The occurrence of a herniated disc is much rarer at the cervical level at the lumbar level.
DIAGNOSTIC:
Physical examination:
Examination:
He stated (see Spinal Pain):
– Installation mode pain;
– The field of occurrence;
– Mechanical or inflammatory schedule;
– Seniority of pain and his progressive profile;
– Its functional impact; the path of painful radiation in the upper limb, noting at the outset the character less systematized radicular pain and paresthesia in the upper limb relative to the lower member. It may nevertheless suspect that:
– A cervical radiculopathy C6 on a painful path to the front of the upper limb to the palm and thumb,
– A cervical radiculopathy C7 (most frequent) pain on the posterior aspect of the upper extremity to the back of the hand and the 2nd and 3rd fingers,
– A cervical radiculopathy C8 on a pain of the internal face of the upper member until the last two fingers;
– The existence of general signs or extraspinal clinical manifestations.
Physical examination:
He’s looking for :
– A contraction of the spinal muscles and trapezoids, with stiffness and loss of cervical lordosis physiological or vicious attitude in bending and rotation;
– Painful elective points palpation of the spine and / or neighborhood of muscles; a limitation of the neck motion in flexion / extension, rotation and latéroflexions;
– The presence of objective neurological signs
– Breach C6: reduction or abolition of biceps and brachioradialis reflexes, motor deficit biceps and finger flexors and wrist, thumb hypoesthesia,
– If C7 achieved: reduction or abolition (or inversion) of the triceps reflex triceps deficit and extensors of the fingers and wrist, hypoesthesia pulp 2nd and 3rd fingers,
– Breach C8: reduction or abolition of cubitopronateur reflex deficit interosseous muscles and hypoesthesia of the last two fingers;
– The presence of any signs of pyramidal series, moving towards a cervical spondylotic myelopathy;
– A clinical examination must be complete, especially if the context does evoke an inflammatory nature of disease (palpation of the supraclavicular and axillary hollow +++).
Additional examinations first line:
In the absence of gravity waves (significant neurological deficit or worsening fast, hyperalgic cervical radiculopathy) or clinical suspicion of an inflammatory nature of pathology, it is not necessary to request the performance of diagnostic tests.
For some, however, it is worth asking at least:
– A determination of erythrocyte sedimentation rate (ESR) and / or C-reactive protein (CRP);
– The standard clichés of the cervical spine: front and profile, open mouth face (releasing C1 / C2) and oblique impacts (releasing the foramen).
Differential diagnosis:
It is necessary to rule out other causes of pain syndrome of upper limb, and even more so that the neurological can result in objective abnormalities crude or nonexistent:
– The periarthritis scapulohumérales (cf. Shoulder pain) can result in root of the upper limb pain often radiating to the arm or the forearm, wrist and hand. However, there is no distal paresthesias and exam easily find painful limitation to the mobilization of the upper limb;
– Epicondylitis is manifested by pain in the outside of the elbow radiating willingly to the forearm and hand. However, there is no acroparesthesia, pain is increased by the grip and movements of supination, and awakened by the pressure of épicondyliennes insertions. A golfer’s elbow can also be sought;
– The carpal tunnel syndrome is particularly misleading because it causes pain and paresthesias of the hands, but also painful radiation upward, sometimes to the shoulder or neck;
– Other conditions must be eliminated: neurovascular compression in the lé challenge cervicothoracic, Parsonage-Turner syndrome;
– Finally, the CRPS of the upper extremity (shoulder-hand syndrome or) can simulate a cervicobrachial neuralgia but no distal paresthesia nor objective neurological abnormalities. However, the review found an array of adhesive capsulitis and trophic disorders of the hand.
ETIOLOGY:
Cervical radiculopathy mechanical speed:
Acute neuralgia cervicobrachial:
In this context, priority should be suspected in the existence of a herniated cervical disc.
The appearance of radicular pain, usually in a young person is either sudden, after a wrong move or sneeze, more progressive after a few days to a few weeks in isolation neck pain.
Cervical radiculopathy is rather aggravated by the movements of the upper limb.
Pain is impulsive coughing and sneezing, and often increased by the supine (and therefore insomniante).
The questioning often difficult to specify the topography of pain and paresthesias, and clinical examination should strive to identify objective neurological abnormalities, high value localisatrice but inconstant.
Rarely, the highlight of the herniated disc is necessary for surgical treatment, it should be considered that in case of significant motor deficit or intractable pain for several weeks of medical treatment.
The scan of the cervical spine shows the herniated disc as a posterior bulging disc in the spinal canal, sometimes median but usually lateral or foraminal, erasing the same root, and sometimes displacing the spinal cord. The scanner can also highlight uncarthrosiques degenerative lesions, often associated with damaged discs.
MRI of the cervical spine tends to supplant the scanner because it provides more valuable information on the size of the spinal canal and the possible existence of spinal signs of suffering. Finally, MRI is significantly more sensitive than the scanner to formally eliminate the causes of neuralgia secondary cervicobrachial.
Chronic cervical radiculopathy:
Neck pain and cervical radiculopathy common:
This term refers to cervical painful manifestations and (pseudo) chronic radicular, responding to various anatomical lesions, readily associated with each other (degenerative disc disease, and facet joint osteoarthritis uncarthrose)
– Subsequent joint syndromes (including occipital neuralgia); cervical radiculopathy complicating the formation of a disco-ostéophytique nodule, usually in the foramen.
Functional neck pain:
Pseudoradiculaires readily supplemented by radiation, they are particularly frequent and should not constitute a diagnosis of elimination of previous causes. They share the same characteristics as functional low back pain (see chapter spinal pain), which they are also often associated. In this context, Lieou Barré-syndrome is the functional gait cervicalgies association to very different subjective manifestations.
Cervical radiculopathy inflammatory pace:
In this case, neck pain or cervicoradiculaire this semiological features evocative:
– Inflammatory schedule (waking in the second part of night, prolonged morning stiffness); progressive worsening without notion of triggering event;
– Impaired general condition and / or fever;
– Raised ESR and CRP.
Multiple diagnoses may be mentioned, justifying the realization of examinations adapted to the context: a study of cerebrospinal fluid, scan, bone scan, MRI …
Infectious diseases:
The seeds are very variable (banal germs, tweezers, Mycobacterium tuberculosis) but we must stress the urgency of vertebral infection diagnosis in the cervical region, because of the frequency of epidural abscess and spinal risk.
Some chronic lymphocytic meningitis (Lyme, immunodéfi ciency virus human, varicella zoster virus, herpes) can cause isolated neck pain or cervical radiculopathy (table meningoradiculitis).
Inflammatory rheumatic diseases:
The cervical spine is often involved in rheumatoid arthritis and spondyloarthritis, usually so late in evolution. In polymyalgia rheumatica, very inflammatory neck pain association with scapular pain is almost constant.
Tumoral pathologies:
Bone tumor pathologies:
This mainly malignancies: metastases or myeloma usually, primary bone tumor, solitary plasmacytoma or lymphoma exceptionally location.
The diagnosis of malignant spinal injury can be raised on plain radiographs (recall that a settlement is cervical vertebral osteoporotic ever), confirmation is provided by MRI, which also clarifies the importance of tumor extension epidural spinal cord and its impact.
In this context of cervical radiculopathy complicating malignancy, should be mentioned Pancoast syndrome, which corresponds to a compression of the C8 and T1 roots by a tumor developed in the supraclavicular fossa, usually a cancer of the pulmonary apex. The full syndrome associated with cervical radiculopathy lysis of the first rib and Horner’s syndrome.
Some benign bone tumors, as conventional rare, can be cited: osteoid osteoma, aneurysmal cyst, eosinophilic granuloma (in children).
Neurological tumor pathologies:
Neuromas primarily, but also meningiomas and ependymomas may be at the origin of cervicoradiculaires pain, particular by their very nature insomniant.
The search for a sublesional reached (pyramidal syndrome) is of course imperative.
The lesion diagnosis is based primarily on MRI of the cervical spine.
TREATMENT:
Medical treatment:
General drug treatments:
See sciatica.
Local drug treatment:
This is especially epidural.
These can be made directly into neck because of the risk of spinal cord injury, and the infiltration is made in lumbar, the patient then being Trendelenburg position for one hour to allow the product to go to the place the nerve root. These epidurals can be repeated (three maximum) for a few days or weeks apart.
Intradural infiltrations are rarely indicated.
Physical treatments:
Wearing a foam cervical collar may be recommended for a brief period at the beginning of evolution.
Physiotherapy has an interest especially in the acute phase, referred to sedative and relaxant massages, physiotherapy or gentle axial manual traction. The osteopathic techniques can be useful in case of torticollis isolated but should be overturned on cases of cervical radiculopathy discogenic origin.
Surgical treatment:
His place in the treatment of cervical radiculopathy discogenic origin is far more limited than the sciatica.
It is reserved only neuralgia cervicobrachial rebels to proper medical treatment continued at least six weeks, very rare situation in practice and cervicobrachial neuralgia with significant motor deficit in the root area and / or spinal cord compression signs (extreme urgency ).
The surgical discectomy, which comprises an anterolateral approach (Cloward technique), is often completed with a interbody fusion by bone grafts or anterior bone plate. Surgery is justified especially as the hernia is associated with arthritic lesions (disco-ostéophytique bead).
It must be followed by permanent wear a neck brace for three weeks.
