W. Va. Code R. § 85-20-36

Current through Register Vol. XLI, No. 45, November 8, 2024

Section 85-20-36 - Treatment Guidelines: Acute Herniated Cervical Disc

36.1. A cervical disc syndrome is a condition in which there is a bulging or rupture of the intervertebral disc. This may be lateral, compressing a root and causing a radiculopathy, or midline, compressing the spinal cord and causing a myelopathy. This most often occurs at the C4-5, C5-6 and the C6-7 disc levels. When the C4-5 disc ruptures there is pressure on the C5 root. This may cause pain over the top of the shoulder in the "epaulet" distribution. Tingling is not common. There may be weakness of the deltoid muscle. Occasionally the biceps reflex is diminished. When the C5-6 disc ruptures there is pressure on the C6 root with pain as well as tingling and decreased sensation over the thumb and index finger, weakness of elbow flexion, and diminution of the biceps and brachial radialis reflexes. When the C6-7 disc ruptures there is pressure on the C7 root with pain and tingling in the index and middle fingers, weakness of elbow extension, and diminution of the triceps reflex. There can be more extensive weakness than noted above, although the description is that of the classic syndrome. There may be changes in other reflexes, and the sensory abnormalities may be somewhat variable. Pain, sensory changes or weakness may predominate because of ill-defined differences in sensibility of the different components of the nerve. Over time the pain may resolve due to permanent damage to pain fibers, leaving the injured worker with motor and sensory dysfunction, which still may merit decompression.

Myelopathic symptoms may occur due to central disc protrusion and cause sensory (particularly posterior column) and motor dysfunction in the arms and legs, and bladder and bowel symptoms.

36.2. The appropriate diagnostic criteria is as follows:

The onset may be sudden or insidious. Neck pain is common, especially at night and with the neck in extension. Neck motions are frequently limited and cause an exacerbation of pain. The hallmark is arm pain and/or paresthesia. The pain is often described as a sharp, shooting pain that radiates from proximal to distal along the anatomic course of the nerve.

The Spurling test (neck extension and tilting the head toward the painful arm followed by axial compression of the cervical spine) is often positive. The neurological exam may be normal if compression is not too severe or there may be weakness, sensory impairment and/or altered reflexes.

36.3. Appropriate diagnostic tests and treatments are as follows:

a. In the face of a typical history and physical examination, plain spine x-rays are indicated since treatment may be altered if there are associated problems such as ostephytes.

b. Non-operative treatment:

1. Cervical traction;

2. Cervical collar may be used; not to exceed one week;

3. Use of analgesics, mild relaxants, and non-steroidal anti-inflammatory drugs;

4. Appropriate physical medicine referral to include physical agents; exercise, and manipulation/mobilization; and

5. Indications for inpatient admission:

A. Inability to control pain; and

B. Progressive neurological deficit.

c. Injured workers with significant neurologic deficit, uncontrollable pain, or who fail to improve after two to four weeks should be referred for consultation to a surgeon who does cervical operations.

d. Neuro-Imaging examinations:

1. Myelography followed by CT scan with contrast medium in place. Myelography with CT scan is the established test for evaluating the presence of nerve root compression. To warrant treatment, abnormalities must relate to the clinical problems of the injured worker. There is no reason to admit an injured worker to a hospital overnight for a myelogram. Persistent post-myelogram syndrome should be treated by hydration, caffeine, and/or blood patch as an outpatient procedure;

2. MRI, although occasionally it may not provide complete information about root compression or bony anatomy; and therefore,

3. EMG and nerve conduction velocity studies may be required to determine exact level of compression and rule out peripheral nerve compression, but should be delayed 21 days from onset of symptoms.

e. Inappropriate diagnostic tests and examinations:

1. Computed tomography without myelographic dye, although this may be helpful for other conditions such as infection or tumor;

2. Myeloscopy;

3. Dermatomal somatosensory evoked potentials;

4. Thermography; and

5. Spinoscopy.

f. Operative treatment:

1. Failure of non-operative treatment to relieve symptoms;

2. Quality of injured worker's life significantly impaired; or

3. Presence of significant or progressive neurologic deficit, either radiculopathy or myelopathy diagnosis confirmed by myelogram with CT scan, or by MRI.

g. Procedure options:

1. Laminectomy with excision of disc or arthritic spur or foraminotomy. Fusion is not indicated for a simple disc. Discharge 2 - 4 days post op. Posterior fusion is not indicated unless approved.

2. Anterior cervical diskectomy, especially in cases where there is medial compression. Discharge 1-3 days post op.

3. Complicated - after wound infection, thrombophlebitis, spinal fluid leak, or other significant complication has been controlled; and

4. Additional physical and/or vocational rehabilitation may be required.

36.4. The estimated duration of care is as follows:

a. Non-operative treatment - if still symptomatic by six weeks, must be referred for surgical consultation; and

b. Operative treatment - depending on degree of neurological impairment and persistent pain. If pain persists over three months after surgery, the injured worker should be referred for multidisciplinary pain management. If a disabling neurological deficit persists more than three months, vocational guidance should be considered. If a fusion has been done, the injured worker may require short and/or long term modified work.

W. Va. Code R. § 85-20-36