Wong et al noted in their systematic review that most patients experienced substantial improvement within 4–6 months. However, the length of non-operative management that has to be attempted is unclear.
BACK BULGING DISK XRAY TRIAL
10 A trial of non-operative management is usually attempted in the absence of these signs. 5 Concerning signs or symptoms that might merit early surgical intervention include progressive neurologic deficits or signs of myelopathy ( Fig. 9 There are no clearly recognized indications for surgery in patients with CDH with radiculopathy. 5 Good to excellent outcomes were reported in up to 90% of patients with non-operative management of cervical radiculopathy. It consists of a number of different modalities including immobilization, physical therapy, manipulation, traction, medication, and cervical steroid injection. Non-surgical treatment is the initial treatment of choice in most CDH patients with radiculopathy. 8 This systematic review also showed that workers’ compensations claims were correlated with more invasive treatment and a poorer prognosis. 8 In the long term, a small proportion of patients appeared to have residual impairments, such as pain and activity limitations however, none of the patients had progressive neurologic deficits or developed myelopathy. 3 A recent systematic review found that substantial improvements in symptoms appear within four to six months, with time to complete recovery spanning 24 to 36 months in most patients. 7 An epidemiologic study by Radhakrishnan et al showed similar findings at four-year follow-up, where nearly 90% of patients with cervical radiculopathy were either asymptomatic or only mildly symptomatic. 7 No radiculopathic patient progressed to myelopathy in this series. A classic study by Lees and Turner featured a long-term follow-up (2–19 years) of 51 patients with radiculopathy: 45% of the patients had only a single episode of pain without recurrence, 30% had mild symptoms, and only 25% had persistent or worsening symptoms. The natural history of CDH with radiculopathy is generally considered favourable however, high-quality studies are lacking. 6 Epidemiologic studies have shown that the C7 root (C6–7 herniation) is the most commonly affected, followed by the C6 (C5–6 herniation) and C8 (C7–T1 herniation) nerve roots. These radicular symptoms may also be associated with reflex changes and motor weakness of the upper extremity. The arm pain typically follows a myotomal pattern, whereas the sensory symptoms (e.g., burning, tingling) follow a dermatomal distribution. 5 Most patients with symptomatic CDH and radiculopathy report severe neck and arm pain. 4 With regards to pathoanatomy, the herniated disc may impinge on the exiting nerve root intraforaminally as it traverses the neuroforamen, or, more commonly, posterolaterally at its take-off from the spinal cord. 3 The aetiology of CDH is multi-factorial and the proposed risk factors include male gender, cigarette smoking, heavy lifting, and occupations involving operating vibrating equipment.
DOI: 10.1302/2058-5220Ĭervical disc herniation (CDH) is a common source of cervical radiculopathy, with an annual incidence of 18.6 per 100,000, and peak presentation in the sixth decade of life. In lumbar disc herniation (LDH), the indications for surgery include imaging confirmation of LDH, consistent with clinical findings, and failure to improve after six weeks of conservative care.Ĭite this article: EFORT Open Rev 2021 6:526-530. Moreover, giant calcified thoracic disc herniations or myelopathy signs on magnetic resonance imaging, even in the absence of neurological symptoms, may benefit from surgical treatment as a preventive measure. In thoracic disc herniation (TDH), the indications for surgery comprise failure of conservative measures and/or worsening neurological symptoms. However, high-quality studies are lacking, and a randomized controlled trial is now underway to clarify the indications. In cervical disc herniation (CDH), the indications for surgery consist of six months of persisting symptoms, not responding to conservative treatment. However, this review summarized the relative indications for surgery in each level. In all levels of disc herniations the absolute surgical indications include deteriorating neurological deficits with myelopathy or cauda equina syndrome.
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