Disc Herniations
- More likely to occur posterolaterally |
- Hard Disc Derangement = older patient with degenerative changes |
- Soft Disc Derangement = young pts, trauma commonly benign |
- Look out for C8,T1 lesions , disc herniations are rare - could be non-mechanical |
- At the Cx lordosis, discs are thinner posteriorly |
- IV Foramina decrease in size caudally from C2-C3 - C6-C7 |
Affected Root
Root |
Symptoms |
C5 |
Pain lateral upper arm to elbow, medial scapula border |
C6 |
Pain in the lateral forearm, thumb and index finger |
C7 |
Neck pain, medial scapula down to middle finger |
C8 |
Neck pain, radiating to the shoulder, ulnar side of forearm and little finger |
T1 |
Pain in shoulder and axilla to olecranon |
Trps that can mimic Radioculopathy
- Supraspinatous - C5
- Infraspinatous - C5-7
- Scalenus Anterior - C5-C7
- Levator Scapulae - C8,T1
Hx findings
- Sharp, Aching pain in neck radiating into arm |
- Sensory Changes in dermatonal fashion , tingling, numbness, loss of sensation |
- Bakody's sign (abducting the shoulder and placing hand on their head) reduces symptoms |
- Coughing, Sneezing/straining (Valsalva) worsens pain |
- Stiffness of neck with decreased ROM |
- Myotomal weakness in muscles supplied by effected nerve root |
- Pain may wake up patient at night (common in neurological pain) |
- If Lx, Consider Cauda Equina - urinary/bowel/erection issues, can you feel between you legs when you wipe after the toilet? Bilateral leg symptoms |
- Tell patient "I'm going to ask some questions, they may be personal but I want to make sure the nerves to your bowel and bladder are working." |
Exam Findings
- Pt head tilts away from side of radicular pain |
- AROM reduced in Extension, rotation and lateral flexion - flexion relieves pain |
- Tenderness of paraspinal cx muscles, Trps in muscles |
- Cx spine compression & Doorbells +ve, Cx distraction relieves pain |
- SMR affected (Diminished & Asymmetrical) |
- Gait, LL reflexes & Hoffmans and Babsinki for suspected myelopathy |
- +ve SLR, Braggards, WLR, +ve Femoral stretch (L2/3, L3/4 NR), Slumps test, Bowstrings, +ve Valsalva |
- Assess for segmental instability (McGills) |
Red Flags
- Hx of cancer |
- Fever |
- Chills |
- Recent unexplained weight loss |
- Immunosuppression |
- Corticosteroid use |
- Suspicion of infection/f# |
- Cauda Equina |
- Symptoms >6 week durations/progressive neurological deficit |
- Imaging must be taken (MRI/CT) |
DDx
- Infection |
- Tumour |
- F# |
- Spondylosis |
- Peripheral Neuropathy |
- Piriformis syndrome |
- Hip/knee pathology |
- Herpes Zoster |
Investigations
- MRI gold standard, CT + Myelography.
- Must correlate with patient's symptoms
Disc Areas
Red = Central
Blue = Subarticular
Green = Foraminal
Orange = Lateral
Yellow = Anterior
Cx and Lx discs
- In Lx spine, a L4/5 paracentral disc will affect the L5 NR |
- A L4/5 Far Lateral Disc will affect the L4 NR |
- In Cx spine, both a Forarminal and Central Disc will affect the NR on the same level - horizontal anatomy |
- Lx - disc herniations more likely to occur at L4/5 or L5/S1 |
Classfications
Disc Bulge - >25% of the disc circumference |
Disc Protrusion - <25% of circumference , base wider than herniation |
Disc Extrusion - <25% of disc circumference - base narrower than herniation |
Disc Sequestration - free fragment of the disc material, no connection of the disc |
Pfirrman grades
0 - Normal |
1 - Disc touches NR |
2- Disc displaces NR |
3 - NR compression |
Risk Factors
- Sedentary Lifestyle/occupation |
- Driving motor vehicles |
- Vibration |
- Smoking |
- Previous full-term pregnancy |
- Increased BMI |
- Increased sacral base angle |
- Tall stature |
- Genetics |
- Aging (degradation of discs molecular structure - more vulnerable to mechanical injury, however discs can dehydrate over time - less nuclear material for herniation) |
- More common in men |
Management
- Ice for 10-15 minutes and every 2-3 hours |
- NSAIDs |
- Anti inflammatory nutrition advice |
- Reduce compressive forces on NR - rest, avoiding positions that aggravate the arm symptoms |
- Manual Traction |
- Myofascial Therapy - Trigger points on QL, lx erectors, psoas, piriformis, gluteals, TFL |
- Electrical stimulation to help with muscle spasm |
- Flossing and tensioning of Nerves when tolerated |
- Full ROM and flexability needs to be considered after pain and inflammation has subsided |
- PIR |
- Home stretching 1-2 times a day for 30 seconds |
- The size of the herniation is not associated with effectiveness with conservative treatment |
- Avascular structure of the disc can prolong recovery times |
- Extension/flexion biased exercises |
- Core exercises (cat/camel, bird dog, dead bug, side bridge) |
- Advice for weight loss if overweight,stoping smoking, sleep, workstation posture, lifting, footwear |
CPR for Traction
Sudden onset of symptoms |
Short duration of symptoms |
No segmental hypomobility |
Limited Lx ext |
Low fear avoidance beliefs |
- >3 of the above predictors = doubles likelihood of great improvement with lumbar traction
Prognosis
- Local LBP patients had a better prognosis than pts with leg symptoms and NR involvement after 2 weeks |
- Local LBP alone (77% improvement) |
- LBP + pain above knee (72% improvement) |
- LBP + pain below knee (61%) |
- LBP and +ve NTT/neurological findings (40%) |
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