Cervical Disc Posterior Sequestration

Cervical disc posterior sequestration is a specific type of intervertebral disc herniation in the neck where a fragment of nucleus pulposus (the jelly-like core of the disc) ruptures through the annulus fibrosus (the tough outer ring) and migrates into the posterior epidural space, completely detaching from the original disc. Unlike typical herniations that remain connected, a sequestered fragment floats freely and can impinge on the spinal cord or nerve roots, often leading to more severe symptoms and a distinct treatment approach RadiopaediaPMC.

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Anatomy of the Cervical Intervertebral Disc

Structure & Location

Each cervical intervertebral disc sits between adjacent cervical vertebral bodies (C2–C7), acting as a fibrocartilaginous joint (a symphysis) to allow slight movement, bear load, and absorb shock. Discs consist of:

• Nucleus pulposus: a gelatinous core rich in water, collagen, and proteoglycans.

• Annulus fibrosus: tough, multi-lamellar rings of type I and II collagen that surround and contain the nucleus Wikipedia.

Origin & Insertion

Discs are anchored superiorly and inferiorly by cartilaginous endplates:

• Superior endplate attaches to the vertebral body above.

• Inferior endplate attaches to the vertebral body below.
  These endplates distribute compressive loads and facilitate nutrient diffusion Stanford Profiles.

Blood Supply

In healthy adults, intervertebral discs are largely avascular. During early life, vessels penetrate the outer annulus and endplates, but these regress, leaving the disc to receive nutrients by diffusion through the endplates from adjacent vertebral body capillaries Wikipedia.

Nerve Supply

Sensory nerve fibers (mainly from the sinuvertebral nerves) innervate the outer one-third of the annulus fibrosus. These nerves can transmit pain signals when the annulus is torn or under strain Wikipedia.

Key Functions

1. Shock absorption: The nucleus pulposus distributes hydraulic pressure under load.

2. Load distribution: Evenly transfers compressive forces across vertebrae.

3. Flexibility & movement: Permits flexion, extension, rotation, and lateral bending.

4. Ligamentous support: The annulus fibrosus helps hold vertebrae together.

5. Spacing of neural foramina: Maintains proper foraminal height, preventing nerve compression.

6. Biomechanical stability: Works with facet joints to preserve spinal integrity Wikipedia.

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Types of Cervical Disc Sequestration

Manabe and Tateishi classified cervical disc sequestrations based on fragment localization within the epidural space:

1. Anterior sequestration: Fragment lies anterior to the dural tube.

2. Lateral sequestration: Fragment migrates laterally, often compressing a nerve root.

3. Lateral drop attack sequestration: Causes sudden drop-attack symptoms due to root or dura irritation.

4. Posterior sequestration: Fragment moves behind the vertebral body, compressing the posterior dural surface PMC.

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Causes of Posterior Disc Sequestration

Degenerative Factors (1–5):

1. Age-related degeneration: Discs lose water and elasticity over time, becoming prone to tearing Mayo ClinicNCBI.

2. Annulus fibrosus tears: Radial or circumferential fissures allow nucleus extrusion NCBI.

3. Disc desiccation: Reduction in proteoglycan content leads to reduced shock absorption Mayo Clinic.

4. Facet joint osteoarthritis: Alters spinal biomechanics, increasing disc stress NCBI.

5. Loss of endplate integrity: Microfractures in endplates facilitate herniation IUTAM Stanford.

Traumatic Factors (6–10):
6. Contact sports injuries: High-impact forces can rupture the annulus NCBIPMC.
7. Automobile accidents: Whiplash hyperflexion/hyperextension can cause acute herniation NCBIPMC.
8. Severe hyperflexion: Extreme forward bending stresses posterior annulus PMC.
9. Severe hyperextension: Extreme backward bending can also tear the annulus PMC.
10. Spinal manipulation (SMT): Rare cases of herniation following cervical adjustment PMC.

Occupational & Mechanical Stress (11–15):
11. Repetitive strain: Continuous heavy lifting or bending Mayo Clinic.
12. Poor posture: Sustained forward head posture increases disc pressure Mayo Clinic.
13. Whole-body vibration: Drivers and machine operators at risk Mayo Clinic.
14. Microtrauma: Minor, cumulative injuries from daily activities Healthline.
15. Frequent neck extension: e.g., hairstylists, painters Mayo Clinic.

Lifestyle & Biological Factors (16–20):
16. Obesity: Extra weight increases axial load on discs Mayo Clinic.
17. Smoking: Reduces disc oxygenation and accelerates degeneration Mayo Clinic.
18. Sedentary lifestyle: Weakens supporting muscles, destabilizing the spine Healthline.
19. Genetic predisposition: Family history of disc disease Mayo Clinic.
20. Congenital spine anomalies: Klippel-Feil syndrome or dysplastic vertebrae PMC.

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Symptoms

Pain Patterns (1–5):

1. Localized neck pain: Often the first symptom NCBIPMC.

2. Radiating arm pain: Follows dermatomal distribution NCBI.

3. Occipital headaches: Due to upper cervical involvement NCBI.

4. Scapular or shoulder pain: Referred from C4–C5 discs NCBI.

5. Pain with neck movement: Worse on extension or rotation NCBI.

Neurological Signs (6–10):
6. Radicular pain: Sharp, electric-like along nerve root NCBI.
7. Paresthesia: Tingling or “pins and needles” NCBI.
8. Numbness: Loss of sensation in affected dermatome PMC.
9. Muscle weakness: In myotomal distribution NCBI.
10. Reflex changes: Hypo- or hyperreflexia in corresponding reflex arcs NCBI.

Myelopathic Features (11–15):
11. Gait disturbance: Spinal cord compression can affect walking PMC.
12. Spasticity: Increased muscle tone in limbs PMC.
13. Hyperreflexia & clonus: Upper motor neuron signs PMC.
14. Lhermitte’s sign: Electric shocks with neck flexion PMC.
15. Sphincter dysfunction: Rare but serious (incontinence) PMC.

Other Findings (16–20):
16. Neck stiffness: Decreased range of motion NCBI.
17. Muscle atrophy: Chronic root compression Radiopaedia.
18. Tingling in fingers: Especially thumb and index finger PMC.
19. Balance problems: Due to spinal cord involvement PMC.
20. Fatigue: Chronic pain leads to muscle fatigue NCBI.

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Diagnostic Tests

Physical Examination (1–5):

1. Spurling’s test: Cervical extension with axial load reproduces radicular pain NCBI.

2. Neck compression test: Axial load on head increases pain NCBI.

3. Distraction test: Lifting head relieves pain NCBI.

4. Lhermitte’s sign: Flexion-induced electrical sensation PMC.

5. Valsalva maneuver: Increases intrathecal pressure, worsening pain if positive Radiopaedia.

Imaging Studies (6–10):
6. Plain X-ray: May show disc space narrowing or osteophytes Radiopaedia.
7. MRI (T2-weighted): Gold standard for visualizing disc fragments and spinal cord compression PMC.
8. MRI (T1-weighted): Helps identify sequestered fragments with moderate to low signal PMC.
9. CT scan: Useful when MRI contraindicated; shows bony anatomy and calcified fragments Radiopaedia.
10. CT myelography: Contrast-enhanced CT for patients unable to undergo MRI Radiopaedia.

Advanced Diagnostics (11–15):
11. Discography: Provocative test to confirm symptomatic disc Wikipedia.
12. Dynamic flexion-extension X-rays: Assess instability Wikipedia.
13. Ultrasound: Emerging for guided injections; limited in deep cervical structures Wikipedia.
14. Diffusion tensor imaging (DTI): Experimental MRI technique for spinal cord integrity Wikipedia.
15. Positron emission tomography (PET): Rarely used; distinguishes infection or tumor from herniation Wikipedia.

Neurophysiological & Lab Tests (16–20):
16. Electromyography (EMG): Detects denervation in affected myotomes NCBI.
17. Nerve conduction studies: Evaluate peripheral nerve involvement NCBI.
18. Somatosensory evoked potentials (SSEPs): Assess dorsal column function NCBI.
19. Motor evoked potentials (MEPs): Evaluate corticospinal tract integrity NCBI.
20. Blood tests (ESR, CRP, RF, HLA-B27): Rule out infection, inflammation, or inflammatory arthropathy PMC.

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Non-pharmacological Treatments

Exercise Therapies (1–5):

1. Cervical traction: Decompresses nerve roots and reduces pain HealthlinePMC.

2. Supervised physiotherapy: Tailored exercises for strength and flexibility PMC.

3. Isometric neck exercises: Gentle muscle activation without movement Healthline.

4. Scalene and sternocleidomastoid stretches: Relieve muscle tension Healthline.

5. Postural correction exercises: Improve head-over-shoulder alignment Mayo Clinic.

Manual & Physical Modalities (6–10):
6. Chiropractic spinal manipulation: Moderate evidence for neck pain relief Mayo Clinic.
7. Massage therapy: Short-term relief of muscle tension Mayo Clinic.
8. Transcutaneous electrical nerve stimulation (TENS): Analgesic via low-voltage currents PMC.
9. Therapeutic ultrasound: Promotes soft tissue healing PMC.
10. Heat and cold therapy: Alternating thermotherapy for inflammation control Healthline.

Complementary & Alternative (11–15):
11. Acupuncture: Modest efficacy in chronic neck pain Mayo Clinic.
12. Acupressure: Similar to acupuncture but without needles PMC.
13. Dry needling: Targets myofascial trigger points PMC.
14. Cupping therapy: May increase local circulation PMC.
15. Kinesio taping: Supports soft tissues and proprioception PMC.

Mind-Body & Lifestyle (16–20):
16. Yoga: Enhances flexibility and reduces stress PMC.
17. Pilates: Core strengthening and spinal stabilization PMC.
18. Mindfulness-based stress reduction: Lowers tension and pain perception PMC.
19. Cognitive behavioral therapy: Addresses pain-related behaviors and coping NCBI.
20. Ergonomic adjustments: Proper desk/chair height, monitor at eye level Mayo Clinic.

Nutrition & Prevention (21–25):
21. Weight management: Reduces axial loading on discs Mayo Clinic.
22. Hydration: Adequate fluid intake to maintain disc hydration Mayo Clinic.
23. Anti-inflammatory diet: Omega-3 fatty acids, antioxidants PMC.
24. Vitamin D & calcium: Support bone health and endplate integrity PMC.
25. Smoking cessation: Slows degenerative changes Mayo Clinic.

Adjunctive Therapies (26–30):
26. Neck collars (limited use): Short-term immobilization during acute flare PMC.
27. Ergonomic pillows: Maintain neutral neck alignment during sleep Healthline.
28. Spinal decompression table: Intermittent mechanical traction PMC.
29. Laser therapy: Low-level laser for pain modulation PMC.
30. Biofeedback: Teaches muscle relaxation techniques NCBI.

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Drug Options

Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) (1–5):

1. Ibuprofen

2. Naproxen

3. Diclofenac

4. Celecoxib

5. Aspirin
   (Common first-line agents for pain and inflammation) NCBIMayo Clinic.

Corticosteroids (6–10):
6. Prednisone (60–80 mg/day, tapering)
7. Methylprednisolone (taper pack)
8. Dexamethasone
9. Triamcinolone (epidural injection)
10. Prednisolone
(Short courses for severe acute pain) NCBIPMC.

Muscle Relaxants (11–15):
11. Cyclobenzaprine (5 mg TID)
12. Tizanidine
13. Baclofen
14. Methocarbamol
15. Diazepam
(For prominent muscle spasms, short-term use) NCBIPMC.

Neuropathic Pain Modulators (16–20):
16. Gabapentin
17. Pregabalin
18. Amitriptyline
19. Nortriptyline
20. Duloxetine
(Target neuropathic pain from nerve root irritation) NCBIPMC.

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Surgical Options

1. Anterior cervical discectomy and fusion (ACDF): Removal of the disc and fusion with bone graft and plate PMC.

2. Anterior cervical corpectomy and fusion (ACCF): Removal of vertebral body and adjacent discs with fusion PMC.

3. Cervical disc arthroplasty (artificial disc): Motion-preserving replacement PMC.

4. Posterior microdiscectomy/foraminotomy: Direct removal via a posterior approach PMC.

5. Laminoplasty: Expansive “open-door” technique to decompress the spinal canal PMC.

6. Laminectomy (± fusion): Removal of laminae to decompress PMC.

7. Endoscopic cervical discectomy: Minimally invasive fragment removal PMC.

8. Posterior laminoforaminotomy: Enlarges neural foramen PMC.

9. Combined anterior-posterior decompression & fusion: For complex multilevel disease PMC.

10. Minimally invasive microendoscopic discectomy: Small-incision approach with endoscope PMC.

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Preventive Measures

1. Regular exercise: Strengthens supporting musculature Mayo Clinic.

2. Good posture: Keeps spinal alignment and reduces disc stress Mayo Clinic.

3. Proper lifting techniques: Bend at knees, not waist Healthline.

4. Ergonomic workspace: Desk/chair setup to maintain neutral spine Mayo Clinic.

5. Healthy weight maintenance: Lowers axial loading Mayo Clinic.

6. Smoking cessation: Reduces disc degeneration risk Mayo Clinic.

7. Adequate hydration: Supports disc nutrition Mayo Clinic.

8. Core strengthening: Improves overall spinal stability PMC.

9. Frequent movement breaks: Avoid prolonged static postures Mayo Clinic.

10. Balanced diet: Adequate calcium, vitamin D, and anti-inflammatory nutrients PMC.

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When to See a Doctor

Seek prompt medical evaluation if you experience:

• Progressive weakness or numbness in arms or legs.

• Loss of bowel or bladder control or saddle anesthesia (perineal numbness).

• Severe, unremitting neck pain not eased by rest or medications after 6 weeks.

• Signs of myelopathy, such as gait disturbance, spasticity, or hyperreflexia.

• Accompanying fever, weight loss, or night sweats, which may indicate infection or malignancy Mayo ClinicPMC.

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Frequently Asked Questions (FAQs)

1. What is posterior sequestration of a cervical disc?
   It’s when a piece of disc material completely detaches and migrates into the space behind the dural sac, potentially causing severe nerve or cord compression RadiopaediaPMC.

2. How does sequestration differ from other herniations?
   Unlike protrusions or extrusions that remain connected, sequestration is a free fragment with no continuity to the parent disc Radiopaedia.

3. What symptoms indicate sequestration?
   Sudden worsening of radicular pain, myelopathic signs (e.g., gait changes), or new neurological deficits can signal a sequestered fragment PMCPMC.

4. Can sequestration heal without surgery?
   Small sequestered fragments sometimes resorb over months with conservative care, but symptomatic cases often require surgical removal PMC.

5. When is surgery necessary?
   Indications include progressive neurological deficits, intractable pain, or myelopathy signs that fail to improve with 6–12 weeks of conservative treatment PMC.

6. Are cervical collars helpful?
   Short-term immobilization can reduce pain during acute flare-ups but should not exceed 1–2 weeks to avoid muscle deconditioning PMC.

7. How long is recovery after ACDF?
   Most patients see pain relief within days to weeks; full fusion and activity return may take 3–6 months PMC.

8. Will I always need fusion?
   Not necessarily; motion-preserving disc arthroplasty is an option for select patients without instability PMC.

9. What are surgical risks?
   Include infection, bleeding, nerve injury, nonunion, and adjacent segment degeneration PMC.

10. Can physical therapy cure sequestration?
    Therapies aim to relieve symptoms and improve function but cannot reattach free fragments PMC.

11. Are epidural steroid injections effective?
    They may reduce inflammation and pain temporarily but do not remove the fragment PMC.

12. What alternative therapies help?
    Acupuncture, yoga, and cognitive behavioral therapy can support pain management PMC.

13. How can I prevent recurrence?
    Maintain core strength, use proper body mechanics, and avoid smoking Mayo Clinic.

14. Does age affect prognosis?
    Younger patients often recover faster; older age may worsen degenerative factors NCBI.

15. When should I see a spine specialist?
    If you have red-flag symptoms (e.g., myelopathy, incontinence) or persistent pain despite 6 weeks of conservative care Mayo Clinic.

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

Last Updated: May 01, 2025.

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