Cervical Disc Herniation: Pathology, Physiotherapy Evaluation, and Rehabilitation Program

Introduction

Cervical disc herniation (CDH) is a common spinal condition characterized by the protrusion or extrusion of intervertebral disc material in the cervical spine, often causing neck pain, radiculopathy, or myelopathy. It affects approximately 1–2% of the general population annually, with a higher prevalence in adults aged 30–50 years. CDH can significantly impact quality of life due to pain, neurological symptoms, and functional limitations. This article explores the pathology of CDH, outlines physiotherapy evaluation techniques, and details a structured rehabilitation program, drawing on evidence from PubMed where relevant.

Pathology of Cervical Disc Herniation

Cervical disc herniation occurs when the nucleus pulposus, the gel-like center of the intervertebral disc, protrudes through a tear in the annulus fibrosus, the fibrous outer layer. This can compress nearby structures, including nerve roots or the spinal cord, leading to a spectrum of symptoms. The cervical spine, comprising seven vertebrae (C1–C7), is particularly susceptible due to its mobility and weight-bearing role in supporting the head.

Pathological Changes

  1. Disc Structure and Degeneration: The intervertebral disc consists of the nucleus pulposus, which provides cushioning, and the annulus fibrosus, which provides structural integrity. With age or repetitive stress, the disc undergoes desiccation (loss of water content), reducing its height and elasticity. This predisposes the annulus to tears, allowing the nucleus to herniate.
  2. Types of Herniation:
    • Protrusion: The nucleus bulges without breaching the annulus.
    • Extrusion: The nucleus breaks through the annulus but remains contiguous with the disc.
    • Sequestration: A fragment of the nucleus detaches and migrates into the spinal canal.
  3. Common Levels: Herniations most commonly occur at C5–C6 and C6–C7 due to increased mechanical stress at these segments.
  4. Pathophysiological Mechanisms:
    • Nerve Root Compression: Herniated material may compress cervical nerve roots, causing radicular pain, sensory loss, or motor weakness in the corresponding dermatome or myotome (e.g., C6 radiculopathy affects the thumb and biceps).
    • Spinal Cord Compression: Larger herniations may compress the spinal cord, leading to cervical myelopathy with symptoms like gait disturbance, hand clumsiness, or spasticity.
    • Inflammatory Response: Herniated disc material triggers an inflammatory cascade, releasing cytokines that exacerbate pain and neural irritation.
  5. Risk Factors: These include aging, repetitive cervical strain (e.g., poor posture, occupational loading), trauma (e.g., whiplash), and genetic predisposition. A PubMed study indicates that polymorphisms in collagen genes may increase susceptibility to disc herniation.

Clinical Presentation

Patients with CDH present with:

Physiotherapy Evaluation

A comprehensive physiotherapy evaluation is essential to assess the severity, identify affected structures, and guide treatment. The evaluation combines subjective and objective components tailored to the patient’s symptoms.

Subjective Assessment

Objective Assessment

  1. Postural Analysis: Observe for forward head posture, rounded shoulders, or loss of cervical lordosis, which may contribute to symptoms or indicate compensatory mechanisms.
  2. Range of Motion (ROM): Measure cervical flexion, extension, lateral flexion, and rotation using a goniometer or inclinometer. Restrictions or pain during movement suggest disc or joint involvement.
  3. Neurological Examination:
    • Sensory Testing: Assess dermatomal sensation (e.g., light touch, pinprick) to identify nerve root involvement.
    • Motor Testing: Evaluate muscle strength in key myotomes (e.g., C5 for deltoid, C6 for wrist extensors).
    • Reflex Testing: Check deep tendon reflexes (e.g., biceps for C5, triceps for C7) for hypo- or hyperreflexia.
  4. Special Tests:
    • Spurling’s Test: Reproduces radicular pain, indicating nerve root compression.
    • Upper Limb Tension Test (ULTT): Assesses neural tension, particularly for radiculopathy.
    • Lhermitte’s Sign: Suggests myelopathy if neck flexion elicits electric-shock sensations.
  5. Palpation: Identify tenderness, muscle spasms, or trigger points in the cervical spine, trapezius, or scalenes.
  6. Functional Testing: Evaluate movement patterns during tasks like reaching or head turning to assess functional limitations.

Imaging and Correlation

Imaging, particularly MRI, is the gold standard for confirming CDH, visualizing disc herniation, and assessing nerve root or spinal cord compression. X-rays may show disc space narrowing or osteophytes, while CT is used if MRI is contraindicated. A PubMed review emphasizes that imaging should correlate with clinical findings, as asymptomatic herniations are common (up to 20% in adults).

Rehabilitation Program

Conservative management, including physiotherapy, is the first-line treatment for most cases of CDH, with surgery reserved for severe or refractory cases. A multimodal rehabilitation program aims to reduce pain, restore function, and prevent recurrence, supported by PubMed evidence where applicable.

Phase 1: Pain Management and Protection (0–4 Weeks)

Goals: Reduce pain and inflammation, protect the cervical spine, and promote patient education.

Phase 2: Mobility and Strengthening (4–8 Weeks)

Goals: Restore cervical ROM, improve muscle strength, and enhance neural mobility.

Phase 3: Functional Restoration and Maintenance (8+ Weeks)

Goals: Enhance functional capacity, prevent recurrence, and promote long-term cervical health.

Special Considerations

Conclusion

Cervical disc herniation is a prevalent condition with significant clinical implications, driven by disc protrusion, nerve root or spinal cord compression, and inflammatory responses. Physiotherapy evaluation, combining subjective history, objective testing, and imaging correlation, guides effective conservative management. A structured rehabilitation program, emphasizing pain relief, mobility restoration, and functional training, is effective for most patients, supported by PubMed evidence. While surgical options exist for severe cases, physiotherapy remains the cornerstone of treatment, improving outcomes and promoting long-term cervical health.