Herniated discs can occur in any part of the spine, but are most common in the neck and low back. Herniated discs are sometimes referred to as ruptured discs or slipped discs. They are usually caused by wear and tear of the disc (called disc degeneration). Sometimes an injury to the neck can cause a disc to herniate. Regardless of the cause, the reason discs herniate is because a tear develops in the outer part of the disc (called the annulus) and the jellylike material on the inside of the disc (called nucleus pulposus) gets forced out of this tear and presses on a nerve. If you think of the disc as a jelly donut, when you squeeze the donut some of the jelly will protrude out. This is very similar to a disc herniation. Several terms are used to describe herniated discs, such as ruptured disc, slipped disc, disc protrusion, or extruded disc. These all refer to the same problem.
You may have been told at some point that you have “bulging discs” in your neck. This is not the same thing as a disc herniation. Bulging discs are very common in the neck (and in the low back), and are the result of very mild arthritic changes. Think of bulging discs as developing wrinkles or gray hairs. Everyone gets them at some point in their lives, some sooner than others. From a surgeon’s perspective, “bulging discs” are common and are not treated surgically. In the majority of cases, bulging discs are not the cause of neck or arm pain.
Patients with cervical herniations usually present with arm pain, burning, numbness or tingling. The location of the pain varies depending on which disc is herniated and which nerve is being pinched. Some patients have weakness in one or more muscles in the arm.For example, a patient with a C6-7 disc herniation may have weakness with elbow extension (weak triceps) because the nerve that is pinched (C7 nerve) innervates the tricep muscle. Other symptoms that may be present include neck pain (usually on the side of the herniation) and pain in the shoulder blade.
Patients usually feel relief when they rest the affected forearm on the top of their head. Also, patients usually have worsening of their arm pain when they look up (neck extension).
Cervical disc herniations are diagnosed with an MRI of the cervical spine. The MRI is a test that shows the discs and nerves in your neck. It will show whether you have a pinched nerve and precisely which nerve(s) is pinched. Remember that most disc herniations get better on their own within a few weeks. So do not be alarmed if your physician does not order an MRI right away.
If you cannot have an MRI (for example, if you have a pacemaker), the test that is ordered is called a CT myelogram.
Most patients with cervical herniations can be treated conservatively with successful outcomes. In fact, about 90% of patients with a cervical disc herniation get better and do not need surgery. In many cases, the disc fragment that has herniated shrinks in size over time (weeks to months), and the pressure on the nerves also decreases accordingly.
Conservative treatment consists of anti-inflammatory medications (motrin, naprosyn), a short period of oral steroids, physical therapy (including traction), and epidural steroid injections. Sometimes time is the best healer and allowing the inflammation to subside will lead to pain relief. Remember that the body is successful in healing itself in the majority of cases. If you have had symptoms for less than a month, you will likely get better without surgery. Even a large herniated disc has the capacity to shrink in size. The body recognizes this disc herniation as a “foreign object”, and starts to resorb the disc over a period of time.
Below is a description of each of nonsurgical treatment modalities:
- Medications: there are several medications to help relieve your pain.
- Over-the-counter medications: The first medications to try are over-the-counter, such as NSAIDs (Advil, Aleve) or Tylenol. Advil and Aleve have anti-inflammatory properties and are pain relievers. Tylenol is a pain reliever but lacks anti-inflammatory properties. It is okay to take an NSAID and Tylenol if one does not work by itself.
- Oral steroids: If your pain is more severe, your doctor may prescribe an oral steroid for a short period of time. Steroids do not have side effects if taken for a few days, but long-term use is not recommended. A common steroid that is prescribed for this problem is called a “Medrol dose pack”. It is taken over a period of 6 days.
- Narcotic pain medications are prescribed for severe pain that is not relieved with the above. These are controlled substances that should only be taken for a short period of time.
- Muscle relaxants are used for spasms. Their effectiveness for disc herniations is limited.
- Physical Therapy – Physical therapy should be one of the first treatments you try for a cervical disc herniation. Your therapist will teach you exercises to perform to strengthen the supporting muscles around your neck. The therapist will also teach you postural exercises that will minimize your pain. Many patients improve after 3-5 weeks of therapy. However, if you feel that your pain is worsening after each therapy session, it may be best to stop the therapy and see your physician. Another component of therapy involves traction. Traction involves pulling on the neck (distracting the neck) to take the pressure off the nerves. While not all patients benefit from traction, it is still worth a try. If you do benefit from traction, your therapist may recommend a “home traction unit” which you can set up in your house.
- Chiropractic Treatment – Chiropractic adjustments are fine to try for small disc herniations as long as your chiropractor avoids forceful, high-velocity manipulative techniques. Gentle low-force techniques are fine and may help some patients. Chiropractic adjustments are generally not recommended for large disc herniations or in cases of spinal cord compression. If chiropractic adjustments are helping your pain, it is fine to continue this treatment. But if you feel worse after adjustments, you should stop immediately.
- Bracing (soft cervical collar) is generally not effective for treating cervical disc herniations.
- Epidural Steroid Injections are commonly recommended for cervical disc herniations. The goal of injections is to calm down the inflammation around the nerves. Disc herniations mechanically compress nerves, and this compression leads to irritation/inflammation of the nerve. Epidurals do not get rid of the disc herniation. They “bathe” the nerve with the anti-inflammatory medicine (cortisone) to hopefully relieve the pain in the arm. These injections are done under fluoroscopy by a pain management specialist. Some patients have long-lasting relief with injections, but others only experience temporary relief. You may get more than one injection, usually at least 2 weeks apart. The total number of injections one should get per year is debatable, but most physicians recommend fewer than 4 injections per year.
If conservative treatment options fail to relieve symptoms, surgery is very successful for the treatment of arm symptoms. Surgery is indicated in the following circumstances:
- If you have significant arm pain/numbness/tingling and have had 6-8 weeks of conservative treatment.
- If you have weakness in one or more muscles in your arm that is either worsening or not improving with time and conservative treatment.
A common question patients ask is “when should I have surgery?”. The answer is a personal one, and depends on the severity of your discomfort, your activity level, occupational demands, and other factors. If there is no weakness in the arm, and pain is the main complaint, surgery should be considered if the pain affects the quality of your life. Some patients can tolerate their pain and wish to avoid surgery. Others have such discomfort that they cannot do things they enjoy and these patients may opt for surgery. Surgery is generally recommended earlier when significant weakness is present.
The most common surgery for this problem is anterior cervical discectomy and fusion (ACDF). Success rates are very high with this surgery. Another option, depending on the location of the herniated disc, is a posterior laminoforaminotomy. With this surgery, a fusion is not performed and the pressure is taken off the nerve from the back of the neck. Your orthopaedic surgeon can determine which procedure is most suitable in your particular situation.