Surgical treatment of laterally ruptured cervical disc

Review of 648 cases, 1939 to 1972

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✓ From the analysis of 648 patients operated on for ruptured cervical discs between 1939 and March of 1972 and a follow-up study of 380 of these patients, the following conclusions seem justified. Osteophytes or hypertrophic spurs rarely produced the classical clinical picture or deficits. Ninety per cent of the patients awakened in the morning with pain in the neck and rhomboid region. Ten per cent had a history of injury, but there was no characteristic pattern as in lumbar discs. Only one patient had a typical hyperextension injury. Anterior chest pain occurred in one-fifth of the cases. Pain in the neck, rhomboid region, and anterior chest was referred from the discs, while the arm pain was usually the result of nerve root compression; however, in a few cases the degenerating disc caused referred pain to the arm without any nerve root pressure. Since accurate diagnosis can be made on clinical grounds, myelography is not necessary in most cases. In our experience conservative treatment was usually unsuccessful while the surgical results were better than in almost any other neurosurgical operation. The nerve root syndromes associated with extruded lateral cervical discs are outlined and the indications and contraindications for myelography discussed.

Abstract

✓ From the analysis of 648 patients operated on for ruptured cervical discs between 1939 and March of 1972 and a follow-up study of 380 of these patients, the following conclusions seem justified. Osteophytes or hypertrophic spurs rarely produced the classical clinical picture or deficits. Ninety per cent of the patients awakened in the morning with pain in the neck and rhomboid region. Ten per cent had a history of injury, but there was no characteristic pattern as in lumbar discs. Only one patient had a typical hyperextension injury. Anterior chest pain occurred in one-fifth of the cases. Pain in the neck, rhomboid region, and anterior chest was referred from the discs, while the arm pain was usually the result of nerve root compression; however, in a few cases the degenerating disc caused referred pain to the arm without any nerve root pressure. Since accurate diagnosis can be made on clinical grounds, myelography is not necessary in most cases. In our experience conservative treatment was usually unsuccessful while the surgical results were better than in almost any other neurosurgical operation. The nerve root syndromes associated with extruded lateral cervical discs are outlined and the indications and contraindications for myelography discussed.

The lesions under discussion in this paper represent actual rupture of the annulus fibrosis of a cervical intervertebral disc with lateral extrusions of pieces of nucleus pulposus or cartilage that compress the various roots of the brachial plexus.

The incidence of ruptured cervical disc is unknown. In the first 20 years covered by this series the ratio of operations for lumbar vs cervical disc was 25 to 1. In 1966 it was 10 to 1 and now is between 6 and 7 to 1 and still dropping. Almost as many have been operated on in the last 4 years as in the previous 27 years.

Clinical Material

The conclusions reached are based on a complete review of the records of 648 patients who had been operated on by us at the Baptist Memorial Hospital between 1939 and March 1, 1972. Approximately 380 of these patients were followed by questionnaire from 1 to 28 years regarding long-term results and the type of work they were doing.

Results and Conclusions

The following conclusions seem justified on the basis of these data and discussions with other neurosurgeons, orthopedists, and neurologists:

  1. There is still much confusion about the cause of neck and arm pain and reason to believe that many of the specialists who handle such cases are incapable of making a diagnosis of a ruptured cervical disc on clinical grounds.

  2. Rarely, if ever, do osteophytes or hypertrophic spurs produce the characteristic clinical pictures or deficits to be discussed; even if an osteophyte is present at the appropriate level, the surgeon will almost always find an extruded fragment of disc on top of it.

  3. Ninety per cent of the patients who had ruptured cervical discs awoke in the morning with pain in the neck or rhomboid region which was followed by arm pain. Only about 10% had a history of any injury preceding the onset of symptoms, and there has been no pattern of injury such as that seen in lumbar discs.

  4. There was only one patient in our entire group who had a typical hyperextension injury (rear-end automobile collision). Compensation cases and lawsuits were extremely rare.

  5. Contrary to some reports in the literature, anterior chest pain occurred in one-fifth of our cases.

  6. One of us (F.M.) did most of his operations with the patient under local anesthesia. The pain in the neck, rhomboid region, and anterior chest was referred pain from the disc itself, while arm pain was usually the result of nerve root compression. It was possible in a degenerating disc to have pain referred to the arm without any nerve root pressure whatever; these patients did not have a neurological deficit. Pain in the neck, rhomboid, or anterior chest regions could result from ruptured discs at any cervical level.

  7. The diagnosis can be me made on clinical grounds as accurately as that of any other lesion in the nervous system. Although a considerable number had no sensory symptoms or demonstrable hypesthesia, practically all had weakness or reflex changes.

  8. Myelography was not necessary in most cases.

  9. In the senior author's experience, conservative treatment consisting primarily of 5 lbs of cervical traction applied with the patient a semi-Fowler's position has usually failed. However, Martin and Corbin2,3 have reported success in a majority of patients using vertical Sayer traction; one of us (J.C.H.S.) has had comparable success in a smaller but significant percentage of cases using the same method. This is difficult to understand because the hole in the annulus is usually paracentral; since the fragment or fragments are extruded laterally under or through the posterior longitudinal ligament it seems virtually impossible for them to find their way back through the hole through which they were extruded.

  10. It was our impression that the results of this operation were better than those of any other operation in neurosurgery with the possible exception of that for trigeminal neuralgia.

Discussion

The rest of this paper will deal with symptoms and signs at various levels in the neck, the indications for or against myelography and surgery, and the complications and results of surgery.

Symptoms and Signs

Contrary to at least one other report5 the signs and symptoms of involvement of the various roots in our series were fairly constant. These characteristic findings are summarized in Table 1.

TABLE 1

Symptoms and signs characteristic of ruptured disc at specific levels in 648 patients

No. of CasesDisc Level*PainNumbnessWeaknessReflexes Absent or Diminished
26 C4–5 neck, scapula, shoulder,lat. aspect upper arm,supra- and infraspinatus,biceps,
 (C—5) ant. chest, upper armdeltoid regiondeltoid, biceps,brachioradialis
  (lat.)brachioradialis (severe),
  ? supinator
171 C5–6 neck, scapula, shoulder,thumb, index fingerbiceps (mild to moderate),biceps
 (C—6) ant. chest, upper arm(sometimes absent)ext. carpi radialis
  (lat.) and forearm(occasionally the only
  (dorsum)weak muscle)
393 C6–7 neck, scapula, shoulder,index, middle fingertriceps (moderate totriceps
 (C—7) ant. chest, upper armmarked)
  (lat.) and forearm
  (dorsum)
50 C7—T1 neck, scapula, ant.little & ring finger,all extensors of wristtriceps
 (C—8) chest, medial aspect ofoccasionally middle(except extensor carpi
  upper and forearmfingerradialis), all flexors
  except flexion of carpi
  radialis & ? palmaris
  longus, all intrinsic
  muscles of hand
4 T1–2 neck, scapula, ant.ulnar side of forearmintrinsic muscles ofnone; Horner's
 (T—1) chest, medial aspect of(usually subjective)hand onlysyndrome present
  upper and forearm
4 multiple 

The nerve compressed is listed in parentheses.

C4–5

The findings typical of a ruptured disc between C4–5 with involvement of a fifth cervical nerve root include pain in the rhomboid region, the shoulder, and occasionally the anterior chest where it is associated with pain down the lateral aspect of the upper arm to about the elbow. The supra- and infraspinatus, deltoid, biceps, and brachioradialis muscles show marked to extreme weakness, and the biceps and brachioradialis reflexes are reduced or absent. Supination of the forearm is also weak, but when the biceps is weak, testing for weakness in supination is not a valid test for weakness of the supinator. Occasionally there is numbness in the distribution of the axillary nerve or on the lateral aspect of the upper arm.

We are convinced that we have missed a large number of extruded discs at this level for three reasons. First, we did not believe that an involvement of one motor root could produce such devastating disability. Second, we made an erroneous diagnosis of Spilane's neuritis, because we did not read carefully what that author had to say in his original 1943 article;4 the biceps and brachioradialis and certain other muscles were never involved, whereas out of 46 cases reported the serratus magnus was involved in 34, the spinati 24, the deltoid 17, the trapezius 11, the sternomastoid 1, and the rhomboids 1. Review of the cases we have called Spillane's neuritis or brachial plexus neuralgia in the past 10 years reveals at least 15 in which the correct diagnosis should have been a classic C-5 root syndrome. In nine of these, the myelogram was reported normal, and in six no myelogram was done. Finally, the myelogram was frequently normal or so near normal that we considered the changes insignificant.

C5–6, C6–7

Table 1 adequately summarizes the classical picture of a ruptured disc between C5–6 with compression of the 6th cervical root and the syndrome of a ruptured disc between C6–7 with compression of the 7th root.

C7-T1

In its classical form, a ruptured disc between C7-T1 produces a useless hand, but there is more variability in the degree of weakness at this level than at any other. We are certain that, as at C4–5, we missed the diagnosis for many years in many of these cases either because we could not believe involvement of one root could be so devastating, or because the myelographic defect was so small (Table 1).

T1–2

We have had only four ruptured discs between T1–2 involving the T-1 root, so we are in no position to be certain about the consistency of these findings summarized in Table 1.

Myelography

Dr. A. B. Baker in his recent presidential address to the American Neurological Association1 complained that many times a myelogram was done on patients before they had even been examined. What is worse, we believe, is to do a myelogram after the examination has shown one of the classical syndromes outlined above. It simply isn't necessary. We believe there is no justification for myelography if a classical C-5 root deficit is present since the myelogram is frequently normal and exploration would be indicated regardless of the findings. When the indications point to a C-6 root involvement, a myelogram should be done only when the weakness of the biceps is minimal and there is no sensory involvement; however, we have more diagnostic trouble here than at any other level because of the unpredictable action of the brachioradialis. Myelography should not be done on patients with minimal weakness in the triceps indicating C-7 root compression, even when there are no sensory symptoms or findings. In cases of suspected C-8 root involvement, myelography is only justified when the weakness of the wrist and hand is minimal. However, a myelogram should be done when the symptoms and signs suggest involvement of the T-1 root between T1–2 simply because of the paucity of cases at this level, and the relative unreliability of any characteristic “syndrome.”

Surgery

In spite of the success of conservative treatment in some cases, operation is indicated when pain and the neurological deficit continue. Certainly, operation is mandatory if severe pain or a severe deficit does not respond to conservative treatment within 1 week.

It is not our purpose to argue whether an extruded disc should be removed from in front or from behind. In the former, there was less postoperative soreness and pain, but we do not yet have enough information to determine the complication rate since we have only done about 25 this way. There are at least two theoretical objections to the anterior approach; one cannot be sure that the nerve root is tight, and it is entirely possible that a fragment might be extruded up or down in the spinal canal and so be missed.

This is not to say that such fragments cannot be missed from the posterior approach; perhaps the most common example is that of an extruded sheet of cartilage plate which makes the foramen extremely tight but does not produce the characteristic nodule under the root. The way to find this elusive fragment is to make an incision through the posterior longitudinal ligament just above the inferior pedicle; if one does not find it there, an incision should be made through the posterior longitudinal ligament just below the superior pedicle. Extreme care should be taken in exposing the area where a fragment has been extruded on top of an osteophyte; this fragment is usually considerably smaller than those with no osteophyte and may easily go down the sucker when the posterior longitudinal ligament is nicked at this point.

We still strenuously object to operating on patients in the upright position when the posterior approach is used, since we believe that air embolism related to this position has caused as many serious complications as has vascular injury in lumbar disc operations.

Mortality and Complications

Up to the present, there have been no deaths or evidence of cord damage in our series. One patient did have an increased deficit in the arm and hand as a result of exploration of two spaces.

In the immediate postoperative period six patients developed symptoms suggestive of what might be called reflex sympathetic dystrophy or causalgia; all of these had intense, burning, bursting pain in the arm and hand which failed to respond to sympathetic block or in the last three cases, Dibenzyline as well. Three of these occurred before the days of electromyography, but the last three showed denervation potentials in all of the roots of the brachial plexus 2 to 3 weeks after onset. We have no idea why this occurs. Fortunately, all have improved to the point where the pain is minor.

Three patients developed a return of symptoms in the immediate postoperative period; at reoperation another fragment of disc was found under the root. Whether these are true recurrences or whether we missed the additional fragment is a matter of speculation; certainly one must make a thorough search to be sure no fragments are left behind. Three other patients developed definite late recurrences at the original level. All six of the patients with “recurrences” had good results following reoperation.

Follow-Up

Table 2 shows the results of a self-evaluation study of 380 patients in the series. A small number stated that they had less than 59% relief. We have been able to get most of these patients back for study; except for neck pain in two instances, all had other lesions causing the pain or numbness in the shoulder, arm, or hand. The most common finding was that of some lesion in the shoulder joint such as bursitis or tendonitis which developed years after surgery. One had carcinoma of the superior sulcus of the lung 6 years later and two had developed tardy ulnar palsy from chronic dislocation of the ulnar nerve at the elbow. Only 4% of our patients changed jobs because of their neck trouble; this, in our opinion, is a better indication of the results of these operations than the patient's self-evaluation.

TABLE 2

Subjective estimate of postoperative improvement and effect on job in 380 patients

Grade of Relief (%)No. of Patients (% of Total)
100 142 (37.3)
90–99 174 (46.6)
80–89 27(6.6)
70–79 25(6.4)
60–69 3(0.8)
50–59 9(2.3)
less than 50 0
same job as pre-op 319 (90%)
new job because of pain 31(4%)

References

  • 1.

    Baker AB: Presidential Address. The neurologist-vintage 1971. Trans Amer Neurol Ass 96:1111971Baker AB: Presidential Address. The neurologist-vintage 1971. Trans Amer Neurol Ass 96:

  • 2.

    Martin GMCorbin KB: An evaluation of conservative treatment for patients with cervical disk syndrome. Proc Staff Meet Mayo Clin 29:3243261954Proc Staff Meet Mayo Clin 29:

  • 3.

    Martin GMCorbin KB: An evaluation of conservative treatment for patients with cervical disk syndrome. Arch Phys Med Rehab 35:87911954Arch Phys Med Rehab 35:

  • 4.

    Spillane JD: Localized neuritis of the shoulder girdle: a report of 46 cases in the MEF. Lancet 2:5325351943Spillane JD: Localized neuritis of the shoulder girdle: a report of 46 cases in the MEF. Lancet 2:

  • 5.

    Yoss RECorbin KBMacCarty CSet al: Significance of symptoms and signs in localization of involved root in cervical disk protrusion. Neurology 7:6736831957Neurology 7:

Article Information

Address reprint requests to: Francis Murphey, M.D., Semmes-Murphey Clinic, Suite 101, Baptist Medical Building, 20 South Dudley, Memphis, Tennessee 38103.

© AANS, except where prohibited by US copyright law.

Headings

References

1.

Baker AB: Presidential Address. The neurologist-vintage 1971. Trans Amer Neurol Ass 96:1111971Baker AB: Presidential Address. The neurologist-vintage 1971. Trans Amer Neurol Ass 96:

2.

Martin GMCorbin KB: An evaluation of conservative treatment for patients with cervical disk syndrome. Proc Staff Meet Mayo Clin 29:3243261954Proc Staff Meet Mayo Clin 29:

3.

Martin GMCorbin KB: An evaluation of conservative treatment for patients with cervical disk syndrome. Arch Phys Med Rehab 35:87911954Arch Phys Med Rehab 35:

4.

Spillane JD: Localized neuritis of the shoulder girdle: a report of 46 cases in the MEF. Lancet 2:5325351943Spillane JD: Localized neuritis of the shoulder girdle: a report of 46 cases in the MEF. Lancet 2:

5.

Yoss RECorbin KBMacCarty CSet al: Significance of symptoms and signs in localization of involved root in cervical disk protrusion. Neurology 7:6736831957Neurology 7:

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