What is the initial management for a patient with neck pain likely due to cervical disc herniation?

Initial Management of Neck Pain Due to Cervical Disc Herniation

The initial management for neck pain likely due to cervical disc herniation should focus on conservative treatment, as 75-90% of patients with cervical radiculopathy achieve symptomatic relief with nonoperative conservative therapy. 1

Clinical Assessment and Red Flags

• Cervical radiculopathy presents with neck and/or upper limb pain with varying degrees of sensory or motor deficits due to cervical nerve root impingement 1
• Common causes include disc herniation, facet or uncovertebral joint hypertrophy, and degenerative spondylosis 2
• Evaluate for red flags that warrant immediate imaging:
  • Trauma history, malignancy, prior neck surgery 2
  • Neurological deficits, suspected infection, abnormal labs (elevated ESR/CRP) 3, 2
  • Fever, leukocytosis, immunosuppression, or history of diabetes 1
  • Intractable pain despite therapy 2

Initial Imaging Approach

• In the absence of red flags, imaging is not required at initial presentation 2
• When imaging is indicated, radiographs are frequently ordered as the first imaging modality for assessment of chronic neck pain 1
• MRI is the most sensitive imaging test for detecting soft tissue abnormalities but should be reserved for patients with persistent symptoms or red flags 1
• CT offers superior depiction of bones but is less sensitive for nerve root compression evaluation 1

Conservative Management

• Conservative treatment is generally successful and should be the first-line approach 4, 5
• Treatment options include:
  • Cervical traction, which has been shown to reduce cervical disc herniation symptoms 6
  • Physical therapy with a home exercise program including cervical lateral flexion stretches 6
  • NSAIDs and activity modification 3
  • Cervical collar immobilization may be considered in some cases 1

When to Consider Surgery

• Surgery is indicated if:

  • Radicular pain is severe and persistent for more than 6-12 weeks despite conservative treatment 4, 5
  • Progressive neurological deficits develop 7
  • Spinal cord compression (myelopathy) is present 5

• Anterior cervical decompression is recommended for longer-term (12 months) improvement in wrist extension, elbow extension, shoulder abduction, and internal rotation compared to physical therapy 1

Important Considerations

• Physical examination findings correlate poorly with MRI evidence of cervical nerve root compression 2
• Degenerative changes are common in asymptomatic individuals (approximately 65% of asymptomatic patients aged 50-59 have radiographic evidence of significant cervical spine degeneration) 2
• With proper patient selection, surgery for cervical disc herniation can lead to excellent results in 80-90% of patients 4
• Cervical disc herniation may occasionally present with contralateral symptoms, which differs from the typical clinical presentation 8

Follow-up Plan

• If symptoms persist despite conservative management for 6-8 weeks, consider advanced imaging (MRI) 5
• If MRI reveals significant pathology with clinical correlation, consider referral to a spine specialist 3
• Monitor for progression of neurological symptoms which may indicate need for surgical intervention 7