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

Test descriptions are written with AI assistance from standard clinical texts. Where a test lists Sources, its description has been checked against them; those sources are independent and do not endorse OsteoKit. Accuracy figures and grades (A–D) appear only when checked against the published study; tests without one are marked “No accuracy study”.

Further reading: full test procedures are described in standard clinical examination texts, e.g. Magee & Manske, Orthopedic Physical Assessment (7th ed.), and Cook & Hegedus, Orthopedic Physical Examination Tests: An Evidence-Based Approach (2nd ed.).

Grade B
A+ABCDGood clinical value: meaningfully changes the diagnosis in one direction (LR 5–10 or 0.1–0.2)
best for ruling OUT (screening).

Upper Limb Tension Test (ULTT)

Procedure

Patient supine. With the shoulder girdle held down, abduct and externally rotate the shoulder, supinate the forearm, extend the wrist and fingers and then the elbow. Add neck side-flexion away from and towards the test side.

Positive Finding

Reproduction of the familiar arm symptoms that changes with neck side-flexion and differs from the other side.

Sensitivity / Specificity

97%/22%

Reference: Wainner RS et al., Spine 2003; PMID 12544957

Interpretation

A negative test makes cervical radiculopathy less likely. A positive test supports nerve irritability but does not identify the root level; use the dermatomes, myotomes and reflexes for that. It is also useful for tracking change.

Sources

Grade C
A+ABCDModest value: a small but usable shift in probability (LR 2–5 or 0.2–0.5)
modest, supportive value.

Spurling's Test (Cervical Compression Test)

Procedure

Patient seated. Extend the neck and side-bend it towards the painful side, then apply gentle downward pressure through the head. Stop if symptoms are severe.

Positive Finding

Reproduction of the familiar radiating arm pain or tingling on the tested side. Local neck pain alone does not count.

Sensitivity / Specificity

50%/86%

Reference: Wainner RS et al., Spine 2003; PMID 12544957

Interpretation

Supports cervical nerve-root irritation from a disc herniation or foraminal narrowing. A negative test does not exclude a herniation. Combine it with the upper limb tension test, distraction test and neurological examination.

Sources

Grade C
A+ABCDModest value: a small but usable shift in probability (LR 2–5 or 0.2–0.5)
modest, supportive value.

Shoulder Abduction (Relief) Test

Procedure

Patient seated. Ask the patient to rest the hand of the symptomatic arm on top of the head.

Positive Finding

The arm pain or tingling eases in this position.

Sensitivity / Specificity

49% (pooled, 2 studies, 177 patients)/76% (pooled)

Reference: Thoomes EJ, Arvanitidis M, van Geest S, van der Windt DA, Verhagen AP, de Graaf M, et al. Diagnostic accuracy of physical examination tests for painful cervical radiculopathy: update of a systematic review and meta-analysis. BMC Musculoskelet Disord. 2026;27(1). Viikari-Juntura E, Porras M, Laasonen EM. Validity of clinical tests in the diagnosis of root compression in cervical disc disease. Spine (Phila Pa 1976). 1989;14(3):253-7.

Interpretation

Relief supports cervical nerve-root compression (usually C4–C6), because the position slackens the nerve root. It helps tell nerve-root pain from shoulder pain. Pooled from a 2026 meta-analysis (Thoomes et al.) of two studies; the larger one compared patients with other people who had neck and arm pain. The evidence is rated very low certainty and the two studies disagreed. Relief makes nerve-root compression somewhat more likely; no relief does not rule it out.

Sources

Grade C
A+ABCDModest value: a small but usable shift in probability (LR 2–5 or 0.2–0.5)
modest, supportive value.

Neck Distraction Test

Procedure

Patient supine. Cradle the occiput and chin and apply a gentle, gradually increasing lift along the line of the spine for a few seconds.

Positive Finding

Relief or reduction of the familiar arm pain or tingling while the neck is lifted.

Sensitivity / Specificity

44%/90%

Reference: Wainner RS et al., Spine 2003; PMID 12544957

Interpretation

Relief supports nerve-root compression and suggests the patient may respond to traction-type treatment. A negative test does not exclude radiculopathy.

Sources

Grade D
A+ABCDLimited value: little effect on the diagnosis on its own
limited standalone value (graded conservatively from a reported range).

Hoffmann's Sign

Procedure

Hold the patient's relaxed middle finger and flick the nail downwards. Test both hands.

Positive Finding

Reflex flexion of the thumb and index finger, especially if on one side only.

Sensitivity / Specificity

58–62%/50–86%

Reference: Jiang Z et al., Global Spine J 2024; PMID 37903098

Interpretation

An upper motor neuron sign suggesting spinal cord compression, for example from a large central disc herniation. A positive sign with other myelopathy signs needs prompt medical referral for MRI.

Sources

No accuracy study

Lhermitte's Sign

Procedure

Patient seated. Ask the patient to bend the head forward, or flex the neck gently, and report any unusual sensations.

Positive Finding

A brief electric-shock sensation running down the spine or into the limbs on neck flexion.

Interpretation

Points to spinal cord irritation, which can occur with a large central disc herniation. A positive sign needs medical referral for MRI. Its absence does not exclude cord compression.

Sources

⚠ 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

Most cervical radiculopathy settles within 8–12 weeks. Mobilisation added to usual care helps short-term pain.

Safety: Before any neck technique, screen for blood-vessel problems in the neck. Progressive weakness, spreading numbness or signs of cord compression: refer, do not treat.

Region

Cervical spine (affected and adjacent segments)

Technique

Articulation, cervical
Grade B
Moderate evidence: supported by at least one good study
A review of 50 trials: mobilisation added to usual care reduced short-term arm and neck pain. Certainty moderate to very low.

Rationale

Gentle, graded movement of the affected segments to ease pain and stiffness without provoking arm symptoms. Best combined with neural mobilisation and exercise.

How it's done & evidence

How it's done

Rhythmic, low-velocity movement of a restricted cervical segment within its passive range, with no thrust. Usually done with the patient supine and the head supported; the amplitude can vary.

Evidence in Cervical Disc Herniation

In a network meta-analysis of 50 trials, joint plus neural mobilisation added to usual care reduced short-term pain more than wait-and-see or sham, and more than usual care alone. An umbrella review also supports mobilisation in radiculopathy with moderate confidence.

Region

Upper limb nerves (median, radial, ulnar)

Technique

Neural mobilisation, upper limb
Grade B
Moderate evidence: supported by at least one good study
A review of 50 trials: neural mobilisation added to usual care improved disability. Certainty moderate to very low.

Rationale

Gentle nerve sliders and tensioners to improve nerve mobility and reduce sensitivity. Kept below the point that brings on arm symptoms.

How it's done & evidence

How it's done

A movement-based treatment aimed at the nerve and the tissues around it. Gentle, rhythmic neck and arm movements either slide the nerve along its path (sliders) or lightly tension it (tensioners), with a median, radial or ulnar bias. One review found sliders helped more in acute pain and tensioners in chronic pain.

Evidence in Cervical Disc Herniation

In the same network meta-analysis, neural mobilisation added to usual care improved pain-related disability more than usual care alone and more than sham. Trials had risk of bias and varied a lot.

Region

Cervical paraspinals, upper trapezius, levator scapulae and SCM

Technique

Soft tissue, neck and shoulder girdle
Grade C
Limited evidence: indirect or low-quality support only
An umbrella review supports soft tissue work in radiculopathy. Confidence moderate; few direct trials.

Rationale

Eases protective muscle guarding around the irritated nerve root so other techniques are more comfortable.

How it's done & evidence

How it's done

Hands-on soft-tissue work (kneading, stretching and sustained pressure) across or along the cervical paraspinals, upper trapezius and levator scapulae, usually with the patient supine.

Evidence in Cervical Disc Herniation

An umbrella review of 35 systematic reviews found soft tissue treatment supported in cervical radiculopathy, with moderate confidence in the reviews' results. Individual trials were of mixed quality.

Region

Upper thoracic spine (T1–T6)

Technique

Articulation, thoracic
Grade C
Limited evidence: indirect or low-quality support only
Indirect. Trials in radiculopathy favour thoracic thrust, not mobilisation.

Rationale

Treats the stiff upper back without moving the irritated neck segments directly.

How it's done & evidence

How it's done

Rhythmic, low-velocity movement of restricted thoracic segments within their passive range, with no thrust. The patient is seated, side-lying or prone. For neck problems the upper thoracic segments (T1–T6) are the usual focus.

Evidence in Cervical Disc Herniation

A 2025 review found very low to low quality evidence that thoracic thrust manipulation beats thoracic mobilisation and other care in cervical radiculopathy. There is little evidence for thoracic mobilisation on its own.

Region

Cervical spine (C2–C7, restricted segments)

Technique

Muscle energy, cervical (C2–C7)
Grade D
Low evidence: expert consensus or could not be verified against literature
No trial comparing MET with usual care or sham in radiculopathy was found.

Rationale

Low-force and patient-powered, so it can be used when the neck is irritable. Used to ease muscle tone and restore segmental motion.

How it's done, cautions & evidence

How it's done

The neck is positioned against the restricted barrier. The patient gently pushes back toward neutral for 3–5 seconds against equal resistance, relaxes, and the neck is taken to the new barrier. Repeat 3–5 times, then re-check.

Cautions

Do not use with fracture, dislocation, infection or muscle tear. Take care with cervical instability (check for it in rheumatoid arthritis and Down syndrome), other rheumatological disease, and recent heart attack or surgery. Use the least force needed, especially in older patients.

Evidence in Cervical Disc Herniation

Searched 12 Oct 2026: no trial compared MET with usual care, sham or no treatment in cervical radiculopathy.

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