Acute cervical disc herniation

　　Acute cervical disc herniation is caused by neck trauma. The main cause of injury is the acceleration of violence causing the head to move quickly, resulting in neck sprain, which is more common in traffic accidents or sports. It can be injured by frontal, rear, or lateral impact, and the disc injury caused by rear-end collision (Rear-end collision) leading to excessive extension and acceleration injury is the most serious. It is generally believed that acute cervical disc herniation occurs on the basis of a certain degree of degenerative change in the intervertebral disc, and it also occurs in intervertebral discs that originally have no obvious degeneration.

　　Intervertebral disc herniation: It is one of the more common spinal diseases in clinical practice. It is mainly caused by degenerative changes of various components of the intervertebral disc (nucleus pulposus, annulus fibrosus, cartilage plate), especially the nucleus pulposus. After degenerative changes of varying degrees, under the action of external factors, the annulus fibrosus of the intervertebral disc breaks, and the nucleus pulposus tissue protrudes (or extrudes) from the broken part to the posterior (lateral) side or within the vertebral canal, thereby stimulating or compressing adjacent tissues such as spinal nerve roots and spinal cord, causing a series of clinical symptoms such as neck, shoulder, lumbar, and leg pain, numbness, etc.

　　History of head and neck trauma:

　　Even a minor neck sprain has an acute onset, without symptoms before onset, and symptoms and signs of compression of the cervical spinal cord or nerve roots appear after onset.

　　Symptoms of the disease:

　　This disease has an acute onset, and most cases have a clear history of head and neck trauma. Some may start with minor injuries, even a stretch can trigger it. The clinical manifestations vary greatly due to the location and degree of compression. According to the location of intervertebral disc herniation and the compressed tissue, the disease can be divided into three types: lateral type, central type, and para-central type.

　　1. Lateral type cervical disc herniation:The prominent part is on the lateral side of the posterior longitudinal ligament and the medial side of the vertebral artery joint, and the protruding intervertebral disc compresses the cervical spinal nerve roots passing through this location, causing radicular compression symptoms.

　　(1) Symptoms: Neck pain, stiffness, limited movement, as if 'fallen asleep'; severe pain may occur when the neck is overextended, which can radiate to the scapula or occiput; on one side of the upper limb, there may be pain or numbness, but it rarely occurs simultaneously on both sides.

　　(2) Signs: The neck is in a rigid position; pain and tenderness over the paravertebral area of the affected segment, and tapping pain; between the spinous processes of the lower cervical spine and the medial side of the scapula, there may be tenderness; positive neck spinal nerve root tension test and Spuring test; changes in sensation, movement, and reflexes in the area innervated by the affected nerve roots, with possible atrophy and muscle weakness in the支配muscles.

　　2. Central Type Cervical Intervertebral Disc Herniation:The protruding part is located in the central part of the vertebral canal, in front of the spinal cord, which can compress both sides of the anterior surface of the spinal cord, producing symptoms of bilateral spinal cord compression.

　　(1) Symptoms: Limb weakness to varying degrees, with the lower limbs often more severe than the upper limbs, manifested as unsteady walking; in severe cases, incomplete or complete paralysis of the limbs may occur; dysfunction of urination and defecation, manifested as urinary retention and difficulty in defecation.

　　(2) Signs: Decreased muscle strength in the limbs to varying degrees; sensory abnormalities, both superficial and deep sensations can be affected, and the level of sensory abnormality varies with the segment of intervertebral disc herniation; increased muscle tension in the limbs; hyperreflexia, with positive patellar and ankle clonus, and pathological signs such as positive Hoffmann and Openheim signs.

　　3. Lateral Central Type Cervical Intervertebral Disc Herniation:The protruding part is biased to one side and located between the cervical spinal nerve roots and the spinal cord, compressing the unilateral nerve roots and spinal cord. In addition to the symptoms and signs of the lateral type, there are also varying degrees of unilateral spinal cord compression symptoms, manifested as atypical Brown-Sequard syndrome. This type is often concealed by severe radicular pain, which masks the symptoms of spinal cord compression. When spinal cord compression is manifested, the condition is often severe.

　　1. Do not fall asleep while driving to avoid the occurrence of this disease due to the driver's emergency braking.

　　2. When doing sports, maintain correct posture and do not overextend the neck.

　　3. For those with intervertebral disc herniation, it is first necessary to change their lifestyle, avoid wearing shoes with heels, and if possible, choose negative shoes. In daily life, one should sleep on a hard bed more often, as sleeping on a hard bed can reduce the pressure on the intervertebral discs.

　　One, Cervical X-ray Film

　　1. The cervical physiological curvature decreases or disappears.

　　2. In young or acute traumatic protrusions, there may be no obvious abnormalities in the vertebral space, but in older individuals, the affected vertebral space may have varying degrees of degenerative changes.

　　3. The shadow of the anterior soft tissue can be widened in intervertebral disc herniation caused by acute hyperextension injury.

　　4. Sometimes, on the dynamic radiograph of the cervical spine, it is possible to show instability of the affected segment.

　　Two, CT Scan

　　Although it is helpful for the diagnosis of this disease, it is often not possible to rely on routine CT scans for diagnosis. CTM (myelography + CT scan) can more clearly show the images of the spinal cord and nerve roots compressed by intervertebral discs. In recent years, some scholars have advocated the use of this method to diagnose cervical intervertebral disc herniation and believe that its value in diagnosing lateral type cervical intervertebral disc herniation is significantly greater than that of MRI.

　　Three, Magnetic Resonance Imaging (MRI)

　　It can directly show the location, type, and degree of injury of the cervical intervertebral disc, providing reliable evidence for the diagnosis, treatment options, and prognosis of cervical disc herniation. The accuracy rate of MRI for the diagnosis of cervical disc herniation is much higher than that of CT and CTM, and clear images can be displayed in central and paracentral cervical disc herniation.

　　1. Central type: the intervertebral disc protrudes in a mass shape from the level of the affected intervertebral space, compressing the central anterior part of the cervical spinal cord. The compressed spinal cord may be bent, flattened, or deformed into a concave shape and move posteriorly, with abnormal signal manifestations, mainly with signal enhancement, and sometimes with空洞 images within the spinal cord.

　　2. Paracentral type: the intervertebral disc protrudes outward in a mass or fragmentary shape, compressing the lateral and one side of the cervical spinal cord, the anterior and lateral aspect of the cervical spinal cord is compressed and deformed, and moves posteriorly or to the healthy side, with local signal enhancement, the radicular nerve moves posteriorly or disappears, and the lateral cervical disc herniation often requires combined diagnosis with CTM.

　　Four. Electromyography

　　Used to determine the damage to the radicular nerve, it has certain significance for the localization of the radicular nerve. Normal electromyogram indicates that the function of the radicular nerve is still good, with a good prognosis.

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　　One. Non-surgical therapy

　　1. Cervical traction can restore the intervertebral disc height of the intervertebral disc protrusion without degeneration, and part of the protruding material may be expected to be retracted. Traction method: sitting or lying down, using a pillow-jaw band (Glisson band) for traction, the weight is 2.0-3.0kg. It is generally believed that continuous traction is better than intermittent traction, with a course of 2 weeks. Traction is suitable for lateral cervical disc herniation, but it may worsen the condition for central cervical disc herniation, so it should be used with caution.

　　2. The main function of neck immobilization is to limit neck movement and enhance the supporting function of the neck, reducing the intradiscal pressure. Simple neck guards can be used generally, and for severe cases with obvious cervical instability, plaster cervical collar fixation can be adopted. Immobilization after traction is beneficial for the recovery of the condition.

　　3. While there are many reports of successful treatments with massage and manipulation, especially heavy-handed manipulation may worsen intervertebral disc herniation and spinal or radicular injuries. In severe cases, paraplegia may occur instantly during manipulation, so caution should be exercised when using them.

　　4. Physiotherapy has certain effects on mild cases with only radicular stimulation symptoms, among which paraffin therapy and iontophoresis with vinegar have better effects.

　　5. Drug treatment for symptomatic treatment, for those with severe pain, sedative analgesic drugs can be used.

　　Second, surgical treatment

　　1. Anterior cervical decompression surgery is suitable for patients with central and para-central disc herniation. The use of a circular saw to decompress and remove the damaged intervertebral disc and perform interbody bone graft fusion has a good effect. For those with pre-existing degeneration, the hyperplastic osteophytes should be removed at the same time to avoid possible compressive substances.

　　2. Posterior cervical decompression surgery is suitable for patients with lateral type cervical disc herniation or multi-segmental involvement, accompanied by spinal canal stenosis or ossification of the posterior longitudinal ligament. For simple disc herniation, a hemilaminectomy and partial facetectomy can be performed to remove the intervertebral disc tissue compressing the nerve root through the decompression hole. If there is spinal canal stenosis or ossification of the posterior longitudinal ligament, a full laminectomy decompression can be performed.

　　3. There are two approaches for cervical disc microsurgical resection: posterior and anterior. In the treatment of cervical soft disc herniation, the choice of approach is still controversial. Aldrich uses the posterolateral approach to treat unilateral nerve root injury and extrusion of nucleus pulposus, achieving good efficacy. The range of small joint excision during the operation depends on the relationship between the nerve root and the protruding intervertebral disc. The advantages of this method are:

　　(1) Simple operation.

　　(2) Small incision and less trauma.

　　(3) Few complications and low risk. However, this operation is only suitable for simple cervical disc herniation. For patients with cervical canal stenosis and ossification of the posterior longitudinal ligament, due to the limited decompression range, the surgical effect is poor, and this method should not be used.

　　4. The cervical disc nucleolysis was proposed and first studied by Bonafe and Lazorthes of France. It is suitable for patients with cervical disc herniation who require surgery. Especially for young patients, if non-surgical treatment is ineffective for several weeks, this method can be chosen. Although many scholars have reported that the efficacy of this method is not inferior to that of surgical treatment, many factors limit its wide application:

　　(1) This method adopts the anterior cervical approach, and the anterior cervical anatomical structure is dense, such as vascular nerve bundles, tracheoesophageal bundles, etc., which increases the difficulty and risk of puncture;

　　(2) There is a potential risk of spinal cord injury when using papain.