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Cervical Herniated Nucleus Pulposus

(Herniated Cervical Disk; Ruptured Cervical Disk; Prolapsed Intervertebral Disk)


Peter J. Moley

, MD, Hospital for Special Surgery

Reviewed/Revised Oct 2022
Topic Resources

Herniated nucleus pulposus is prolapse of an intervertebral disk through a tear in the surrounding annulus fibrosus. The tear causes pain due to irritation of sensory nerves in the disk, and when the disk impinges on an adjacent nerve root, a segmental radiculopathy with paresthesias and weakness in the distribution of the affected root results. Diagnosis is usually confirmed by MRI or CT. Treatment of mild cases is with analgesics, activity modification, and physical therapy. Bed rest is rarely indicated. Patients with progressive or severe neurologic deficits, intractable pain, conservative treatment failure, or cervical myelopathy may require immediate or later elective surgery (eg, diskectomy, laminectomy).

Spinal vertebrae are separated by fibrocartilaginous disks consisting of an outer annulus fibrosus and an inner nucleus pulposus. When degenerative changes (with or without trauma) result in protrusion or rupture of the nucleus through the annulus fibrosus in the lumbosacral or cervical area, the nucleus is displaced posterolaterally or posteriorly into the extradural space.

Herniated disks are common.

Symptoms and Signs of Cervical Herniated Nucleus Pulposus

Herniated disks often cause no symptoms, or they may cause symptoms and signs in the distribution of affected nerve roots. Pain usually develops suddenly, and neck pain is typically relieved by rest and modification of activity. In contrast, nerve root pain caused by an epidural tumor or abscess begins more insidiously, and neck pain is worse at night while in bed.

In patients with cervical disc herniations, there can be pain with flexion or combined extension and rotation, which can radiate to the upper extremities. Muscle weakness, numbness, and paresthesias can also be present in the upper extremities.

Diagnosis of Cervical Herniated Nucleus Pulposus

  • MRI or CT

Diagnosis is usually suspected based on history and physical examination findings and confirmed by MRI or CT.

Physical examination should assess cervical spine movement and how it relates to the patient's symptoms. Neurological examination should include assessment of motor strength, sensation, and deep tendon reflexes. Passively extending the cervical spine, rotating the head to the side of the patient symptoms, and applying axial compression (Spurling or nerve compression test) may produce radicular pain in the upper extremity on the side to which the head is rotated.

MRI or CT can identify the cause and precise level of the lesion. Rarely (ie, when MRI is contraindicated and CT is inconclusive), CT myelography is necessary. Electrodiagnostic testing may help identify the involved root.

Because an asymptomatic herniated disk is common, the clinician must carefully correlate symptoms with MRI abnormalities before invasive procedures are considered.

Treatment of Cervical Herniated Nucleus Pulposus

  • Conservative treatment initially

  • Invasive procedures, sometimes including surgery, if neurologic deficits are progressive or severe

Because a herniated disk desiccates and shrinks over time, symptoms tend to abate regardless of treatment. Up to 85% of patients with back pain—regardless of cause—recover without surgery within 6 weeks.

Conservative treatment

Treatment of a herniated disk should be conservative, unless neurologic deficits are progressive or severe. Heavy or vigorous physical activity is restricted, but ambulation and light activity (eg, lifting objects < 2.5 to 5 kg [about 5 to 10 lb] using correct techniques) are permitted as tolerated; prolonged bed rest (including traction) is no longer indicated.

Acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs), or other analgesics should be used as needed to relieve pain. If symptoms are not relieved with nonopioid analgesics, corticosteroids can be given systemically or as an epidural injection; however, analgesia tends to be modest and temporary. Oral methylprednisolone may be given, tapered over 6 days, starting with 24 mg daily and decreased by 4 mg a day.

In selected patients, gabapentin and amitriptyline are often used for refractory neuropathic pain.

Physical therapy and home exercises can improve posture and strengthen neck muscles and thus reduce spinal movements that further irritate or compress the nerve root. Traction can relieve symptoms in the cervical spine.

Invasive procedures

Invasive procedures should be considered for the following:

Immediate surgical evaluation is needed if clinical findings of spinal cord compression correlate with MRI abnormalities.

Anterior diskectomy and cervical fusion are the most common treatments for cervical radiculopathies. Laminectomies are not performed alone without posterior fusion due to the complication of cervical kyphosis.

Dissolving herniated disk material with local injections of the enzyme chymopapain is not recommended.

If cervical radiculopathies are accompanied by signs of spinal cord compression, surgical decompression is needed immediately; otherwise, it is done electively when nonsurgical treatments are ineffective.

Key Points

  • Cervical herniated disks are common and usually affect nerve roots at C6 and C7.

  • If symptoms develop suddenly and neck pain is relieved with rest, suspect a herniated disk rather than an epidural tumor or abscess.

  • Recommend analgesics, light activity as tolerated, and exercises to improve posture and strength; however, if pain or deficits are severe or worsening, consider invasive procedures.

Drugs Mentioned In This Article

Drug Name Select Trade
7T Gummy ES, Acephen, Aceta, Actamin, Adult Pain Relief, Anacin Aspirin Free, Apra, Children's Acetaminophen, Children's Pain & Fever , Comtrex Sore Throat Relief, ED-APAP, ElixSure Fever/Pain, Feverall, Genapap, Genebs, Goody's Back & Body Pain, Infantaire, Infants' Acetaminophen, LIQUID PAIN RELIEF, Little Fevers, Little Remedies Infant Fever + Pain Reliever, Mapap, Mapap Arthritis Pain, Mapap Infants, Mapap Junior, M-PAP, Nortemp, Ofirmev, Pain & Fever , Pain and Fever , PAIN RELIEF , PAIN RELIEF Extra Strength, Panadol, PediaCare Children's Fever Reducer/Pain Reliever, PediaCare Children's Smooth Metls Fever Reducer/Pain Reliever, PediaCare Infant's Fever Reducer/Pain Reliever, Pediaphen, PHARBETOL, Plus PHARMA, Q-Pap, Q-Pap Extra Strength, Silapap, Triaminic Fever Reducer and Pain Reliever, Triaminic Infant Fever Reducer and Pain Reliever, Tylenol, Tylenol 8 Hour, Tylenol 8 Hour Arthritis Pain, Tylenol 8 Hour Muscle Aches & Pain, Tylenol Arthritis Pain, Tylenol Children's, Tylenol Children's Pain+Fever, Tylenol CrushableTablet, Tylenol Extra Strength, Tylenol Infants', Tylenol Infants Pain + Fever, Tylenol Junior Strength, Tylenol Pain + Fever, Tylenol Regular Strength, Tylenol Sore Throat, XS No Aspirin, XS Pain Reliever
A-Methapred, Depmedalone-40, Depmedalone-80 , Depo-Medrol, Medrol, Medrol Dosepak, Solu-Medrol
Active-PAC with Gabapentin, Gabarone , Gralise, Horizant, Neurontin
Elavil, Tryptanol, Vanatrip
NOTE: This is the Professional Version. CONSUMERS: View Consumer Version
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