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Cervical Annular Tears at C4–C5

Dr. Lisa S. Apfel MD - Spine and Neurosurgery Dr. Lisa S. Apfel MD - Spine and Neurosurgery
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Degenerative Bones, Joints, and Spine Care (A - Z)

A cervical annular tear at C4–C5 is a small crack or fissure in the annulus fibrosus—the tough outer ring—of the intervertebral disc located between the fourth and fifth cervical vertebrae in the neck. Most annular tears are asymptomatic, but when tears extend into the outer, innervated layers of the annulus, they can cause localized “discogenic” pain or even lead to disc herniation if the inner nucleus pulposus extrudes through the tear NCBISpine & Orthopedic Center.

Anatomy of the C4–C5 Intervertebral Disc

  1. Structure
    The intervertebral disc at C4–C5 consists of:

    • Annulus fibrosus: Concentric lamellae of type I and II collagen fibers forming a tough outer ring.

    • Nucleus pulposus: Gelatinous core rich in proteoglycans that distributes compressive forces WikipediaPhysiopedia.

  2. Location
    Situated between the vertebral bodies of C4 and C5, just anterior to the spinal cord and nerve roots exiting via the neural foramina Wikipedia.

  3. Origin & Insertion
    The annulus attaches to the vertebral endplates via Sharpey’s fibers at the ring apophysis, anchoring the disc to the adjacent vertebrae Wheeless’ Textbook of Orthopaedics.

  4. Blood Supply

    • Peripheral annulus fibrosus: A few capillaries from the metaphyseal arteries and endplate vessels supply the outer third.

    • Inner annulus & nucleus: Avascular; rely on diffusion through vertebral endplates for nutrients Wheeless’ Textbook of Orthopaedics.

  5. Nerve Supply
    Sensory fibers from the sinuvertebral nerves and gray rami communicantes penetrate the outer third of the annulus; dorsal root ganglion fibers also contribute PMC.

  6. Functions (6)

    • Shock absorption: Distributes compressive loads evenly.

    • Load bearing: Supports axial and bending forces.

    • Flexibility: Permits controlled motion (flexion, extension, rotation).

    • Stability: Maintains intervertebral spacing and alignment.

    • Protection: Guards nerve roots by preserving foraminal height.

    • Ligamentous support: Acts as a fibrocartilaginous joint (symphysis) linking vertebrae WikipediaKenhub.

Types of Annular Tears

  1. Radial tears
    Begin in the inner annulus and extend outward toward the periphery; often degenerative and can lead to herniation Spine & Orthopedic Center.

  2. Peripheral (rim) tears
    Located in the outer fibers of the annulus, commonly due to acute trauma or bone spurs Spine & Orthopedic Center.

  3. Concentric (circumferential) tears
    Occur between lamellae of the annulus, encircling the nucleus; typically from injury or repetitive stress Spine & Orthopedic Center.

Causes

  1. Age-related degeneration: Natural “wear and tear” leading to disc dehydration and reduced elasticity BEST Health Systemspine.md.

  2. Repetitive microtrauma: Chronic strain from poor posture, desk work, or smartphone use Florida Surgery ConsultantsAdvanced Spine Center.

  3. Acute trauma (whiplash): Sudden hyperextension‐flexion injuries in car accidents Florida Surgery ConsultantsAdvanced Spine Center.

  4. Heavy lifting: Improper technique placing excessive axial load on cervical discs Florida Surgery Consultants.

  5. High-impact sports: Football, rugby collisions stressing the cervical discs BEST Health System.

  6. Obesity: Increased axial load accelerates disc wear Spine-health.

  7. Smoking: Impairs disc nutrition, accelerating degeneration Spine-health.

  8. Genetic predisposition: Family history linked to earlier disc degeneration Spine-health.

  9. Poor posture: Forward head carriage increases disc stress Florida Surgery Consultants.

  10. Occupational strain: Nursing, construction, or assembly line work Advanced Spine Center.

  11. Vibrational trauma: Prolonged exposure in truck drivers, heavy machinery operators Florida Surgery Consultants.

  12. Metabolic disorders: Diabetes mellitus can impair microvascular disc nutrition Spine-health.

  13. Inflammatory arthritis: Conditions like rheumatoid arthritis can weaken disc structures Spine-health.

  14. Osteoporosis: Vertebral endplate weakening alters disc biomechanics spine.md.

  15. Facet joint disease: Hypertrophy or osteophytes can spur annular stress Advanced Spine Center.

  16. Congenital anomalies: Dysplastic vertebrae leading to uneven disc loading Spine-health.

  17. Biomechanical overload: Repetitive neck extension/flexion cycles Advanced Spine Center.

  18. Nutritional deficiencies: Low vitamin D impairs collagen maintenance adrspine.com.

  19. Facet capsule injury: Alters load distribution, stressing the annulus Advanced Spine Center.

  20. Prior cervical surgery: Altered load and instability at adjacent levels Spine-health.

Symptoms

  1. Neck pain: Localized, often sharp or aching Integrity Spine & Orthopedics.

  2. Radiating arm pain: Pain following a dermatomal pattern from C4–C5 Advanced Spine Center.

  3. Numbness: Paresthesia in shoulder, upper arm Bonati Spine Institute.

  4. Tingling: “Pins and needles” sensation in the deltoid region Bonati Spine Institute.

  5. Muscle weakness: Deltoid or biceps strength reduction Bonati Spine Institute.

  6. Stiffness: Loss of normal neck mobility VSI® (Virginia Spine Institute).

  7. Headaches: Occipital or tension‐type headaches Verywell Health.

  8. Muscle spasm: Involuntary neck muscle tightening Deuk Spine.

  9. Pain on movement: Worse with flexion, extension, rotation Advanced Spine Center.

  10. Aggravation with coughing/sneezing: Increases intradiscal pressure Integrity Spine & Orthopedics.

  11. Radiculopathy signs: Positive Spurling’s test reproduction of pain Spine & Orthopedic Center.

  12. Reduced reflexes: Diminished biceps reflex Wikipedia.

  13. Sensory loss: Impaired light touch or pinprick in C5 dermatome Wikipedia.

  14. Gait disturbance: If myelopathy develops Verywell Health.

  15. Balance issues: Cervical proprioceptor disruption Verywell Health.

  16. Fatigue: Due to chronic pain Verywell Health.

  17. Sleep disturbance: Pain interferes with restful sleep Integrity Spine & Orthopedics.

  18. Autonomic signs: Rarely, sweating or flushing in arm Verywell Health.

  19. Neck crepitus: Grating sensation on movement Verywell Health.

  20. Discogenic pain: Localized “deep” ache without nerve root signs NCBI.

Diagnostic Tests

  1. X-ray (AP, lateral): Rules out fractures, alignment issues Advanced Spine Center.

  2. Flexion-extension X-ray: Detects instability or spondylolisthesis OrthoInfo.

  3. Computed Tomography (CT): Visualizes bony anatomy, osteophytes Advanced Spine Center.

  4. Magnetic Resonance Imaging (MRI): Gold standard to see disc tears and nerve compression Advanced Spine Center.

  5. CT discography: Dye injection highlights annular fissures Spine & Orthopedic Center.

  6. Provocative discography: Reproduces pain with intradiscal injection Spine & Orthopedic Center.

  7. Myelography: X-ray/CT after intrathecal contrast to assess canal compromise Spine & Orthopedic Center.

  8. Neurological examination: Strength, reflexes, sensation assessment Advanced Spine Center.

  9. Spurling’s test: Lateral head compression to elicit radicular pain Spine & Orthopedic Center.

  10. Neck distraction test: Relieves pain when gentle axial traction is applied OrthoInfo.

  11. Shoulder abduction relief test: Arm placed on head reduces radicular pain Cleveland Clinic.

  12. Hoffmann’s sign: Flicking nail of middle finger causes thumb flexion (myelopathy sign) Wikipedia.

  13. Babinski’s sign: Upgoing plantar response (myelopathy) Wikipedia.

  14. Electromyography (EMG): Detects denervation in affected myotomes NCBI.

  15. Nerve Conduction Studies (NCS): Assesses peripheral nerve function PMC.

  16. Muscle strength testing: Manual muscle grading of C5 distribution Advanced Spine Center.

  17. Sensory examination: Pinprick and light-touch testing in dermatomes Wikipedia.

  18. Reflex tests: Biceps (C5), brachioradialis (C6) Wikipedia.

  19. Lhermitte’s sign: Neck flexion produces electric-shock sensation down spine Wikipedia.

  20. Diagnostic nerve block: Local anesthetic injection to confirm pain source Deuk Spine.

Non-Pharmacological Treatments

  1. Rest: Short-term activity modification to reduce inflammation USA Spine Care.

  2. Heat therapy (warm compresses): Relaxes muscles, improves circulation USA Spine Care.

  3. Cold therapy (ice packs): Reduces swelling, numbs pain USA Spine Care.

  4. Physical therapy: Guided exercises and manual techniques USA Spine Care.

  5. Stretching exercises: Improves flexibility of neck muscles USA Spine Care.

  6. Strength training (isometrics): Stabilizes cervical spine USA Spine Care.

  7. Low-impact exercise: Swimming or walking to maintain mobility USA Spine Care.

  8. Transcutaneous electrical nerve stimulation (TENS): Electrical stimulation for pain relief USA Spine Care.

  9. Massage therapy: Relieves muscle tension USA Spine Care.

  10. Acupuncture: Stimulates pain-modulating pathways USA Spine Care.

  11. Yoga: Gentle stretching and relaxation USA Spine Care.

  12. Herbal topical treatments: Natural anti-inflammatory gels USA Spine Care.

  13. Chiropractic care: Spinal adjustments and mobilizations USA Spine Care.

  14. Cervical traction: Mechanical decompression of nerve roots OrthoInfo.

  15. Ergonomic adjustments: Optimal desk/chair height and monitor position Wikipedia.

  16. Posture training: Education on neutral spine alignment Florida Surgery Consultants.

  17. Body mechanics training: Safe lifting and movement strategies Wikipedia.

  18. Patient education: Self-care techniques and pain management Wikipedia.

  19. Joint mobilization: Gentle glide techniques by a therapist Wikipedia.

  20. Cervical manipulation: High-velocity, low-amplitude thrusts Wikipedia.

  21. Thoracic manipulation: Mid-back adjustments to off-load the neck Wikipedia.

  22. Motor control exercises: Cranio-cervical flexion training Wikipedia.

  23. Low-level laser therapy: Reduces pain and improves function Wikipedia.

  24. Cognitive behavioral therapy: Addresses pain-related anxiety Wikipedia.

  25. Mechanical traction: Intermittent traction devices Wikipedia.

  26. Radiofrequency denervation: Ablation of painful facet nerves Wikipedia.

  27. Neural mobilization: Nerve gliding exercises physicourses-platform.com.

  28. Spinal mobilization: Soft-tissue techniques to restore joint play physicourses-platform.com.

  29. Pilates exercises: Core stabilization and posture control physicourses-platform.com.

  30. Hydrotherapy: Aquatic exercises to reduce load on the spine physicourses-platform.com.

Drugs

  1. Ibuprofen (NSAID) for inflammation and pain OrthoInfo.

  2. Naproxen (NSAID) long-acting anti-inflammatory OrthoInfo.

  3. Diclofenac (NSAID) oral or topical gel OrthoInfo.

  4. Acetaminophen (analgesic) for mild pain OrthoInfo.

  5. Celecoxib (COX-2 inhibitor) GI-safer NSAID OrthoInfo.

  6. Prednisone (oral corticosteroid) short‐term anti-inflammatory OrthoInfo.

  7. Methylprednisolone (epidural steroid injection) local anti-inflammatory Florida Surgery Consultants.

  8. Cyclobenzaprine (muscle relaxant) for spasm relief OrthoInfo.

  9. Baclofen (muscle relaxant) for severe spasm OrthoInfo.

  10. Tizanidine (muscle relaxant) short‐acting spasm control OrthoInfo.

  11. Gabapentin (neuropathic agent) off-label for discogenic pain Verywell Health.

  12. Pregabalin (neuropathic agent) reduces nerve pain Verywell Health.

  13. Amitriptyline (TCA) low-dose for neuropathic pain Verywell Health.

  14. Duloxetine (SNRI) neuropathic and chronic pain Verywell Health.

  15. Tramadol (opioid agonist) moderate-severe pain OrthoInfo.

  16. Codeine (opioid) short-term severe pain OrthoInfo.

  17. Capsaicin cream (topical) depletes substance P Verywell Health.

  18. Lidocaine patch (topical anesthetic) local pain relief Verywell Health.

  19. Ketorolac (NSAID, IM) acute pain in clinic OrthoInfo.

  20. Acetaminophen/codeine (combination) for breakthrough pain OrthoInfo.

Surgeries

  1. Anterior Cervical Discectomy and Fusion (ACDF): Remove disc, fuse C4–C5 OrthoInfo.

  2. Cervical Disc Arthroplasty: Remove disc, implant motion-preserving prosthesis Florida Surgery Consultants.

  3. Posterior Cervical Foraminotomy: Widen nerve exit through a posterior approach Florida Surgery Consultants.

  4. Laminoplasty: Reconstruct lamina to decompress spinal cord OrthoInfo.

  5. Laminectomy: Remove lamina entirely for decompression OrthoInfo.

  6. Microscopic Discectomy: Minimally invasive removal of herniated disc fragment OrthoInfo.

  7. Endoscopic Discectomy: Tear repair via endoscope, less tissue disruption OrthoInfo.

  8. Posterior Fusion: Instrumented fusion via back of neck for instability OrthoInfo.

  9. Annuloplasty: Radiofrequency ablation or thermal repair of annulus Spine & Orthopedic Center.

  10. Foraminotomy with Fusion: Combine nerve decompression and stabilization OrthoInfo.

Prevention Strategies

  1. Ergonomic workstations: Proper monitor height, chair support Wikipedia.

  2. Safe lifting techniques: Use legs, not neck or back scosteo.com.

  3. Posture awareness: Neutral spine alignment Florida Surgery Consultants.

  4. Regular exercise: Strengthens neck and core muscles USA Spine Care.

  5. Weight management: Reduces axial load on cervical discs Spine-health.

  6. Smoking cessation: Improves disc nutrition Spine-health.

  7. Hydration: Maintains disc height and elasticity Kenhub.

  8. Neck stretches: Daily gentle mobilization BEST Health System.

  9. Core stabilization: Support spine via abdominal strength physicourses-platform.com.

  10. Stress management: Reduces muscle tension Wikipedia.

When to See a Doctor

See a healthcare provider promptly if you experience:

  • Progressive or severe arm weakness or numbness

  • Loss of bladder/bowel control or balance issues

  • Intractable pain unrelieved by conservative measures

  • Signs of myelopathy (e.g., gait disturbance, hyperreflexia)

  • Red-flag signs: fever, unexplained weight loss, night sweats Wikipedia.

FAQs

  1. What is a cervical annular tear?
    A small tear in the annulus fibrosus of the C4–C5 disc, which can be painful if it reaches the nerve-rich outer layers NCBI.

  2. How is it diagnosed?
    Primarily with MRI, but CT discography may be used to visualize the tear directly Spine & Orthopedic Center.

  3. Can annular tears heal on their own?
    Yes—minor tears often heal with rest and conservative care due to some self-repair in the outer annulus NCBI.

  4. What are the first-line treatments?
    Rest, NSAIDs, and physical therapy to reduce pain and strengthen supporting muscles OrthoInfo.

  5. When is surgery necessary?
    For persistent pain refractory to 6–12 weeks of conservative care or progressive neurological deficits australian.physio.

  6. Can annular tears cause herniated discs?
    Yes—radial tears can allow nucleus pulposus to bulge or herniate through the annulus Spine & Orthopedic Center.

  7. How long is recovery?
    Conservative recovery typically takes 6–12 weeks; surgical recovery varies by procedure Centeno Schultz.

  8. Are injections safe?
    Epidural steroid injections are generally safe but carry risks like infection or bleeding Deuk Spine.

  9. Will I need a neck collar?
    Soft collars may be used short-term for pain relief but long-term use isn’t recommended Wikipedia.

  10. Is physical therapy painful?
    It may cause temporary discomfort but is tailored to avoid exacerbating your pain Medmastery.

  11. Can I work out with an annular tear?
    Low-impact, guided exercises are encouraged; avoid heavy lifting or high-impact sports USA Spine Care.

  12. What exercises help?
    Chin tucks, cervical mobilizations, and gentle stretches improve mobility and reduce pain Verywell Health.

  13. Are there natural remedies?
    Acupuncture, massage, and topical herbal gels can complement medical treatment USA Spine Care.

  14. Can poor posture cause a tear?
    Yes—sustained forward head posture increases disc stress and risk of tears Florida Surgery Consultants.

  15. How do I prevent recurrence?
    Maintain good posture, regular exercise, ergonomic work habits, and avoid smoking to keep discs healthy Spine-health.

Disclaimer: Each person’s journey is unique, treatment plan, life style, food habit, hormonal condition, immune system, chronic disease condition, geological location, weather and previous medical  history is also unique. So always seek the best advice from a qualified medical professional or health care provider before trying any treatments to ensure to find out the best plan for you. This guide is for general information and educational purposes only. Regular check-ups and awareness can help to manage and prevent complications associated with these diseases conditions. If you or someone are suffering from this disease condition bookmark this website or share with someone who might find it useful! Boost your knowledge and stay ahead in your health journey. We always try to ensure that the content is regularly updated to reflect the latest medical research and treatment options. Thank you for giving your valuable time to read the article.

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

Last Updated: May 03, 2025.

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PDF Document For This Disease Conditions

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  11. https://en.wikipedia.org/wiki/Muscle
  12. https://en.wikipedia.org/wiki/List_of_skeletal_muscles_of_the_human_body
  13. https://medlineplus.gov/ency/imagepages/19841.htm
  14. https://www.britannica.com/science/human-muscle-system
  15. https://training.seer.cancer.gov/anatomy/muscular/types.html
  16. https://www.britannica.com/science/human-muscle-system
  17. https://www.sciencedirect.com/topics/medicine-and-dentistry/skeletal-muscle
  18. https://academic.oup.com/nar/article/32/5/1792/2380623
  19. https://onlinelibrary.wiley.com/journal/10974598
  20. https://medlineplus.gov/skinconditions.html
  21. https://en.wikipedia.org/wiki/Category:Kidney_diseases
  22. https://kidney.org.au/your-kidneys/what-is-kidney-disease/types-of-kidney-disease
  23. https://www.niddk.nih.gov/health-information/kidney-disease
  24. https://www.kidney.org/kidney-topics/chronic-kidney-disease-ckd
  25. https://www.kidneyfund.org/all-about-kidneys/types-kidney-diseases
  26. https://www.aad.org/about/burden-of-skin-disease
  27. https://www.usa.gov/federal-agencies/national-institute-of-arthritis-musculoskeletal-and-skin-diseases
  28. https://www.cdc.gov/niosh/topics/skin/default.html
  29. https://www.mayoclinic.org/diseases-conditions/brain-tumor/symptoms-causes/syc-20350084
  30. https://www.ninds.nih.gov/Disorders/Patient-Caregiver-Education/Understanding-Sleep
  31. https://www.cdc.gov/traumaticbraininjury/index.html
  32. https://www.skincancer.org/
  33. https://illnesshacker.com/
  34. https://endinglines.com/
  35. https://www.jaad.org/
  36. https://www.psoriasis.org/about-psoriasis/
  37. https://books.google.com/books?
  38. https://www.niams.nih.gov/health-topics/skin-diseases
  39. https://cms.centerwatch.com/directories/1067-fda-approved-drugs/topic/292-skin-infections-disorders
  40. https://www.fda.gov/files/drugs/published/Acute-Bacterial-Skin-and-Skin-Structure-Infections—Developing-Drugs-for-Treatment.pdf
  41. https://dermnetnz.org/topics
  42. https://www.aaaai.org/conditions-treatments/allergies/skin-allergy
  43. https://www.sciencedirect.com/topics/medicine-and-dentistry/occupational-skin-disease
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  45. https://www.nibib.nih.gov/
  46. https://www.nei.nih.gov/
  47. https://en.wikipedia.org/wiki/List_of_skin_conditions
  48. https://en.wikipedia.org/?title=List_of_skin_diseases&redirect=no
  49. https://en.wikipedia.org/wiki/Skin_condition
  50. https://oxfordtreatment.com/
  51. https://www.nidcd.nih.gov/health/
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  53. https://www.nccih.nih.gov/health
  54. https://catalog.ninds.nih.gov/
  55. https://www.aarda.org/diseaselist/
  56. https://www.ninds.nih.gov/Disorders/Patient-Caregiver-Education/Fact-Sheets
  57. https://www.nibib.nih.gov/
  58. https://www.nia.nih.gov/health/topics
  59. https://www.nichd.nih.gov/
  60. https://www.nimh.nih.gov/health/topics
  61. https://www.nichd.nih.gov/
  62. https://www.niehs.nih.gov
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  64. https://www.nhlbi.nih.gov/health-topics
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  66. https://www.nichd.nih.gov/health/topics
  67. https://rarediseases.info.nih.gov/diseases
  68. https://beta.rarediseases.info.nih.gov/diseases
  69. https://orwh.od.nih.gov/

References

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