What is the appropriate management for a patient with a disc bulge or central protrusion at C5-6 with cord impingement?

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Management of C5-6 Disc Bulge/Central Protrusion with Cord Impingement

For a patient with disc bulge or central protrusion at C5-6 causing cord impingement, immediate surgical decompression within 24 hours is recommended to prevent permanent neurological deterioration and optimize recovery outcomes. 1

Immediate Management

Corticosteroid Administration

  • Initiate high-dose dexamethasone immediately upon clinical suspicion of cord compression, even before MRI confirmation. 1
  • Standard dosing is 96 mg/day of dexamethasone, though this carries significant toxicity risk (11-29% side effects including GI perforation). 1
  • If MRI is negative, steroids can be rapidly de-escalated. 1
  • Corticosteroids reduce cord edema and ischemia, preventing permanent damage. 1

Urgent MRI Imaging

  • Obtain MRI of the entire cervical spine immediately to confirm diagnosis and guide surgical planning. 1
  • MRI has superior sensitivity compared to CT for detecting disc herniation, epidural hematoma, and cord compression. 1
  • MRI identifies disc herniation in 36% of cervical spinal cord injury cases and can change surgical approach (anterior vs. posterior decompression). 1
  • MRI diagnosis of spinal cord compression is associated with improved neurologic prognosis (OR = 2.83,95% CI: 1.10-7.28). 1

Surgical Decision-Making

Indications for Emergency Surgery

Surgery should be performed within 24 hours of neurological deficit onset. 1

  • Early surgery (≤24 hours) is associated with:

    • Improved neurological recovery (RR = 8.9,95% CI [1.12-70.64], P = 0.01). 1
    • Better mean ASIA scores at discharge. 1
    • Higher rates of ambulatory recovery. 1

  • Surgical decompression is the standard of care for cord compression with neurologic deficits. 1

Surgical Approach Selection

  • Anterior cervical discectomy and fusion (ACDF) is typically preferred for central disc protrusions at C5-6. 2, 3
  • The presence of large herniated disc on MRI determines whether anterior approach alone is sufficient or if combined anterior-posterior decompression is needed. 1
  • Posterior decompression may be considered if multilevel stenosis is present. 1

Intraoperative Monitoring

  • Use somatosensory evoked potentials (SSEPs) and motor evoked potentials (MEPs) during surgery to detect intraoperative cord injury. 1
  • Changes in evoked potentials during positioning or decompression can predict postoperative neurological deterioration. 1

Conservative Management Considerations

When Surgery May Be Delayed

Conservative management is NOT appropriate when cord impingement is present with objective neurological findings. 1

However, if the patient has:

  • Radiculopathy alone without myelopathy
  • No objective cord compression on MRI
  • Disc protrusion <4mm without central canal stenosis

Then aggressive non-surgical treatment may be attempted initially, including:

  • Cervical traction
  • Physical therapy with specific exercises
  • Anti-inflammatory medications
  • Patient education 2

Important caveat: 24 of 26 patients (92%) with cervical disc herniation and radiculopathy were successfully managed non-operatively in one study, but these patients did NOT have cord impingement. 2

Critical Pitfalls to Avoid

Timing Errors

  • Do not delay surgery beyond 24 hours once neurological deficits are documented. 1
  • Patients operated after 24 hours have significantly worse neurological outcomes. 1
  • Even patients with complete motor deficits can recover ambulatory function if decompressed early. 1

Misdiagnosis Risk

  • Central disc protrusions at C5-6 can present with atypical symptoms including contralateral symptoms, ascending radiculopathy, or predominant upper extremity involvement. 3, 4
  • Do not rely solely on symptom lateralization to determine surgical side. 4
  • Upper cervical lesions may present with suboccipital pain, loss of hand dexterity, and facial paresthesias. 3

Post-operative Deterioration

  • Some patients may experience temporary worsening of neurological symptoms immediately post-operatively due to cord manipulation or reperfusion injury. 1
  • Increased cord signal and expansion on post-operative MRI may occur even with technically successful decompression. 1

Prognosis

  • Patients decompressed within 48 hours while still ambulatory have 81% chance of remaining ambulatory, compared to 63% with delayed treatment. 1
  • Patients with some preservation of perineal sensation have better recovery potential. 1
  • Complete resolution of radicular symptoms occurs in most patients after appropriate surgical decompression. 2, 4

References

1
Guideline

Guideline Directed Topic Overview

Dr.Oracle Medical Advisory Board & Editors, 2025

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Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

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