C4–C5 Cervical Disc Extrusion

A C4–C5 cervical disc extrusion occurs when the soft, jelly-like center (nucleus pulposus) of the intervertebral disc between the fourth (C4) and fifth (C5) cervical vertebrae bursts through its tough outer ring (annulus fibrosus) and pushes into the spinal canal. This can irritate or compress nearby nerve roots—most commonly the C5 nerve—leading to neck pain, arm pain, numbness, tingling, and muscle weakness. Disc extrusions at this level are less common than at C5–C6 but can still significantly impact daily function and quality of life. Deuk Spine

Anatomy of the C4–C5 Intervertebral Disc

Structure and Location

The C4–C5 intervertebral disc sits between the fourth (C4) and fifth (C5) cervical vertebral bodies in the neck. Like all intervertebral discs, it consists of two main parts:

• Nucleus pulposus: A soft, jelly-like core rich in water and proteoglycans, which absorbs compressive loads.

• Annulus fibrosus: A tough, laminated ring of fibrocartilage that surrounds and contains the nucleus, resisting tensile and shear forces. WikipediaRadiopaedia

Origin and Insertion

• Origin (superior attachment): The disc’s annulus fibrosus firmly attaches to the inferior endplate of the C4 vertebral body via Sharpey’s fibers.

• Insertion (inferior attachment): Similarly, it anchors onto the superior endplate of C5. These robust attachments prevent disc migration and maintain spinal alignment. Wikipedia

Blood Supply

• Cartilaginous endplates receive small arterial branches from the vertebral arteries and segmental radicular arteries, which penetrate the adjacent vertebral bone and nourish the disc margins.

• Nucleus pulposus itself is avascular; it relies on diffusion of nutrients (glucose, oxygen) through the endplates from nearby capillaries. PubMedKenhub

Nerve Supply

• Innervation is primarily via the sinuvertebral (recurrent meningeal) nerves, which supply the outer one-third of the annulus fibrosus and the endplates. These nerves transmit nociceptive (pain) signals when the disc is injured or inflamed. PubMed

Functions

1. Shock absorption: The nucleus pulposus disperses compressive loads, protecting vertebral bodies during movement.

2. Load distribution: Evenly transmits forces across the vertebral bodies, reducing stress concentrations.

3. Mobility: Allows slight flexion, extension, rotation, and lateral bending of the cervical spine.

4. Stability: Acts as a fibrocartilaginous joint (symphysis) holding C4 and C5 together.

5. Foraminal spacing: Maintains intervertebral height, preserving neural foramen size for nerve roots.

6. Friction prevention: Prevents vertebral bodies from grinding directly against each other. RadiopaediaKenhub

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Types of Disc Herniation

Disc herniations are classified by the morphology of the displaced nucleus:

• Bulging: Symmetrical extension of the annulus beyond vertebral margins without a full-thickness tear.

• Protrusion: Focal displacement where the base of the herniated material is wider than its outward extent.

• Extrusion: Nuclear material breaks through the annulus into the spinal canal, but remains connected to the disc (the herniated fragment’s length exceeds its base) Wikipedia.

• Sequestration: A free fragment of nucleus pulposus loses continuity with the parent disc, potentially migrating within the canal.

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Causes of C4–C5 Disc Extrusion

1. Age-related degeneration (disc dehydration, loss of proteoglycan) Mayo ClinicMayo Clinic

2. Repetitive microtrauma (occupational bending/twisting) Mayo Clinic

3. Acute trauma (falls, motor vehicle accidents)

4. Heavy lifting with improper technique Mayo Clinic

5. Smoking, which impairs disc nutrition Mayo Clinic

6. Genetic predisposition to disc degeneration Mayo Clinic

7. Obesity, increasing axial load

8. Poor posture (forward head posture)

9. Vibration exposure (e.g., heavy machinery operators)

10. Cervical spondylosis leading to annular tears Mayo Clinic

11. Long-term corticosteroid use, diminishing disc integrity

12. Inflammatory arthritis (e.g., rheumatoid arthritis)

13. Congenital disc abnormalities

14. Osteoporosis causing endplate microfractures

15. Diabetes mellitus, accelerating glycation of disc proteins

16. Poor ergonomics (workstation without neck support)

17. Chronic dehydration, reducing disc hydration

18. Excessive neck extension/compression (diving injury)

19. Infection (discitis weakening annulus)

20. Repeated steroid injections, weakening annular fibers

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Symptoms

1. Neck pain, often sharp or burning Mayo Clinic

2. Radicular arm pain following C5 dermatome (lateral shoulder, upper arm)

3. Paresthesia (numbness, tingling) in C5 distribution

4. Muscle weakness in deltoid and biceps

5. Reduced reflexes, especially biceps reflex

6. Stiffness and reduced cervical range of motion

7. Scapular pain or “winged” scapula discomfort

8. Headache originating at the base of the skull

9. Muscle spasms in trapezius and paraspinals

10. Sensory changes (hypoesthesia) over lateral arm

11. Burning dysesthesia in upper limb

12. Clumsiness when reaching or lifting overhead

13. Lhermitte’s sign (electric-shock sensation with neck flexion)

14. Gait disturbance if myelopathy develops

15. Bowel/bladder dysfunction (rare but serious myelopathy sign)

16. Atrophy of deltoid over time

17. Pain aggravated by coughing/sneezing

18. Night pain disturbing sleep

19. Pallesthesia loss (vibration sense)

20. Autonomic changes (rare: sweating alterations)

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Diagnostic Tests

1. History & physical examination, focusing on radicular signs NCBI

2. Neurological exam (motor strength, reflexes, sensation)

3. Spurling’s test (foraminal compression reproducing radicular pain)

4. Lhermitte’s sign assessment

5. Cervical X-rays (alignment, spondylotic changes)

6. Flexion-extension radiographs (instability)

7. Magnetic Resonance Imaging (MRI) – gold standard for disc pathology

8. Computed Tomography (CT) – bony detail when MRI contraindicated

9. CT myelogram (contrast-enhanced canal imaging)

10. Discography (provocative testing of discogenic pain)

11. Electromyography (EMG) – assesses nerve root irritation

12. Nerve conduction studies (NCV) – evaluates peripheral nerve function

13. Bone scan (rules out infection, neoplasm)

14. Ultrasonography (dynamic soft-tissue evaluation)

15. Blood tests: ESR/CRP (rule out infection/inflammation)

16. Cervical traction test (symptom relief with traction)

17. Myelography (contrast under fluoroscopy to visualize cord compression)

18. Blood glucose (evaluate diabetic neuropathy confounders)

19. DEXA scan (if osteoporosis suspected)

20. CT angiography (if vascular compromise suspected)

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Non-Pharmacological Treatments

1. Physical therapy: tailored cervical strengthening and stretching NCBI

2. Cervical traction (manual or mechanical)

3. Manual therapy (gentle mobilizations)

4. Chiropractic manipulation (careful cervical adjustments)

5. Acupuncture

6. Massage therapy

7. Heat therapy (moist hot packs)

8. Cold therapy (ice packs)

9. Transcutaneous Electrical Nerve Stimulation (TENS)

10. Ultrasound therapy

11. Low-level laser therapy

12. Cervical collar (soft or rigid for short-term relief)

13. Postural correction (ergonomic training)

14. Ergonomic workstation adjustments

15. McKenzie exercises (self-mobilization techniques)

16. Williams flexion exercises

17. Yoga for neck health

18. Pilates focusing on core and neck stability

19. Hydrotherapy (aquatic exercises)

20. Spinal decompression therapy

21. Stress management (biofeedback, relaxation)

22. Mindfulness meditation

23. Sleep position optimization (neck-supporting pillows)

24. Weight management to reduce axial load

25. Smoking cessation

26. Post-injury activity modification

27. Ergonomic driving posture

28. Neck braces during heavy lifting

29. Breathing exercises (reduce muscle tension)

30. Visualization techniques for pain control

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Drugs

1. Ibuprofen (NSAID)

2. Naproxen (NSAID)

3. Diclofenac (NSAID)

4. Acetaminophen

5. Prednisone (oral corticosteroid taper)

6. Cyclobenzaprine (muscle relaxant)

7. Tizanidine (muscle relaxant)

8. Gabapentin (neuropathic pain)

9. Pregabalin (neuropathic pain)

10. Amitriptyline (tricyclic antidepressant for pain)

11. Duloxetine (SNRI)

12. Tramadol (weak opioid)

13. Codeine (opioid)

14. Methylprednisolone (epidural steroid injection)

15. Lidocaine patch

16. Topical NSAIDs (diclofenac gel)

17. Capsaicin cream

18. Baclofen (muscle relaxant)

19. Ketorolac (injectable NSAID)

20. Methocarbamol (muscle relaxant)

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Surgical Options

1. Anterior Cervical Discectomy and Fusion (ACDF) NCBI

2. Cervical Disc Arthroplasty (artificial disc replacement)

3. Posterior Cervical Foraminotomy

4. Posterior Microdiscectomy

5. Laminectomy

6. Laminoplasty

7. Corpectomy (removal of vertebral body segment)

8. Minimally Invasive Endoscopic Discectomy

9. Posterior Cervical Fusion

10. Anterior Cervical Corpectomy and Fusion

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Prevention Strategies

1. Maintain good posture during sitting and standing Mayo Clinic

2. Ergonomic workstations (monitor at eye level)

3. Proper lifting technique (use legs, not back)

4. Regular neck stretching and strengthening

5. Weight management to reduce cervical load

6. Smoking cessation

7. Stay hydrated for disc health

8. Take frequent breaks during prolonged sitting

9. Use supportive pillows when sleeping

10. Avoid repetitive neck extension

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When to See a Doctor

Seek medical evaluation promptly if you experience:

• Severe or worsening neck/arm pain unresponsive to 2–4 weeks of home care

• Progressive muscle weakness or numbness in your arms

• Loss of bowel or bladder control (sign of spinal cord compression)

• Ataxia or gait disturbance

• Intractable night pain that awakens you

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Frequently Asked Questions

1. What is a C4–C5 disc extrusion?
   A C4–C5 disc extrusion occurs when the inner nucleo-pulposus pushes through a tear in the outer annulus fibrosus at the level between the fourth and fifth cervical vertebrae, entering the spinal canal Wikipedia.

2. How does extrusion differ from bulging or protrusion?
   In extrusion, the herniated material breaks through the annulus and its length beyond the disc margin is greater than its base, whereas in protrusion the annulus remains intact and bulging is a non-focal extension of the annulus WikipediaMayo Clinic.

3. What causes C4–C5 disc extrusions?
   Most commonly due to age-related degeneration, repetitive stress, or sudden trauma. Risk factors include smoking, obesity, genetics, and poor ergonomics Mayo ClinicMayo Clinic.

4. What symptoms should I expect?
   Neck pain radiating to the shoulder and arm (C5 dermatome), numbness, muscle weakness (deltoid and biceps), and diminished reflexes. Severe cases may cause myelopathy (spinal cord compression) signs like gait instability Mayo Clinic.

5. How is it diagnosed?
   Diagnosis relies on history, physical exam (Spurling’s test), and imaging—MRI is the gold standard; CT and X-rays may supplement. EMG/NCV help assess nerve root involvement NCBI.

6. Can it heal without surgery?
   Yes—over 80% improve with conservative care (physical therapy, medications) within 6–8 weeks Mayo Clinic.

7. When is surgery necessary?
   Indications include intractable pain despite 6–12 weeks of conservative treatment, progressive neurological deficits, or signs of myelopathy (e.g., bowel/bladder dysfunction) Mayo Clinic.

8. What does recovery involve after ACDF?
   Typically 4–6 weeks of limited activity, followed by gradual return to neck exercises and normal activities over 3–6 months NCBI.

9. Are there risks to surgery?
   Potential complications: infection, non-union of fusion, adjacent segment disease, nerve injury, dysphagia, hoarseness.

10. What exercises are beneficial?
    Isometric neck stabilization, gentle cervical stretches, scapular retractions, and core strengthening under a therapist’s guidance NCBI.

11. Can lifestyle changes prevent recurrence?
    Yes—maintaining ideal body weight, ergonomic work habits, regular neck exercises, and avoiding smoking all help Mayo Clinic.

12. What is the long-term outlook?
    Most patients return to normal activities with minimal symptoms. Some may develop adjacent segment degeneration later.

13. Is physical therapy effective?
    Yes—targeted PT reduces pain, improves mobility, and strengthens supporting muscles NCBI.

14. Can disc extrusions cause spinal cord damage?
    Large extrusions can compress the cord, leading to myelopathy—symptoms include gait disturbance, hand clumsiness, and bladder issues Mayo Clinic.

15. How do I choose between fusion and arthroplasty?
    Decision depends on patient age, activity level, disc degeneration severity, and surgeon expertise. Artificial disc replacement preserves motion, whereas fusion offers greater stability NCBI.

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The article is written by Team Rxharun and reviewed by the Rx Editorial Board Members

Last Updated: April 29, 2025.

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