may need to undergo surgical intervention. Very occasionally, a massive herniated cervical disc may cause quadriparesis in the form of weakness of all four extremities.

Most of the patient with cervical disc problems get better with conservative means in four to six weeks. Those who do not get better may need surgical intervention. After surgical intervention for cervical disc, patients usually are better in six to eight weeks and can get back to a normal life in eight to 12 weeks. Patients with one level fusions usually can get back to a normal life which was like pre-disc disease. Patients with multiple level surgeries may have some restrictions for their life.

A disc, which is herniated, cannot be pushed into the place, because there is a deficiency on the outer most layer, and it will come back again. The options for such a disc, if it is creating symptoms and is not improving with conservative means is to remove a part or all of it. They’re certain other options, which have been experimented and researched with, including use of heat or cryotherapy or laser. These methodologies have not been able to give promising and long-lasting results and are not the usual mode of treatment.

Cervical disc herniation is most common at C5-6, followed by C6-7 levels. Patients with herniation at two levels, like C5-6 and C6-7, and have symptoms due to both levels, as well as special investigations like x-ray and MRI confirming the involvement of the levels, may need surgery on both levels. The surgery is like doing it on one level, except that two levels are operated and fused with the plate and screws.

These patients have a longer recover as compared to single level and have a little more restriction of movement of the neck, as compared to a single level. The chances of failure of a fusion is also increased by a very small percent as compared to single level fusion. Patients who undergo spine fusion for more than two levels are at a higher risk as well as have a longer healing period as compared to patients who undergo fusion for two or less levels.

Surgery, if indicated, can be done in a patient who has had infection in the past. The surgeon must be cognizant about such a history and will take due diligence to avoid having an infection in the surgical site. These include use of correct and appropriate antibiotics before and after surgery, and keeping the patient informed as well as regular follow up, to diagnose an infection if it happens and treat it accordingly. These patients are at a higher risk of getting infected, especially if the infection was in the same surgical site where they have been operated.