What is the management approach for cervical disc bulge (herniated disc in the neck)?

Management of Cervical Disc Bulge

Non-operative treatment is the appropriate initial approach for cervical disc bulge, with 75-90% of patients achieving symptomatic improvement without surgery. 1

Initial Conservative Management (First-Line Treatment)

Begin with a structured 6-week minimum trial of conservative therapy before considering surgical intervention. 1 This approach is supported by evidence showing 90% of acute cervical radiculopathy patients improve with non-operative management. 1

Conservative Treatment Components:

• Physical therapy with active exercises (not just passive modalities) - demonstrates statistically significant clinical improvement and achieves comparable outcomes to surgery at 12 months 1
• Anti-inflammatory medications to reduce nerve root inflammation 1
• Activity modification to avoid aggravating movements 1
• Cervical collar immobilization for short-term pain relief during acute phase 1
• Longitudinal cervical traction may provide symptomatic relief 2

Critical pitfall to avoid: Do not rely solely on passive modalities (heat, ultrasound, electrical stimulation). These should only be adjuncts to active rehabilitation, and should be discontinued as soon as the patient can tolerate active exercises. 3

Diagnostic Confirmation

MRI is the preferred initial imaging modality to confirm nerve root compression and correlate anatomic findings with clinical symptoms. 1 CT provides superior bone visualization for assessing osteophyte formation and foraminal stenosis. 1

Essential clinical correlation: MRI findings must always correlate with clinical symptoms (arm pain, dermatomal sensory changes, myotomal weakness) because false positives and false negatives are common. 1 Do not operate based on imaging alone without corresponding clinical findings.

Surgical Indications

Surgery is indicated when:

• Persistent symptoms despite 6+ weeks of adequate conservative treatment 1
• Progressive neurological deficits (worsening weakness, sensory loss) 1
• Significant functional deficit impacting quality of life 1
• Myelopathy signs (upper motor neuron findings, gait disturbance, cord compression) 4

Surgical Options and Outcomes:

Anterior Cervical Discectomy and Fusion (ACDF) is the primary surgical approach:

• Provides rapid relief (3-4 months) of arm/neck pain, weakness, and sensory loss compared to continued conservative care 1
• 80-90% success rate for arm pain relief 1
• Anterior cervical plating (instrumentation) reduces pseudarthrosis risk and maintains cervical lordosis, particularly important for single-level fusion 1
• Interbody cage provides immediate structural support and maintains disc height, critical for foraminal decompression 1

Posterior laminoforaminotomy is an alternative approach:

• Effective for soft lateral disc herniations or foraminal stenosis 1
• Preserves motion without anterior approach risks 1
• Variable success rates (52-99%) with potential for recurrent symptoms in up to 30% of patients 1

Treatment Algorithm

1. Weeks 0-6: Structured conservative therapy with physical therapy, NSAIDs, activity modification, possible cervical collar
2. Week 6 assessment: If 75-90% improvement achieved, continue conservative care with gradual return to activities
3. If inadequate improvement at 6 weeks: Consider surgical consultation if functional deficits persist or worsen
4. Surgical decision: ACDF preferred for central/paracentral disc herniations; posterior approach for lateral soft disc herniations
5. Post-operative: Long-term outcomes at 12 months comparable between surgical and non-surgical approaches, though surgery provides more rapid relief 1

Key caveat: While long-term outcomes (12 months) may be comparable between surgical and conservative treatments, surgery provides significantly more rapid symptom relief (3-4 months versus 12 months). 1 This makes surgery appropriate for patients with significant functional impairment who cannot tolerate prolonged conservative treatment.