Cervical disc prolapse occurs when a cervical disc herniates and compresses the nerve root. The cervical spine has 7 vertebrae and 6 intervertebral discs that act as shock absorbers and allow motion. A disc is composed of an inner nucleus pulposus surrounded by the outer annulus fibrosus. Common sites of prolapse are C5-C6 and C6-C7. Clinical features include neck pain radiating to the arm. Imaging like MRI or CT is used to confirm prolapse. Treatment involves rest, medications, traction and surgery like anterior cervical discectomy if non-operative measures fail.

1. CERVICAL DISC PROLAPSE
DR.THOUSEEFA MAJEED
M S Orthopaedics PG
VMKVMCH Salem

2. Anatomy

3. Cervical vertebrae
2 TYPES
– Atypical
• Axis (C 1 )
• Atlas (C 2 )
• C 7
– Typical
• C 3-6

5. • 7 Vertebrae
• 6 Inter vertebral discs
• 8 Pairs of exiting nerve
roots
• Cervical spine gives a
normal lordosis

6. • Individual vertebrae are
connected to each other by
facet joints.
• The inter-body joints contain a
specialized structures called
intervertebral discs.
• The discs are found
throughout the vertebrae
except for the first and second
vertebrae.

7. DISC
• Disc is an avascular fibro-
cartilagenous material
• It is composed of two vertebral
end plates
• Consists of an internal nucleus
pulposus surrounded by the
external fibrous the annulus
fibrosus.
Annulus
Fibrosus
Nucleus
pulposus

8.  Vertebral end plates are 1mm thick sheets made of
fibrocartilage and hyaline cartilage.
 As age increases hyaline cartilage gets converted in to
fibrocartilage.

9. Nucleus pulposus
 Made up of type II-Collagen
 Contains 80 to 90% of water.
 Proteoglycan 65%
 Collagen 15 to 20 %0

10. Annulus fibrosus
• Made up of Type I Collagen
• 12 concentric layer of
lamellae with alternate
layer of collagen.
Annulus fibrous contains
• 60 to 70% of water.
• 50 to 60% of collagen
• 20% of proteoglycan.

11. Functions of disc
• Act as a shock absorber
• Ligaments by holding
together
• Allows compressive,
tensile, and rotational
motion

12. CERVICAL DISC PROLAPSE

13. History
 In 1838 - Herniation of the cervical disc was
identified by Key.
 In 1934 -Mixter and Barr reported disc herniation

14. Incidence and Etiology
 Common in men.
 Male :Female - 1.4:1
 Factors associated with injury are
 Frequent lifting of heavy objects on the job
 Cigarette Smoking
 Frequent diving from a board.

15. Pathopysiology
 Physiological annular degeneration.
 Frank extrusion of nuclear material
 As the degeneration proceeds there is hypermobility of the
segment resulting of the instability or degenerative arthritic
change.
 Internal disruption of the disc with annular tears results in
disc prolapse.

17. Types of prolapse
• Central
• Posterolateral
• Foraminal
• Extraforaminal

18. Common sites of cervical disc prolapse
 C5-C6
 More motion occurs between C5 and C6
 C6-C7 prolapse occurs in older patients

19. Cervical disc prolapse
 7 cervical vetebrae
 8 cervical nerve roots.
 First cervical root exists
between occiput and C1
 6th cervical root exists
between C5 and C6
 8th cervical root exists
between C7 and T1

20. A herniated disc impinges upon the nerve root
exiting above the disc and passing through the
near by foramen result in involvement of one
specific neurologic level

21. Each cervical root exists cephalad to the
pedicle of the vertebrae
This relationship changes at thoracic spine
because the C8 root exists between C7 and T1
pedicles ,requiring the T1 nerve root to exits
caudal or below the pedicle.

22. • Cervical disc Prolapse is
usually in the postero-lateral
direction, because the strong
posterior longitudinal
ligament prevents direct
posterior herniation.

23. • Unlike the lumbar region, the nerves pass directly laterally
from the cervical cord to their neural foramen, so that the
herniation compresses the nerve at that level.

24. Clinical Features
 Neck pain radiating to the arm or chest
 Numbness in the fingers
 Motor weakness of the arm.
 Mimics cardiac disease with chest and arm pain.
 Vertebral artery compression results in dizziness, tinnitus,
blurring of vision and retroocular pain.

25. Clinical examination
Restricted cervical spine movements.
The head is often moderately flexed, and tilted
towards the side of the pain in some patients but
occasionally away from it in others.
If the disc herniation is longstanding there may be
weakness & wasting in the appropriate muscle
group.

26. • C5 nerve root compression
Motor : Weakness of the deltoid
and biceps.
Sensory: upper lateral arm and
elbow.
Reflex-Biceps

27. • C6 nerve root compression
Motor: weakness of the biceps
and extensor carpi radialis brevis
and longus.
Sensory: lateral forearm, thumb
and index finger
Reflex – Biceps , Brachioradialis

28. • C7 nerve root compression
Motor: weakness of the
triceps, wrist flexion and
finger extension.
Sensory: middle finger
Reflex- Triceps

29. • C8 nerve root compression
Motor: weakness of the
interossei and finger flexors
and flexor carpi ulnaris.
Sensory: ulnar border of the
arm.
Reflex- no reflex changes

30. T-I Nerve root compression
Motor – weakness of
introssei muscles
Sensory – Medial aspect
of L –I
Reflex changes - None

31. SPECIAL TESTS
Sperlings Maneuver
• Extension and Ipsilateral rotation of the neck should
produce patients radicular pain
Lhermittes sign (Barber Chair Phenomenon)
• Flexion or extension produces electric shock like
sensations extend from spine and shoot to the limbs.

32. Compression test
Compression test
• Presses the head gently
down while the patient
is lying or sitting.
• Increase in radicular
pain

33. Distraction test
Distraction test
• Evaluates the effect of
traction on the relief of
pain .
• Place palm of one hand
under the chin & other
under the occiput and
gently lift the head

34. Confirmatory imaging
 X-Ray.
 Computerized Tomography (CT)
 Magnetic resonance imaging (MRI)
 Myelogram

35. X-RAY

36. MRI

38. Myelogram

39. Odom classification
 Type I : unilateral soft disc protrusion with nerve root
compression.
 Type II : foraminal spur or hard disc with nerve root
compression.
 Type III: medial soft disc protrusion with spinal root
compression.
 Type IV : transverse ridge or cervical spondylosis with
spinal cord compression.

40. TREATMENT
Non operative management:
 Rest
 Cervical Collar
 Ice
 Anti inflammatory agents with active mobilization.
 Muscle relaxents also can be given
 Cervical muscle strengthening excercises
 Cervical traction with weight less than 10 lbs.

41. OPERATIVE TREATMENT
Indications of surgery
 Failure of non-operative pain management
 Increasing and significant neurological deficit
 Cervical myelopathy

42. Surgical treatment:
• The most commonly performed surgeries for cervical
disc prolapse are:
– Cervical foraminotomy with excision of the disc
prolapse.
– Anterior cervical discectomy, with subsequent
fusion.

43.  Soft lateral discs are easily removed with the posterior
approach
 Soft central or hard discs are treated with anterior approach
 Spinal fusion are preceded with anterior approach with bone
grafting.
 Use of bone graft the collapse of the disc space and
maintains adequate foraminal disc.

44. Minimally invasive posterior approach
to the cervical spine
Indications:
 Radiculopathy
 Lateral disc herniation
 Foramnial stenosis
 Persistent or recurrent nerve root symptoms.

45. Contraindications:
 Pure axial neck pain without neurologic symptoms.
 Cervical instability
 Symptomatic central disc herniation
 Kyphotic deformity that would make posterior
decompression.

46. ANTERIOR APPROACH TO THE
CERVICAL DISCS
Three basic technique done are
Cloward technique.
Smith-Robinson technique.
Bailey-badgley technqiue.

47. Cloward technique
 Cloward technique involves making a round hole
centered at the disc space. A slightly larger, round
iliac crest into the disc space hole.

48. Smith robinson technique
It involves inserting a cortical strut of iliac
crest into the disc space after removing the
disc and cartilaginous endplate.

49. Bailey-badgley technique
 The technique involves the creation of slot in superior and
inferior vertebral bodies.
 This technique is most applicable to reconstruction when
one or more vertbrae are excised.
 Biomechanically the smith robinson technique provides the
greatest stability and least risk of extrusion.

50. ANTERIOR APPROACH
 Patient positioned supine, with bolster placed under the
shoulder.
 A 5-8 cms long transverse skin incision is made on skin
crease ipsilateral to the radiculopathy.
 Skin, subcutaneous tissue and platysma muscle are incised.
 Blunt dissection to access the anterior column of the
cervical spine.

51.  Carotid artery and sternocleidomastoid muscle are
retracted laterally and the muscle, trachea and
esophagus medial.
 Prevertebral fascia is split to expose the anterior
column of the cervical spine.
 longus colli muscle is identified and medial portion of
the muscle is excised to expose transverse process.

53.  using a high speed drill, a drill is made between
uncovertebral joint.
 Posterior longitudinal ligament is exposed and the lateral
remnant of the uncinate process are dissceted.
 The remaining uncinate process is removed and
decompression of the nerve root is done.
 A portion of the posterior longitudinal ligament is
removed to find hidden ruptured disc.

54. Posterior approach
 Midline incision is made on the spinous process.
 Ligamentum nuchae are divided, subperiosteal
division of the paravertebral muscles.
 With high speed burr minimal bone is removed.
 Ligamentum flavum is excised
 With the help of microscope the herniated nucleus
pulposus is removed.

55. CERVICAL DISC ARTHROPLASTY
 The primary argument favoring these device is that
adjacent segment degeneration is minimized.
 Maintenance of motion is better with arthroplasty.
 Complication includes implant migration,
heterotrophic ossification and recurrent radiculopathy.

56. THANK
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