Cervical Herniated Disc - Nitin Bhatia, MD

Sechrest: Hello, I'm Dr. Randale Sechrest, your host for eOrthopodTV. Today I have with me Dr. Nitin Bhatia. Dr. Bhatia is a spine surgeon who is the Chief of Spine Surgery at University of California Irvine. Dr. Bhatia did his undergraduate training at Stanford. He then went on to Baylor College of Medicine where he completed his M.D. Degree. From there he did orthopedic surgery training at UCLA. From there he finished a spine fellowship at the University of Miami. Today he practices complex spine surgery at University of California Irvine. Good day Dr. Bhatia.

Bhatia: Thank you for having me.

Sechrest: Dr. what I would like to discuss over the next 20 minutes is the concept of a herniated disc in the neck. I mean, everybody hears the term herniated disc, bulging disc, those sorts of terns. Define for us what that means when it occurs in the neck.

Bhatia: Sure. Well, I think first of all we have to what is the disc. And, the disc is the shock absorbing unit of the spine. So the spinal column and the vertebral column as we know it is made up of the bones or the vertebral bodies. In between the bodies, which are cylinders of bone is a disc. So, it goes bone disc, bone disc and those discs allow the bones to move and allow them to have impact and those discs absorb that impact. The discs themselves are made up of two kinds of structures, the outside or annulus is actually a very tough outer cover, it's almost like a cloth like cover and the inside is a jelly and we call that the nucleus pulposus. I always use food references because I'm always hungry when I'm working so, it's kind of like a jelly donut, it's a firm outside with a jellylike inside and you can imagine if you took a jelly donut, you could kind of roll it around, put some impact on it and that's the exact function of the discs. Now, if you took that same jelly donut or disc and squeezed it a little too hard, some of that jelly may rupture out or bulge out of the side and that's the herniated disc part. It's when some of that jelly from the inside bulges out of the disc because of an abnormal pressure usually that was put on the disc.

Sechrest: Now, how does that occur? I mean, is this usually associated with an injury? Is this something that just occurs? How does a herniated disc get to be herniated?

Bhatia: Although we typically talk about it being associated with an injury, either a car accident or lifting a heavy suitcase or a box, most patients say they don't know what started it. They just woke up one morning and boom their neck was hurting and usually one of their arms was burning or on fire, it felt like it had a searing pain in it. So, usually patients don't know of a specific trauma that caused it, but there's probably if we looked really closely some abnormal motion that would cause the disc to herniate or bulge.

Sechrest: Now, there's all sorts of other discussions about neck pain and some people just have neck pain. And, sometimes we tell people, well that's because of degenerative disc disease or it's because of degenerative arthritis. And then, there's this whole concept of whiplash. You know, patients being in a car wreck having whiplash. What's the difference between all these things?

Bhatia: That's a great question. And, that's actually really a tough question because these are all kind of different ends of a spectrum of neck problems. So, a herniated disc when we really talk about it, it's that ruptured jelly or ruptured nucleus pulposus or nucleus. It's usually pushing on then a nerve and causing pain shooting down the arm.

Sechrest: Okay.

Bhatia: The notion of neck pain or pain in the back of the neck for example, that's usually caused by one of two things. Either arthritic type changes which we call degenerative disc disease. Now with degenerative disc disease the discs do bulge a little, but instead of having one spot where the jelly pops out, the whole disc kind of bulges out because it collapses down a little and tends to bulge and that's the degeneration. That just happens with everybody with time. In fact, if you obtain and MRI scan on 100 people who had no neck problems, probably the majority of them will have some abnormalities like that seen on an MRI scan.

Sechrest: So a bulge disc and a herniated disc in your mind are two different things.

Bhatia: They're slightly different. Correct.

Sechrest: And whiplash. So we've heard about whiplash. Is whiplash a herniated disc? Does whiplash cause a herniated disc or are these two separate concepts altogether?

Bhatia: They are two separate concepts altogether. So, whiplash is more of a muscle injury in the neck. You know, classically we talk about the car accident hit from behind and the neck snaps forward and back and the muscles get spasms and that's the whiplash type injury.

Sechrest: So that's more of a soft tissue injury that does not necessarily involve the disc at all.

Bhatia: Exactly.

Sechrest: Okay. And then I guess the final concept to help people distinguish or help understand the difference. The whole concept of arthritis in the neck as it relates to a herniated disc. Again, are these two different concepts or are they related?

Bhatia: They are two different concepts. Everybody gradually gets some arthritis in the neck and for most people it doesn't cause any problems. For some people it causes some pain in the neck. But, a herniated disc tends to occur usually at a somewhat younger age, people in their 30s, 40s and 50s. And, usually that occurs suddenly so it's not a degenerative progressive problem like arthritis and it usually affects one level of the neck versus more of the levels of the neck like arthritis would.

Sechrest: So, let's define the ideal patient or the common presentation I guess for a person who has a herniated disc. Define that patient for me.

Bhatia: Probably the classic person who has a herniated disc is someone in their 30s or 50s who probably had just occasional or even no neck problems who all of a sudden have an onset of some neck pain with pain shooting down one of their arms. They may also have numbness, tingling or weakness in that arm as well.

Sechrest: So if I have those symptoms and I'm wondering what I should do, what's my first step? I mean, do I go to the Emergency Room? Is this a dangerous thing? Should I go make an appointment with my regular primary care physician or do I go straight to the spine surgeon?

Bhatia: A lot of it depends on how severe the problem is. If it's just a little numbness and tingling and it's not too bad, I would probably say start with your regular doctor, get a check up. They'll usually start a treatment of conservative therapy such as anti-inflammatory medications, physical therapy, maybe a little traction. Some of these mild treatments to try to get you better. If it's worse and if the pain is now becoming more severe or especially if there's any weakness or it's getting worse, then definitely an evaluation by a spine surgeon is necessary.

Sechrest: How do you make this diagnosis? I mean, if I present to my doctor, whether it's my primary care physician, Emergency Room or a spine surgeon. How typically do these physicians make the diagnosis of a herniated disc?

Bhatia: Usually it starts off, the majority of the diagnosis is made even without any sort of testing. So, when the patient comes and says, you know doc, all of a sudden my shoulder and arm started burning, it's going all the way down to my fingertips and I feel a little weak in the arm, that's a pretty clear diagnosis of a herniated disc already just on that. And so, the history portion of it or the story of what's happened is really important and on physical examination we can check for weakness or problems in the reflexes or see if the nerves are irritated in the area where we think they are. And then, finally we use the diagnostic tests like an x-ray and especially an MRI scan to confirm the diagnosis that we thought it was.

Sechrest: Okay, and is that usually the best test to get, the MRI scan? Is that what you typically use to sort of say, that's what we've got.

Bhatia: It is. An x-ray is great for looking at the bones but it doesn't show us the things that are soft so it doesn't show us the discs or the nerves. An MRI scan fills in those gaps. It shows us the discs, it shows us the nerves and we can actually see the herniated disc pushing on the nerves on the MRI scan.

Sechrest: Now do you feel that there's any need for any other testing? I mean, if that pretty much fits and you're convinced that this is a herniated disc, is there any other testing that you would recommend patients go through before you begin treatment on that patient?

Bhatia: Usually if it's pretty clear on the history of physical and MRI, that's about all the testing we need. Some people come in and either it's not quite an exact position we would think it would be in and the disc is smaller than we thought it would be, there's something that doesn't quite fit in which case I think more diagnostic testing is necessary. So we can do a test like an EMG which is a muscle and nerve test to see if the muscles and nerves are irritated or a specialized CAT scan to get a better look at the nerve.

Sechrest: You know, one thing that we probably should mention and because you're an orthopedic surgeon as well as a spin surgeon I think you'll have a specific interest in this and that is some patients come in with just shoulder pain and there's always this classic trap with the patient with a herniated disc who comes in and presents with shoulder pain and we spend the first three visits thinking they've got a shoulder problem.

Bhatia: Right.

Sechrest: And we don't think sometimes that maybe this is a radicular pain. So, I think one of the things that always ought to be kept in mind is that sometimes these herniated discs, they pinch the nerve and we get pain down in the arm somewhere but there's no neck pain. So, you all of a sudden say __????__.

Bhatia: It's very common in fact. A lot of patients come in and I tell them, you know, the problem is you have a disc herniation in your neck and they look at me and say, but my neck doesn't hurt, my neck feels fine and only after you see the picture and explain how that pressure on a nerve in the neck causes pain down here or up here do we all get on the same page that it's actually been caused by the neck that's otherwise not painful.

Sechrest: Well, now that we've made the diagnosis and we know that this person, this patient has a herniated disc in their neck, what are our treatment options?

Bhatia: Well, the options start with conservative treatments which is always the first line of treatment that we try. So, anti-inflammatory medications, sometimes even a light dose of oral steroids, physical therapy. If those don't work or the pain is significant enough where those aren't going to help, we can try an injection around the irritated nerve. Normally it's usually one level of disc that's herniated pushing on one particular nerve. So, we can inject a little steroid and this is called an epidural steroid injection. Some spine surgeons do them and sometimes, and in my practice, our pain management physicians do them and that can really help alleviate the pain. Now it's not always a permanent relief because it doesn't actually fix the disc herniation. All it does is kind of put a band-aid over the problem while the body tries to fix it. The good news about disc herniations is that if they happen all of a sudden, the body can try to fix it and 90% of them will get better on their own within about three months from the time they started.

Sechrest: So, we're trying to buy them some time with all of these conservative treatments. You know, there's a few conservative treatments that patients always ask me about. One's chiropractic. You know, everybody wants to know will chiropractic hurt or help this. What are your thoughts on that?

Bhatia: I think chiropractic treatment is great. The one time I don't like chiropractic treatment is when I know that there's pressure on the nerves because I think then especially manipulations will cause extra sudden pressure and probably cause more irritation of the nerves. But, I think for especially chronic spine problems, chiropractic treatment can be a great adjunct treatment to a lot of patients. But, in this case I would probably avoid it.

Sechrest: The other piece is the physical therapy. You know, we send patients to physical therapy and the physical therapists do lots of things. They do what we call modalities which are, you know, massage, the TENS unit, neurostim, ultrasound, heat packs, all sorts of things to try to reduce the pain. One of the things that I've found useful and I would like your opinion on it and that is the cervical traction. That's become very popular and with some of these pinched nerves, I find that the cervical traction that they use works fairly well.

Bhatia: I agree and I think for these patients, as I mentioned, one of the things that we're really looking for is kind of temporary relief while the body tries to fix this disc herniation on it's own and so the modalities, ultrasound, iontophoresis, TENS, all these things can really help as well as cervical traction. Cervical traction is also nice because you can buy a very inexpensive home traction device where that adds a little pressure to the neck and the patient can do it on their own at home on a daily basis and it takes just a little pressure off of that nerve and maybe causes some relief.

Sechrest: Do you have any opinion on medication treatment for this. I mean, you mentioned anti-inflammatories. Obviously there's some other medications that we use for these acute pain, one's narcotics, just pain pills, and the other are the newer nerve pain medications that we use that they used to be seizure medications but there's a whole raft of them that we use to try to calm down nerve pain, especially this pain going into the arm. What's your feeling on, one let's talk about narcotics a little bit and it's use for cervical radiculopathy from a herniated disc? And then these other medications that we sometimes use with them?

Bhatia: Sure.

Sechrest: What are your thoughts?

Bhatia: Well, honestly I'm not a huge fan of the narcotics for pain in the acute setting. If someone comes in in real pain we have to get the pain under control and in that case narcotics are great. But, the worry with narcotics for myself and any practitioner and patient is how addictive are they. And what we don't want to do is put someone on really high dose narcotics all of a sudden, make them drowsiness enough where they can't function in their regular life and just mask a problem that's ongoing and let it go on for months and months and months. I do think we need to take the edge off and so narcotics provide that excellent role.

Sechrest: So a temporary use.

Bhatia: Exactly. And then the nerve stabilizing agents that I call them which you __????__to they used to be seizure medications and the two main ones are Gabapentin which is also called Neurontin and a new one called Lyrica which I think work wonderfully for temporary pain relief for nerves that are irritated both in the arms and the legs.

Sechrest: Once you get to the point that, you know, maybe this has gone on for three months and we're not seeing any resolution. It may have improved a little bit, it may not have, still having a lot of problems. What drives you to make the decision as to when surgery is necessary?

Bhatia: Well, I think you've hit on a lot of the reasons why surgery may be necessary already. One of the patient groups who may need surgery are people who have tried these things, who have pain but don't have any weakness and we've tried the anti-inflammatories and the nerve medicines and the injections and they just haven't gotten any better and they're still miserable. The other group of patients who really need surgery may be a little more quickly are people who come in and they're in so much pain that they just can't function. They're in so much pain they can't go to work, they can't move their arm because it hurts so much. And, then the group of patients who come in and they're not only in pain but they have a weakness in the arm and that's very worrisome because when you have weakness, the longer you have it probably the more likely it will become permanent. And so, for most patients who fortunately fall in that first category, it's just pain and it's bad but it's not debilitating, we try all the other treatments and if they don't work and it's been two or three months, then we're probably looking at surgery and then for people whose pain is really bad or who have weakness, it's probably surgery sooner rather than later to get the pressure off of the nerves and allow the nerves to heal and recover faster and get the patient back to life and work and all the other things they want to be doing as quickly as possible.

Sechrest: Okay. Let's talk a little bit about the options for surgery for a herniated disc. I mean, is this a condition that has a tried and true method for fixing this? Have we settled on one thing to fix this or do we have multiple surgical options?

Bhatia: Well, I think like most things in medicine there are multiple options, but I think there's probably one that most surgeons would agree on is probably the gold standard or the one that most people use and that's what we call an cervical discectomy where we come in from the front of the neck or anterior, go in and take out the disc that's herniated and then we reconstruct where we've taken the disc out with what we call a fusion so the whole procedure is an cervical discectomy and fusion and it works absolutely wonderfully. It's essentially outpatient surgery now so, you if you have surgery in the morning you can go home in the evening or usually the next morning as soon as you wake up from surgery the pain is essentially all gone and the recovery is very rapid. There's very minimal post operative discomfort and extremely, extremely low complication rate.

Sechrest: Well, you've mentioned that it was very successful. Like 100%?

Bhatia: It's probably not quite 100% but it's probably in the mid 90s maybe even higher than that, high 90s.

Sechrest: And when it fails, what normally happens that it doesn't work?

Bhatia: Usually it's one of two things. Number one, part of the surgery involves what we call a fusion. When we have to take the disc out we have to reconstruct it and some patients it might not heal correctly. And, certain patients are a little higher risk of that, people who smoke, people with diabetes, just because the blood flow to that area isn't quite as good so they have a little higher rate of non healing of that fusion. Some patients, even though we go in and clean out the nerves and do everything right, the nerves may have sustained some permanent damage so they may have some residual nerve problems afterwards.

Sechrest: And, I think what you said before is that the longer you wait, the more likely that it to occur.

Bhatia: Exactly.

Sechrest: So that's one reason for doing it, maybe if it's not getting better, sooner rather than later.

Bhatia: Exactly.

Sechrest: You mentioned reconstructing and doing the fusion so, if I can paraphrase what this procedure involves, it is going in, taking out the disc first, so going in with a microscope, getting that fragment off the nerve, and to do that you have to go through the disc so you have to destroy the disc.

Bhatia: Exactly.

Sechrest: And then putting a bone graft in there. In the old days we just put a bone graft in there. Now days most people use a plate. Is that your preference to use a metal plate?

Bhatia: It is, and the metal plate is adventitious for a few reasons. Number one, it allows us to get the patients out of any sort of neck collar more rapidly. It allows us to get the moving and back to work and back to life more rapidly. And, it also increases the rates of fusion and decreases some of the other complications that you may have if you don't use a plate.

Sechrest: Now, do you ever recommend taking that plate out?

Bhatia: No, usually not. Occasionally patients may have some discomfort from the plate but it's quite rare. So, in general I say just leave it alone if it's not bothering you.

Sechrest: And, you had mentioned people get back to work very quickly after this. Give me the normal scenario about, you know, if you have a discectomy and fusion tomorrow, how long till you're well, till you forget about this happening to you?

Bhatia: Most people, they're up walking the same day of surgery, eating like normal, it's essentially the same day, home within 24 hours. Usually within seven days feeling really good, people who work at a desk job can be back to work in two weeks, maybe three weeks. Maybe even sooner than that if I operate on say, someone who's a computer programmer, they're usually working from home with in a week on their computer. The professional athletes I take care of, I usually hold them out of professional sports for six weeks, especially contact sports. But once that time period is up you can usually get back to doing 100% of the activities you want to do.

Sechrest: Okay, that sounds like a very successful procedure for a fairly common problem. Again, one of those things that nobody likes to talk about but, what are the risks of this procedure? I mean, what are the risks to me as patient if I'm going to have this surgery.

Bhatia: Fortunately the risks are very small. The risks involve bleeding, you lose a few drops of blood, maybe a tablespoon at most, so the risk of a transfusion is extremely low. One of the risks that people always worry about is risk to the spinal cord or nerves and are they going to wake up paralyzed or with a weak arm and we use an operating microscope to really see everything beautifully, we use a spinal cord monitor that checks the nerves throughout the surgery so we can tell if anythings wrong and then fundamentally important is experience for the surgeon. A surgeon who only does spine surgery, has lots of experience in neck surgery is really critical to a good outcome. There are some small risks with the approach through the front of the neck so your throat may be sore for a few days and voice may be hoarse for a few days but that's usually transient and it gets better. Besides that, those are really the only risks.

Sechrest: Okay. And, you know, obviously people are always worried about, they're operating on my neck, could I be paralyzed, I mean how realistic is that really?

Bhatia: It does happen, but extremely, extremely rarely. Knock on wood, I've never had any in my practice ever, but if you look around the country, the risk is probably between 1/2,000 and 1/5000 if that high and that's why, you know, you go to a surgeon who uses spinal cord monitoring and uses a microscope and who has lots of experience doing these kinds of surgeries to diminish those risks as low as possible.

Sechrest: Okay. And, I think from our discussion today, this is a very common thing so people should not be too, I mean everybody's concerned when they have to have surgery, there's a joke that the definition of minor surgery is surgery on somebody else. But, I think that this is a very common thing that is done every day in this country and is relatively well tolerated by patients.

Bhatia: Exactly. It's probably the second most common surgery we do in America. It's extremely well tolerated and if you asked spine surgeons, you know, name one or two of the surgeries that you would have on yourself, this is probably going to be number one or two on anybody's list.

Sechrest: Great. Any last minute comments to patients who are faced with trying to figure this out for themselves if they think they have a herniated disc? Anything we haven't covered today that you would either recommend to patients or caution patients about relating to a herniated disc in the neck?

Bhatia: Sure. As I mentioned, the gold standard and that thing that most of us use is the discectomy and fusion. Now days there are a few other options that are available, one involves a discectomy and then a disc replacement which is an interesting new option for patients. The long term studies are still coming up but so far things look very good and that's becoming a bigger and bigger part of my practice. It's usually only good for people with disc herniations at one level. The one other option is a small procedure through the back of the neck where we just open up the area for the nerve but some of the results aren't quite as good as doing it through the front of the neck. It's not quite as high a percentage rate of success. Overall what the patients want to do is make sure they are seeing a spine surgeon who has lots of experience in this, that they're seeing a fellowship trained spine surgeon who only does spine surgery and that they're very comfortable with the surgeon, if they're not, see another surgeon, get a second opinion, make sure you're happy with that surgeons credentials and your relationship with them but it really is a wonderful surgery if you do need one with great results and very rapid recovery.

Sechrest: So, in the future we may be seeing more artificial disc replacements to treat this problem and maybe a shift from the tried and true cervical discectomy and fusion into the artificial disc.

Bhatia: I think you will. I think in the neck you will see more and more artificial discs being used.

Sechrest: But at this point in time, you would not tell a patient that that's preferable. That if somebody has said cervical discectomy and fusion is what you need, that's a pretty legitimate.

Bhatia: That's still the gold standard and in fact when we say that the disc replacements are successful, it's because we're comparing them to the fusions and we know the fusions work so well and it looks like at least in the short term the disc replacements have comparable results. The big question is what's going to happen 10 and 15 years down the road.

Sechrest: Well, thanks. Very good information for people and patients faced with understanding a herniated disc in the neck and I think that's good information so, thank you very much.

Bhatia: My pleasure. Thank you.

Sechrest: Thanks for watching today. If you have questions about the topic that we discussed today, or any orthopedic topic, be sure to visit eOrthopod.com and if you're an orthopedic surgeon or health care provider interested in participating as a guest on eOrthopodTV, you'll also find instructions on how to apply to become a guest on the eOrthopodTV. Thanks for watching.