Understanding Cervical Disc Herniations and What To Do About Them

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Published on: June 30, 2017

By Meredith Griffin PT, DPT

C6/7 Posterior

In the image you can see what many hope to never see on their MRI, a spinal disc herniation or herniated nucleus pulposis (HNP). For decades it was believed that if you had an HNP you were doomed for surgery and all you could do is hope that the results of the surgery were good (decreased pain, improved sensation, etc). Our society has developed a one track mind in wanting a quick fix and thinking that the only way to manage a problem like this is to go under the knife and cut it out. More recent research has shown that alt-hough there my be “abnormal” findings on various imaging, that does not justify surgery despite the fact that the many surgeons use this as their rational. In fact, we are finding that it is more abnormal to not have changes on imaging, or what are being called by some experts as “wrinkles on the inside.” If you have any “abnormal” findings on your x-ray, MRI, CT scan, etc, I would like to congratulate you on being just like the vast majority of the human population. These are considered age-related changes and are normal. Any-thing from arthritis to stenosis to disc herniations are all part of the normal aging process and are a result of being mobile organisms. Imaging studies have found that arthritic changes have been noted and can begin in the human body as early as the mid-20’s. More studies have also found little to no correlation between find-ings on imaging and patient reports of symptoms and pain levels. The problem becomes when pain impedes our lifestyles.

In the case of HNPs, there can be pain, sensation changes (numbness, tingling, etc), and weakness from disuse. In most cases, it is not the HNP itself that is most concerning but the effects that it may have on the surrounding structures, such as nerve roots exiting the spinal cord. Depending on the location in the spine and severity of the herniation, the presentation of symptoms (pain, weakness, sensation loss) may be minimally noticeable to significant functional limitations. When a herniation leads to true neurologic weakness and disability, then surgery may become a necessary option to decrease structural neural compression and prevent permanent nerve damage. Surgical options include a “simple” extraction of the herniated material or a complete disc replacement. Spinal disc replacements have been effective for some patients but continue to require improvement and innovation. In the majority of people with HNPs however, surgery is not necessary to maintain function. One of

Stages of disc herniation severity. Degeneration/ protrusion and Prolapse are considered incomplete herniations as the nuclear material remains within the disc. Extrusion and sequestration are complete herniations as the outer portion of the disc has been completely compromised.

the best indications of need for surgery is failure to improve with conservative measures (physical therapy, home traction, injections, etc). Despite the benefits that can be had from con-servative measures, there is a large portion of the population with HNPs that never have physical therapy prior to surgery. This again, speaks to the current (and unfortunate) societal mindset.

Biologically and physiologically, HNPs have the potential for extensive diversity. Very rarely are two herniations identical. A herniation can occur in the posterior, posterior-lateral, lateral, or anterior portions of the disc with posterior-lateral being the most common. The severity of the herniation can also vary (Figure 2).

Functionally, HNPs can vary even more. Individuals may be living with a seques- trated nucleus pulposis, where the nuclear material has completely exited the out- er rings of the spinal disc, but have no symptoms or complaints. Others may just start to show some degeneration of the disc but be completely disabled by pain.

The primary difference between these cases is the individual themselves. How a person’s brain interprets the signals being brought to it by the nerves is the primary determining factor of the level of disability an individual will experience.  The brain takes all the information about the current issue and interprets it based on past experiences, current stressors, emotional and mental states, and current knowledge of the problem to determine the most appropriate response. If the brain determines that the signals are potentially dangerous, it will alert the individual with the sensation of pain. Pain is the brain’s way of protecting the body to prevent further potential damage and is completely normal. The comic image, although meant in jest, makes a valid point that the presenting injury is not indicative of the pain that the individual reports feeling. It is the brain that has the final say in the level of pain that is felt. When pain becomes constant, debilitating, or is limiting activities, action to address the pain needs to be taken. For further explanations and information on the topic of pain, follow the links below. I highly recommend the Lorimer Mosley TED talk for a wonderful description of how pain is produced.

For a few quick introductions to the source and cause of pain, follow the links below:

Lorimer Mosley TED talk: https://www.youtube.com/watch?v=gwd-wLdIHjs&feature=youtu.be “Understanding pain in 5 minutes”: https://www.youtube.com/watch?v=5KrUL8tOaQs

When it comes to treatment for HNPs, patients are typically treated based on their symptom presentation and what they report as improving their symptoms. Some treatments that have been found to be effective for symptoms related to disc herniations have been stretching, traction, and strengthening. Home cervical traction has found to be very beneficial for some patients but the price can be a bit daunting. The most common traction unit is the Saunder’s

Saunder’s Home Cervical Traction Unit

Home cervical traction (Figure 4). Home traction units like this run between about $100-$1000, but insurance may cover some of the cost. Insurance coverage usually requires that you have completed some skilled physical therapy and have a doctor’s prescription for it. The concept of the Saunder’s-like units is simple in that it uses air pressure (similar to a bicycle pump) to apply a distraction force through the neck. These units must be used with the patient laying on their back which may not always be convenient or comfortable but does allow for full relaxation of the cervical muscles and unweights the head from the neck. They also require the direction of a skilled physical therapist to adjust the unit appropriately and instruct in proper use, including specifying the amount of pressure to apply by using the dial on the pump itself.

Other, more affordable options are those like the Pneu Portable Cervical Traction unit (Figure 5). These units range between $20-$300. It has not been my experience that insurance will cover any of the cost of these units. These work similar to a blood pressure cuff but have no gauge to monitor the pressure being applied to the neck. They do allow the patient to use the unit while sitting up and carrying on with daily activities, however readers should be

Pneu Portable Cervical Traction Unit

cautioned not to wear these too much as the cervical muscles may become very weak due to dis- use while in the unit. There are known cases of patients presenting to therapy clinics due to wearing the unit all day for pain relief that then were unable to go without the unit due to weakened neck muscles, and being unable to hold their own head up. Recommendations will vary based on the patient presentation, but I have recommended a maximum wear time of 10 minutes, 2-3 times per day for my patients. A drawback of being able to use the unit in sitting is that the weight of the head is not taken off simply with positioning, so the amount of pres- sure that has to be used to gain the same effect as the Saunder’s units is much greater. Individuals with claustrophobia may also have difficulty tolerating this unit as it does apply some pressure around the neck.

It is recommended to visit a physical therapist for a full evaluation and individualized treatment prior to beginning use of any trac- tion unit to identify any underlying musculoskeletal pathologies and determine if traction is an appropriate treatment.

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