What is a cervical disc bulge?

The cervical spine (i.e. neck) comprises of many bones known as vertebrae, each of which is separated by a disc (figure 1). The disc comprises of many layers of strong connective tissue wrapping around the disc. In the middle of the disc lies a soft jelly-like substance which is capable of changing shape. When this jelly-like substance protrudes from the disc due to a tear in several layers of the connective tissue, this is known as a disc bulge.

To understand the mechanism of a cervical disc bulge, it is useful to liken the disc to a vanilla slice. Imagine a vanilla slice wrapped in five layers of sandwich wrap. The top and bottom layers of pastry represent the vertebra (bones), the custard represents the jelly-like substance of the disc and the sandwich wrap represents the connective tissue around the disc. If you were now to pinch the front of that vanilla slice, you could imagine, the custard would squeeze towards the back of the vanilla slice and may tear two or three layers of sandwich wrap at the back of the vanilla slice. As a result the custard is no longer supported as effectively at the back of the vanilla slice and therefore bulges out at this location. In the disc, the situation is the same. Bending the neck forward closes down the front of the disc, pushing the jelly-like substance within the disc towards the back. Overtime or suddenly, this may tear several layers of connective tissue at the back of the disc resulting in a cervical disc bulge.

Causes of a cervical disc bulge

There are four main activities in everyday life which typically cause disc bulges in the neck provided they are forceful, repetitive or prolonged enough. These include: bending the neck forwards, poor posture (slouching) especially during sleep or sitting (figures 2 & 3), activities using your arms in front of the body (e.g. washing dishes, driving etc.) and lifting. Twisting or side bending movements of the neck may also contribute to injury by focusing stress on one side of the disc. Occasionally, cervical disc bulges may occur following a trivial movement involving bending forward such as picking up a small object or sneezing. In these instances, the disc has normally been subject to repetitive or prolonged bending, slouching or lifting forces leading up to the incident. Often a cervical disc bulge will occur upon waking after a long sleep in an awkward position.

Signs and symptoms of a cervical disc bulge

Patients with a cervical disc bulge typically experience one sided neck pain which is most common in the lower neck region. In some cases, symptoms may be felt centrally or on both sides of the neck. The symptoms associated with a cervical disc bulge are sometimes accompanied with pain radiating down the arm (sometimes as far as the hand and fingers) or into the shoulder blade region, or in some cases, headaches. Muscle spasm, pins and needles, numbness or weakness may also be present. Occasionally the neck may be noticeably out of alignment, with pain preventing the patient from straightening the neck. Movements of the neck are generally restricted, particularly to one side.

Patients with a cervical disc bulge may experience a sudden onset of neck pain during the causative activity, however, it is also common for patients to experience pain and stiffness after the provocative activity, particularly the next morning. Symptoms are often worse with sustained postures such as reading, driving, sitting at a computer or watching television. Symptoms may also be exacerbated by activities using the arms in front of the body (such as cooking, ironing, vacuuming etc.), prolonged sitting (especially if slouched), lifting and with certain neck movements involving rotation, side bending, bending forwards or backwards. Sneezing may also aggravate symptoms. Patients with a cervical disc bulge will often experience pain and stiffness that is worse first thing in the morning.

Diagnosis of a cervical disc bulge

A thorough subjective and objective examination from a physiotherapist is usually sufficient to diagnose a cervical disc bulge. Investigations such as an MRI or CT scan may be required to confirm diagnosis.

Prognosis of a cervical disc bulge

In patients with the perfect balance of activities, the injured cervical disc may be pushed back into position in as little as three days. Typically, however, patients will take approximately 2 to 3 weeks to push their disc back 'in'. Once the disc is 'in', the patient should be pain free and have full movement. However, the torn connective tissue at the back of the disc only begins to heal from this point. It takes approximately six weeks of consistently keeping the disc 'in' to allow the torn tissue to heal to approximately 80% of its original strength.

In some patients with one or more severe disc bulges, or severe degenerative changes in addition to their bulging disc(s), it may not be possible to push the bulging disc back into position. In these cases rehabilitation may be significantly prolonged.

Contributing factors to the development of a cervical disc bulge

Several factors may contribute to the development of a cervical disc bulge. These need to be assessed and corrected with direction from the treating physiotherapist and may include:

• poor posture
• poor core stability
• a sedentary lifestyle
• muscle tightness
• muscle weakness
• joint stiffness
• poor lifting technique
• a lifestyle involving large amounts of bending, slouching, shoulders forward or lifting activities

Physiotherapy for a cervical disc bulge

Physiotherapy treatment for a cervical disc bulge is vital to hasten healing, reduce the likelihood of recurrence and ensure an optimal outcome. Treatment may comprise:

• soft tissue massage
• electrotherapy (e.g. ultrasound)
• the use of Postural Taping
• the use of a Postural Support
• mobilization
• traction
• the use of a cervical collar
• the use of a Lumbar Support for sitting
• dry needling
• exercises to push the disc back 'in' and to improve strength, core stability, flexibility and posture
• education
• activity modification advice
• biomechanical correction
• ergonomic advice
• clinical Pilates
• a functional restoration program
• a gradual return to activity program

Other intervention for a cervical disc bulge

Despite appropriate physiotherapy management, a small percentage of patients with a cervical disc bulge fail to improve and may require other intervention. This may include further investigations such as an X-ray, CT scan or MRI, pharmaceutical intervention, corticosteroid injection, assessment from a specialist or sometimes surgery. The treating physiotherapist can advise on appropriate management and will refer to the appropriate medical authority if it is warranted clinically. In cases of persisting or worsening neurological symptoms (such as pins and needles, numbness and weakness), surgery may be indicated.

Exercises for a cervical disc bulge

The following exercises are commonly prescribed to patients with this condition. You should discuss the suitability of these exercises with your physiotherapist prior to beginning them. Generally, they should be performed provided they do not cause or increase symptoms.

Initial Exercises

Chin Tucks

Begin sitting or standing tall with your back and neck straight, shoulders should be back slightly (figure 6). Tuck your chin in until you feel a mild to moderate stretch pain-free. Keep your eyes and nose facing forwards. Hold for 2 seconds and repeat 10 times provided there is no increase in symptoms. Repeat 5 times daily.

Figure 6 – Chin Tucks

Shoulder Blade Squeezes

Begin sitting or standing tall with your back straight (figure 7). Squeeze your shoulder blades together as hard and far as possible pain-free. Hold for 5 seconds and repeat 10 times provided there is no increase in symptoms. Repeat 5 times daily.

Figure 7 – Shoulder Blade Squeezes