Management of Soft Cervical Disc Herniation: Controversies and Complication Avoidance

Summary of Key Points

Cervical soft disc herniation can lead to a variety of presentations
Nonsurgical management is often successful.
Anterior cervical discectomy and fusion, cervical total disc replacement, and posterior cervical laminoforaminotomy are all safe and efficacious procedures with a good evidence basis for treatment of cervical soft disc herniation.
Surgeons should be aware of strategies for avoiding and managing common complications of anterior and cervical surgical approaches to cervical soft disc herniations.
The choice of surgical procedure following failure of nonsurgical management should be individualized based on a careful analysis of radiographic pathology in conjunction with patient history and physical examination findings.

The pathogenesis of cervical disc herniation is complex and elaborated elsewhere in this textbook. In brief, the progression of cervical degenerative disc disease results in desiccation of the nucleus pulposus, reducing disc biomechanical function and causing herniation of the nucleus pulposus through the thin dorsal annular fibers. Cervical soft disc herniation can lead to a variety of presentations. Most commonly patients present with radiculopathy, with or without neck pain. Cervical radiculopathy has an incidence of 107/100,000 for males and 65/100,000 for females. ^, Large disc herniations or concurrent spondylotic disease may result in a presentation of myelopathy.

The management of cervical disc herniation is nuanced. Nonsurgical management is often successful, including some combination of activity modification, physical therapy, antiinflammatory medications, and spinal injections. Surgical intervention should be considered with persistence of severe pain after 6 to 12 weeks of nonsurgical therapy or with significant or progressive neurological deficit. Spontaneous regression of soft disc herniation has been reported.

The goals of surgical intervention are to alleviate neck and radicular pain and prevent progression of neurological deficit via decompression of neural elements.

Approach to Surgical Decision Making

In determining the surgical options, the contributing pathology must be understood. Degenerative cervical spine pathology is often a spectrum of disease that can ultimately manifest with herniated nucleus pulposus (HNP). Therefore it is likely that, even with a clear soft disc herniation, there will be some degree of cervical spondylotic disease as well. It is important to evaluate how this may be contributing to symptomatology when determining the appropriate management and intervention for these patients. One epidemiological study found that only 21.9% of patients with cervical radiculopathy had isolated disc herniation, whereas 68.4% had foraminal spondylosis alone or in combination with disc herniation.

Classifying the disc herniation into the following categories will help with decision-making regarding the surgical approach: central protrusion ( Fig. 111.1A ), paracentral disc protrusion (see Fig. 111.1B ), and foraminal (see Fig. 111.1C ).

Fig. 111.1, Types of soft disc herniations.

In addition, it is important to establish the degree of contributing spondylotic disease. If there is significant foraminal or central osteophytic disease, this may limit the surgical options. If there is concern for instability, this should be evaluated with flexion-extension films.

Finally, the patient’s clinical presentation is of paramount importance. The clinician must determine if the symptoms and physical examination are most consistent with myelopathy, radiculopathy, or myeloradiculopathy. Additionally, it is helpful to assess for the presence and degree of axial neck pain. With this information, a surgical approach to soft disc herniation can be obtained.

Surgical Options for Soft Disc Herniation

Anterior Approaches

Anterior cervical discectomy and fusion

Anterior cervical discectomy and fusion (ACDF) has been the gold-standard treatment for cervical soft disc herniation and cervical spondylotic disease since it was first described by Smith and Robinson in 1955. This procedure allows for complete discectomy, disc height restoration, direct and indirect foraminal decompression, central decompression, and removal of HNP. In addition, fusion across the disc space enhanced by interbody graft and plating results in stabilization. Despite ACDF having satisfactory results in 90% to 95% of patients, more attention has been focused on alternative surgical options. Long-term follow-up of cervical fusion patients and a more nuanced understanding of the biomechanical stresses of fusion has led to a greater appreciation of the negative effects that fusion has on adjacent segment disease. Symptomatic adjacent segment disease leading to reoperation has been reported to occur at a rate of 0.7% per year following ACDF.

Cervical total disc replacement

Cervical total disc replacement (CTDR) was first described by Cummins in 1991. The indications for CTDR are radiculopathy with one- or two-level cervical soft disc herniation because of central or paracentral disc herniation. One of the goals of motion preservation in CTDR is to reduce the rate of adjacent segment disease. Benefits of CTDR include discectomy, disc height restoration, near-physiological motion preservation, indirect decompression, and removal of HNP. There is extensive literature analyzing the incidence of adjacent segment disease after CTDR and with follow-up approaching 10 years, with some studies suggest a reduced incidence with CTDR. See for a demonstration of CTDR.

Video 111.1 Cervical total disc replacement. (From Coric D, Parish J, Boltes MO. M6-C artificial disc placement. Neurosurg Focus. 2017;42(Video Suppl 1).)

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