Cervical Disc Herniation

Spine

Overview

Cervical disc herniation occurs when the nucleus pulposus of an intervertebral disc protrudes through a weakened annulus fibrosus, potentially compressing nerve roots or the spinal cord. This condition commonly affects the C5-C6 and C6-C7 levels and can present with radicular pain, neurological deficits, or myelopathic symptoms depending on the degree and location of compression. Management ranges from conservative care to surgical intervention based on severity and symptom progression.

Pathophysiology

The cervical intervertebral disc undergoes degenerative changes with loss of hydration and structural integrity in the nucleus pulposus. Mechanical stress, trauma, or repetitive strain causes the disc material to herniate posteriorly or posterolaterally through tears in the annulus fibrosus. This herniation can compress adjacent nerve roots (causing radiculopathy) or, if central, compress the spinal cord (causing myelopathy). Inflammatory mediators released from the herniated disc material contribute to nerve root irritation and pain sensitization. Age-related changes, cervical instability, and segmental dysfunction increase herniation risk.

Patient Education

Cervical disc herniation responds well to conservative management in most cases; early activity modification, posture correction, and gradual exercise can prevent progression and reduce symptoms over 6-12 weeks.

Typical Presentation

Site

Unilateral or bilateral neck pain; ipsilateral shoulder, arm, and hand pain following dermatomal pattern (commonly C5, C6, or C7 distribution)

Quality

Sharp, burning, or electric shock-like radicular pain; may include deep aching neck pain

Intensity

Mild to severe (4-9/10); varies with position and activity; often worse in morning or with sustained postures

Aggravating

Neck extension, rotation toward affected side, Valsalva maneuver, prolonged sitting, overhead activities, cervical compression

Relieving

Neck flexion, arm elevation (hand behind head), recumbency, gentle traction, anti-inflammatory medications, heat

Associated

Weakness in myotome distribution (triceps, wrist extensors, grip strength); sensory changes in dermatomal pattern; diminished reflexes; possible occipital headache; stiffness and guarding of neck musculature; possible upper extremity paresthesia

Orthopaedic Tests

Spurling's Test (Cervical Compression Test)

Procedure

Patient seated or standing; examiner extends and laterally flexes the cervical spine toward the affected side, then applies gentle axial compression through the head. Positive if radicular pain is reproduced down the affected arm.

Positive Finding

Reproduction of radicular pain or numbness/tingling down the arm ipsilateral to the herniation

Sensitivity / Specificity

50–60% / 93–95%

Tong et al., 2007, Spine; Viikari-Juntura et al., 1989, Spine

Interpretation

High specificity suggests cervical nerve root compression or irritation; negative test does not exclude disc herniation. Most useful when positive in combination with other clinical findings.

Lhermitte's Sign

Procedure

Patient seated or standing; examiner passively flexes the cervical spine by guiding the chin toward the chest. Patient reports any electric shock-like sensation radiating down the spine or into the limbs.

Positive Finding

Electric shock or tingling sensation radiating into the spine, arms, or lower extremities with neck flexion

Sensitivity / Specificity

20–30% / 80–90%

Interpretation

Suggests spinal cord irritation or myelopathy from disc herniation; high specificity but poor sensitivity limits its use as a standalone test. Often associated with central or posterolateral herniation.

Cervical Radicular Pattern Assessment (Upper Limb Tension Test / Brachial Plexus Tension Test)

Procedure

Patient supine or seated; examiner abducts the arm to 90°, externally rotates the shoulder, extends the elbow, and extends the wrist. Cervical spine may be laterally flexed away from affected side. Test is positive if radicular symptoms are reproduced.

Positive Finding

Radicular pain, numbness, or tingling in the distribution of the cervical nerve root corresponding to the herniation level

Sensitivity / Specificity

40–50% / 70–75%

Viikari-Juntura et al., 1989, Spine; Rubinstein et al., 2007, Cochrane

Interpretation

Assesses nerve root mechanosensitivity and irritability; useful for identifying which nerve root is involved and measuring treatment response. Moderate specificity requires integration with imaging and other tests.

Shoulder Abduction (Relief) Test

Procedure

Patient seated with arm at rest; examiner abducts the shoulder to approximately 90° and supports the arm/hand, allowing relaxation. Positive if radicular pain is relieved or diminished in this position.

Positive Finding

Relief or significant reduction of arm pain or radicular symptoms when the shoulder is abducted and supported

Sensitivity / Specificity

50–70% / 85–90%

Uchihara et al., 1994, Journal of Neurology; See current literature

Interpretation

Suggests cervical nerve root involvement; relief implies reduced nerve root tension. Often indicates C5 or C6 radiculopathy. High specificity makes it useful as a confirmatory test.

Neck Distraction Test

Procedure

Patient supine or seated; examiner supports the head and gently applies longitudinal traction/distraction through the cervical spine, gradually relieving compressive forces. Positive if radicular pain is relieved.

Positive Finding

Reduction or relief of radicular arm pain or neurological symptoms with gentle cervical traction

Sensitivity / Specificity

40–60% / 60–70%

Tong et al., 2007, Spine; Saal et al., 1996, Spine

Interpretation

Suggests nerve root compression amenable to mechanical decompression; relief supports diagnosis of compressive pathology. Moderate sensitivity and specificity; most useful as part of multimodal assessment.

Hoffmann's Sign

Procedure

Patient's hand relaxed and supported; examiner flicks the tip of the patient's middle finger downward, releasing quickly. Examiner observes for involuntary thumb flexion and adduction.

Positive Finding

Brisk involuntary flexion and adduction of the thumb in response to flicking the middle finger (hyperreflexia indicator)

Sensitivity / Specificity

50–70% / 95%+

Interpretation

Suggests cervical myelopathy or spinal cord compression from central or posterolateral disc herniation. Highly specific; indicates upper motor neuron involvement and more severe pathology requiring urgent imaging and possible intervention.

⚠ Red Flags

  • •Progressive myelopathic symptoms: bilateral symptoms, gait disturbance, loss of fine motor control, or bowel/bladder dysfunction
  • •Severe progressive neurological deficit with motor weakness or sensory loss
  • •Acute quadriplegia or respiratory compromise suggesting cord compression
  • •Signs of vertebral artery compression: dizziness, visual disturbance, drop attacks
  • •History of trauma with severe pain or neurological signs
  • •Fever, unexplained weight loss, or history of malignancy with new cervical symptoms suggesting systemic pathology

⚡ Yellow Flags

  • •High pain catastrophizing and fear avoidance behaviours
  • •Persistent psychosocial distress or depression affecting recovery
  • •Delayed or poor response to appropriate conservative management
  • •Overreliance on imaging findings as explanation for all symptoms, resisting non-structural explanations
  • •Work-related stress or pending litigation related to symptoms
  • •Poor compliance with rehabilitation or avoidance of all activity

Osteopathic Techniques

Region

Cervical spine and neck musculature

Technique

Soft Tissue

Rationale

Releases myofascial tension in upper trapezius, levator scapulae, sternocleidomastoid, and suboccipital muscles to reduce protective guarding, improve segmental mobility, and reduce pain-spasm cycle. Reduces local inflammation and promotes tissue fluid exchange.

Region

Cervical spine (affected and adjacent segments)

Technique

MET

Rationale

Muscle energy techniques restore normal segmental mechanics and reduce guarding without aggressive manipulation. Particularly effective at limiting excessive extension and improving ipsilateral rotation; enhances proprioceptive feedback and stabilization.

Region

Thoracic inlet, first rib, and shoulder girdle

Technique

Articulation

Rationale

Mobilization of thoracic inlet and upper thoracic spine reduces referred tension and improves cervical posture. First rib and clavicular restrictions contribute to radicular symptoms; articulation restores normal neurovascular outflow from thoracic outlet.

Region

Cervical spine (general mobilization)

Technique

Functional

Rationale

Functional techniques identify and treat the segment in its neutral, ease position, promoting self-correction and proprioceptive resolution without stress to already compromised disc. Suitable for acute presentations and severe symptoms where HVLA is contraindicated.

Region

Cervical sympathetic chain, thoracic outlet

Technique

Lymphatic

Rationale

Enhances lymphatic drainage and venous return in the neck and upper thorax, reducing local tissue swelling and inflammation around compressed nerve roots. Improves fluid dynamics supporting disc recovery.

Region

Occipital base, atlanto-axial, and suboccipital region

Technique

Cranial

Rationale

Release of cranial base restrictions and occipital-atlas dysfunction improves vertebrobasilar blood flow and reduces referred pain patterns. Balances autonomic tone and supports parasympathetic modulation of pain.

Add-On Approaches

Chinese Medicine

Traditional Chinese Medicine approaches cervical disc herniation through acupuncture targeting meridian pathways (Bladder, Triple Burner, Gallbladder meridians), moxibustion for cold-deficiency types, and herbal prescriptions (e.g., Juan Bi Tang) to promote Qi and blood circulation, reduce inflammation, and restore cervical mobility. Cupping and gua sha may address local stagnation.

Chiropractic

Chiropractic management includes cervical manipulation and mobilization focused on restoring segmental mobility, particularly at C5-C6 and C6-C7 levels, combined with flexion-distraction techniques and postural correction. HVLA manipulation is contraindicated in acute presentations or severe myelopathy; diversified or gonstead adjustments are common approaches in uncomplicated cases.

Physiotherapy

Physiotherapy emphasizes cervical stabilization exercises, particularly deep cervical flexors (Craniocervical Flexion Test protocol), progressive strengthening of scapular stabilizers, postural retraining, and graded activity progression. Modalities include cervical traction, electrotherapy for pain modulation, and proprioceptive training. McKenzie directional preference assessment guides exercise selection.

Remedial Massage

Remedial massage targets upper trapezius, levator scapulae, rhomboid, and suboccipital myofascial tensions through deep tissue techniques, trigger point release, and soft tissue mobilization. Emphasis on releasing protective guarding and addressing cervical-thoracic junction restriction; myofascial release and cross-friction techniques support healing and restore tissue extensibility.

Rehabilitation Exercises

Cervical Flexion and Extension (Pain-Free Range)

Range of MotionBeginner

Cervical Lateral Flexion (Ear-to-Shoulder)

Range of MotionBeginner

Cervical Rotation (Chin-to-Shoulder), Avoiding Compression

Range of MotionBeginner

Upper Trapezius Stretch (Cervical Lateral Flexion with Hand Assistance)

StretchingBeginner

Levator Scapulae Stretch (Downward Head Rotation with Contralateral Flexion)

StretchingBeginner

Pectoral Stretch (Doorway or Corner Stretch with Arm Abduction)

StretchingIntermediate

Craniocervical Flexion (Deep Cervical Flexor Activation, Supine)

StrengtheningBeginner

Scapular Stabilization (Prone Rows or Resistance Band Rows)

StrengtheningIntermediate

Cervical Isometric Resistance (Four Directions: Flexion, Extension, Rotation, Lateral Flexion)

StrengtheningIntermediate

Chin Tuck (Cervical Retraction) for Posture and Deep Cervical Flexor Activation

PosturalBeginner

Thoracic Extension over Foam Roller (Restoring Thoracic Kyphosis and Reducing Cervical Extension)

PosturalIntermediate

Proprioceptive Head Repositioning (Cervical Proprioception Retraining with Eyes Open/Closed)

BalanceIntermediate

Referral Criteria

  • •Progressive myelopathic symptoms: bilateral symptoms, gait disturbance, loss of fine motor control, or bowel/bladder dysfunction requiring urgent MRI and neurosurgical consultation
  • •Severe or progressive motor deficit (grade 3/5 or worse) unresponsive to conservative management within 4-6 weeks
  • •Signs of vertebral artery insufficiency: dizziness, visual disturbance, or drop attacks suggesting vascular compression
  • •Failure to improve with 6-8 weeks of appropriate conservative management and symptom persistence affecting function and quality of life
  • •Acute severe pain with signs of cord compression on imaging (MRI) indicating surgical candidate
  • •Suspected systemic disease (fever, unexplained weight loss, night sweats, history of cancer) requiring medical investigation
  • •Significant psychosocial distress, depression, or anxiety not managed within primary care, requiring mental health support
  • •Suspected underlying instability or ligamentous injury (laxity on imaging) requiring specialist orthopedic assessment