Cervical Disc Herniation Treatment in Tel Aviv

Cervical Levels & Nerve Root Patterns

Disc herniation location determines clinical presentation. C6 and C7 nerve roots account for 85% of symptomatic cases (Radhakrishnan et al., Brain 1994). The foraminal diameter narrows by 20-30% during extension and ipsilateral lateral flexion — which is why these movements are typically provocative.

Red Flags: Radiculopathy vs Myelopathy

Myelopathy (spinal cord compression) is a surgical emergency. Identify and refer immediately if any of these signs are present.

The Science of Cervical Disc Herniation

A cervical disc consists of two components: the nucleus pulposus — a gel-like inner core rich in proteoglycans and water (80% water in a healthy disc) — and the annulus fibrosus, a series of 12-20 concentric fibrocartilaginous rings surrounding it. The nucleus acts as a hydraulic shock absorber, distributing compressive forces evenly across the disc. With age, repeated loading, or acute trauma, the annulus develops fissures, allowing the nucleus to migrate outward (prolapse) or fully breach the annular wall (extrusion).

A herniation does not necessarily mean nerve compression: the degree of inflammatory mediators released (PLA2, IL-1β, TNF-α) around the herniated material is a stronger predictor of radicular symptoms than size alone. This is why some large herniations on MRI are asymptomatic, while smaller ones can produce severe pain.

Spurling Test & Clinical Assessment

The Spurling test (specificity 93%, sensitivity 30-50%) reproduces radicular pain and confirms nerve root irritation. Manoeuvre: ipsilateral rotation + extension + gentle axial compression. A positive test = arm pain in dermatomal pattern.

• Distraction test: relieves arm pain with axial unloading (sensitivity 40-50%, specificity 80-100%)
• ULTT (Upper Limb Tension Test): assesses neural mobility — pain reproduction = positive
• Neurological screen: reflexes (biceps C5-6, brachioradialis C6, triceps C7), myotomes, dermatomes
• Imaging (MRI): indicated for progressive deficit, myelopathy signs, or failure of 6-12 weeks conservative care

Treatment Hierarchy: Conservative First

Sampath 2000 (JBJS, n=1550): 75-90% of cervical radiculopathy resolves conservatively at 12 months. Peul 2007 (NEJM): surgery accelerates relief by 4-6 weeks but outcomes are equal at 1 year. Conservative care is the recommended first-line approach.

• Phase 1 (Weeks 1-2): gentle cervical traction (intermittent, 5-10 min), isometric neck stabilisation, scapular stabilisation, pain modulation
• Phase 2 (Weeks 3-4): neural mobilisation (ULTT progression), cervical ROM exercises, postural correction, McKenzie directional preference
• Phase 3 (Weeks 5-8): progressive strengthening (isometric → isotonic), deep neck flexor retraining (Jull protocol), functional training
• Phase 4 (Weeks 9-12): sport-specific drills, cervical stability load progression, return-to-activity, recurrence prevention

Neural Mobilisation Techniques

Neural mobilisation addresses mechanosensitivity of the brachial plexus and peripheral nerves. Two approaches:

Slider techniques move the nerve bed in opposite directions simultaneously (e.g., elbow flexion while depressing the shoulder), creating a sliding motion through surrounding tissues without increasing tension. Used in the acute/subacute phase when the nerve is highly irritable. Tensioner techniques increase tension throughout the entire neural pathway and are reserved for chronic or less irritable presentations. Nee & Butler (Man Ther 2013) found neural mobilisation reduces arm pain by a mean of 2.3/10 VAS with moderate effect size.

• ULTT1 (median nerve): shoulder abduction + external rotation → elbow extension → forearm supination → wrist extension
• ULTT2 (radial nerve): similar but with wrist flexion and thumb adduction
• ULTT3 (ulnar nerve): elbow flexion with wrist extension and ulnar deviation

Cervical Traction Protocols

Mechanical traction enlarges the intervertebral foramen by 1-2mm and decompresses the nerve root. Indicated in radiculopathy with positive Distraction test. A Cochrane review (Graham et al., 2008) found moderate evidence for short-term pain relief when combined with manual therapy and exercise.

• Intermittent traction: 7-12 kg, 25-35° flexion, 15-30 sec hold, 2-3× per session
• Sustained traction: 10-15 lbs, 10-20 min holds, once weekly after acute phase
• Contraindicated if myelopathy, vertebral instability, or rheumatoid arthritis affecting C-spine
• Combine with postural correction, deep neck flexor training, and ROM exercises

Return to Work and Activity

Continued activity (with ergonomic modification) leads to better outcomes than sick leave for cervical disc herniation. Key workplace adjustments include: monitor height at eye level to reduce cervical extension loading, document holders adjacent to the screen to avoid sustained neck rotation, and positional changes every 30-45 minutes. Full return to pre-injury activity is expected in 85-90% of patients treated conservatively at 3-6 months (Sampath et al., JBJS 2000).