Some idiot who wasn’t paying attention slammed into your car. You had what you first thought was “just a whiplash.” That hurt, but you thought you could just laugh it off and your neck injury would be ok in a few days.
But over time it just hurt worse. Pain, numbness and tingling radiated down one or both shoulders and arms.
Eventually, a doctor had you slide into a long, noisy metal tube for an MRI (magnetic resonance imaging) scan. Now your doctor says you have something called a herniated disc that will require a lot more treatment than you ever imagined.
What do you need to know?
- Know your cervical spine anatomy.
Your spine is a stack of 33 interlocking bones called vertebra, processes, and coccyx (tailbone). Your spinal cord runs from your brain down the middle of this stack of vertebrae to nerves that branch off to your arms, legs, and various body parts.
Your neck (cervical spine) supports your head, which weighs about 10 pounds, regardless of the amount of knowledge the brain does or does not hold. As your head rotates, the cervical spine has the most range of motion of any part of the spine.
The cervical spine includes seven vertebrae numbered C1 to C7. The first vertebra (C1) is ring-shaped and connects directly to the skull. This joint allows for the nodding (“yes” motion) of the head. The second vertebra (C2) is a peg-shaped axis, with a projection called the odontoid, around which the atlas pivots. This joint enables you to make the side-to-side or “no” motion of your head.
- Know your vertebral anatomy.
Every vertebra in the spine has three main parts: a drum-shaped bone designed to bear weight and withstand compression, an arch-shaped bone that protects the spinal cord, and star-shaped processes that serve as outriggers for muscle attachments.
Between the bony vertebrae are spongy cushions called intervertebral discs that serve as shock absorbers, keeping the bones from rubbing together. Discs are often compared to a radial car tire. An outer ring called the annulus contains crisscrossing fibrous bands sort of like the tire tread. Inside each disc is a gel-filled center called the nucleus sort of like tire tube.
Another popular analogy is to compare a disc to a jelly donut, with the annulus compared to the bread and the nucleus to the jelly.
On the back of each vertebra are projections of bone that form the vertebral arch, which consists of two supporting bones called pedicles and two layers of tissue called laminae. Within the spinal canal are the spinal cord, ligaments, fat, and blood vessels. Beneath each pedicle, a pair of spinal nerves exit emerge from the spinal cord and go through openings called foramen to branch out through your body.
Connecting vertebrae are facet joints that allow movement of the spine. Each vertebra has four facet joints, two attaching to the vertebra above (superior facets), and two that connect to the vertebra below (inferior facets.)
Wiring all this together are ligaments, tough bands that connect the vertebrae, protect the discs, and stabilize the spine. The three principal ligaments of the spine are the anterior longitudinal ligament (ALL), ligamentum flavum, and posterior longitudinal ligament (PLL).
- Know the anatomy of your spinal cord and spinal nerves.
The spinal cord is the thickness of your thumb and runs about 18 inches from the brainstem to the first lumbar vertebra protected within the spinal canal. Any damage to the spinal cord can cause paralysis and loss of sensation below the level of injury. A spinal cord injury in the cervical spine (neck) may cause quadriplegia (also called tetraplegia), total or partial loss of both motor and sensory in the arms and legs. A spinal cord injury to the thoracic or lumbar area may cause paraplegia, the loss of motor and sensory function in the legs and trunk.
Branching off the spinal cord are 31 pairs of spinal nerves. These act as “telephone lines” carrying messages back and forth between various body parts and the spinal cord, and thence to the brain, to control sensation and movement. The front (ventral) root carries motor impulses from the brain and the back (dorsal) root carries sensory impulses to the brain. The spinal nerves go down the spinal canal alongside the spinal cord, until reaching the intervertebral foramen from which is exits to communicate with the appropriate body parts.
Once a spinal nerve passes through the intervertebral foramen, it forms two branches. The smaller branch (posterior primary ramus) turns toward the back to supply the skin and muscles of the back of the body. The larger branch (anterior primary ramus) turns the opposite direction to the skin and muscles of the front of your body. The spinal nerves are numbered by the vertebrae above which they exit the spinal canal. The eight cervical spinal nerves are numbered C1 through C8.
The spinal nerves communicate sensory and motor messages with specific areas that form a striped pattern across the body called dermatomes. Doctors use dermatome patterns to diagnose the location of a spinal problem based on the area of pain or muscle weakness.
- Know about disc bulges and herniations.
As we age, the annulus in all those intervertebral discs begins to dry out and become less flexible. That natural degeneration happens to everyone, often without causing any pain. Many senior athletes have spines that would look like forty miles of bad road in an MRI image but can run marathons and triathlons just fine.
With age and reduced flexibility, we become more vulnerable to disc injuries with any sort of trauma. It can be as simple as lifting something heavy or sudden twists and turns.
Often, however, people go along in life just fine despite silent degeneration in the spine until a trauma, such as is common in a motor vehicle collision involving sudden kinetic forces greater than encountered in daily life.
The mechanism of injury in a rear-end collision “whiplash” includes head acceleration backward and forward, pressure on nerve root ganglia, stretching of facet capsules, or damage to facet articular cartilage. Studies of the biomechanics of kinetic forces demonstrate four mechanisms of injury in rear-impact collisions. These include vertebral intersegmental rotations, facet capsule shearing, facet pinching, and rapid increase of pressure around the cervical nerve roots. All these occur suddenly and simultaneously. The angle of head rotation at the time of impact can surprisingly decrease the extent of the injury. The neck’s response to whiplash-type impacts is modified by impact awareness, muscles studied, and direction of impact. The peak bending moment of the lower neck and the peak angular acceleration of the head are predictors for the risk of neck injury in a rear-end collision.
The kinetic forces in any form of auto collision – rear end, sideswipe, t-bone or head-on – can injury intervertebral discs. Many factors in collisions affect the extent of the injury, including the direction of impact, impact velocity, change in velocity (i.e. delta-v), restraint use or misuse, and the presence or absence of airbags. Cervical (neck) disc injuries are most common in rear-end and sideswipe collisions.
When collision forces cause damage to the annulus of a disc, the nucleus can push out, creating a disc bulge that presses on a spinal nerve serving a specific area of the body. When the nucleus oozes out the annulus, like jelly squirting out of a jelly donut, it can compress on one or more nerves can cause radiculopathy — severe pain, numbness, tingling, and even loss of motor function. This is a herniated disc, also known as a “slipped disc.”
Cervical radiculopathy occurs when a herniated disc in your neck compresses or irritates a nerve in your neck that emerges from your spinal cord. This nerve compression can cause pain that radiates into your shoulder, and muscle weakness and numbness radiating down through your arm and hand.
When a herniated disc pinches the spinal cord, this may lead to symptoms referred to as myelopathy. Symptoms of cervical myelopathy include neck and arm pain, tingling and numbness, and problems with your fine motor functions such as threading a needle, buttoning a shirt, or writing. When a herniated disc compresses both exiting nerves and the spinal cord that is referred to as myeloradiculopathy. Cervical myelopathy can cause an unsteady gait, loss of body consciousness of whether your hands and feet are, and in severe cases weakness of arms and legs and loss of bladder and bowel control.
- Know about non-surgical treatments for cervical disc herniations.
Surgery is not the first option unless there is an emergency, such as a disc pinching the spinal cord causing weakness. Because conservative, non-surgical treatments can take a long time and involve a lot of pain in the interim, people who require immediate surgery sometimes consider themselves fortunate by comparison.
Conservative, non-surgical treatments for cervical disc injuries include:
- Anti-inflammatory medications (NSAIDs). Ibuprofen medications such as Advil and Motrin and COX-2 inhibitors such as Celebrex help reduce pain due to
- Drugs such as Depo-Medrol (methylprednisolone) may be taken as pills to reduce inflammation over the course of a week.
- Muscle relaxants. Muscle spasm in the area of a disc herniation can cause pain, so muscle relaxers help to alleviate that.
- Anti-depressants. Tricyclic antidepressants, known by several brand names, can reduce nerve pain and aid sleep.
- Medications intended primarily to control seizures may also alleviate nerve pain caused by a herniated cervical disc.
- Opioids. These heavy-duty pain medications are sued for severe pain from a herniated disc, but as addictive drugs must be used only for limited times and with select patients.
- Physical therapy and other conservative treatments.
- Physical therapy. Exercises to stretch your neck muscles may help reduce the pain of a herniated disc.
- Limitation of painful activity. When you have a herniated cervical disc, your doctor or physical therapist may advise you to avoid heavy lifting, overhead reaching, and neck rotation which may exacerbate pain in the period following a disc herniation.
- Neck braces. While often lampooned in jokes about “phony” whiplash injuries, a cervical brace or soft cervical collar provide some rest for the cervical spine.
- Epidural Steroid Injection involves the injection of an anti-inflammatory steroid space next to discs. An epidural steroid injection can treat pain at several levels in the spine. The purpose is to decrease inflammation directly around the affected nerve roots and behind the discs. Often medical and insurance company protocols require a series of two or three epidural steroid injections before scheduling surgery.
- Nerve Root Block involves the injection of an anesthetic to relieve pain and pinpoint the location of the irritated nerve for diagnostic purposes.
For a person who is accustomed to an active lifestyle, the long journey of these conservative treatments can be a maddening diminution of the overall quality of life.
- Know about your cervical disc surgical options.
When and if all else fails, physicians will discuss with you surgical options for treatment of your herniated cervical disc.
- Cervical nerve root rhizotomy is a percutaneous neural destructive technique that uses radiofrequency pulses to numb sensory nerve tissues that come from the muscles and enter the spinal cord to reduce neck pain. Once inactivated, the nerves cannot conduct pain sensations to the brain, thus decreasing or eliminating the pain completely. A cervical dorsal root rhizotomy may be used as pinched nerve treatment or to help relieve cervical neck pain. This is a minimally invasive procedure that provides symptomatic pain relief for many patients but is not the ultimate answer for a fully herniated disc.
- ACDF: Anterior Cervical Discectomy and Fusion is perhaps the most common form of neck surgery for herniated cervical discs. It involves removal of the damaged disc, relieving pressure on the spinal cord or nerve root pressure. By taking away that pressure on the nerve, it and reduce re;ated pain, weakness, numbness, and tingling. You will sleep through this surgery under general anesthesia. Your surgeon will make a horizontal incision two or three inches long in the front of your neck, and work through that opening.
ACDF surgery has two parts:
- Anterior cervical discectomy. Going in from the anterior, or front, of the cervical spine (neck), the surgeon removes the disc from between two vertebrae.
- Fusion. A fusion of vertebrae is done at the same time as the discectomy to stabilize that portion of the cervical spine. Fusion involves placing bone graft or implants where the disc originally was to provide stability and strength to the area. ACDF may at one or more levels of the cervical spine.
Traditionally, the fusion was done with a plug of bone taken from the patient’s pelvis, called autograft bone. Patients often complained that pain at the donor site in the hip was much worse than pain in the neck.
The most common ACDF procedure today is the use of allograft bone from a bone bank, harvested from a cadaver. Because there is no living tissue in the allograft bone graft, so there is little chance of graft rejection, like with an organ transplant. The speed of healing may be slower with allograft bone, particularly if there are multiple levels of vertebrae to be fused, and there is a very slight risk of disease transmission, roughly 1 in 200,000 to 1 in one million.
There are also manufactured bone graft substitutes that have no potential for disease transmission but do carry risks of inflammatory reactions.
With any of these fusion methods, doctors often secure the vertebra with metal plates and screws.
Cervical fusion and fixation eliminate flexion in that part of the cervical spine. As a result, the levels above and below the fusion encounter more significant stress over time, potentially accelerating degeneration of the discs above and below the fusion, also known as adjacent level disease.
Cervical disc replacement surgery involves implantation of a manufactured artificial disc. Artificial discs are made of very hard plastic and metal, are attached to e adjacent vertebrae, and can mimic the normal motion of the intervertebral discs.In comparison to spinal fusion surgery, the potential benefits of artificial disc technology include more spine mobility after surgery and less stress on adjacent discs. Artificial discs are especially popular with younger and more athletic patients who look forward to many active years.
Several artificial discs are currently being used in Europe. As these gain approval from the U.S. Food and Drug Administration, options for disc replacement surgery are continually increasing.
While artificial cervical discs can preserve motion at the operated segment in most patients, their durability over a patient’s life expectancy and effectiveness in reducing the rate of deterioration adjacent cervical levels are not yet entirely clear.
- Know about permanent impairment ratings.
Even after your entirely successful treatment for a herniated cervical disc, you will have some degree of permanent impairment as measured by the American Medical Association Guides to Evaluation of Permanent Impairment. The AMA Guides provide an objective framework for quantifying permanent impairment in patients who have an injury resulting in long-term loss of a body part or body function.
An impairment rating is not the same thing as a disability. A person may have a reasonably high impairment rating but still enjoy a full, active, productive life. Conversely, one may have ongoing pain and functional limitations that impede the quality of life but do not translate into a comparable impairment rating.
Impairment ratings are more significant in determining settlements in workers compensation claims than in car crash liability cases. However, even a small percentage of impairment rating may be presented to a jury as validation of a “thorn in the flesh” in assessing pain and suffering.
In cases of herniated cervical discs, there is a range of potential impairment ratings, briefly and incompletely summarized as follows:
- 5% to 8% impairment of the whole person. Cervical disc herniation with radiculopathy improved after non-operative treatment.
- 15% to 18% impairment of the whole person. Cervical disc herniation with radiculopathy improved after surgery.
- 25% to 28% impairment of the whole person. Loss of segmental integrity or loss motion after an attempt at surgical repair.
- 35% to 38% impairment of the whole person. Significant upper extremity impairment requiring the use of external functional or adaptive devices, due to total neurological loss at a single level or severe, multilevel neurologic dysfunction.
We have decades of experience litigating cases involving neck and back injuries, including herniated cervical discs, cervical fusion surgeries, and impairment ratings. If you or a loved one have a herniated cervical disc due to someone else’s negligence, call us at 404-253-7862.
Mr. Shigley is the first Georgia lawyer to earn three national board certifications in his practice area from the National Board of Trial Advocacy – in Civil Trial Law, Civil Practice Law and Truck Accident Law. He is a board member of the Academy of Truck Accident Attorneys, and former chair of the American Association for Justice Motor Vehicle Collision, Highway & Premises Liability Section, which includes the Trucking Litigation Group. He is lead author of Georgia Law of Torts: Trial Preparation and Practice, now in its tenth annual edition with Thomson Reuters West.
His law practice is focused on catastrophic injury and wrongful death including those arising from commercial trucking accidents and those involving brain, neck, back, spinal cord, amputation, and burn injuries.
In 2011-12, Mr. Shigley was president of the State Bar of Georgia, which includes all the lawyers and judges in Georgia. He also is a former chair of the Institute for Legal Education in Georgia (board member 2008-2020, chair 2012-13), State Bar of Georgia Tort & Insurance Practice Section (1994-95), and the Georgia Insurance Law Institute (1994).
A former prosecutor and former insurance defense lawyer, Mr. Shigley is a graduate of Furman University and Emory University Law School. He is a widower, father of two adult children, and an elder in his church. When time permits, he enjoys travel, backpacking, and scuba diving.