NMS

7/14/99

 

Cervical Disc Herniation

·        Insidious—no known origin, almost no history

·        Motor signs are a early sign of disc herniation

·        In lumbar spine, get sensory signs first

·        Problem w/hypertrophy of Luschka joints and surrounding ligaments which can

·        >12mm you are in the possibility of encroaching on neural structures

·        These are a rare occurrence

·        1.PLL is wide across the disc and spans the entire width of the disc

·        2. PLL is thicker and stronger than in the lumbar spine

·        3. Nucleus pulposus is more anterior than the rest of the spine

·        4. Nerve root is inferior to the disc material

·        5. The Luschka joint is a barrier to the disc movement

·        Never the first choice on the differential

·        In the lumbar spine these problems are common

·        Most disc lesions are insidious or idiopathic in the cervical spine, occur w/out a history, unlike the lumbar spine

·        Early signs of impingement is a motor dysfunction, followed by pain and tingleing only on orthopedic testing. This is the opposite in the lumbar spine

·        Von luschka joints can hypertrophy and cause pain and injury in the cervical spine and is worse than a disc bulge and far more common

·        The best management of a DJD is adjustments and soft tissue work

·        The spinal canal width is 22mm at C1 and 20mm at C2 then 17mm from C3 down, at 12mm or below there is a possibility of impingement, at 10mm or below there will be impingement.

·        Disc bulges in the cervical spine can cause pain shooting down the leg.

·        As the anterior portion of the cord is impinged, there is a bilateral pattern of impingement.

·        If a patient extends the head and there is bilateral pain down the leg then there is a likelyhood of a cord compression and result in an UMNL muscle weakness, and hyperreflexia, and may indicate a presence of a Babinski sign.

·        Disc bulges can result in LMNL to the arm on that side and UMNL to the leg on that side.

·        Disc bulges can compromise the vertebral artery in the rarest of cases.

·        Discs are innervated and can be a site of pain, discs that have been injured may become innervated but those that have not been injured are not innervated

·        In the cervical spine the disc can bulge through the PLL and cause cord compression and would affect the legs but not the arms.

·        Hypertrophy or spurring is caused by the disc peeling away the PLL from the periosteum (this can cause all of the symptoms of CES) the disc material then moves into the space followed by fibrosing and calcification of the space between the bone and the PLL resulting in a spurr.

·        Facet spurring affects the sensory portion, but luschka hypertrophy causes motor losses.