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Matt Berg Tyler Golden
} Structures involved: ◦ Disc annulus ◦ Nucleus pulposus ◦ Spinal cord ◦ Nerve root
} Epidemiological studies have shown an increase in herniations during lifting, lifting and twisting, and twisting alone1
} Repetitive flexion alone showed increase in posterior or posterolateral herniation
} Axial load – head down tackling/hitting12
} Most common nerve root compressed is C7 from herniation of disk between C6 and C72
} Symptoms – neck pain, upper extremity pain, sensory symptoms (burning, numbness, tingling) weakness3 ◦ C7 nerve root compression
} Herniation can cause compression of spinal cord and/or nerve root
} Diagnostic imaging: CT or MRI1
} Focus on alleviating symptoms
} Medications3,15 ◦ NSAIDS ◦ Methylprednisolone ◦ Epidural steroid injection
} Modalities7 ◦ Ultrasound ◦ Moist hot pack ◦ TENS therapy
} Study examined the effect of applying a steroid injection in the transforaminal space to help alleviate pain.
} Injection site was at the posterior wall of the foramen
} Unfortunately only a 1/3 of patients gained any benefit.16
} Cervical traction3,10 ◦ Rehabilitation program with cervical traction compared
to without traction. � 15 sessions (5 days per week – 3 weeks) � Intermittent traction - 7 second traction, 5 second rest –
total of 20 min
◦ Showed a significant reduction in arm and neck pain with an increase in grip strength for the affected side.
◦ Another study also showed an increase in grip strength when traction was involved in rehabilitation program.4
} Proper posture8
◦ A forward head posture creates stress on the anterior portion of the disc causing it to bulge/herniate posteriorly
} Muscle strengthening
} If symptoms persist for an extended period of time with conservative treatment, surgery is suggested. ◦ 6 weeks
} Return to play NFL athletes with cervical disc herniation.13 ◦ Total of 16 football players – any position (13/16
were linemen, linebackers, and defensive backs) ◦ 9 returned to play � 1 surgery � 8 non-surgical rehab ◦ Allowed to return to play once symptoms are
alleviated and does not show spinal cord compression on MRI
} There are two primary surgeries performed to help alleviate symptoms5
} Anterior or Posterior Decompression and Fusion
} Disc Arthoplasty
} This surgery is compromised of removal of the damaged disc and burring of the adjacent levels before inserting a bone graft.
} Anterior entrance is through the Platysma muscle of the neck (most common).
} Posterior entrance is the midline of the neck on the dorsal side
} Patients had improved neck flexion and muscular endurance following5
} Patients also remarked decrease in pain for 12 months and improvement of quality of life.
} https://www.youtube.com/watch?v=yfSkOF_DAfA
} Replacement of the damaged disc with a synthetic disc (Bryan disc)
} In one study they compared 242 arthoplasty vs. 221 fusion
} Concluded that both surgeries improved pain and quality of life.
} But at 48 months the arthoplasty had significantlly greater pain reduction in neck and in arm pain6
Bryan disc polyurethane nucleus with two titanium plates.
} Guidelines were scarce to come by as the research due to individual recommendations
} Other factors were how many levels were needing to be fixed, age, activity level etc.
} Also even though studies remarked a decrease in neck pain and disability scores some nerve damage could have become permanent.
} Nerve damage could reverse or it could not cases are unique.
} Initial Rehabilitation 0-6 weeks
} Goals: Safe mobilization of patient, Posture, full shoulder ROM, gentle neck movements, patient pacing, Upper/Lower proprioception, deep neck flexor activation, RTW 4-6 wk., Core stability.
} Restrictions: Avoid driving, Lift nothing heavier than 1kg, Sleep no neutral cervical spine position, Sitting should be done in a supportive chair,
} Recovery Phase 6 weeks-6 months
} Goals: Increased normal activity and function, Graded return to sport/gym, increase lifting, regain functional cervical spine movement, Regain normal glenohumeral and scapular ROM dynamics
} Restrictions: Avoid lifting heavier than 10kg, no breast stroke or front crawl until 6 months, Running not allowed until 3-6 months
} Other guidelines general guidelines
} Care of the wound
} Communication with the surgical team
} Collar guidelines will fluctuate.
} Need to maintain posture
} Walking is very beneficial
} Chin to chest
} Chin tucks Ex: Maintain pressure on inflated blood pressure cuff
} Isometric strengthening
} Band exercises
} Gentle assisted PROM done by clinician initially } Look over shoulders
} Ear to shoulders
} Look ups
} SHOULD ALL BE DONE GENTLY
} Balance empty binders on head (helps with posture
} Head on foam rollers
} Head Balance with forehand on table
} Swiss ball exercises
} Need to make sure bone graft has taken 3-6 months
} Full ROM and strength (Upper Trapezius strengthening)
} Consult with physician if nerve pain is still present
} If playing contact sports need imaging to confirm healing12
} 1. Marshall LW, McGill SM. The role of axial torque in disc herniation. Clin Biomech. 2010;25(1):6-9. doi:10.1016/j.clinbiomech.2009.09.003.
} 2. Oral A, Sindel D, Ketenci A. Evidence-Based Physical Medicine and Rehabilitation Strategies for Patients with Cervical Radiculopathy Due to Disc Herniation. Türkiye Fiz Tip Ve Rehabil Derg. 2014;60(1):47-53. doi:10.5152/tftrd.2014.76735.
} 3. Sari H, Akarirmak ü., Karacan I, Akman H. Evaluation of Effects of Cervical Traction on Spinal Structures by Computerized Tomography. Adv Physiother. 2003;5(3):114-121. doi:10.1080/14038190310016517.
} 4. Joghataei MT, Massoud Arab A, Khaksar H. The effect of cervical traction combined with conventional therapy on grip strength on patients with cervical radiculopathy. Clin Rehabil. 2004;18(8):879-887. doi:10.1191/0269215504cr828oa.
} 5. Löfgren H, Johansen F, Skogar ö, Levander B. Reduced pain after surgery for cervical disc protrusion/stenosis: a 2 year clinical follow-up. Disabil Rehabil. 2003;25(18):1033-1043. doi:10.1080/09638280310001596478.
} 6. Sasso RC, Anderson PA, Riew KD, Heller JG. Results of Cervical Arthroplasty Compared with Anterior Discectomy and Fusion: Four-Year Clinical Outcomes in a Prospective, Randomized Controlled Trial. J Bone Jt Surg Am. 2011;93(18). doi:10.2106/JBJS.J.00476.
} 7. Boyles R, Toy P, Mellon J, Hayes M, Hammer B. Effectiveness of manual physical therapy in the treatment of cervical radiculopathy: a systematic review. J Man Manip Ther. 2011;19(3):135-142. doi:10.1179/2042618611Y.0000000011.
} 8. Diab AA, Moustafa IM. The efficacy of forward head correction on nerve root function and pain in cervical spondylotic radiculopathy: a randomized trial. Clin Rehabil. 2012;26(4):351-361. doi:10.1177/0269215511419536.
} 9. Peolsson A, Vavruch L, Öberg B. Disability after anterior decompression and fusion for cervical disc disease. Adv Physiother. 2002;4(3):111-124.
} 10. Traksiyon Sİ, Servikal HDSO. Cervical Intermittent Traction: Does it Really Work in Cervical Radiculopathy Due to Herniated Disc? 2012. http://ftrdergisi.com/sayilar/209/buyuk/277-2821.pdf. Accessed November 29, 2015.
} 11. physiotherapy_rehabilitation_guidelines_-_ccervical_ant_fusion.pdf.
} 12. Torg J s., Ramsey-Emrhein J a. Management guidelines for participation in collision activities with congenital, developmental, or postinjury lesions involving the cervical spine. Clin J Sport Med. 1997;7(4):273-291.
} 13. Meredith DS, Jones KJ, Barnes R, Rodeo SA, Cammisa FP, Warren RF. Operative and Nonoperative Treatment of Cervical Disc Herniation in National Football League Athletes. Am J Sports Med. 2013;41(9):2054-2058. doi:10.1177/0363546513493247.
} 14. Y S, S H, A K, S A, K O. Clinical outcomes of cervical spinal cord injuries without radiographic evidence of trauma. Spinal Cord. 1998;36(8):567-573. doi:10.1038/sj.sc.3100595.
} 15. Skovrlj B, Qureshi SA. Management of Cervical Injuries in Athletes: Timing of Treatment. Oper Tech Sports Med. 2013;21(3):164-169. doi:10.1053/j.otsm.2013.10.004.
} 16. Klessinger S, Freund W, Karpel-Massler G, Halatsch M-E. Response to Transforaminal Injection of Steroids and Correlation to MRI Findings in Patients with Cervical Radicular Pain or Radiculopathy due to Disc Herniation or Spondylosis. Pain Med. 2014;15(6):929-937.
