The course and prognostic factors of symptomatic cervical disc herniation with radiculopathy: a systematic review of the literature

doi:10.1016/j.spinee.2014.02.032

The Spine Journal

Volume 14, Issue 8, 1 August 2014, Pages 1781-1789

https://doi.org/10.1016/j.spinee.2014.02.032 Get rights and content

Abstract

Background context

Cervical spine disc herniation is a disabling source of cervical radiculopathy. However, little is known about its course and prognosis. Understanding the course and prognosis of symptomatic cervical disc herniation is necessary to guide patients' expectations and assist clinicians in managing patients.

Purpose

To describe the natural history, clinical course, and prognostic factors of symptomatic cervical disc herniations with radiculopathy.

Study design

Systematic review of the literature and best evidence synthesis.

Methods

A systematic search of MEDLINE, EMBASE, CINAHL, SportsDiscus, and the Cochrane Central Register of Controlled Trials from inception to 2013 was conducted to retrieve eligible articles. Eligible articles were critically appraised using the Scottish Intercollegiate Guidelines Network criteria. The results from articles with low risk of bias were analyzed using best evidence synthesis principles.

Results

We identified 1,221 articles. Of those, eight articles were eligible and three were accepted as having a low risk of bias. Two studies pertained to course and one study pertained to prognosis. Most patients with symptomatic cervical disc herniations with radiculopathy initially present with intense pain and moderate levels of disability. However, substantial improvements tend to occur within the first 4 to 6 months post-onset. Time to complete recovery ranged from 24 to 36 months in, approximately, 83% of patients. Patients with a workers' compensation claim appeared to have a poorer prognosis.

Conclusions

Our best evidence synthesis describes the best available evidence on the course and prognosis of cervical disc herniations with radiculopathy. Most patients with symptomatic cervical spine disc herniation with radiculopathy recover. Possible recurrences and time to complete recovery need to be further studied. More studies are also needed to understand the prognostic factors for this condition.

Introduction

Cervical spine disc herniation is a common source of cervical radiculopathy [1]. In Rochester, Minnesota, the annual incidence of cervical disc herniations is 18.6 per 100,000 residents and the incidence peaks in the sixth decade of life [2]. The etiology of cervical spine disc herniations is multifactorial [3], [4], [5]. The proposed risk factors include male gender, present cigarette-smoking, heavy lifting, frequent diving from a board, and occupation [3], [4], [5]. Preliminary evidence suggests the incidence of cervical disc herniations is higher in army aviators, professional drivers, and those who operate vibrating equipment [4], [5]. However, one study reported only 14.8% of cases had a history of physical exertion or trauma preceding the onset of symptoms [2].

Most patients with symptomatic cervical disc herniations and radiculopathy report severe neck and arm pain [6]. The arm pain typically follows a myotomal pattern, whereas the sensory symptoms (eg, burning, tingling) follow a dermatomal distribution [6]. These radicular symptoms may also be associated with reflex changes and motor weakness of the upper extremity [6]. Conservative care is recommended as the first line of treatment for symptomatic disc herniations with radiculopathy [6]. It is estimated that 26% of patients with cervical radiculopathy require surgery [2]. Surgery should be considered when pain persists after conservative therapy for 6 to 12 weeks or when there is evidence of progression of a functionally important motor deficit [6].

Despite the persistence of pain and potentially debilitating symptoms, little is known about the natural history and clinical course of cervical disc herniation. This makes it difficult to manage the condition clinically and understand treatment effectiveness and prognosis. Information about prognostic factors can aid clinicians in the identification of patients at risk of developing chronic pain and disability. Identifying modifiable prognostic factors is particularly important because modification of these factors may assist clinicians and/or patients in removing barriers to recovery. The purpose of our systematic review is to describe the natural history, clinical course, and prognostic factors of symptomatic cervical disc herniations with radiculopathy.

Section snippets

Registration of review

The protocol for our systematic review was registered on PROSPERO (CRD42012003259) and can be accessed at www.crd.york.ac.uk/PROSPERO/display_record.asp?ID=CRD42012003259.

Search strategy

A search strategy was developed with the assistance of a library scientist. Five electronic databases were searched (MEDLINE, EMBASE, CINAHL, SportsDiscus, and the Cochrane Central Register of Controlled Trials [The Cochrane Library]) from inception until June 15, 2013. The reference lists in relevant Cochrane systematic

Literature search

Our literature search yielded 1,221 articles (Figure). We excluded 352 duplicates and therefore, screened 869 titles and abstracts for eligibility. Of those, 861 articles did not meet the eligibility criteria. We critically appraised eight articles [15], [17], [18], [19], [20], [21], [22] and three were deemed scientifically admissible. All scientifically admissible studies (two cohort studies and one cohort within a randomized trial) described the course and/or the prognostic factors for

Discussion

The results of our systematic review suggest that the course of cervical disc herniations with radiculopathy is favourable. Substantial improvements appear to occur in 4 to 6 months postonset for acute and chronic cases, with time to complete recovery spanning 24 to 36 months in most subjects. In the long-term, a small proportion of patients appear to have residual impairments, such as pain and activity limitations. None of the patients in the reviewed articles had progressive neurologic

Key points

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The quality of the current literature on the course and prognostic factors of symptomatic cervical disc herniations with radiculopathy is poor.
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Most patients with cervical disc herniations with radiculopathy experience substantial improvements within 4 to 6 months postonset. Time to complete recovery ranged from 24 to 36 months in most patients.
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Patients did not have progressive neurologic deficits or develop myelopathy in the long term. However, it is unknown if patients with cervical disc

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: FDA device/drug status: Not applicable.

: Author disclosures: JJW: Nothing to disclose. PC: Nothing to disclose. JJQ: Nothing to disclose. PJS: Nothing to disclose. SAM: Consulting: Ontario Chiropractic Association (B), Centre for Effective Practice (B), Paid directly to institution; Grants: Ontario Chiropractic Association (B).

: The disclosure key can be found on the Table of Contents and at www.TheSpineJournalOnline.com.

: Funding: None.

View full text

Review ArticleThe course and prognostic factors of symptomatic cervical disc herniation with radiculopathy: a systematic review of the literature

Abstract

Background context

Purpose

Study design

Methods

Results

Conclusions

Introduction

Section snippets

Registration of review

Search strategy

Literature search

Discussion

Key points

Pain

Spine J

Pain

Incidence and epidemiology of cervical radiculopathy in the United States Military: 2000 to 2009

J Spinal Disord Tech

Epidemiology of cervical radiculopathy: a population-based study from Rochester, Minnesota, 1976 through 1990

Brain

Prolapsed cervical intervertebral disc in male professional drivers in Denmark 1981-1990: a longitudinal study of hospitalizations

Spine

Herniated nucleus pulposus: rates and outcomes among U.S. army aviators

Aviat Space Environ Med

An epidemiological study of acute prolapsed cervical intervertebral disc

J Bone Joint Surg Am

Cervical radiculopathy

N Engl J Med

Chinese herbal medicine for chronic neck pain due to cervical degenerative disc disease

Cochrane Database Syst Rev

Single or double-level anterior interbody fusion techniques for cervical degenerative disc disease

Cochrane Database Syst Rev

A new system for grading recommendations in evidence based guidelines

BMJ

A systematic review of the prognosis of acute whiplash and a new conceptual framework to synthesize the literature

Spine

Review Article
The course and prognostic factors of symptomatic cervical disc herniation with radiculopathy: a systematic review of the literature