cervical disc herniation

[kierandj]

Hi friends,

What are my best treatment options for c5-c6 cervical disc herniation with radicular pain and myotomal weakness associated. what should i advise re- exercise, ADL's etc...etc...

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[linbin]

hi
the first line of treatment should be relative rest,use of collar if needed.if traction is relieving pain try it out.ones the spasm is settled.try deep neck flexor strengthening which is the core muscle of neck.passive physiologic movement can follow then within the painfree range.
postural correction,stretching if needed

[CenteredHealth]

Looking at the bomechanics of the cervical spine is also highly effective in treating cervical dics herniations. Without getting in to the probable dysfunctions of the upper cervical spine (C0-C3) which always cause compensatory motions in the mid to lower c-spine, let us look at the typical pathological dysfunctions of C5-C6.

Typically what one will find on inspection is that C5 has sheared itself anterior on C6. This is evident on palpation, but also when asking the patient to extend his/her neck. On active neck extension one will not find segmental movement throughout the c-spine but rather you will see a hinging at the C5 level that we called 'Pez Head' (named after the Pez candies dispensers). This anterior displacement of C5 will bias the C5 disc posteriorly. Also, please keep in mind that the individual vertebral bodies are able to rotate upon eachother. So, another typical dysfucntion of C5 is that of being rotated either to the right or left coupled with side bending. Remember that vertebral rotation increases intradiscal pressure and will contribute to disc herniation as well as side bending which will bias a disc herniation to one side (i.e. side bending left will bias a disc herniation right).

Biomecnahics according to Fryette's Laws states that the typical cervical spine (C3-C7) has what is called Type II motion, in which mobility is depenedent upon the facet joints, and dysfunctions will be rotated and side bent to the same side. Again in keeping with C5, the typical dysfunction will be either FRSL or FRSR, meaning that C5 is flexed, rotated and sidebent to the right or left. This dysfunction will bias the C5 disc posterior and to either the right or left side depending on the side of rotation and side bending.

Begining to adjust these mechanics will make a world of difference to the patient, as it will decrease the protective neural responce, decrease sympathetic tone throughout the cervical spine, decrease protective muscle spasm, improve cervical mobility, decrease paresthesias, decrease radiculopathy, improve blood flow, improve strength, etc.

Correcting these mechanics even has the potential for eliminating the disc herniation all together. It has been confirmed for me via MRI imaging.

Of courese I would integrate this work with an appropriate stretching regieme, modalities as necessary and neuromuscular re-education.

[jesspt]

Correcting these mechanics even has the potential for eliminating the disc herniation all together. It has been confirmed for me via MRI imaging.

I think I'd like to see a reference for that, if you've got it handy. Or, are you talking about strictly personal experience?

[CenteredHealth]

I think I'd like to see a reference for that, if you've got it handy. Or, are you talking about strictly personal experience?

Hi Jess. Again thank you for challenging my posts, I find it refreshing.

The majority of information that I spoke of in this post comes form Osteopathic Medicine. For information regarding biomechanics and osteopathy I will refer you to Fred Mitchell and Harrison Fryette. There are many others, but I believe this is a good start.

Regarding a disc herniation repairing, are you to say that it is not possible? If the body can overcome Cancer, can it not repair a herniated disc? The body has an amazing ability to heal itself, which can see on a daily basis. Remember homeostasis? Unfortunately Western Medicine has partially forgotten this concept. Anyway...

The disc herniation... I have been privileged to work with many people suffering from disc herniations, and of them all there are two that stick out in my head because fortunately for us they had both pre- and post-treatment MRI imaging. The results were undeniable and life changing. The doctors were amazed, the patients themselves were amazed and yes, even I was amazed.

Every now and then something comes along in your life that takes everything you thought you knew and throws it out the window. They were beautiful experiences to live through as they completely expanded and deepened my understanding of the human body.

Thanks Jess, looking forward to your reply.

[sharileedahl]

No matter where we are in the world, things get a little emotional when we talk about evidence based practice!!!
There are a couple good discussions regarding the same subject under the tag "ebp".

Personally, I feel there is something very important to remember. I agree that evidence-based practice is extremely important. To validate what we do to insurers, funders, clients, other professions...... That is the reason that I read the amount of research that I do.
BUT...research has to start somewhere. It will start based on a case study or even purely a therapist's intuition.
I love citing research when talking about treatment plans but I am also very interested in learning more about the fascial system and myofascial release....bit of a contradiction really. But...it just makes sense to me. And once I learn a little more, apply a little more maybe I (or someone else who actually wants to do research) can make it make sense to other people?? (Or I'll figure out I was wrong!)

To ask someone to provide research to back up what they do is fine. But I don't think we can totally discredit everything they have to say if they can't.
Example: According to research, not too long ago I would have to have people doing VMO setting exercises and taping for PFPS and nothing else. My gut (and my eyes) were telling me something else so I had people work more on gluts, body awareness... And (yahoo) now in the past couple years I'm actually seeing research backing that up.
I would be surprised if there isn't anyone out there that has done something treatment wise that just makes sense to them then later (maybe months or years later) gets the pat on the back from a research article that tells them they are on the right track.
So yes....read research, critically evaluate it, use it where you can, let it optimize your treatment but remember not everything has been studied yet. Your unproven theories might be the outcome of the next body of research.

[CenteredHealth]

sharileedahl

Thank you very much for your informative thoughts. I couldn't have said things more eloquently myself.

EBP is a necessary part of our field for various reasons, most of which you have pointed out. And as you said, the research has to start somewhere; typically with a new treatment technique, new philosophy, or so on. There will always be pioneers in our field (and every other for that matter) who push the envelope and develop new thoughts, ideas and treatment approaches. Again as sharileedahl put it "Your unproven theories may become the outcome of the next body of research."

Thanks again.

[jesspt]

I should clarify my previous post. I read Centered's previous post quickly, and at first blush, I thought that s/he was imlpying that s/he had researched or reviewed literature that implicated the resorbption of cervical HNP after application of osteopathic therapy princliples. I requested a reference because I was unfamiliar with data that supported this in the cervical spine.

Centered -
I'm familiar with Mitchell and Fryette's work. In the interest of full disclosure, and at the risk of being unpopluar and sounding inflammatory, I can't say that I find the osteopathic approach overly usefull, and that's primarily for it's strict allegiance/reliance on Fyrette's laws and palpatory positional diagnosis. But, that's a discussion for another post, probably.


sharileedahl -
I'm in no way saying that we can entirely discredit what an individual is saying if they are unable to provide a reference that suports their position. But, we should keep what they say in appropriate perspective. Using Sackett's hierarchy of evidence, what Centered says (or what I say, for that matter) falls under the heading of expert opinion (3.B) at best, and more likely under personal communication (4). See the link below:
A Hierarchy of Evidence
I certainly don't have evidence for everything I do in the clinic. If I stuck only to those interventions that were well researched and with outcomes data, I'd be twiddling my thumbs for about 70%-80% of the day. But, if there is evidence regarding a particluar intervention's efficacy, and it is applicable to the patient I'm treating, that is always the first intervention I use. I try to use EBM as Sackett has proposed, which does not rule out using interventions that have not been studied in formal, blinded, randomized, controlled trials, but does require us to use these types of interventions as a secondary or tertiary method of treatment when other treatments with a larger body of evidence supporting their efficacy exist.
I think this is where people start to bristle when discussing EBM - they think that if it hasn't been studied, the EBM police will come and chastise them. EBM practitioners use treatments that don't meet the highest level of evidence all the time. They probably just don't use it as a first line of treatment.

[CenteredHealth]

Thanks for your input Jess, especially regarding EBP. I am, however, very curious about your thoughts concerning Osteopathy, Fryette's Laws of spinal mechanics and so on. I would love to hear your perspective, so please reply or begin another thread if you like. Thanks again.

[sharileedahl]

Just wanted to send a quick apology. Reread this post this morning and it sounds like I'm calling you guys "emotional"! I think I was responding after reading a couple other posts to this site on EBP (which did get a wee bit emotional).
I have however enjoyed reading the communication back and forth between you (jesspt and CenteredHealth). It's always interesting to see how two (or more) opinions can both be very well informed.

[jesspt]

Centered -

I'd be happy to start another thread. Give me a day or two...the clinic's crazy now.