As a disc degenerates, the soft inner gel in the disc can leak back into the spinal canal. This is known as disc herniation, or herniated disc. Once inside the spinal canal, the herniated disc material then puts pressure on the nerve, causing pain to radiate down the nerve leading to sciatica or leg pain (from a lumbar herniated disc) or arm pain (from a cervical herniated disc).

Cervical Disc Herniation

A cervical herniated disc is diagnosed when the inner core of a disc in the neck herniates, or leaks out of the disc, and presses on an adjacent nerve root. It usually develops in the 30-to-50-year-old age group. While a cervical herniated disc may originate from some sort of trauma or neck injury, the symptoms commonly start spontaneously.

The arm pain from a cervical herniated disc results because the herniated disc material “pinches” or presses on a cervical nerve, causing pain to radiate along the nerve pathway down the arm. Along with the arm pain, numbness and tingling can be present down the arm and into the fingertips. Muscle weakness may also be present.

The discs in the cervical spine are not very large; however, there is also not a lot of space available for the nerves. This means that even a small cervical disc herniation may impinge on the nerve and cause significant pain. The arm pain is usually most severe as the nerve first becomes pinched.

Symptoms of a Cervical Herniated Disc

A herniated disc in the neck can cause a variety of symptoms in the neck, arm, hand, and fingers, as well as parts of the shoulder. The pain patterns and neurological deficits are largely determined by the location of the herniated disc.

The cervical spine is constructed around the vertebrae, or the 7 stacked bony building blocks in the spine. They are numbered top to bottom C1 through C7. The nerve that is affected by the cervical disc herniation is the one exiting the spine at that level, so at the C5-C6 level it is the C6 nerve root that is affected.For example:

C4-C5 (C5 nerve root): A herniation at this level can cause shoulder pain and weakness in the deltoid muscle at the top of the upper arm, and does not usually cause numbness or tingling.

C5-C6 (C6 nerve root): A C5-C6 disc herniation can cause weakness in the biceps (muscles in the front of the upper arms) and wrist extensor muscles. Numbness and tingling along with pain can radiate to the thumb side of the hand. This is one of the most common levels for a cervical disc herniation to occur.

C6-C7 (C7 nerve root): A herniated disc in this area can cause weakness in the triceps (muscles in the back of the upper arm and extending to the forearm) and the finger extensor muscles. Numbness and tingling along with pain can radiate down the triceps and into the middle finger. This level is also one of the most common areas for a cervical disc herniation.

C7-T1 (C8 nerve root): This level is located at the very bottom of the neck, where the cervical spine meets the thoracic, or upper, back. A herniation here can cause weakness with handgrip, along with numbness and tingling and pain that radiates down the arm to the little finger side of hand.

These are typical pain patterns associated with a cervical disc herniation, but they are not absolute. Some people are simply wired up differently than others, and therefore their arm pain and other symptoms will be different. The pain pattern from a cervical herniated disc is referred to as a cervical radiculopathy.

Special diagnostic tests: After the initial exam, special diagnostic imaging tests may be required to better diagnose a cervical herniated disc.

MRI Scan to Identify a Cervical Herniated Disc

The single best test to diagnose a herniated disc is an MRI (Magnetic Resonance Imaging) scan. An MRI scan can image any nerve root pinching caused by a herniated cervical disc.

CT Scan with Myelogram

An MRI is the best first test, although occasionally a CT scan with a myelogram may also be ordered, as it is more sensitive and can diagnose even subtle cases of nerve root pinching.

While a CT scan with myelogram is more sensitive it is also a slightly invasive test, as the myelogram dye must be injected into the spinal canal as part of the procedure. Because of the injection, a CT scan with myelogram is not usually the first test ordered.

Plain CT scans (without myelogram) are for the most part not useful for the diagnosis of a herniated cervical disc.

EMG to Identify Other Conditions Causing Pain

Occasionally, an EMG (electromyography) may also be requested. An EMG is an electrical test that is done by stimulating specific nerves and inserting needles into various muscles in the arms or legs that may be affected from a pinched nerve. If the muscles have lost their normal innervation, there will be spontaneous electrical activity.

An EMG can also help rule out other nerve entrapment syndromes that can give one arm pain, such as carpal tunnel syndrome, brachial plexitis, ulnar nerve entrapment, thoracic outlet syndrome, among other conditions.

Conservative Treatment for Cervical Disc Herniation

The majority of the time, the arm pain from a cervical herniated disc can be controlled with medication, and non-surgical (also called conservative) treatments alone are enough to resolve the symptoms.

Once the arm pain starts to improve it is unlikely to return. If the arm pain gets better it is acceptable to continue with nonsurgical treatment, as there really is no literature that supports the theory that surgery for cervical disc herniation helps the nerve root heal quicker.

All treatments for a cervical herniated disc are essentially designed to help resolve the arm pain, and usually the weakness and numbness/tingling will resolve with time.

Medications

When the initial pain from a cervical herniated disc hits, anti-inflammatory medications (NSAIDs) such as ibuprofen (e.g., Advil, Nuprin, Motrin) or COX-2 inhibitors (e.g. Celebrex) can help reduce the pain.

The pain caused by a cervical herniated disc is caused by a combination of two processes:

• Pinching of the nerve root
• Inflammation associated with the disc material itself

Therefore, taking anti-inflammatory medications to remove some of the inflammation can reduce this component of the pain while the pressure component (pinching of the nerve root) resolves.

For patients with severe pain from a herniated disc, oral steroids (such as Prednisone or a Medrol Dose Pak) may give even better pain relief. However, these medications can only be used for a short period of time (one week).

Nonsurgical Treatments

In addition to anti-inflammatory medications mentioned above, there are a number of non-surgical treatment options that can help alleviate the pain from a cervical herniated disc, such as:

Physical therapy and exercise. Just as in the lumbar spine, Mckenzie exercises can be used to help reduce the pain in the arm. In the initial period a physical therapist may also opt to use modalities, such as heat/ice or ultrasound, to help reduce muscle spasm.

Cervical traction. Traction on the head can help reduce pressure over the nerve root. It does not work for everyone but is easy to do, and if effective the patient can use a home traction device.

Chiropractic manipulation. Gentle manual manipulation can help reduce the joint dysfunction that may be an added component of the pain. This type of low-velocity manipulation is referred to as mobilization. Any high velocity manipulation, often referred to as an adjustment, should be avoided as they can make the pain worse, or worsen any neurological damage.

Osteopathic medicine. Gentle osteopathic manipulation manipulation and special techniques to restore normal joint motion can be helpful in reducing pain from a cervical herniated disc.

Activity modification. Some types of activities may tend to exacerbate the herniated disc pain and it is reasonable to avoid these activities to keep from irritating the nerve root. Such activities may include heavy lifting (e.g. over 50 pounds), activities that can cause increased vibration and compression to the cervical spine (boating, snowmobile riding, running, etc.), and overhead activities that require prolonged neck extension and/or rotation.

Bracing. In some instances a cervical collar or brace may be recommended to help provide some rest for the cervical spine.

Medications. In addition to the anti-inflammatory medications mentioned above, narcotic agents (painkillers, or opioids) might be used on a temporary basis to help reduce the pain and discomfort from a cervical herniated disc. Also, muscle relaxants or certain anti-depressants may help reduce the nerve-type pain (neuropathic pain) and help restore normal sleep patterns.

Injections. Cervical Epidural steroid injections or selective nerve root blocks can be helpful to reduce inflammation in cases of severe pain from a cervical herniated disc, and can be very effective if accompanied by a comprehensive rehabilitation program that may involve a number of the above treatments.

Physicians who provide the above treatments for a cervical herniated disc may include family practitioners, physiatrists (physical medicine and rehabilitation physicians), osteopathic physicians, neurologists, and orthopedic spine surgeons.

Cervical Disc Herniation-Surgical Treatment

Most episodes of arm pain due to a cervical herniated disc will resolve over a period of weeks to a couple of months. However, if the pain lasts longer than 6 to 12 weeks, or if the pain and disability are severe, spine surgery may be a reasonable option.

Spine surgery for a cervical herniated disc is generally reliable. The success rate is about 95 to 98% in terms of providing relief of arm pain.

With an experienced spine surgeon, the surgery should carry a low risk of failure or complication, and can be done with a minimal amount of postoperative pain and morbidity (unwanted aftereffects).

The surgery for a cervical herniated disc can be done a number of different ways: Anterior cervical discectomy and spine fusion (ACDF): This is the most common method among spine surgeons for most cervical herniated discs. In this surgery, the disc is removed through a small one-inch incision in the front of the neck. After removing the disc, the disc space itself is fused. A plate can be added in front of the graft for added stability and possibly a better fusion rate.

Posterior cervical discectomy: This is similar to a posterior (from the back) lumbar discectomy, and for discs that occur laterally out in the neural foramen (the “tunnel” that the nerve travels through to exit the spinal canal) it may be a reasonable approach. However, it is technically more difficult than an anterior approach because there are a lot of veins in this area that can result in a lot of bleeding, and the bleeding limits visualization during the surgery. This approach also necessitates more manipulation to the spinal cord.

Cervical artificial disc replacement: Like an ACDF, an artificial disc surgery involves removing the affected disc through a small incision in the front of the neck. However, instead of a fusion in the disc space, an artificial disc is placed in the disc space. The goal of the artificial disc is to mimic the form and function of the original disc.

Although any major surgery has possible risks and complications, with an experienced spine surgeon serious complications from cervical disc surgery should be rare. The two most common surgeries, ACDF and artificial disc, are both considered reliable surgeries with favorable outcomes in terms of reducing the patients pain.

Postoperative Care for Cervical Herniated Disc Surgery

For anterior surgery, such as an ACDF and artificial disc, there usually is not a great deal of postoperative pain. The surgery is done through a small incision in the front of the neck, and the spine can be accessed in between tissue planes that do not require cutting. This type of surgery usually can be done either outpatient (going home the same day as surgery) or with one overnight stay in the hospital.

The pain in the arm usually goes away fairly quickly, although it may take weeks to months for the arm weakness and numbness to subside. It is not uncommon to have some neck pain for a while.

Postoperatively, most spine surgeons prescribe a neck brace, although the type of brace and length of usage is variable. Also, most spine surgeons will ask their patients to limit their activities postoperatively, although the amount of restrictions and the length of time tend to vary. Ask your spine surgeon before the surgery what his or her usual protocol is regarding postoperative care.

Thoracic Disc Herniation

A herniated disc in the upper back can occur when the inner gelatinous material of an intervertebral disc leaks out of the inside of the disc. A thoracic herniated disc can cause upper back pain and other symptoms, such as radiating pain or numbness.

Specific symptoms of a thoracic herniated disc are usually different depending on where the disc herniates, as the herniated disc material in the upper back can either impinge on an exiting nerve root or on the spinal cord itself.

Thoracic Degenerative Disc Disease

Thoracic disc disease is conceptually similar to disc disorders in the cervical and lumbar spine, but symptomatic lesions (anatomical problems related to the symptoms) are far less common.

The most common location for thoracic disc disorders is at the thoracolumbar (the thoracic and lumbar parts of the spinal column) junction (T8-T12) in the mid back. The true incidence is unknown because many thoracic disc disorders do not cause thoracic back pain or other symptoms, and they comprise only a very small percent of all herniated disc treatment surgeries.

In one study, 90 asymptomatic patients (with no pain or other symptoms) were evaluated with thoracic MRI scans. These were the findings:

73% of patients were found to have disc abnormalities in the upper back, such as a thoracic herniated disc or thoracic degenerative disc disease 37% specifically had a thoracic herniated disc 29% had radiographic evidence of spinal cord impingement identified on the MRI.

These patients were followed for 26 months and none of them developed thoracic back pain from their thoracic disc disorders.

The fact that so many people had thoracic herniated discs but no pain or symptoms is important to mention, as it shows that people may have both upper back pain and a thoracic herniated disc, but that the disc disorder may not be the cause of the thoracic back pain – it may just be an incidental finding.

In fact, there are many causes of upper back pain that are much more common than a herniated disc, and a correct diagnosis of the cause of the patient’s pain is more important than whether or not an MRI scan shows a thoracic disc herniation.

Doctors typically classify thoracic herniated discs as being caused by either one of two sources: Degenerative disc disease.

Many thoracic herniated discs occur from gradual wear and tear on the disc, which leads to settling of the vertebral bodies and calcification about the disc space.

Trauma to the upper back. Traumatic herniated discs are defined as those associated with a significant traumatic event that caused the abrupt onset of symptoms.

Thoracic Disc Herniation From Degenerative Disc Disease:

When symptomatic of degenerative disc disease, the symptoms of a thoracic herniated disk most commonly occur between the 4th and 6th decades of life and usually develop very gradually.

With degenerative disc disease, the patient’s thoracic back pain and other symptoms are often present for a longer period of time prior to consultation with a physician.

Thoracic Disc Herniation

Any injury that causes a high degree of sudden force on the discs in the upper spine could lead to a thoracic herniated disc. Examples of a traumatic event that may lead to a thoracic herniated disc include a fall or sports injury that places sudden force on the upper back.

Thoracic herniated discs tend to occur in younger patients prior to significant degenerative disc changes. While in most cases some history of mild trauma has led to an exacerbation of the patient’s symptoms, a mild trauma (such as reaching up while twisting) will usually just worsen symptoms from a degenerated disc.

Regardless of the cause of the thoracic back pain, getting a correct diagnosis is critical because it will guide treatment of the thoracic herniated disc.

Thoracic Disc Herniation Symptomatology:

Pain is the most common symptom of a thoracic herniated disc and may be isolated to the upper back or radiate in a dermatomal (single nerve root) pattern. Thoracic back pain may be exacerbated when coughing or sneezing.

Radiating pain may be perceived to be in the chest or belly, and this leads to a quite different diagnosis that will need to include an assessment of heart, lung, kidney and gastrointestinal disorders as well as other non-spine musculoskeletal causes.

Within the spine itself there are also many other disorders that can have similar presenting symptoms of upper back pain and/or radiating pain, such as a spine fracture (e.g. from osteoporosis), infection, tumor, and certain metabolic disorders

If the disc herniates into the spinal cord area, the thoracic herniated disk may also present with myelopathy (spinal cord dysfunction). This may be evident by sensory disturbances (such as numbness) below the level of compression, difficulty with balance and walking, lower extremity weakness, or bowel or bladder dysfunction.

Thoracic Disc Herniation Diagnosis:

The first step in diagnosing a thoracic herniated disc always includes a good patient medical history and physical examination. The spine physician will begin by getting a better understanding of the patient’s symptoms, including the:

• Location of the pain
• Severity of the pain
• Type of pain (numbness, weakness, burning, etc.)

The physician will often follow up by learning if any injuries occurred prior to the thoracic back pain or if any other problems (weight loss, fevers, illnesses, difficulty urinating) were recently present before the upper back pain. The physician will then perform a physical examination.

This combination of the patient’s description of how the pain feels, where it occurs, when it occurs, etc., as well as the spine physician’s physical examination, should yield clues to help localize the lesion to the thoracic spine.

Diagnostic Tests:

If a thoracic herniated disc is suspected as the underlying cause of the pain, there are several diagnostic tests that can confirm the diagnosis and provide additional information, including:

X-rays – While plain x-rays will not show a thoracic herniated disc, they may be used to help localize injuries in cases of trauma as well as aid in identifying spinal instability.

Magnetic Resonance Imaging (MRI) – An MRI utilizes a powerful magnet attached to a computer to produce images of the spine. A painless and often accurate test, an MRI scan is the most useful imaging tool to identify disc pathology.In some cases, a physician may seek even more detailed information beyond an MRI and order the following tests:

Computer Topography (CT) – A CT scan involves the use of a computer that constructs a cross-dimensional, three-dimensional image of the spine after processing data from an X-ray beam rotated around the spine.

Myelogram – A myelogram involves the injection of a special dye into the spinal column, with an X-ray taken to examine any pressure on the spine and any problems with the discs or vertebrae.

In cases where an MRI scan is contraindicated, a post-myelogram CT can help identify an area of external compression, but it will not yield information about injury within the substance of the cord (myelomalacia).

Thoracic Disc Herniation Treatment:

The vast majority of thoracic herniated disc symptoms can be treated without thoracic surgery. There are a variety of nonsurgical treatment options that can be tried, and often patients will need to try several, or a combination of different treatments, to find what works best for them.

Non-Surgical Treatments for Thoracic Herniated Discs

Non-surgical treatment options for symptoms of a thoracic herniated disc will typically include one or a combination of the following:

A short period of rest (e.g. one or two days) and activity modification (eliminating the activities and positions that worsen or cause the thoracic back pain). After a short period or rest, the patient should return to activity as tolerated. Gentle exercise, such as walking, is a good way to return to activity.

Narcotic and non-narcotic analgesic medications to help reduce the thoracic back pain. Narcotic pain medication is usually only prescribed to treat severe upper back pain for a short period of time. For mild or moderate thoracic back pain, an overthe- counter pain reliever such as acetaminophen (e.g. Tylenol) is commonly recommended for thoracic herniated discs. • Anti-inflammatory agents, to help reduce inflammation around the herniated disc in the upper back, including:

• Medications (NSAIDs – such as ibuprofen or a COX-2 inhibitor, or oral steroids)
• Anti-inflammatory injections (such as an epidural steroid injection)
• Ice packs (applied to the painful area for 15–20 minutes at a time, as often as necessary)
• Manual manipulation (usually performed by a chiropractor or an osteopathic doctor)
• Strengthening exercises (such as core stabilization exercises)

The patient’s activity levels should be progressed gradually over a 6 to 12 week period as symptoms improve. In the vast majority of cases, the natural history of thoracic disc herniation is one of improvement with one or a combination of the above conservative (non-operative) treatments.

Thoracic Disc Herniation Surgery

Thoracic herniated disc surgery is indicated in only rare instances when a herniated disc leads to myelopathy (spinal cord dysfunction), progressive neurologic deficits, or intolerable pain.

Typically, these symptoms occur following an acute traumatic herniated disc with myelopathy. The thoracic surgery to address these symptoms, called a decompression, is designed to take the pressure off the spinal cord or nerve root.

Different Approaches to Thoracic Surgery

Historically, the surgical approach for a decompression was performed in a laminectomy approached from the posterior (behind). Outcomes were poor in large part because retraction on the spinal cord is not well tolerated and most thoracic herniated discs have a central component that cannot be reached without spinal cord retraction.

More recently, one of the following surgical approaches will be used:

For central and centro-lateral herniations, an open thoracotomy may be performed from an anterior trans-thoracic approach (a front approach that crosses the thoracic spine). This involves approaching the spine through the chest cavity (instead of through the back). In some centers, the procedure may be done as a minimally invasive VATS (Video Assisted Thoracic Surgery) procedure, which involves the use of several small incisions, small scopes and a video screen.

Lateral herniated discs can be reached through a posterolateral approach (from behind and the side) known as a costotransversectomy, which involves removal of rib and transverse process (a small bone attached to the spine) to allow access to the disc space.

Thoracic herniated disc surgery is reserved for cases of myelopathy, progressive lower extremity weakness, and intolerable radicular pain that does not get better with non-surgical treatments.

Thoracic Herniated Disc Surgery Outcomes

In cases where thoracic surgery was indicated, two researchers evaluated 19 patients treated with either costotransversectomy or trans-thoracic decompression of a thoracic disc herniation.

The following was reported:

16 patients with good or excellent outcomes 3 patients with fair or poor results 2 of the poor outcomes were in the costotransversectomy group.

With these results in mind, the researchers opined that the trans-thoracic approach should be the preferred approach.

In a separate study, other researchers reported 76% satisfactory results in 29 patients who underwent a Video Assisted Thoracic Surgery procedure, the minimally invasive trans-thoracic approach to the thoracic disc space.

Lumbar Disc Herniation

As a disc degenerates and breaks down, the inner core can leak out through the outer portion of the disc, and this condition is known as a disc herniation or a herniated disc. The weak spot in the outer core of the intervertebral disc is directly under the spinal nerve root, so a herniation in this area puts direct pressure on the nerve.

The nerve runs through the leg, and any type of pinched nerve in the lower spine can cause pain to radiate along the path of the nerve through the buttock and down the leg. This type of pain is also called sciatica or a radiculopathy.

Lumbar Herniated Disc Symptoms

General symptoms typically include one or a combination of the following:

• Leg pain (sciatica), which may occur with or without lower back pain. Typically the leg pain is worse than the lower back pain.
• Numbness, weakness and/or tingling in the leg
• Lower back pain and/or pain in the buttock
• Loss of bladder or bowel control (rare), which may be an indication of a serious medical condition called cauda equina syndrome.

L4-L5 and L5-S1 Disc Herniation Symptoms

The vast majority of disc herniations will occur toward the bottom of the spine at L4- L5 or L5- S1 levels. In addition to typical sciatica symptoms, nerve impingement at these levels can lead to:

L5 nerve impingement (at the L4 – L5 level) from a herniated disc can cause weakness in extending the big toe and potentially in the ankle (foot drop). Numbness and pain can be felt on top of the foot, and the pain may also radiate into the buttock.

S1 nerve impingement (at the L5 – S1 level) from a herniated disc may cause loss of the ankle reflex and/or weakness in ankle push off (patients cannot do toe rises). Numbness and pain can radiate down to the sole or outside of the foot.

Lumbar Disc Herniation Treatment

In most cases, if a patient’s pain is going to get better it will start to do so within about six weeks.

While waiting to see if the symptoms will abate on their own, several non-surgical treatments can help alleviate the pain and facilitate long term healing. The most common herniated disc nonsurgical treatments include:

• Physical therapy
• Osteopathic/chiropractic manipulation (manual manipulation)
• Heat and/or ice therapy
• Non-steroidal anti-inflammatory drugs (NSAIDs)
• Oral steroids (e.g. prednisone or methyprednisolone)
• An epidural (cortisone) injection

If the pain and other symptoms continue after six weeks, and if the pain is severe, it is reasonable to consider microdiscectomy surgery as an option.

Lumbar Herniated Disc Surgery

A microdiscectomy is designed to take the pressure off the nerve root and to provide the nerve with a better healing environment. Usually, only the small portion of the disc that is pushing against the nerve root needs to be removed, and the majority of the intervertebral disc remains intact.

Using microsurgical techniques and a small incision, a microdiscectomy can usually be done on an outpatient basis or with one overnight stay in the hospital, and most patients can return to work full duty in one to three weeks. With an experienced surgeon, the success rate of this surgery should be about 95%.

Recurrent Disc Herniation

Unfortunately, approximately 10% of patients will experience another disc herniation at the same location. This recurrence is most likely to happen early in the postoperative period (within the first three months), although it can happen years later. Usually a recurrence can be handled with another microdiscectomy..

If it recurs multiple times, a lumbar fusion surgery to stop the motion at the disc level and remove all of the disc material may be considered.