Nonoperative Treatment of Cervical Disc Herniation

By: ALI E. GUY, M.D., Director of Pain Management, Medalliance, Bronx, NY
Thursday, December 13, 2012
Specialty: 

The treatment for nonoperative cervical disc herniation begins with an accurate history and physical examination. There may be other comorbidities present with cervical disc herniation, such as shoulder problems, fibromyalgia or myofascial pain syndromes. The source of pain can be from muscle, nerve root, disc or facet. Most cervical disc herniations improve on their own within six to 12 weeks with little or no treatment. Less than 3% require surgery. 

Cause of Cervical Disc Herniation

In a young, healthy adult, the most common cause of disc herniation is a sudden stress, such as trauma. This occurs during movements resulting from sudden flexion, extension, twisting or rotational forces working on the spine. It may also result from a fall or an automobile accident. It can occur immediately, gradually, or over weeks or months. Other causes of disc herniation can be the aging process, poor posture and a stressful job.

The diagnostic approach begins with a good history, physical exam and plain X-rays to rule out other problems, such as infections or severe arthritis causing osteophytes, which lead to nerve root compression that can cause radiculopathy. MRIs are often used to assess cervical spinal cord pathology to see if there are small or large disc herniations, severe spinal stenosis, facet arthropathy or possibly a tumor compressing the nerve root. Electromyography is a very useful tool used in cases of radiculopathy or any unexplained arm pain lasting more than three to four weeks with or without any neurological deficits.

Available Treatment Options

Medications: Commonly used over-the-counter analgesics, such as plain Tylenol, Advil or Aleve; Nonsteroidal anti-inflammatory drugs; Oral steroids with tapering; Muscle relaxants; Topical pain medications, such as Lidoderm patch and Terocin lotion (combination of four different topical agents such as capsaicin, lidocaine, menthol and salicylates); Narcotic analgesics (which should only be used short term — no more than one to three weeks)

Physical therapy is one of the most popular, widely used and effective means of safely treating cervical disc herniation.

Chiropractic: Only low-velocity, gentle mobilization techniques should be used; all high-velocity techniques should be avoided.

Spinal decompression table: This has some role, but its efficacy has not yet been proven. The treatment is expensive and is usually not covered by third-party insurance companies.

Bracing: This helps but should only be used for a few days. (Patients should never go to bed with braces on.)

Interventional Pain Management Procedures

Trigger point injections: This procedure is used to inactivate trigger points and provide prompt relief 
of symptoms.

Cervical steroid interlaminar epidural injections: The first cervical epidural injection is both diagnostic and therapeutic. It is usually injected at the level of C7-T1 by way of an interlaminar approach. If the first injection gives the patient significant relief, the next one could be tried in two weeks. If that continues to give the patient relief, a third injection could be administered typically two months later.

Cervical facet injections: In cases where the cervical disc herniation exists with cervical facet arthropathy and the patient has had three cervical epidural injections, the patient is a candidate for diagnostic and therapeutic first cervical facet injection. If this works, as many as three can be given.

Radiofrequency ablation is a procedure used when the patient has responded to cervical facet injections and the terminal branches of the medial branches are burnt off by either pulsed radiofrequency or heat.

Dorsal column stimulation implant: If all of the above treatments fail, the patient is now a surgical candidate and should be referred promptly to a spinal surgeon or neurosurgeon for surgical intervention.