West Virginia Code of State Rules › Agency 85 - Workers' Compensation › Title 85 - PROCEDURAL RULE WORKERS' COMPENSATION RULES OF THE WEST VIRGINIA INSURANCE COMMISSIONER › Series 85-20 - Medical Management Of Claims, Guidelines For Impairment Evaluations, Evidence, And Ratings, And Ranges Of Permanent Partial Disability Awards › Section 85-20-36 - Treatment Guidelines: Acute Herniated Cervical Disc

Current through Register Vol. XLI, No. 28, July 12, 2024
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.