Lymphatic Drainage/Lymphadenopathy is a significant clinical finding associated with acute infection, granulomatous disease, autoimmune disease, and malignancy. The involvement of specific nodal groups is an indicator of pathologically-affected organs and tissues, especially in the context of malignancy. As such, intimate knowledge of the anatomic relationships of the lymphatic nodal levels and the structures they drain is critical in the delivery of appropriate therapy in many patients with cancers of the head and neck.
Blood Supply Lymphatic Drainage
The head and neck contains a rich and elaborate lymphatic network of more than 300 nodes and their intermediate channels. Aponeuroses bind them together with the muscles, nerves, and vessels of the head and neck. These lymphatic chains are strongly lateralized and typically do not directly communicate between left and right in the absence of a pathologic process. This lymphatic drainage originates at the base of the skull, then proceeds to the jugular chain adjacent to the internal jugular vein. From there it moves into the spinal accessory chain adjacent to the spinal accessory nerve, or cranial nerve XI, and then meets the supraclavicular chain. The lymphatics then drain on both sides. On the left side, they drain either directly into the vasculature via the jugulo-subclavian venous confluence or directly into the thoracic duct. On the right side, they flow directly into the lymphatic duct. Conversely, most structures drain ipsilaterally, except in the case of structures situated at the anatomic midlines. These include the nasopharynx, pharyngeal wall, base of the tongue, soft palate, and larynx. The lymph nodes of the neck are further classified by level. These levels are Ia, Ib, II, III, IV, V, VI, VII, VIII, IX, X. [1][2][3][4][5]
Level Ia: Submental Group
Anatomy
Level I nodes are those bounded by the mandible superiorly and laterally and by the hyoid bone inferiorly. Level Ia contains the submental nodal group, bounded superiorly by the symphysis menti and inferiorly by the hyoid bone. It is bounded anteriorly by the platysma muscle, posteriorly by the mylohyoid muscles, laterally by the anterior belly of the digastric muscle, and medially by the virtual anatomic midline. These boundaries form a triangular region also termed the submental triangle.
Drainage
This group drains the skin of the mental region, or chin, the mid-lower lip, the anterior portion of the oral tongue, and the floor of the mouth.
Associated primary malignancies
These nodes most often contain metastatic deposits from malignancies of the floor of the mouth, anterior oral tongue, mandibular alveolar ridge, and lower lip.
Level Ib: Submandibular Group
Anatomy
Level Ib contains the submandibular nodal group, bounded superiorly by the mylohyoid muscle and inferiorly by the hyoid bone. It is bounded anteriorly by the symphysis menti, posteriorly by the posterior edge of the submandibular gland, laterally by the inner surface of the mandible, and medially by the digastric muscle. These boundaries form a triangular region also termed the submandibular triangle.
Drainage
They drain the efferent lymphatics from level Ia, the lower nasal cavity, both the hard and soft palates, and both maxillary and mandibular alveolar ridges. They also drain them from the skin and mucosa of the cheek, both upper and lower lips, the floor of the mouth, and the anterior oral tongue.
Associated primary malignancies
These nodes most often contain metastatic deposits from malignancies of the oral cavity, anterior nasal cavity, soft-tissues of the mid-face, and submandibular gland.
Level II: Upper Jugular Group
Anatomy
Level II represents the beginning of the jugular chain. It contains the upper jugular nodal group, adjacent to the top third of the internal jugular vein (IJV) and upper spinal accessory nerve. It is bounded superiorly by the insertion of the posterior belly of the digastric muscle into the mastoid process, and inferiorly by the caudal border of the hyoid bone or alternatively, as a surgical landmark, the carotid bifurcation. It is bounded anteriorly by the posterior edge of the submandibular gland, posteriorly by the posterior edge of the sternocleidomastoid muscle (SCM), laterally by the medial surface of the SCM, and medially by the internal carotid artery and scalenus muscle.
Drainage
This group drains the efferent lymphatics of the face, parotid gland, level Ia, level Ib, and retropharyngeal nodes. It receives direct drainage from the nasal cavity, the entire pharyngeal axis, larynx, external auditory canal, middle ear, and the sublingual and submandibular glands.
Associated primary malignancies
These nodes most often contain metastatic deposits from malignancies of the nasal and oral cavities, nasopharynx, oropharynx, hypopharynx, larynx, and major salivary glands. It is the most commonly involved nodal level. [6][7][8][9][10]
Level III: Middle Jugular Group
Anatomy
Level III contains the middle jugular nodal group, adjacent to the middle third of the IJV. It is bounded superiorly by the caudal border of the hyoid bone, and inferiorly by the caudal edge of the cricoid cartilage or alternatively, as a surgical landmark, the plan where the omohyoid muscle crosses the IJV. It is also bounded anteriorly by the anterior edge of the SCM, or the posterior third of the thyrohyoid muscle, and posteriorly by the posterior border of the SCM. Finally, it is bordered laterally by the medial surface of the SCM, and medially by the internal carotid artery and scalenus muscle.
Drainage
This group drains the efferent lymphatics from level II and level V, and partially from the retropharyngeal, pretracheal, and recurrent laryngeal nodes. It receives direct drainage from the base of the tongue, tonsils, larynx, hypopharynx, and thyroid gland.
Associated primary malignancies
These nodes most often contain metastatic deposits from malignancies of the oral cavity, nasopharynx, oropharynx, hypopharynx, and larynx. [11][12][13][14][15]
Level IVa: Lower Jugular Group
Anatomy
Level IVa contains the lower jugular nodal group adjacent to the inferior third of the IJV. It is bounded superiorly by the caudal border of the cricoid cartilage, and inferiorly by a virtual level two centimeters superior to the sternoclavicular joint, based off surgical conventions of level IVa dissection. It is bounded anteriorly by the anterior edge of the SCM (more superiorly) and the body of the SCM (more inferiorly), and posteriorly by the posterior edge of the SCM (more superiorly) and the SM(more inferiorly. This group is also laterally bound by the medial edge of the SCM (more superiorly) and the lateral edge of the SCM (more inferiorly). Finally, it is medially bordered by the medial edge of the common carotid artery, the medial edge of the thyroid gland and scalenus muscle (more superiorly), and the medial edge of the SCM (more inferiorly).
Drainage
This group drains the efferent lymphatics from levels III and V, and partially from the retropharyngeal, pretracheal, and recurrent laryngeal nodes. It receives direct drainage from the larynx, hypopharynx, and thyroid gland.
Associated primary malignancies
These nodes most often contain metastatic deposits from malignancies of the hypopharynx, larynx, thyroid, cervical esophagus, and rarely, the anterior oral cavity. Deposits from the anterior oral cavity can manifest without proximal nodal involvement.
Level IVb: Medial Supraclavicular Group
Anatomy
This nodal group is a continuation of level IVa to the superior edge of the sternal manubrium. It is bounded anteriorly by the deep surface of the SCM. Posteriorly, it is bound by the anterior edge of the scalenus muscle (more superiorly) and the lung apex, brachiocephalic vein, and artery on the right, as well as the common carotid and subclavian arteries on the left (more inferiorly). It is bounded laterally by the lateral edge of the scalenus muscle, and medially by the medial border of the common carotid artery which is also adjacent to level VI.
Drainage
This group drains the efferent lymphatics from levels IVa and Vc, and partially from the pretracheal and recurrent laryngeal nodes. It receives direct drainage from the larynx, trachea, hypopharynx, esophagus, and thyroid gland.
Associated primary malignancies
These nodes most often contain metastatic deposits from malignancies of the hypopharynx, subglottic larynx, trachea, thyroid, and cervical esophagus.
Level Va and Vb: Posterior Triangle Group
Anatomy
These nodal groups are contained with the posterior triangle. They are situated posteriorly to the SCM, and adjacent to the inferior portion of the spinal accessory nerve and transverse cervical vessels. It is bounded superiorly by the superior edge of the hyoid bone and inferiorly by a virtual plane crossing the transverse vessels. It is bound anteriorly by the posterior margin of the SCM, and posteriorly by the anterior border of the trapezius muscle. It is also bound by the platysma muscle and skin laterally, and by the levator scapulae (more superiorly) and scalenus muscle (more inferiorly) medially. A virtual plane at the inferior edge of the cricoid cartilage divides this group into upper, or Va, and lower, or Vb, posterior triangles.
Drainage
These nodal groups drain the efferent lymphatics from the occipital, retro-auricular, occipital, and parietal scalp nodes. It receives direct drainage from the skin of the lateral and posterior neck and shoulder, the nasopharynx, oropharynx, and thyroid gland.
Associated primary malignancies
These nodes most often contain metastatic deposits from malignancies of the nasopharynx, oropharynx, and thyroid.
Level Vc: Lateral Supraclavicular Group
Anatomy
This nodal group is a continuation of levels Va and Vb; it contains the lateral supraclavicular group. It is bounded superiorly by a virtual plan crossing the transverse vessels, and inferiorly by a virtual plan 2 cm superior to the sternoclavicular join. It is also bounded anteriorly by the skin and posteriorly by the anterior border of the trapezius muscles (more superiorly) and the serratus anterior (more inferiorly). Laterally, it is bounded by the trapezius muscle (more superiorly) and the clavicle (more inferiorly). Medially, it is bordered by the scalenus muscle and lateral edge of the SCM, and is directly adjacent to the lateral edge of level IVa.
Drainage
This group drains the efferent lymphatics from levels Va and Vb.
Associated primary malignancies
These nodes most often contain metastatic deposits from malignancies of the nasopharynx.
Level VI: Anterior Compartment Group
The anterior compartment contains this nodal group, which is symmetric about the anatomic midline. It is also further subdivided into the superficially-located anterior jugular nodes, or level VIa, and the deeper pre-laryngeal, pre-tracheal, and para-tracheal (recurrent laryngeal) nodes, or level VIb. Level VIa
Anatomy
Level VIa is bounded superiorly by the inferior edge of level Ib and inferiorly by the superior edge of the sternal manubrium. It is bounded anteriorly by the skin and platysma, posteriorly by the anterior surface of the infrahyoid muscles, and bilaterally by the anterior edges of the SCMs.
Drainage
Level VIa drains the integuments of the lower face and the anterior neck.
Associated primary malignancies
These nodes most often contain metastatic deposits from malignancies of the lower lip and soft tissues of the chin, such as advanced gingiva-mandibular carcinoma.
Level VIb
Anatomy
Level VIb is bounded superiorly by the superior edge of the thyroid cartilage and inferiorly by the superior border of the sternal manubrium. It is also bounded anteriorly by the posterior margin of the infrahyoid muscles, and posteriorly by the anterior larynx, thyroid gland, and trachea at the midline, the pre-vertebral muscles on the right, and the esophagus on the left. This group is bordered laterally by the common carotid artery and medially by the lateral aspects of the trachea and esophagus.
Drainage
Level VIb drains the efferent lymphatics from the anterior floor of the mouth, tip of the oral tongue, lower lip, thyroid gland, glottic and supraglottic larynx, hypopharynx, and cervical esophagus.
Associated primary malignancies
These nodes most often contain metastatic deposits from malignancies of the lower lip, oral cavity (floor of the mouth and anterior oral tongue), thyroid, glottic and subglottic larynx, the apex of the piriform sinus, and the cervical esophagus. [16][17]
Level VII: Prevertebral Compartment Group, including Levels VIIa and VIIbLevel VIIa
Retropharyngeal Nodes
Anatomy
These nodes are contained in the retropharyngeal space. They are divided into medial and lateral subgroups. The lateral groups are bounded superiorly by the superior edge of the C1 vertebral body, or the hard palate, and inferiorly by the superior edge of the body of the hyoid bone. Anteriorly, they are bounded by the posterior edge of the superior/middle pharyngeal constrictor muscles. They are bordered posteriorly by the longus capitis and longus colli muscles, laterally by the medial edge of the internal carotid artery, and medially by a virtual line parallel to the lateral edge of the longus capitis muscle. The medial groups are approximated at the midline and not well-defined.
Drainage
These nodes drain the efferent lymphatics from the nasopharynx, eustachian tube, and soft palate.
Associated primary malignancies
These nodes most often contain metastatic deposits from malignancies of the nasopharynx, pharyngeal wall, and oropharynx including tonsillar fossa and soft palate.
Level VIIb: Retrostyloid Nodes
Anatomy
These nodes are contained in the fatty space surrounding the large vessels of the neck leading to the jugular foramen. They are the superior continuation of level II. Level VIIb is bounded superiorly by the jugular foramen at the base of skull, and inferiorly by the inferior edge of the lateral process of the C1 vertebral body, the superior boundary of level II. These nodes are bounded anteriorly by the posterior edge of the prestyloid parapharyngeal space, and posteriorly by the C1 vertebral body and base of skull. Finally, they are bordered laterally by the styloid process and deep parotid lobe, and medially by the medial edge of the internal carotid artery.
Drainage
These nodes drain the efferent lymphatics from the nasopharynx.
Associated primary malignancies
These nodes most often contain metastatic deposits from malignancies of the nasopharynx and anywhere in the head and neck resulting in significant infiltration of upper-level II nodes causing via retrograde flow.
Level VIII: Parotid Group
Anatomy
This group includes the subcutaneous pre-auricular, superficial and deep intraparotid, and subparotid nodes. It is bounded superiorly by the zygomatic arch and external auditory canal, and inferiorly by the mandibular angle. This group is bounded anteriorly by the posterior edge of the mandibular ramus, the posterior edge of the masseter muscle (more laterally), and medial pterygoid muscle (medially). It is also bordered posteriorly by the anterior edge of the SCM (more laterally) and posterior belly of the digastric muscle (more medially). These nodes are bordered laterally by superficial muscular aponeurotic system (SMAS) layer within the subcutaneous tissues, and medially by the styloid process and muscle.
Drainage
These nodes drain the efferent lymphatics from the frontal and temporal skin, eyelids, conjunctivae, auricles, external acoustic meatus, tympanum, nasal cavities, the root of the nose, nasopharynx, and the eustachian tube.
Associated primary malignancies
These nodes most often contain metastatic deposits from malignancies of the previously named draining structures, as well as the orbit, external auditory canal, and parotid gland.[18]
Level IX: Buccofacial group
Anatomy
This group contains the malar and the buccofacial nodes. These are superficial nodes surrounding the facial vessels on the external surface of the buccinator muscle. It is bounded superiorly by the inferior edge of the orbit and inferiorly by the inferior border of the mandible. It is also bounded anteriorly by the SMAS layer within the subcutaneous tissue, and posteriorly by the anterior edge of the masseter muscle and the corpus adiposum buccae. The lateral border is the SMAS layer, and the medial border is the buccinator muscle.
Drainage
These nodes drain the efferent vessels of the nose, eyelids, and cheek.
Associated primary malignancies
These nodes most often contain metastatic deposits from malignancies of the facial skin, nose, and buccal mucosa, as well as the maxillary sinus if invading soft tissues of the cheek.
Level X: Posterior Skull Group, including Levels Xa and Xb
Level Xa: Retroauricular and Subauricular Nodes
Anatomy
This group includes superficial nodes on the mastoid process. It is bounded superiorly by the superior edge of the external auditory canal, and inferiorly by the mastoid tip. It is also bounded anteriorly by the anterior edge of the mastoid (inferiorly) and posterior edge of the external auditory canal (superiorly), and posteriorly by the posterior edge of the SCM. This group is bordered laterally by subcutaneous tissue, and medially by the splenius capitis muscles (inferiorly) and the temporal bone (superiorly).
Drainage
These nodes drain the efferent vessels from the posterior auricular surface, external auditory canal, and adjacent scalp.
Associated primary malignancies
These nodes most often contain metastatic deposits from malignancies of the retro-auricular skin.
Level Xb: Occipital Nodes
Anatomy
This group is the superior and superficial continuation of level Va. It is bounded superiorly by the external occipital protuberance, and inferiorly by the superior border of level V. It is also bounded anteriorly by the posterior edge of the SCM, which is the posterior border of level Xa, and posteriorly by the anterior/lateral side of the trapezius muscle. Finally, this group is bordered laterally by subcutaneous tissues, and medially by the splenius capitis muscle.
Drainage
These nodes drain efferent vessels from the posterior hairy scalp.
Associated primary malignancies
These nodes most often contain metastatic deposits from malignancies of the occipital skin. [5]
Slipped Cervical Disc /Herniated Cervical Disc (also called bulged, slipped or ruptured) is a fragment of the disc nucleus that is pushed out of the annulus, into the spinal canal through a tear or rupture in the annulus. Discs that become herniated usually are in an early stage of degeneration. The spinal canal has limited space, which is inadequate for the spinal nerve and the displaced herniated disc fragment. Due to this displacement, the disc presses on spinal nerves, often producing pain, which may be severe.
Types Of Cervical Disc Herniation
Doctors categorize slipped disks by severity
Disc Degeneration – Chemical changes associated with aging causes discs to weaken, but without a herniation.
Bulging disk – With age, the intervertebral disk may lose fluid and become dried out. As this happens, the spongy disk (which is located between the bony parts of the spine and acts as a “shock absorber”) becomes compressed. This may lead to the breakdown of the tough outer ring. This lets the nucleus, or the inside of the ring, to bulge out. This is called a bulging disk.
Protrusion –The disk bulges out between the vertebrae, but its outermost layer is still intact.
Extrusion – There is a tear in the outermost layer of the spinal disk, causing spinal disk tissue to spill out. But the tissue that has come out is still connected to the disk.
Sequestration – Spinal disk tissue has entered the spinal canal and is no longer directly attached to the disk.
Ruptured or herniated disk – As the disk continues to break down, or with continued stress on the spine, the inner nucleus pulposus may actually rupture out from the annulus. This is a ruptured, or herniated, disk. The fragments of disc material can then press on the nerve roots located just behind the disk space. This can cause pain, weakness, numbness, or changes in sensation.
Causes Of Slipped Cervical Disc
The differential diagnosis for lumbosacral radiculopathy should include (but is not limited to) the following
Degenerative conditions of the spine (most common causes)
Spondylolisthesis – in the degenerative setting, this occurs as a result of a pathologic cascade including intervertebral disc degeneration, ensuing intersegmental instability, and facet joint arthropathy
Spinal stenosis – It causes especially in older age in maximum people.
Adult isthmic spondylolisthesis – is typically caused by an acquired defect in the par interarticularis
Pars defects (i.e. spondylolysis) in adults are most often secondary to repetitive microtrauma.
Trauma (e.g. burst fractures with bony fragment retropulsion)
Clinicians should recognize spinal fractures can occur in younger, healthy patient populations secondary to high-energy injuries (e.g. MVA, fall from height) or secondary low energy injuries and spontaneous fractures in the elderly populations, including any patient with osteoporosis
Associated hemorrhage from the injury can result in a deteriorating clinical and neurologic exam.
Benign or malignant tumors
Metastatic tumors (most common)
Primary tumors
Ependymoma
Schwannoma
Neurofibroma
Lymphoma
Lipomas
Paraganglioma
Ganglioneuroma
Osteoblastoma
Infection
Osteodiscitis
Osteomyelitis
Epidural abscess
Fungal infections (e.g. Tuberculosis)
Other infections: lyme disease, HIV/AIDS-defining ilnesses, Herpes zoster (HZ)
History – Progressive motor/sensory loss, new urinary retention or incontinence, new fecal incontinence
Physical exam – Saddle anesthesia, anal sphincter atony, significant motor deficits of multiple myotomes
Fracture
History – Significant trauma (relative to age), Prolonged corticosteroid use, osteoporosis, and age greater than 70 years
Physical exam – Contusions, abrasions, tenderness to palpation over spinous processes
Infection
History – Spinal procedure within the last 12 months, Intravenous drug use, Immunosuppression, prior lumbar spine surgery
Physical exam – Fever, wound in the spinal region, localized pain, and tenderness
Malignancy
History – History of metastatic cancer, unexplained weight loss
Physical exam – Focal tenderness to palpation in the setting of risk factors
Symptoms Of Slipped Cervical Disc
The primary signs and symptoms of
LDH is radicular pain – sensory abnormalities, and weakness in the distribution of one or more lumbosacral nerve roots [rx, rx]. Focal paresis, restricted trunk flexion, and increases in leg pain with straining, coughing, and sneezing are also indicative [rx, rx]. Patients frequently report increased pain when sitting, which is known to increase disc pressure by nearly 40% [rx].
Pain that is relieved with sitting for forwarding flexion – is more consistent with lumbar spinal stenosis (LSS), as the latter motion increases disc pressure by 100–400% and would likely increase pain in isolated LDH [rx]. Rainville et al. recently compared signs of LDH with LSS and found that LSS patients are more likely to have increased medical comorbidities, lower levels of disability and leg pain, abnormal Achilles reflexes, and pain primarily in the posterior knee [rx].
Numbness or tingling – People who have a herniated disk often have radiating numbness or tingling in the body part served by the affected nerves.
Weakness – Muscles served by the affected nerves tend to weaken. This can cause you to stumble, or affect your ability to lift or hold items.
Pain in the neck, back, low back, arms, or legs
Inability to bend or rotate the neck or back
Numbness or tingling in the neck, shoulders, arms, hands, hips, legs, or feet
Weakness in the arms or legs
Limping when walking
Increased pain when coughing, sneezing, reaching, or sitting
Inability to stand up straight; being “stuck” in a position, such as stooped forward or leaning to the side
Difficulty getting up from a chair
Inability to remain in 1 position for a long period of time, such as sitting or standing, due to pain
Pain that is worse in the morning
This is a sharp, often shooting pain that extends from the buttock down the back of one leg. It is caused by pressure on the spinal nerve.
Numbness or a tingling sensation in the leg and/or foot
Weakness in the leg and/or foot
Loss of bladder or bowel control. This is extremely rare and may indicate a more serious problem called cauda equina syndrome. This condition is caused by the spinal nerve roots being compressed.
Diagnosis of Slipped Cervical Disc
Special Tests
Lasègue’s Test
Slump Test
Muscle Weakness or Paresis
Reflexes
Hyperextension Test The patient needs to passively mobilize the trunk over the full range of extension, while the knees stay extended. The test indicates that the radiant pain is caused by disc herniation if the pan deteriorates.
Manual Testing and Sensory Testing Look for hypoaesthesia, hypoalgesia, tingling, or numbness.
Physical Examination
The clinician should assess the patient’s range of motion (ROM), as this can indicate the severity of pain and degeneration. A thorough neurological examination is necessary to evaluate sensory disturbances, motor weakness, and deep tendon reflex abnormalities. Careful attention should also focus on any sign of spinal cord dysfunction.
Typical findings of solitary nerve lesions due to compression by a herniated disc in the cervical spine
C2 Nerve – eye or ear pain, headache. History of rheumatoid arthritis or atlantoaxial instability
C3, C4 Nerve – vague neck, and trapezial tenderness and muscle spasms
C5 Nerve – neck, shoulder, and scapula pain. Lateral arm paresthesia. Primary motions affected include shoulder abduction and elbow flexion. May also observe weakness with shoulder flexion, external rotation, and forearm supination. Diminished biceps reflex.
C6 Nerve – neck, shoulder, and scapula pain. Paresthesia of the lateral forearm, lateral hand, and lateral two digits. Primary motions affected include elbow flexion and wrist extension. May also observe weakness with shoulder abduction, external rotation, and forearm supination and pronation — diminished brachioradialis reflex.
C7 Nerve – neck and shoulder pain. Paresthesia of the posterior forearm and third digit. Primary motions affected include elbow extension and wrist flexion. Diminished triceps reflex
C8 Nerve – neck and shoulder pain. Paresthesia of the medial forearm, medial hand, and medial two digits. Weakness during finger flexion, handgrip, and thumb extension.
T1 Nerve – Neck and shoulder pain. Paresthesia of the medial forearm. A weakness of finger abduction and adduction.[rx]
Lab values
Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) – These are inflammatory markers that should be obtained If a chronic inflammatory condition is suspected (rheumatoid arthritis, polymyalgia rheumatic, seronegative spondyloarthropathy). These can also be beneficial if an infectious etiology is suspected.
Complete blood count (CBC) with differential – Useful to obtain in instances when infection or malignancy is suspected.
Radiological
Patients with equivocal studies may opt for a discography when conservative measures fail. Electrophysiological studies can be performed to evaluate and elucidate the nerve roots affected by injured cervical disc.[rx][rx]
X-ray – Plain radiography is an initial and inexpensive method of evaluating the cervical spine for an osseous injury. In chronic disc degeneration, decreased disc height and osteophytes can be seen. There is a higher incidence of cervical cord injury demonstrated with the use of plain radiographs in the assessment of cervical spine stenosis. The Torg ratio is the sagittal canal/vertebral body ratio measured on cervical spine lateral radiographs. The normal value is 1.0. A ratio of 0.8 and below has been considered indicative of cervical spinal stenosis.
MRI – Magnetic resonance imaging is the best modality to assess cord compression and disc herniation. T2 weighted views are preferred. Findings include decreased disc height, reduced signal intensity, and spondylotic osteophytes.
CT Scan – This imaging is the most sensitive test to examine the bony structures of the spine. It can also show calcified herniated discs or any insidious process that may result in bony loss or destruction. In patients that are unable to or are otherwise ineligible to undergo an MRI, CT myelography can be used as an alternative to visualize a herniated disc.
Electrodiagnostic testing – (Electromyography and nerve conduction studies) can be an option in patients that demonstrate equivocal symptoms or imaging findings as well as to rule out the presence of a peripheral mononeuropathy. The sensitivity of detecting cervical radiculopathy with electrodiagnostic testing ranges from 50% to 71%.[rx]
Treatment Slipped Cervical Disc
Patient Education
Use of hot or cold packs for comfort and to decreased inflammation
Avoidance of inciting activities or prolonged sitting/standing
Practicing good, erect posture
Engaging in exercises to increase core strength
Gentle stretching of the lumbar spine and hamstrings
Regular light exercises such as walking, swimming, or aromatherapy
Conservative Treatments – Acute cervical radiculopathies secondary to a herniated disc are typically managed with non-surgical treatments as the majority of patients (75 to 90%) will improve. Modalities that can be used include[rx][rx][rx]:
Collar Immobilization – In patients with acute neck pain, a short course (approximately one week) of collar immobilization may be beneficial during the acute inflammatory period.
Traction – May be beneficial in reducing the radicular symptoms associated with disc herniations. Theoretically, traction would widen the neuroforamen and relieve the stress placed on the affected nerve, which, in turn, would result in the improvement of symptoms. This therapy involves placing approximately 8 to 12 lbs of traction at an angle of approximately 24 degrees of neck flexion over a period of 15 to 20 minutes.
Physical Therapy – Commonly prescribed after a short period of rest and immobilization. Modalities include a range of motion exercises, strengthening exercises, ice, heat, ultrasound, and electrical stimulation therapy. Despite their frequent use, no evidence demonstrates their efficacy over placebo. However, there is no proven harm, and with a possible benefit, their use is recommended in the absence of myelopathy.
Cervical Manipulation – There is limited evidence suggesting that cervical manipulation may provide short-term benefits for neck pain and cervicogenic headaches. Complications from manipulation are rare and can include worsening radiculopathy, myelopathy, spinal cord injury, and vertebral artery injury. These complications occur ranging from 5 to 10 per 10 million manipulations.
Medication
Non-steroidal anti-inflammatory drugs (NSAIDs) – These painkillers belong to the same group of drugs as acetylsalicylic acid (ASA, the drug in medicines like “Aspirin”). NSAIDs that may be an option for the treatment of include diclofenac, ibuprofen, and naproxen. Anti-inflammatory drugs are drugs that reduce inflammation. This includes substances produced by the body itself like cortisone. It also includes artificial substances like ASA – acetylsalicylic acid (or “aspirin”) or ibuprofen –, which relieve pain and reduce fever as well as reducing inflammation.
Acetaminophen (paracetamol) – Acetaminophen (paracetamol) is also a painkiller, but it is not an NSAID. It is well tolerated and can be used as an alternative to NSAIDs – especially for people who do not tolerate NSAID painkillers because of things like stomach problems or asthma. But higher doses of acetaminophen can cause liver and kidney damage. The package insert advises adults not to take more than 4 grams (4000 mg) per day. This is the amount in, for example, 8 tablets containing 500 milligrams each. It is not only important to take the right dose, but also to wait long enough between doses.
Opioids – Strong painkillers that may only be used under medical supervision. Opioids are available in many different strengths, and some are available in the form of a patch. Morphine, for example, is a very strong drug, while tramadol is a weaker opioid. These drugs may have a number of different side effects, some of which are serious. They range from nausea, vomiting and constipation to dizziness, breathing problems, and blood pressure fluctuation. Taking these drugs for a long time can lead to habitual use and physical dependence.
Skeletal Muscle relaxant – If muscle spasms are prominent, the addition of a muscle relaxant may merit consideration for a short period. For example, cyclobenzaprine is an option at a dose of 5 mg taken orally three times daily. Antidepressants (amitriptyline) and anticonvulsants (gabapentin and pregabalin) have been used to treat neuropathic pain, and they can provide a moderate analgesic effect.
Steroids – Anti-inflammatory drugs that can be used to treat various diseases systemically. That means that they are taken as tablets or injected. The drug spreads throughout the entire body to soothe inflammation and relieve pain. Steroids may increase the risk of gastric ulcers, osteoporosis, infections, skin problems, glaucoma, and glucose metabolism disorders.
Muscle relaxants – Sedatives which also relax the muscles. Like other psychotropic medications, they can cause fatigue and drowsiness, and affect your ability to drive. Muscle relaxants can also affect liver functions and cause gastro-intestinal complications. Drugs from the benzodiazepine group, such as tetrazepam, can lead to dependency if they are taken for longer than two weeks.
Anticonvulsants – These medications are typically used to treat epilepsy, but some are approved for treating nerve pain (neuralgia). Their side effects include drowsiness and fatigue. This can affect your ability to drive.
Antidepressants – These drugs are usually used for treating depression. Some of them are also approved for the treatment of pain. Possible side effects include nausea, dry mouth, low blood pressure, irregular heartbeat, and fatigue.
Topical Medications – These prescription-strength creams, gels, ointments, patches, and sprays help relieve pain and inflammation through the skin.
Calcium & vitamin D3 – to improve bone health and healing fracture. As a general rule, men and women age 50 and older should consume 1,200 milligrams of calcium a day, and 600 international units of vitamin D a day.
Glucosamine & Diacerein, Chondroitin sulfate – can be used to tightening the loose tension, cartilage, ligament, and cartilage, ligament regenerate cartilage or inhabit the further degeneration of cartilage, ligament
Injections near the spine – Injection therapy uses mostly local anesthetics and/or anti-inflammatory medications like corticosteroids (for example cortisone). These drugs are injected into the area immediately surrounding the affected nerve root. There are different ways of doing this:
In lumbar spinal nerve analgesia (LSPA) – the medication is injected directly at the point where the nerve root exits the spinal canal. This has a numbing effect on the nerve root.
In lumbar epidural analgesia – the medication is injected into what is known as the epidural space (“epidural injection”). The epidural space surrounds the spinal cord and the spinal fluid in the spinal canal. This is also where the nerve roots are located. During this treatment, the spine is monitored using computer tomography or X-rays to make sure that the injection is placed at exactly the right spot.
Interventional Treatments – Spinal steroid injections are a common alternative to surgery. Perineural injections (translaminar and transforaminal epidurals, selective nerve root blocks) are an option with pathological confirmation by MRI. These procedures should take place under radiologic guidance.[15]
Surgical
Brief Surgical Techniques
Total Disc Replacement (TDR) and Anterior Cervical Discectomy and Fusion (ACDF)
Surgical exposure of the desired vertebral level is achieved through an anterior cervical incision. Subcutaneous dissection is performed to allow for adequate mobilization to tissue incision. The discectomy is performed with pituitary rongeurs, curette, and a burr drill to remove affected disc.
The posterior longitudinal ligament can be left in situ depending on the severity of the herniation. The center of the disc is identified. A keel is made using the burr after which the disc is removed and disc replacement performed. A similar surgical method is used for anterior cervical discectomy and fusion, the difference is the type of implant, which can be an interbody cage with an anterior cervical plate or a standalone cage.
Laminectomy
A cervical laminectomy removes the lamina on one or both sides to increase the axial space available for the spinal cord. Clinically indicated for spinal stenosis or cervical disc disease involving more than three levels of disc degeneration with anterior spinal cord compression.
Single-level cervical disc herniation is usually managed with the anterior approach. The complications of the posterior approach include instability resulting in kyphosis, recalcitrant myofascial pain, and occipital headaches.
Laminoplasty
The kyphotic deformity is a well-known complication of laminectomy. To preserve the posterior wall of the spinal canal while decompressing the spinal canal a Z-plasty technique for the lamina was developed. The variant of the procedure uses a hinged door for the lamina.
Laminoplasty is commonly indicated for multilevel spondylotic myelopathy. Nerve root injury is seen in about 11% of the surgeries. This complication is unique to laminoplasty, and the suggested etiology is traction on the nerve root with the posterior migration of the spinal cord.
Interventional Treatments
Spinal steroid injections are a common alternative to surgery.
Perineural injections (translaminar and transforaminal epidurals, selective nerve root blocks) are an option with pathological confirmation by MRI. These procedures should take place under radiologic guidance.[rx]
In the past few years, neuromodulation techniques have been used to a large extent to manage radicular pain secondary to disc herniations.[rx]
These neuromodulatory techniques consist mainly of Spinal cord stimulation devices[rx] and Intrathecal pain pump.[rx] For patients who are not candidates for surgical intervention, these devices offer minimally invasive efficacious treatment options.
Complications
Complications from steroid injections are typically mild and range between 3% to 35% of cases. Other, more serious complications can include[5]:
Nerve injury
Infection
Epidural hematoma
Epidural abscess
Spinal cord infarction
Infection
Recurrent laryngeal, superior laryngeal, and hypoglossal nerve injuries
Posterior Cervical Disc Herniation/Herniated Cervical Disc (also called bulged, slipped or ruptured) is a fragment of the disc nucleus that is pushed out of the annulus, into the spinal canal through a tear or rupture in the annulus. Discs that become herniated usually are in an early stage of degeneration. The spinal canal has limited space, which is inadequate for the spinal nerve and the displaced herniated disc fragment. Due to this displacement, the disc presses on spinal nerves, often producing pain, which may be severe.
Types Of Cervical Disc Herniation
Doctors categorize slipped disks by severity
Disc Degeneration – Chemical changes associated with aging causes discs to weaken, but without a herniation.
Bulging disk – With age, the intervertebral disk may lose fluid and become dried out. As this happens, the spongy disk (which is located between the bony parts of the spine and acts as a “shock absorber”) becomes compressed. This may lead to the breakdown of the tough outer ring. This lets the nucleus, or the inside of the ring, to bulge out. This is called a bulging disk.
Protrusion –The disk bulges out between the vertebrae, but its outermost layer is still intact.
Extrusion – There is a tear in the outermost layer of the spinal disk, causing spinal disk tissue to spill out. But the tissue that has come out is still connected to the disk.
Sequestration – Spinal disk tissue has entered the spinal canal and is no longer directly attached to the disk.
Ruptured or herniated disk – As the disk continues to break down, or with continued stress on the spine, the inner nucleus pulposus may actually rupture out from the annulus. This is a ruptured, or herniated, disk. The fragments of disc material can then press on the nerve roots located just behind the disk space. This can cause pain, weakness, numbness, or changes in sensation.
Causes Of Posterior Cervical Disc Herniation
The differential diagnosis for lumbosacral radiculopathy should include (but is not limited to) the following
Degenerative conditions of the spine (most common causes)
Spondylolisthesis – in the degenerative setting, this occurs as a result of a pathologic cascade including intervertebral disc degeneration, ensuing intersegmental instability, and facet joint arthropathy
Spinal stenosis – It causes especially in older age in maximum people.
Adult isthmic spondylolisthesis – is typically caused by an acquired defect in the par interarticularis
Pars defects (i.e. spondylolysis) in adults are most often secondary to repetitive microtrauma.
Trauma (e.g. burst fractures with bony fragment retropulsion)
Clinicians should recognize spinal fractures can occur in younger, healthy patient populations secondary to high-energy injuries (e.g. MVA, fall from height) or secondary low energy injuries and spontaneous fractures in the elderly populations, including any patient with osteoporosis
Associated hemorrhage from the injury can result in a deteriorating clinical and neurologic exam.
Benign or malignant tumors
Metastatic tumors (most common)
Primary tumors
Ependymoma
Schwannoma
Neurofibroma
Lymphoma
Lipomas
Paraganglioma
Ganglioneuroma
Osteoblastoma
Infection
Osteodiscitis
Osteomyelitis
Epidural abscess
Fungal infections (e.g. Tuberculosis)
Other infections: lyme disease, HIV/AIDS-defining ilnesses, Herpes zoster (HZ)
History – Progressive motor/sensory loss, new urinary retention or incontinence, new fecal incontinence
Physical exam – Saddle anesthesia, anal sphincter atony, significant motor deficits of multiple myotomes
Fracture
History – Significant trauma (relative to age), Prolonged corticosteroid use, osteoporosis, and age greater than 70 years
Physical exam – Contusions, abrasions, tenderness to palpation over spinous processes
Infection
History – Spinal procedure within the last 12 months, Intravenous drug use, Immunosuppression, prior lumbar spine surgery
Physical exam – Fever, wound in the spinal region, localized pain, and tenderness
Malignancy
History – History of metastatic cancer, unexplained weight loss
Physical exam – Focal tenderness to palpation in the setting of risk factors
Symptoms Of Posterior Cervical Disc Herniation
The primary signs and symptoms of
LDH is radicular pain – sensory abnormalities, and weakness in the distribution of one or more lumbosacral nerve roots [rx, rx]. Focal paresis, restricted trunk flexion, and increases in leg pain with straining, coughing, and sneezing are also indicative [rx, rx]. Patients frequently report increased pain when sitting, which is known to increase disc pressure by nearly 40% [rx].
Pain that is relieved with sitting for forwarding flexion – is more consistent with lumbar spinal stenosis (LSS), as the latter motion increases disc pressure by 100–400% and would likely increase pain in isolated LDH [rx]. Rainville et al. recently compared signs of LDH with LSS and found that LSS patients are more likely to have increased medical comorbidities, lower levels of disability and leg pain, abnormal Achilles reflexes, and pain primarily in the posterior knee [rx].
Numbness or tingling – People who have a herniated disk often have radiating numbness or tingling in the body part served by the affected nerves.
Weakness – Muscles served by the affected nerves tend to weaken. This can cause you to stumble, or affect your ability to lift or hold items.
Pain in the neck, back, low back, arms, or legs
Inability to bend or rotate the neck or back
Numbness or tingling in the neck, shoulders, arms, hands, hips, legs, or feet
Weakness in the arms or legs
Limping when walking
Increased pain when coughing, sneezing, reaching, or sitting
Inability to stand up straight; being “stuck” in a position, such as stooped forward or leaning to the side
Difficulty getting up from a chair
Inability to remain in 1 position for a long period of time, such as sitting or standing, due to pain
Pain that is worse in the morning
This is a sharp, often shooting pain that extends from the buttock down the back of one leg. It is caused by pressure on the spinal nerve.
Numbness or a tingling sensation in the leg and/or foot
Weakness in the leg and/or foot
Loss of bladder or bowel control. This is extremely rare and may indicate a more serious problem called cauda equina syndrome. This condition is caused by the spinal nerve roots being compressed.
Diagnosis of Posterior Cervical Disc Herniation
Special Tests
Lasègue’s Test
Slump Test
Muscle Weakness or Paresis
Reflexes
Hyperextension Test The patient needs to passively mobilize the trunk over the full range of extension, while the knees stay extended. The test indicates that the radiant pain is caused by disc herniation if the pan deteriorates.
Manual Testing and Sensory Testing Look for hypoaesthesia, hypoalgesia, tingling, or numbness.
Physical Examination
The clinician should assess the patient’s range of motion (ROM), as this can indicate the severity of pain and degeneration. A thorough neurological examination is necessary to evaluate sensory disturbances, motor weakness, and deep tendon reflex abnormalities. Careful attention should also focus on any sign of spinal cord dysfunction.
Typical findings of solitary nerve lesions due to compression by a herniated disc in the cervical spine
C2 Nerve – eye or ear pain, headache. History of rheumatoid arthritis or atlantoaxial instability
C3, C4 Nerve – vague neck, and trapezial tenderness and muscle spasms
C5 Nerve – neck, shoulder, and scapula pain. Lateral arm paresthesia. Primary motions affected include shoulder abduction and elbow flexion. May also observe weakness with shoulder flexion, external rotation, and forearm supination. Diminished biceps reflex.
C6 Nerve – neck, shoulder, and scapula pain. Paresthesia of the lateral forearm, lateral hand, and lateral two digits. Primary motions affected include elbow flexion and wrist extension. May also observe weakness with shoulder abduction, external rotation, and forearm supination and pronation — diminished brachioradialis reflex.
C7 Nerve – neck and shoulder pain. Paresthesia of the posterior forearm and third digit. Primary motions affected include elbow extension and wrist flexion. Diminished triceps reflex
C8 Nerve – neck and shoulder pain. Paresthesia of the medial forearm, medial hand, and medial two digits. Weakness during finger flexion, handgrip, and thumb extension.
T1 Nerve – Neck and shoulder pain. Paresthesia of the medial forearm. A weakness of finger abduction and adduction.[rx]
Lab values
Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) – These are inflammatory markers that should be obtained If a chronic inflammatory condition is suspected (rheumatoid arthritis, polymyalgia rheumatic, seronegative spondyloarthropathy). These can also be beneficial if an infectious etiology is suspected.
Complete blood count (CBC) with differential – Useful to obtain in instances when infection or malignancy is suspected.
Radiological
Patients with equivocal studies may opt for a discography when conservative measures fail. Electrophysiological studies can be performed to evaluate and elucidate the nerve roots affected by injured cervical disc.[rx][rx]
X-ray – Plain radiography is an initial and inexpensive method of evaluating the cervical spine for an osseous injury. In chronic disc degeneration, decreased disc height and osteophytes can be seen. There is a higher incidence of cervical cord injury demonstrated with the use of plain radiographs in the assessment of cervical spine stenosis. The Torg ratio is the sagittal canal/vertebral body ratio measured on cervical spine lateral radiographs. The normal value is 1.0. A ratio of 0.8 and below has been considered indicative of cervical spinal stenosis.
MRI – Magnetic resonance imaging is the best modality to assess cord compression and disc herniation. T2 weighted views are preferred. Findings include decreased disc height, reduced signal intensity, and spondylotic osteophytes.
CT Scan – This imaging is the most sensitive test to examine the bony structures of the spine. It can also show calcified herniated discs or any insidious process that may result in bony loss or destruction. In patients that are unable to or are otherwise ineligible to undergo an MRI, CT myelography can be used as an alternative to visualize a herniated disc.
Electrodiagnostic testing – (Electromyography and nerve conduction studies) can be an option in patients that demonstrate equivocal symptoms or imaging findings as well as to rule out the presence of a peripheral mononeuropathy. The sensitivity of detecting cervical radiculopathy with electrodiagnostic testing ranges from 50% to 71%.[rx]
Treatment Posterior Cervical Disc Herniation
Patient Education
Use of hot or cold packs for comfort and to decreased inflammation
Avoidance of inciting activities or prolonged sitting/standing
Practicing good, erect posture
Engaging in exercises to increase core strength
Gentle stretching of the lumbar spine and hamstrings
Regular light exercises such as walking, swimming, or aromatherapy
Conservative Treatments – Acute cervical radiculopathies secondary to a herniated disc are typically managed with non-surgical treatments as the majority of patients (75 to 90%) will improve. Modalities that can be used include[rx][rx][rx]:
Collar Immobilization – In patients with acute neck pain, a short course (approximately one week) of collar immobilization may be beneficial during the acute inflammatory period.
Traction – May be beneficial in reducing the radicular symptoms associated with disc herniations. Theoretically, traction would widen the neuroforamen and relieve the stress placed on the affected nerve, which, in turn, would result in the improvement of symptoms. This therapy involves placing approximately 8 to 12 lbs of traction at an angle of approximately 24 degrees of neck flexion over a period of 15 to 20 minutes.
Physical Therapy – Commonly prescribed after a short period of rest and immobilization. Modalities include a range of motion exercises, strengthening exercises, ice, heat, ultrasound, and electrical stimulation therapy. Despite their frequent use, no evidence demonstrates their efficacy over placebo. However, there is no proven harm, and with a possible benefit, their use is recommended in the absence of myelopathy.
Cervical Manipulation – There is limited evidence suggesting that cervical manipulation may provide short-term benefits for neck pain and cervicogenic headaches. Complications from manipulation are rare and can include worsening radiculopathy, myelopathy, spinal cord injury, and vertebral artery injury. These complications occur ranging from 5 to 10 per 10 million manipulations.
Medication
Non-steroidal anti-inflammatory drugs (NSAIDs) – These painkillers belong to the same group of drugs as acetylsalicylic acid (ASA, the drug in medicines like “Aspirin”). NSAIDs that may be an option for the treatment of sciatica include diclofenac, ibuprofen, and naproxen. Anti-inflammatory drugs are drugs that reduce inflammation. This includes substances produced by the body itself like cortisone. It also includes artificial substances like ASA – acetylsalicylic acid (or “aspirin”) or ibuprofen –, which relieve pain and reduce fever as well as reducing inflammation.
Acetaminophen (paracetamol) – Acetaminophen (paracetamol) is also a painkiller, but it is not an NSAID. It is well tolerated and can be used as an alternative to NSAIDs – especially for people who do not tolerate NSAID painkillers because of things like stomach problems or asthma. But higher doses of acetaminophen can cause liver and kidney damage. The package insert advises adults not to take more than 4 grams (4000 mg) per day. This is the amount in, for example, 8 tablets containing 500 milligrams each. It is not only important to take the right dose, but also to wait long enough between doses.
Opioids – Strong painkillers that may only be used under medical supervision. Opioids are available in many different strengths, and some are available in the form of a patch. Morphine, for example, is a very strong drug, while tramadol is a weaker opioid. These drugs may have a number of different side effects, some of which are serious. They range from nausea, vomiting and constipation to dizziness, breathing problems, and blood pressure fluctuation. Taking these drugs for a long time can lead to habitual use and physical dependence.
Skeletal Muscle relaxant – If muscle spasms are prominent, the addition of a muscle relaxant may merit consideration for a short period. For example, cyclobenzaprine is an option at a dose of 5 mg taken orally three times daily. Antidepressants (amitriptyline) and anticonvulsants (gabapentin and pregabalin) have been used to treat neuropathic pain, and they can provide a moderate analgesic effect.
Steroids – Anti-inflammatory drugs that can be used to treat various diseases systemically. That means that they are taken as tablets or injected. The drug spreads throughout the entire body to soothe inflammation and relieve pain. Steroids may increase the risk of gastric ulcers, osteoporosis, infections, skin problems, glaucoma, and glucose metabolism disorders.
Muscle relaxants – Sedatives which also relax the muscles. Like other psychotropic medications, they can cause fatigue and drowsiness, and affect your ability to drive. Muscle relaxants can also affect liver functions and cause gastro-intestinal complications. Drugs from the benzodiazepine group, such as tetrazepam, can lead to dependency if they are taken for longer than two weeks.
Anticonvulsants – These medications are typically used to treat epilepsy, but some are approved for treating nerve pain (neuralgia). Their side effects include drowsiness and fatigue. This can affect your ability to drive.
Antidepressants – These drugs are usually used for treating depression. Some of them are also approved for the treatment of pain. Possible side effects include nausea, dry mouth, low blood pressure, irregular heartbeat, and fatigue.
Topical Medications – These prescription-strength creams, gels, ointments, patches, and sprays help relieve pain and inflammation through the skin.
Calcium & vitamin D3 – to improve bone health and healing fracture. As a general rule, men and women age 50 and older should consume 1,200 milligrams of calcium a day, and 600 international units of vitamin D a day.
Glucosamine & Diacerein, Chondroitin sulfate – can be used to tightening the loose tension, cartilage, ligament, and cartilage, ligament regenerate cartilage or inhabit the further degeneration of cartilage, ligament
Injections near the spine – Injection therapy uses mostly local anesthetics and/or anti-inflammatory medications like corticosteroids (for example cortisone). These drugs are injected into the area immediately surrounding the affected nerve root. There are different ways of doing this:
In lumbar spinal nerve analgesia (LSPA) – the medication is injected directly at the point where the nerve root exits the spinal canal. This has a numbing effect on the nerve root.
In lumbar epidural analgesia – the medication is injected into what is known as the epidural space (“epidural injection”). The epidural space surrounds the spinal cord and the spinal fluid in the spinal canal. This is also where the nerve roots are located. During this treatment, the spine is monitored using computer tomography or X-rays to make sure that the injection is placed at exactly the right spot.
Interventional Treatments – Spinal steroid injections are a common alternative to surgery. Perineural injections (translaminar and transforaminal epidurals, selective nerve root blocks) are an option with pathological confirmation by MRI. These procedures should take place under radiologic guidance.[15]
Surgical
Brief Surgical Techniques
Total Disc Replacement (TDR) and Anterior Cervical Discectomy and Fusion (ACDF)
Surgical exposure of the desired vertebral level is achieved through an anterior cervical incision. Subcutaneous dissection is performed to allow for adequate mobilization to tissue incision. The discectomy is performed with pituitary rongeurs, curette, and a burr drill to remove affected disc.
The posterior longitudinal ligament can be left in situ depending on the severity of the herniation. The center of the disc is identified. A keel is made using the burr after which the disc is removed and disc replacement performed. A similar surgical method is used for anterior cervical discectomy and fusion, the difference is the type of implant, which can be an interbody cage with an anterior cervical plate or a standalone cage.
Laminectomy
A cervical laminectomy removes the lamina on one or both sides to increase the axial space available for the spinal cord. Clinically indicated for spinal stenosis or cervical disc disease involving more than three levels of disc degeneration with anterior spinal cord compression.
Single-level cervical disc herniation is usually managed with the anterior approach. The complications of the posterior approach include instability resulting in kyphosis, recalcitrant myofascial pain, and occipital headaches.
Laminoplasty
The kyphotic deformity is a well-known complication of laminectomy. To preserve the posterior wall of the spinal canal while decompressing the spinal canal a Z-plasty technique for the lamina was developed. The variant of the procedure uses a hinged door for the lamina.
Laminoplasty is commonly indicated for multilevel spondylotic myelopathy. Nerve root injury is seen in about 11% of the surgeries. This complication is unique to laminoplasty, and the suggested etiology is traction on the nerve root with the posterior migration of the spinal cord.
Interventional Treatments
Spinal steroid injections are a common alternative to surgery.
Perineural injections (translaminar and transforaminal epidurals, selective nerve root blocks) are an option with pathological confirmation by MRI. These procedures should take place under radiologic guidance.[rx]
In the past few years, neuromodulation techniques have been used to a large extent to manage radicular pain secondary to disc herniations.[rx]
These neuromodulatory techniques consist mainly of Spinal cord stimulation devices[rx] and Intrathecal pain pump.[rx] For patients who are not candidates for surgical intervention, these devices offer minimally invasive efficacious treatment options.
Complications
Complications from steroid injections are typically mild and range between 3% to 35% of cases. Other, more serious complications can include[5]:
Nerve injury
Infection
Epidural hematoma
Epidural abscess
Spinal cord infarction
Infection
Recurrent laryngeal, superior laryngeal, and hypoglossal nerve injuries
Posterior Cervical Bulging Disc/Herniated Cervical Disc (also called bulged, slipped or ruptured) is a fragment of the disc nucleus that is pushed out of the annulus, into the spinal canal through a tear or rupture in the annulus. Discs that become herniated usually are in an early stage of degeneration. The spinal canal has limited space, which is inadequate for the spinal nerve and the displaced herniated disc fragment. Due to this displacement, the disc presses on spinal nerves, often producing pain, which may be severe.
Types Of Posterior Cervical Bulging Disc
Doctors categorize slipped disks by severity
Disc Degeneration – Chemical changes associated with aging causes discs to weaken, but without a herniation.
Bulging disk – With age, the intervertebral disk may lose fluid and become dried out. As this happens, the spongy disk (which is located between the bony parts of the spine and acts as a “shock absorber”) becomes compressed. This may lead to the breakdown of the tough outer ring. This lets the nucleus, or the inside of the ring, to bulge out. This is called a bulging disk.
Protrusion –The disk bulges out between the vertebrae, but its outermost layer is still intact.
Extrusion – There is a tear in the outermost layer of the spinal disk, causing spinal disk tissue to spill out. But the tissue that has come out is still connected to the disk.
Sequestration – Spinal disk tissue has entered the spinal canal and is no longer directly attached to the disk.
Ruptured or herniated disk – As the disk continues to break down, or with continued stress on the spine, the inner nucleus pulposus may actually rupture out from the annulus. This is a ruptured, or herniated, disk. The fragments of disc material can then press on the nerve roots located just behind the disk space. This can cause pain, weakness, numbness, or changes in sensation.
Causes Of Posterior Cervical Bulging Disc
The differential diagnosis for lumbosacral radiculopathy should include (but is not limited to) the following
Degenerative conditions of the spine (most common causes)
Spondylolisthesis – in the degenerative setting, this occurs as a result of a pathologic cascade including intervertebral disc degeneration, ensuing intersegmental instability, and facet joint arthropathy
Spinal stenosis – It causes especially in older age in maximum people.
Adult isthmic spondylolisthesis – is typically caused by an acquired defect in the par interarticularis
Pars defects (i.e. spondylolysis) in adults are most often secondary to repetitive microtrauma.
Trauma (e.g. burst fractures with bony fragment retropulsion)
Clinicians should recognize spinal fractures can occur in younger, healthy patient populations secondary to high-energy injuries (e.g. MVA, fall from height) or secondary low energy injuries and spontaneous fractures in the elderly populations, including any patient with osteoporosis
Associated hemorrhage from the injury can result in a deteriorating clinical and neurologic exam.
Benign or malignant tumors
Metastatic tumors (most common)
Primary tumors
Ependymoma
Schwannoma
Neurofibroma
Lymphoma
Lipomas
Paraganglioma
Ganglioneuroma
Osteoblastoma
Infection
Osteodiscitis
Osteomyelitis
Epidural abscess
Fungal infections (e.g. Tuberculosis)
Other infections: lyme disease, HIV/AIDS-defining ilnesses, Herpes zoster (HZ)
History – Progressive motor/sensory loss, new urinary retention or incontinence, new fecal incontinence
Physical exam – Saddle anesthesia, anal sphincter atony, significant motor deficits of multiple myotomes
Fracture
History – Significant trauma (relative to age), Prolonged corticosteroid use, osteoporosis, and age greater than 70 years
Physical exam – Contusions, abrasions, tenderness to palpation over spinous processes
Infection
History – Spinal procedure within the last 12 months, Intravenous drug use, Immunosuppression, prior lumbar spine surgery
Physical exam – Fever, wound in the spinal region, localized pain, and tenderness
Malignancy
History – History of metastatic cancer, unexplained weight loss
Physical exam – Focal tenderness to palpation in the setting of risk factors
Symptoms Of Posterior Cervical Bulging Disc
The primary signs and symptoms of
LDH is radicular pain – sensory abnormalities, and weakness in the distribution of one or more lumbosacral nerve roots [rx, rx]. Focal paresis, restricted trunk flexion, and increases in leg pain with straining, coughing, and sneezing are also indicative [rx, rx]. Patients frequently report increased pain when sitting, which is known to increase disc pressure by nearly 40% [rx].
Pain that is relieved with sitting for forwarding flexion – is more consistent with lumbar spinal stenosis (LSS), as the latter motion increases disc pressure by 100–400% and would likely increase pain in isolated LDH [rx]. Rainville et al. recently compared signs of LDH with LSS and found that LSS patients are more likely to have increased medical comorbidities, lower levels of disability and leg pain, abnormal Achilles reflexes, and pain primarily in the posterior knee [rx].
Numbness or tingling – People who have a herniated disk often have radiating numbness or tingling in the body part served by the affected nerves.
Weakness – Muscles served by the affected nerves tend to weaken. This can cause you to stumble, or affect your ability to lift or hold items.
Pain in the neck, back, low back, arms, or legs
Inability to bend or rotate the neck or back
Numbness or tingling in the neck, shoulders, arms, hands, hips, legs, or feet
Weakness in the arms or legs
Limping when walking
Increased pain when coughing, sneezing, reaching, or sitting
Inability to stand up straight; being “stuck” in a position, such as stooped forward or leaning to the side
Difficulty getting up from a chair
Inability to remain in 1 position for a long period of time, such as sitting or standing, due to pain
Pain that is worse in the morning
This is a sharp, often shooting pain that extends from the buttock down the back of one leg. It is caused by pressure on the spinal nerve.
Numbness or a tingling sensation in the leg and/or foot
Weakness in the leg and/or foot
Loss of bladder or bowel control. This is extremely rare and may indicate a more serious problem called cauda equina syndrome. This condition is caused by the spinal nerve roots being compressed.
Diagnosis of Posterior Cervical Bulging Disc
Special Tests
Lasègue’s Test
Slump Test
Muscle Weakness or Paresis
Reflexes
Hyperextension Test The patient needs to passively mobilize the trunk over the full range of extension, while the knees stay extended. The test indicates that the radiant pain is caused by disc herniation if the pan deteriorates.
Manual Testing and Sensory Testing Look for hypoaesthesia, hypoalgesia, tingling, or numbness.
Physical Examination
The clinician should assess the patient’s range of motion (ROM), as this can indicate the severity of pain and degeneration. A thorough neurological examination is necessary to evaluate sensory disturbances, motor weakness, and deep tendon reflex abnormalities. Careful attention should also focus on any sign of spinal cord dysfunction.
Typical findings of solitary nerve lesions due to compression by a herniated disc in the cervical spine
C2 Nerve – eye or ear pain, headache. History of rheumatoid arthritis or atlantoaxial instability
C3, C4 Nerve – vague neck, and trapezial tenderness and muscle spasms
C5 Nerve – neck, shoulder, and scapula pain. Lateral arm paresthesia. Primary motions affected include shoulder abduction and elbow flexion. May also observe weakness with shoulder flexion, external rotation, and forearm supination. Diminished biceps reflex.
C6 Nerve – neck, shoulder, and scapula pain. Paresthesia of the lateral forearm, lateral hand, and lateral two digits. Primary motions affected include elbow flexion and wrist extension. May also observe weakness with shoulder abduction, external rotation, and forearm supination and pronation — diminished brachioradialis reflex.
C7 Nerve – neck and shoulder pain. Paresthesia of the posterior forearm and third digit. Primary motions affected include elbow extension and wrist flexion. Diminished triceps reflex
C8 Nerve – neck and shoulder pain. Paresthesia of the medial forearm, medial hand, and medial two digits. Weakness during finger flexion, handgrip, and thumb extension.
T1 Nerve – Neck and shoulder pain. Paresthesia of the medial forearm. A weakness of finger abduction and adduction.[rx]
Lab values
Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) – These are inflammatory markers that should be obtained If a chronic inflammatory condition is suspected (rheumatoid arthritis, polymyalgia rheumatic, seronegative spondyloarthropathy). These can also be beneficial if an infectious etiology is suspected.
Complete blood count (CBC) with differential – Useful to obtain in instances when infection or malignancy is suspected.
Radiological
Patients with equivocal studies may opt for a discography when conservative measures fail. Electrophysiological studies can be performed to evaluate and elucidate the nerve roots affected by injured cervical disc.[rx][rx]
X-ray – Plain radiography is an initial and inexpensive method of evaluating the cervical spine for an osseous injury. In chronic disc degeneration, decreased disc height and osteophytes can be seen. There is a higher incidence of cervical cord injury demonstrated with the use of plain radiographs in the assessment of cervical spine stenosis. The Torg ratio is the sagittal canal/vertebral body ratio measured on cervical spine lateral radiographs. The normal value is 1.0. A ratio of 0.8 and below has been considered indicative of cervical spinal stenosis.
MRI – Magnetic resonance imaging is the best modality to assess cord compression and disc herniation. T2 weighted views are preferred. Findings include decreased disc height, reduced signal intensity, and spondylotic osteophytes.
CT Scan – This imaging is the most sensitive test to examine the bony structures of the spine. It can also show calcified herniated discs or any insidious process that may result in bony loss or destruction. In patients that are unable to or are otherwise ineligible to undergo an MRI, CT myelography can be used as an alternative to visualize a herniated disc.
Electrodiagnostic testing – (Electromyography and nerve conduction studies) can be an option in patients that demonstrate equivocal symptoms or imaging findings as well as to rule out the presence of a peripheral mononeuropathy. The sensitivity of detecting cervical radiculopathy with electrodiagnostic testing ranges from 50% to 71%.[rx]
Treatment Posterior Cervical Bulging Disc
Patient Education
Use of hot or cold packs for comfort and to decreased inflammation
Avoidance of inciting activities or prolonged sitting/standing
Practicing good, erect posture
Engaging in exercises to increase core strength
Gentle stretching of the lumbar spine and hamstrings
Regular light exercises such as walking, swimming, or aromatherapy
Conservative Treatments – Acute cervical radiculopathies secondary to a herniated disc are typically managed with non-surgical treatments as the majority of patients (75 to 90%) will improve. Modalities that can be used include[rx][rx][rx]:
Collar Immobilization – In patients with acute neck pain, a short course (approximately one week) of collar immobilization may be beneficial during the acute inflammatory period.
Traction – May be beneficial in reducing the radicular symptoms associated with disc herniations. Theoretically, traction would widen the neuroforamen and relieve the stress placed on the affected nerve, which, in turn, would result in the improvement of symptoms. This therapy involves placing approximately 8 to 12 lbs of traction at an angle of approximately 24 degrees of neck flexion over a period of 15 to 20 minutes.
Physical Therapy – Commonly prescribed after a short period of rest and immobilization. Modalities include a range of motion exercises, strengthening exercises, ice, heat, ultrasound, and electrical stimulation therapy. Despite their frequent use, no evidence demonstrates their efficacy over placebo. However, there is no proven harm, and with a possible benefit, their use is recommended in the absence of myelopathy.
Cervical Manipulation – There is limited evidence suggesting that cervical manipulation may provide short-term benefits for neck pain and cervicogenic headaches. Complications from manipulation are rare and can include worsening radiculopathy, myelopathy, spinal cord injury, and vertebral artery injury. These complications occur ranging from 5 to 10 per 10 million manipulations.
Medication
Non-steroidal anti-inflammatory drugs (NSAIDs) – These painkillers belong to the same group of drugs as acetylsalicylic acid (ASA, the drug in medicines like “Aspirin”). NSAIDs that may be an option for the treatment of sciatica include diclofenac, ibuprofen, and naproxen. Anti-inflammatory drugs are drugs that reduce inflammation. This includes substances produced by the body itself like cortisone. It also includes artificial substances like ASA – acetylsalicylic acid (or “aspirin”) or ibuprofen –, which relieve pain and reduce fever as well as reducing inflammation.
Acetaminophen (paracetamol) – Acetaminophen (paracetamol) is also a painkiller, but it is not an NSAID. It is well tolerated and can be used as an alternative to NSAIDs – especially for people who do not tolerate NSAID painkillers because of things like stomach problems or asthma. But higher doses of acetaminophen can cause liver and kidney damage. The package insert advises adults not to take more than 4 grams (4000 mg) per day. This is the amount in, for example, 8 tablets containing 500 milligrams each. It is not only important to take the right dose, but also to wait long enough between doses.
Opioids – Strong painkillers that may only be used under medical supervision. Opioids are available in many different strengths, and some are available in the form of a patch. Morphine, for example, is a very strong drug, while tramadol is a weaker opioid. These drugs may have a number of different side effects, some of which are serious. They range from nausea, vomiting and constipation to dizziness, breathing problems, and blood pressure fluctuation. Taking these drugs for a long time can lead to habitual use and physical dependence.
Skeletal Muscle relaxant – If muscle spasms are prominent, the addition of a muscle relaxant may merit consideration for a short period. For example, cyclobenzaprine is an option at a dose of 5 mg taken orally three times daily. Antidepressants (amitriptyline) and anticonvulsants (gabapentin and pregabalin) have been used to treat neuropathic pain, and they can provide a moderate analgesic effect.
Steroids – Anti-inflammatory drugs that can be used to treat various diseases systemically. That means that they are taken as tablets or injected. The drug spreads throughout the entire body to soothe inflammation and relieve pain. Steroids may increase the risk of gastric ulcers, osteoporosis, infections, skin problems, glaucoma, and glucose metabolism disorders.
Muscle relaxants – Sedatives which also relax the muscles. Like other psychotropic medications, they can cause fatigue and drowsiness, and affect your ability to drive. Muscle relaxants can also affect liver functions and cause gastro-intestinal complications. Drugs from the benzodiazepine group, such as tetrazepam, can lead to dependency if they are taken for longer than two weeks.
Anticonvulsants – These medications are typically used to treat epilepsy, but some are approved for treating nerve pain (neuralgia). Their side effects include drowsiness and fatigue. This can affect your ability to drive.
Antidepressants – These drugs are usually used for treating depression. Some of them are also approved for the treatment of pain. Possible side effects include nausea, dry mouth, low blood pressure, irregular heartbeat, and fatigue.
Topical Medications – These prescription-strength creams, gels, ointments, patches, and sprays help relieve pain and inflammation through the skin.
Calcium & vitamin D3 – to improve bone health and healing fracture. As a general rule, men and women age 50 and older should consume 1,200 milligrams of calcium a day, and 600 international units of vitamin D a day.
Glucosamine & Diacerein, Chondroitin sulfate – can be used to tightening the loose tension, cartilage, ligament, and cartilage, ligament regenerate cartilage or inhabit the further degeneration of cartilage, ligament
Injections near the spine – Injection therapy uses mostly local anesthetics and/or anti-inflammatory medications like corticosteroids (for example cortisone). These drugs are injected into the area immediately surrounding the affected nerve root. There are different ways of doing this:
In lumbar spinal nerve analgesia (LSPA) – the medication is injected directly at the point where the nerve root exits the spinal canal. This has a numbing effect on the nerve root.
In lumbar epidural analgesia – the medication is injected into what is known as the epidural space (“epidural injection”). The epidural space surrounds the spinal cord and the spinal fluid in the spinal canal. This is also where the nerve roots are located. During this treatment, the spine is monitored using computer tomography or X-rays to make sure that the injection is placed at exactly the right spot.
Interventional Treatments – Spinal steroid injections are a common alternative to surgery. Perineural injections (translaminar and transforaminal epidurals, selective nerve root blocks) are an option with pathological confirmation by MRI. These procedures should take place under radiologic guidance.[15]
Surgical
Brief Surgical Techniques
Total Disc Replacement (TDR) and Anterior Cervical Discectomy and Fusion (ACDF)
Surgical exposure of the desired vertebral level is achieved through an anterior cervical incision. Subcutaneous dissection is performed to allow for adequate mobilization to tissue incision. The discectomy is performed with pituitary rongeurs, curette, and a burr drill to remove affected disc.
The posterior longitudinal ligament can be left in situ depending on the severity of the herniation. The center of the disc is identified. A keel is made using the burr after which the disc is removed and disc replacement performed. A similar surgical method is used for anterior cervical discectomy and fusion, the difference is the type of implant, which can be an interbody cage with an anterior cervical plate or a standalone cage.
Laminectomy
A cervical laminectomy removes the lamina on one or both sides to increase the axial space available for the spinal cord. Clinically indicated for spinal stenosis or cervical disc disease involving more than three levels of disc degeneration with anterior spinal cord compression.
Single-level cervical disc herniation is usually managed with the anterior approach. The complications of the posterior approach include instability resulting in kyphosis, recalcitrant myofascial pain, and occipital headaches.
Laminoplasty
The kyphotic deformity is a well-known complication of laminectomy. To preserve the posterior wall of the spinal canal while decompressing the spinal canal a Z-plasty technique for the lamina was developed. The variant of the procedure uses a hinged door for the lamina.
Laminoplasty is commonly indicated for multilevel spondylotic myelopathy. Nerve root injury is seen in about 11% of the surgeries. This complication is unique to laminoplasty, and the suggested etiology is traction on the nerve root with the posterior migration of the spinal cord.
Interventional Treatments
Spinal steroid injections are a common alternative to surgery.
Perineural injections (translaminar and transforaminal epidurals, selective nerve root blocks) are an option with pathological confirmation by MRI. These procedures should take place under radiologic guidance.[rx]
In the past few years, neuromodulation techniques have been used to a large extent to manage radicular pain secondary to disc herniations.[rx]
These neuromodulatory techniques consist mainly of Spinal cord stimulation devices[rx] and Intrathecal pain pump.[rx] For patients who are not candidates for surgical intervention, these devices offer minimally invasive efficacious treatment options.
Complications
Complications from steroid injections are typically mild and range between 3% to 35% of cases. Other, more serious complications can include[5]:
Nerve injury
Infection
Epidural hematoma
Epidural abscess
Spinal cord infarction
Infection
Recurrent laryngeal, superior laryngeal, and hypoglossal nerve injuries
Cervical Bulging Disc /Herniated Cervical Disc (also called bulged, slipped or ruptured) is a fragment of the disc nucleus that is pushed out of the annulus, into the spinal canal through a tear or rupture in the annulus. Discs that become herniated usually are in an early stage of degeneration. The spinal canal has limited space, which is inadequate for the spinal nerve and the displaced herniated disc fragment. Due to this displacement, the disc presses on spinal nerves, often producing pain, which may be severe.
Types Of Cervical Bulging Disc
Doctors categorize slipped disks by severity
Disc Degeneration – Chemical changes associated with aging causes discs to weaken, but without a herniation.
Bulging disk – With age, the intervertebral disk may lose fluid and become dried out. As this happens, the spongy disk (which is located between the bony parts of the spine and acts as a “shock absorber”) becomes compressed. This may lead to the breakdown of the tough outer ring. This lets the nucleus, or the inside of the ring, to bulge out. This is called a bulging disk.
Protrusion –The disk bulges out between the vertebrae, but its outermost layer is still intact.
Extrusion – There is a tear in the outermost layer of the spinal disk, causing spinal disk tissue to spill out. But the tissue that has come out is still connected to the disk.
Sequestration – Spinal disk tissue has entered the spinal canal and is no longer directly attached to the disk.
Ruptured or herniated disk – As the disk continues to break down, or with continued stress on the spine, the inner nucleus pulposus may actually rupture out from the annulus. This is a ruptured, or herniated, disk. The fragments of disc material can then press on the nerve roots located just behind the disk space. This can cause pain, weakness, numbness, or changes in sensation.
Causes Of Cervical Bulging Disc
The differential diagnosis for lumbosacral radiculopathy should include (but is not limited to) the following
Degenerative conditions of the spine (most common causes)
Spondylolisthesis – in the degenerative setting, this occurs as a result of a pathologic cascade including intervertebral disc degeneration, ensuing intersegmental instability, and facet joint arthropathy
Spinal stenosis – It causes especially in older age in maximum people.
Adult isthmic spondylolisthesis – is typically caused by an acquired defect in the par interarticularis
Pars defects (i.e. spondylolysis) in adults are most often secondary to repetitive microtrauma.
Trauma (e.g. burst fractures with bony fragment retropulsion)
Clinicians should recognize spinal fractures can occur in younger, healthy patient populations secondary to high-energy injuries (e.g. MVA, fall from height) or secondary low energy injuries and spontaneous fractures in the elderly populations, including any patient with osteoporosis
Associated hemorrhage from the injury can result in a deteriorating clinical and neurologic exam.
Benign or malignant tumors
Metastatic tumors (most common)
Primary tumors
Ependymoma
Schwannoma
Neurofibroma
Lymphoma
Lipomas
Paraganglioma
Ganglioneuroma
Osteoblastoma
Infection
Osteodiscitis
Osteomyelitis
Epidural abscess
Fungal infections (e.g. Tuberculosis)
Other infections: lyme disease, HIV/AIDS-defining ilnesses, Herpes zoster (HZ)
History – Progressive motor/sensory loss, new urinary retention or incontinence, new fecal incontinence
Physical exam – Saddle anesthesia, anal sphincter atony, significant motor deficits of multiple myotomes
Fracture
History – Significant trauma (relative to age), Prolonged corticosteroid use, osteoporosis, and age greater than 70 years
Physical exam – Contusions, abrasions, tenderness to palpation over spinous processes
Infection
History – Spinal procedure within the last 12 months, Intravenous drug use, Immunosuppression, prior lumbar spine surgery
Physical exam – Fever, wound in the spinal region, localized pain, and tenderness
Malignancy
History – History of metastatic cancer, unexplained weight loss
Physical exam – Focal tenderness to palpation in the setting of risk factors
Symptoms Of Cervical Bulging Disc
The primary signs and symptoms of
LDH is radicular pain – sensory abnormalities, and weakness in the distribution of one or more lumbosacral nerve roots [rx, rx]. Focal paresis, restricted trunk flexion, and increases in leg pain with straining, coughing, and sneezing are also indicative [rx, rx]. Patients frequently report increased pain when sitting, which is known to increase disc pressure by nearly 40% [rx].
Pain that is relieved with sitting for forwarding flexion – is more consistent with lumbar spinal stenosis (LSS), as the latter motion increases disc pressure by 100–400% and would likely increase pain in isolated LDH [rx]. Rainville et al. recently compared signs of LDH with LSS and found that LSS patients are more likely to have increased medical comorbidities, lower levels of disability and leg pain, abnormal Achilles reflexes, and pain primarily in the posterior knee [rx].
Numbness or tingling – People who have a herniated disk often have radiating numbness or tingling in the body part served by the affected nerves.
Weakness – Muscles served by the affected nerves tend to weaken. This can cause you to stumble, or affect your ability to lift or hold items.
Pain in the neck, back, low back, arms, or legs
Inability to bend or rotate the neck or back
Numbness or tingling in the neck, shoulders, arms, hands, hips, legs, or feet
Weakness in the arms or legs
Limping when walking
Increased pain when coughing, sneezing, reaching, or sitting
Inability to stand up straight; being “stuck” in a position, such as stooped forward or leaning to the side
Difficulty getting up from a chair
Inability to remain in 1 position for a long period of time, such as sitting or standing, due to pain
Pain that is worse in the morning
This is a sharp, often shooting pain that extends from the buttock down the back of one leg. It is caused by pressure on the spinal nerve.
Numbness or a tingling sensation in the leg and/or foot
Weakness in the leg and/or foot
Loss of bladder or bowel control. This is extremely rare and may indicate a more serious problem called cauda equina syndrome. This condition is caused by the spinal nerve roots being compressed.
Diagnosis of Cervical Bulging Disc
Special Tests
Lasègue’s Test
Slump Test
Muscle Weakness or Paresis
Reflexes
Hyperextension Test The patient needs to passively mobilize the trunk over the full range of extension, while the knees stay extended. The test indicates that the radiant pain is caused by disc herniation if the pan deteriorates.
Manual Testing and Sensory Testing Look for hypoaesthesia, hypoalgesia, tingling, or numbness.
Physical Examination
The clinician should assess the patient’s range of motion (ROM), as this can indicate the severity of pain and degeneration. A thorough neurological examination is necessary to evaluate sensory disturbances, motor weakness, and deep tendon reflex abnormalities. Careful attention should also focus on any sign of spinal cord dysfunction.
Typical findings of solitary nerve lesions due to compression by a herniated disc in the cervical spine
C2 Nerve – eye or ear pain, headache. History of rheumatoid arthritis or atlantoaxial instability
C3, C4 Nerve – vague neck, and trapezial tenderness and muscle spasms
C5 Nerve – neck, shoulder, and scapula pain. Lateral arm paresthesia. Primary motions affected include shoulder abduction and elbow flexion. May also observe weakness with shoulder flexion, external rotation, and forearm supination. Diminished biceps reflex.
C6 Nerve – neck, shoulder, and scapula pain. Paresthesia of the lateral forearm, lateral hand, and lateral two digits. Primary motions affected include elbow flexion and wrist extension. May also observe weakness with shoulder abduction, external rotation, and forearm supination and pronation — diminished brachioradialis reflex.
C7 Nerve – neck and shoulder pain. Paresthesia of the posterior forearm and third digit. Primary motions affected include elbow extension and wrist flexion. Diminished triceps reflex
C8 Nerve – neck and shoulder pain. Paresthesia of the medial forearm, medial hand, and medial two digits. Weakness during finger flexion, handgrip, and thumb extension.
T1 Nerve – Neck and shoulder pain. Paresthesia of the medial forearm. A weakness of finger abduction and adduction.[rx]
Lab values
Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) – These are inflammatory markers that should be obtained If a chronic inflammatory condition is suspected (rheumatoid arthritis, polymyalgia rheumatic, seronegative spondyloarthropathy). These can also be beneficial if an infectious etiology is suspected.
Complete blood count (CBC) with differential – Useful to obtain in instances when infection or malignancy is suspected.
Radiological
Patients with equivocal studies may opt for a discography when conservative measures fail. Electrophysiological studies can be performed to evaluate and elucidate the nerve roots affected by injured cervical disc.[rx][rx]
X-ray – Plain radiography is an initial and inexpensive method of evaluating the cervical spine for an osseous injury. In chronic disc degeneration, decreased disc height and osteophytes can be seen. There is a higher incidence of cervical cord injury demonstrated with the use of plain radiographs in the assessment of cervical spine stenosis. The Torg ratio is the sagittal canal/vertebral body ratio measured on cervical spine lateral radiographs. The normal value is 1.0. A ratio of 0.8 and below has been considered indicative of cervical spinal stenosis.
MRI – Magnetic resonance imaging is the best modality to assess cord compression and disc herniation. T2 weighted views are preferred. Findings include decreased disc height, reduced signal intensity, and spondylotic osteophytes.
CT Scan – This imaging is the most sensitive test to examine the bony structures of the spine. It can also show calcified herniated discs or any insidious process that may result in bony loss or destruction. In patients that are unable to or are otherwise ineligible to undergo an MRI, CT myelography can be used as an alternative to visualize a herniated disc.
Electrodiagnostic testing – (Electromyography and nerve conduction studies) can be an option in patients that demonstrate equivocal symptoms or imaging findings as well as to rule out the presence of a peripheral mononeuropathy. The sensitivity of detecting cervical radiculopathy with electrodiagnostic testing ranges from 50% to 71%.[rx]
Treatment Cervical Bulging Disc
Patient Education
Use of hot or cold packs for comfort and to decreased inflammation
Avoidance of inciting activities or prolonged sitting/standing
Practicing good, erect posture
Engaging in exercises to increase core strength
Gentle stretching of the lumbar spine and hamstrings
Regular light exercises such as walking, swimming, or aromatherapy
Conservative Treatments – Acute cervical radiculopathies secondary to a herniated disc are typically managed with non-surgical treatments as the majority of patients (75 to 90%) will improve. Modalities that can be used include[rx][rx][rx]:
Collar Immobilization – In patients with acute neck pain, a short course (approximately one week) of collar immobilization may be beneficial during the acute inflammatory period.
Traction – May be beneficial in reducing the radicular symptoms associated with disc herniations. Theoretically, traction would widen the neuroforamen and relieve the stress placed on the affected nerve, which, in turn, would result in the improvement of symptoms. This therapy involves placing approximately 8 to 12 lbs of traction at an angle of approximately 24 degrees of neck flexion over a period of 15 to 20 minutes.
Physical Therapy – Commonly prescribed after a short period of rest and immobilization. Modalities include a range of motion exercises, strengthening exercises, ice, heat, ultrasound, and electrical stimulation therapy. Despite their frequent use, no evidence demonstrates their efficacy over placebo. However, there is no proven harm, and with a possible benefit, their use is recommended in the absence of myelopathy.
Cervical Manipulation – There is limited evidence suggesting that cervical manipulation may provide short-term benefits for neck pain and cervicogenic headaches. Complications from manipulation are rare and can include worsening radiculopathy, myelopathy, spinal cord injury, and vertebral artery injury. These complications occur ranging from 5 to 10 per 10 million manipulations.
Medication
Non-steroidal anti-inflammatory drugs (NSAIDs) – These painkillers belong to the same group of drugs as acetylsalicylic acid (ASA, the drug in medicines like “Aspirin”). NSAIDs that may be an option for the treatment of sciatica include diclofenac, ibuprofen, and naproxen. Anti-inflammatory drugs are drugs that reduce inflammation. This includes substances produced by the body itself like cortisone. It also includes artificial substances like ASA – acetylsalicylic acid (or “aspirin”) or ibuprofen –, which relieve pain and reduce fever as well as reducing inflammation.
Acetaminophen (paracetamol) – Acetaminophen (paracetamol) is also a painkiller, but it is not an NSAID. It is well tolerated and can be used as an alternative to NSAIDs – especially for people who do not tolerate NSAID painkillers because of things like stomach problems or asthma. But higher doses of acetaminophen can cause liver and kidney damage. The package insert advises adults not to take more than 4 grams (4000 mg) per day. This is the amount in, for example, 8 tablets containing 500 milligrams each. It is not only important to take the right dose, but also to wait long enough between doses.
Opioids – Strong painkillers that may only be used under medical supervision. Opioids are available in many different strengths, and some are available in the form of a patch. Morphine, for example, is a very strong drug, while tramadol is a weaker opioid. These drugs may have a number of different side effects, some of which are serious. They range from nausea, vomiting and constipation to dizziness, breathing problems, and blood pressure fluctuation. Taking these drugs for a long time can lead to habitual use and physical dependence.
Skeletal Muscle relaxant – If muscle spasms are prominent, the addition of a muscle relaxant may merit consideration for a short period. For example, cyclobenzaprine is an option at a dose of 5 mg taken orally three times daily. Antidepressants (amitriptyline) and anticonvulsants (gabapentin and pregabalin) have been used to treat neuropathic pain, and they can provide a moderate analgesic effect.
Steroids – Anti-inflammatory drugs that can be used to treat various diseases systemically. That means that they are taken as tablets or injected. The drug spreads throughout the entire body to soothe inflammation and relieve pain. Steroids may increase the risk of gastric ulcers, osteoporosis, infections, skin problems, glaucoma, and glucose metabolism disorders.
Muscle relaxants – Sedatives which also relax the muscles. Like other psychotropic medications, they can cause fatigue and drowsiness, and affect your ability to drive. Muscle relaxants can also affect liver functions and cause gastro-intestinal complications. Drugs from the benzodiazepine group, such as tetrazepam, can lead to dependency if they are taken for longer than two weeks.
Anticonvulsants – These medications are typically used to treat epilepsy, but some are approved for treating nerve pain (neuralgia). Their side effects include drowsiness and fatigue. This can affect your ability to drive.
Antidepressants – These drugs are usually used for treating depression. Some of them are also approved for the treatment of pain. Possible side effects include nausea, dry mouth, low blood pressure, irregular heartbeat, and fatigue.
Topical Medications – These prescription-strength creams, gels, ointments, patches, and sprays help relieve pain and inflammation through the skin.
Calcium & vitamin D3 – to improve bone health and healing fracture. As a general rule, men and women age 50 and older should consume 1,200 milligrams of calcium a day, and 600 international units of vitamin D a day.
Glucosamine & Diacerein, Chondroitin sulfate – can be used to tightening the loose tension, cartilage, ligament, and cartilage, ligament regenerate cartilage or inhabit the further degeneration of cartilage, ligament
Injections near the spine – Injection therapy uses mostly local anesthetics and/or anti-inflammatory medications like corticosteroids (for example cortisone). These drugs are injected into the area immediately surrounding the affected nerve root. There are different ways of doing this:
In lumbar spinal nerve analgesia (LSPA) – the medication is injected directly at the point where the nerve root exits the spinal canal. This has a numbing effect on the nerve root.
In lumbar epidural analgesia – the medication is injected into what is known as the epidural space (“epidural injection”). The epidural space surrounds the spinal cord and the spinal fluid in the spinal canal. This is also where the nerve roots are located. During this treatment, the spine is monitored using computer tomography or X-rays to make sure that the injection is placed at exactly the right spot.
Interventional Treatments – Spinal steroid injections are a common alternative to surgery. Perineural injections (translaminar and transforaminal epidurals, selective nerve root blocks) are an option with pathological confirmation by MRI. These procedures should take place under radiologic guidance.[15]
Surgical
Brief Surgical Techniques
Total Disc Replacement (TDR) and Anterior Cervical Discectomy and Fusion (ACDF)
Surgical exposure of the desired vertebral level is achieved through an anterior cervical incision. Subcutaneous dissection is performed to allow for adequate mobilization to tissue incision. The discectomy is performed with pituitary rongeurs, curette, and a burr drill to remove affected disc.
The posterior longitudinal ligament can be left in situ depending on the severity of the herniation. The center of the disc is identified. A keel is made using the burr after which the disc is removed and disc replacement performed. A similar surgical method is used for anterior cervical discectomy and fusion, the difference is the type of implant, which can be an interbody cage with an anterior cervical plate or a standalone cage.
Laminectomy
A cervical laminectomy removes the lamina on one or both sides to increase the axial space available for the spinal cord. Clinically indicated for spinal stenosis or cervical disc disease involving more than three levels of disc degeneration with anterior spinal cord compression.
Single-level cervical disc herniation is usually managed with the anterior approach. The complications of the posterior approach include instability resulting in kyphosis, recalcitrant myofascial pain, and occipital headaches.
Laminoplasty
The kyphotic deformity is a well-known complication of laminectomy. To preserve the posterior wall of the spinal canal while decompressing the spinal canal a Z-plasty technique for the lamina was developed. The variant of the procedure uses a hinged door for the lamina.
Laminoplasty is commonly indicated for multilevel spondylotic myelopathy. Nerve root injury is seen in about 11% of the surgeries. This complication is unique to laminoplasty, and the suggested etiology is traction on the nerve root with the posterior migration of the spinal cord.
Interventional Treatments
Spinal steroid injections are a common alternative to surgery.
Perineural injections (translaminar and transforaminal epidurals, selective nerve root blocks) are an option with pathological confirmation by MRI. These procedures should take place under radiologic guidance.[rx]
In the past few years, neuromodulation techniques have been used to a large extent to manage radicular pain secondary to disc herniations.[rx]
These neuromodulatory techniques consist mainly of Spinal cord stimulation devices[rx] and Intrathecal pain pump.[rx] For patients who are not candidates for surgical intervention, these devices offer minimally invasive efficacious treatment options.
Complications
Complications from steroid injections are typically mild and range between 3% to 35% of cases. Other, more serious complications can include[5]:
Nerve injury
Infection
Epidural hematoma
Epidural abscess
Spinal cord infarction
Infection
Recurrent laryngeal, superior laryngeal, and hypoglossal nerve injuries
Herniated Cervical Disc (also called bulged, slipped or ruptured) is a fragment of the disc nucleus that is pushed out of the annulus, into the spinal canal through a tear or rupture in the annulus. Discs that become herniated usually are in an early stage of degeneration. The spinal canal has limited space, which is inadequate for the spinal nerve and the displaced herniated disc fragment. Due to this displacement, the disc presses on spinal nerves, often producing pain, which may be severe.
Types Of Herniated Cervical Disc
Doctors categorize slipped disks by severity
Disc Degeneration – Chemical changes associated with aging causes discs to weaken, but without a herniation.
Bulging disk – With age, the intervertebral disk may lose fluid and become dried out. As this happens, the spongy disk (which is located between the bony parts of the spine and acts as a “shock absorber”) becomes compressed. This may lead to the breakdown of the tough outer ring. This lets the nucleus, or the inside of the ring, to bulge out. This is called a bulging disk.
Protrusion –The disk bulges out between the vertebrae, but its outermost layer is still intact.
Extrusion – There is a tear in the outermost layer of the spinal disk, causing spinal disk tissue to spill out. But the tissue that has come out is still connected to the disk.
Sequestration – Spinal disk tissue has entered the spinal canal and is no longer directly attached to the disk.
Ruptured or herniated disk – As the disk continues to break down, or with continued stress on the spine, the inner nucleus pulposus may actually rupture out from the annulus. This is a ruptured, or herniated, disk. The fragments of disc material can then press on the nerve roots located just behind the disk space. This can cause pain, weakness, numbness, or changes in sensation.
Causes Of Herniated Cervical Disc
The differential diagnosis for lumbosacral radiculopathy should include (but is not limited to) the following
Degenerative conditions of the spine (most common causes)
Spondylolisthesis – in the degenerative setting, this occurs as a result of a pathologic cascade including intervertebral disc degeneration, ensuing intersegmental instability, and facet joint arthropathy
Spinal stenosis – It causes especially in older age in maximum people.
Adult isthmic spondylolisthesis – is typically caused by an acquired defect in the par interarticularis
Pars defects (i.e. spondylolysis) in adults are most often secondary to repetitive microtrauma.
Trauma (e.g. burst fractures with bony fragment retropulsion)
Clinicians should recognize spinal fractures can occur in younger, healthy patient populations secondary to high-energy injuries (e.g. MVA, fall from height) or secondary low energy injuries and spontaneous fractures in the elderly populations, including any patient with osteoporosis
Associated hemorrhage from the injury can result in a deteriorating clinical and neurologic exam.
Benign or malignant tumors
Metastatic tumors (most common)
Primary tumors
Ependymoma
Schwannoma
Neurofibroma
Lymphoma
Lipomas
Paraganglioma
Ganglioneuroma
Osteoblastoma
Infection
Osteodiscitis
Osteomyelitis
Epidural abscess
Fungal infections (e.g. Tuberculosis)
Other infections: lyme disease, HIV/AIDS-defining ilnesses, Herpes zoster (HZ)
History – Progressive motor/sensory loss, new urinary retention or incontinence, new fecal incontinence
Physical exam – Saddle anesthesia, anal sphincter atony, significant motor deficits of multiple myotomes
Fracture
History – Significant trauma (relative to age), Prolonged corticosteroid use, osteoporosis, and age greater than 70 years
Physical exam – Contusions, abrasions, tenderness to palpation over spinous processes
Infection
History – Spinal procedure within the last 12 months, Intravenous drug use, Immunosuppression, prior lumbar spine surgery
Physical exam – Fever, wound in the spinal region, localized pain, and tenderness
Malignancy
History – History of metastatic cancer, unexplained weight loss
Physical exam – Focal tenderness to palpation in the setting of risk factors
Symptoms Of Herniated Cervical Disc
The primary signs and symptoms of
LDH is radicular pain – sensory abnormalities, and weakness in the distribution of one or more lumbosacral nerve roots [rx, rx]. Focal paresis, restricted trunk flexion, and increases in leg pain with straining, coughing, and sneezing are also indicative [rx, rx]. Patients frequently report increased pain when sitting, which is known to increase disc pressure by nearly 40% [rx].
Pain that is relieved with sitting for forwarding flexion – is more consistent with lumbar spinal stenosis (LSS), as the latter motion increases disc pressure by 100–400% and would likely increase pain in isolated LDH [rx]. Rainville et al. recently compared signs of LDH with LSS and found that LSS patients are more likely to have increased medical comorbidities, lower levels of disability and leg pain, abnormal Achilles reflexes, and pain primarily in the posterior knee [rx].
Numbness or tingling – People who have a herniated disk often have radiating numbness or tingling in the body part served by the affected nerves.
Weakness – Muscles served by the affected nerves tend to weaken. This can cause you to stumble, or affect your ability to lift or hold items.
Pain in the neck, back, low back, arms, or legs
Inability to bend or rotate the neck or back
Numbness or tingling in the neck, shoulders, arms, hands, hips, legs, or feet
Weakness in the arms or legs
Limping when walking
Increased pain when coughing, sneezing, reaching, or sitting
Inability to stand up straight; being “stuck” in a position, such as stooped forward or leaning to the side
Difficulty getting up from a chair
Inability to remain in 1 position for a long period of time, such as sitting or standing, due to pain
Pain that is worse in the morning
This is a sharp, often shooting pain that extends from the buttock down the back of one leg. It is caused by pressure on the spinal nerve.
Numbness or a tingling sensation in the leg and/or foot
Weakness in the leg and/or foot
Loss of bladder or bowel control. This is extremely rare and may indicate a more serious problem called cauda equina syndrome. This condition is caused by the spinal nerve roots being compressed.
Diagnosis of Herniated Cervical Disc
Special Tests
Lasègue’s Test
Slump Test
Muscle Weakness or Paresis
Reflexes
Hyperextension Test The patient needs to passively mobilize the trunk over the full range of extension, while the knees stay extended. The test indicates that the radiant pain is caused by disc herniation if the pan deteriorates.
Manual Testing and Sensory Testing Look for hypoaesthesia, hypoalgesia, tingling, or numbness.
Physical Examination
The clinician should assess the patient’s range of motion (ROM), as this can indicate the severity of pain and degeneration. A thorough neurological examination is necessary to evaluate sensory disturbances, motor weakness, and deep tendon reflex abnormalities. Careful attention should also focus on any sign of spinal cord dysfunction.
Typical findings of solitary nerve lesions due to compression by a herniated disc in the cervical spine
C2 Nerve – eye or ear pain, headache. History of rheumatoid arthritis or atlantoaxial instability
C3, C4 Nerve – vague neck, and trapezial tenderness and muscle spasms
C5 Nerve – neck, shoulder, and scapula pain. Lateral arm paresthesia. Primary motions affected include shoulder abduction and elbow flexion. May also observe weakness with shoulder flexion, external rotation, and forearm supination. Diminished biceps reflex.
C6 Nerve – neck, shoulder, and scapula pain. Paresthesia of the lateral forearm, lateral hand, and lateral two digits. Primary motions affected include elbow flexion and wrist extension. May also observe weakness with shoulder abduction, external rotation, and forearm supination and pronation — diminished brachioradialis reflex.
C7 Nerve – neck and shoulder pain. Paresthesia of the posterior forearm and third digit. Primary motions affected include elbow extension and wrist flexion. Diminished triceps reflex
C8 Nerve – neck and shoulder pain. Paresthesia of the medial forearm, medial hand, and medial two digits. Weakness during finger flexion, handgrip, and thumb extension.
T1 Nerve – Neck and shoulder pain. Paresthesia of the medial forearm. A weakness of finger abduction and adduction.[rx]
Lab values
Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) – These are inflammatory markers that should be obtained If a chronic inflammatory condition is suspected (rheumatoid arthritis, polymyalgia rheumatic, seronegative spondyloarthropathy). These can also be beneficial if an infectious etiology is suspected.
Complete blood count (CBC) with differential – Useful to obtain in instances when infection or malignancy is suspected.
Radiological
Patients with equivocal studies may opt for a discography when conservative measures fail. Electrophysiological studies can be performed to evaluate and elucidate the nerve roots affected by injured cervical disc.[rx][rx]
X-ray – Plain radiography is an initial and inexpensive method of evaluating the cervical spine for an osseous injury. In chronic disc degeneration, decreased disc height and osteophytes can be seen. There is a higher incidence of cervical cord injury demonstrated with the use of plain radiographs in the assessment of cervical spine stenosis. The Torg ratio is the sagittal canal/vertebral body ratio measured on cervical spine lateral radiographs. The normal value is 1.0. A ratio of 0.8 and below has been considered indicative of cervical spinal stenosis.
MRI – Magnetic resonance imaging is the best modality to assess cord compression and disc herniation. T2 weighted views are preferred. Findings include decreased disc height, reduced signal intensity, and spondylotic osteophytes.
CT Scan – This imaging is the most sensitive test to examine the bony structures of the spine. It can also show calcified herniated discs or any insidious process that may result in bony loss or destruction. In patients that are unable to or are otherwise ineligible to undergo an MRI, CT myelography can be used as an alternative to visualize a herniated disc.
Electrodiagnostic testing – (Electromyography and nerve conduction studies) can be an option in patients that demonstrate equivocal symptoms or imaging findings as well as to rule out the presence of a peripheral mononeuropathy. The sensitivity of detecting cervical radiculopathy with electrodiagnostic testing ranges from 50% to 71%.[rx]
Treatment Herniated Cervical Disc
Patient Education
Use of hot or cold packs for comfort and to decreased inflammation
Avoidance of inciting activities or prolonged sitting/standing
Practicing good, erect posture
Engaging in exercises to increase core strength
Gentle stretching of the lumbar spine and hamstrings
Regular light exercises such as walking, swimming, or aromatherapy
Conservative Treatments – Acute cervical radiculopathies secondary to a herniated disc are typically managed with non-surgical treatments as the majority of patients (75 to 90%) will improve. Modalities that can be used include[rx][rx][rx]:
Collar Immobilization – In patients with acute neck pain, a short course (approximately one week) of collar immobilization may be beneficial during the acute inflammatory period.
Traction – May be beneficial in reducing the radicular symptoms associated with disc herniations. Theoretically, traction would widen the neuroforamen and relieve the stress placed on the affected nerve, which, in turn, would result in the improvement of symptoms. This therapy involves placing approximately 8 to 12 lbs of traction at an angle of approximately 24 degrees of neck flexion over a period of 15 to 20 minutes.
Physical Therapy – Commonly prescribed after a short period of rest and immobilization. Modalities include a range of motion exercises, strengthening exercises, ice, heat, ultrasound, and electrical stimulation therapy. Despite their frequent use, no evidence demonstrates their efficacy over placebo. However, there is no proven harm, and with a possible benefit, their use is recommended in the absence of myelopathy.
Cervical Manipulation – There is limited evidence suggesting that cervical manipulation may provide short-term benefits for neck pain and cervicogenic headaches. Complications from manipulation are rare and can include worsening radiculopathy, myelopathy, spinal cord injury, and vertebral artery injury. These complications occur ranging from 5 to 10 per 10 million manipulations.
Medication
Non-steroidal anti-inflammatory drugs (NSAIDs) – These painkillers belong to the same group of drugs as acetylsalicylic acid (ASA, the drug in medicines like “Aspirin”). NSAIDs that may be an option for the treatment of sciatica include diclofenac, ibuprofen, and naproxen. Anti-inflammatory drugs are drugs that reduce inflammation. This includes substances produced by the body itself like cortisone. It also includes artificial substances like ASA – acetylsalicylic acid (or “aspirin”) or ibuprofen –, which relieve pain and reduce fever as well as reducing inflammation.
Acetaminophen (paracetamol) – Acetaminophen (paracetamol) is also a painkiller, but it is not an NSAID. It is well tolerated and can be used as an alternative to NSAIDs – especially for people who do not tolerate NSAID painkillers because of things like stomach problems or asthma. But higher doses of acetaminophen can cause liver and kidney damage. The package insert advises adults not to take more than 4 grams (4000 mg) per day. This is the amount in, for example, 8 tablets containing 500 milligrams each. It is not only important to take the right dose, but also to wait long enough between doses.
Opioids – Strong painkillers that may only be used under medical supervision. Opioids are available in many different strengths, and some are available in the form of a patch. Morphine, for example, is a very strong drug, while tramadol is a weaker opioid. These drugs may have a number of different side effects, some of which are serious. They range from nausea, vomiting and constipation to dizziness, breathing problems, and blood pressure fluctuation. Taking these drugs for a long time can lead to habitual use and physical dependence.
Skeletal Muscle relaxant – If muscle spasms are prominent, the addition of a muscle relaxant may merit consideration for a short period. For example, cyclobenzaprine is an option at a dose of 5 mg taken orally three times daily. Antidepressants (amitriptyline) and anticonvulsants (gabapentin and pregabalin) have been used to treat neuropathic pain, and they can provide a moderate analgesic effect.
Steroids – Anti-inflammatory drugs that can be used to treat various diseases systemically. That means that they are taken as tablets or injected. The drug spreads throughout the entire body to soothe inflammation and relieve pain. Steroids may increase the risk of gastric ulcers, osteoporosis, infections, skin problems, glaucoma, and glucose metabolism disorders.
Muscle relaxants – Sedatives which also relax the muscles. Like other psychotropic medications, they can cause fatigue and drowsiness, and affect your ability to drive. Muscle relaxants can also affect liver functions and cause gastro-intestinal complications. Drugs from the benzodiazepine group, such as tetrazepam, can lead to dependency if they are taken for longer than two weeks.
Anticonvulsants – These medications are typically used to treat epilepsy, but some are approved for treating nerve pain (neuralgia). Their side effects include drowsiness and fatigue. This can affect your ability to drive.
Antidepressants – These drugs are usually used for treating depression. Some of them are also approved for the treatment of pain. Possible side effects include nausea, dry mouth, low blood pressure, irregular heartbeat, and fatigue.
Topical Medications – These prescription-strength creams, gels, ointments, patches, and sprays help relieve pain and inflammation through the skin.
Calcium & vitamin D3 – to improve bone health and healing fracture. As a general rule, men and women age 50 and older should consume 1,200 milligrams of calcium a day, and 600 international units of vitamin D a day.
Glucosamine & Diacerein, Chondroitin sulfate – can be used to tightening the loose tension, cartilage, ligament, and cartilage, ligament regenerate cartilage or inhabit the further degeneration of cartilage, ligament
Injections near the spine – Injection therapy uses mostly local anesthetics and/or anti-inflammatory medications like corticosteroids (for example cortisone). These drugs are injected into the area immediately surrounding the affected nerve root. There are different ways of doing this:
In lumbar spinal nerve analgesia (LSPA) – the medication is injected directly at the point where the nerve root exits the spinal canal. This has a numbing effect on the nerve root.
In lumbar epidural analgesia – the medication is injected into what is known as the epidural space (“epidural injection”). The epidural space surrounds the spinal cord and the spinal fluid in the spinal canal. This is also where the nerve roots are located. During this treatment, the spine is monitored using computer tomography or X-rays to make sure that the injection is placed at exactly the right spot.
Interventional Treatments – Spinal steroid injections are a common alternative to surgery. Perineural injections (translaminar and transforaminal epidurals, selective nerve root blocks) are an option with pathological confirmation by MRI. These procedures should take place under radiologic guidance.[15]
Surgical
Brief Surgical Techniques
Total Disc Replacement (TDR) and Anterior Cervical Discectomy and Fusion (ACDF)
Surgical exposure of the desired vertebral level is achieved through an anterior cervical incision. Subcutaneous dissection is performed to allow for adequate mobilization to tissue incision. The discectomy is performed with pituitary rongeurs, curette, and a burr drill to remove affected disc.
The posterior longitudinal ligament can be left in situ depending on the severity of the herniation. The center of the disc is identified. A keel is made using the burr after which the disc is removed and disc replacement performed. A similar surgical method is used for anterior cervical discectomy and fusion, the difference is the type of implant, which can be an interbody cage with an anterior cervical plate or a standalone cage.
Laminectomy
A cervical laminectomy removes the lamina on one or both sides to increase the axial space available for the spinal cord. Clinically indicated for spinal stenosis or cervical disc disease involving more than three levels of disc degeneration with anterior spinal cord compression.
Single-level cervical disc herniation is usually managed with the anterior approach. The complications of the posterior approach include instability resulting in kyphosis, recalcitrant myofascial pain, and occipital headaches.
Laminoplasty
The kyphotic deformity is a well-known complication of laminectomy. To preserve the posterior wall of the spinal canal while decompressing the spinal canal a Z-plasty technique for the lamina was developed. The variant of the procedure uses a hinged door for the lamina.
Laminoplasty is commonly indicated for multilevel spondylotic myelopathy. Nerve root injury is seen in about 11% of the surgeries. This complication is unique to laminoplasty, and the suggested etiology is traction on the nerve root with the posterior migration of the spinal cord.
Interventional Treatments
Spinal steroid injections are a common alternative to surgery.
Perineural injections (translaminar and transforaminal epidurals, selective nerve root blocks) are an option with pathological confirmation by MRI. These procedures should take place under radiologic guidance.[rx]
In the past few years, neuromodulation techniques have been used to a large extent to manage radicular pain secondary to disc herniations.[rx]
These neuromodulatory techniques consist mainly of Spinal cord stimulation devices[rx] and Intrathecal pain pump.[rx] For patients who are not candidates for surgical intervention, these devices offer minimally invasive efficacious treatment options.
Complications
Complications from steroid injections are typically mild and range between 3% to 35% of cases. Other, more serious complications can include[5]:
Nerve injury
Infection
Epidural hematoma
Epidural abscess
Spinal cord infarction
Infection
Recurrent laryngeal, superior laryngeal, and hypoglossal nerve injuries
Anal Cancer/Cancers of the anal canal are rare, comprising approximately 10% of malignancies in the anorectal region, although its incidence has been increasing over the past several decades.[rx][rx] While the traditional approach to treatment was with abdominoperineal resection (APR), this has evolved in the modern era to concurrent chemoradiation as organ-preserving treatment.
Types of Anal Cancer
Several types of tumors may be found in the anus. While some of them are malignant (cancer), others are benign (not cancer) or precancerous (may develop into cancer). The main types of anal cancer are
Benign tumors – Tumors that are benign are noncancerous tumors. In the anus, this can include polyps, skin tags, granular cell tumors, and genital warts (condylomas).
Precancerous conditions – This refers to benign tumors that may become malignant over time, which is common in anal intraepithelial neoplasia (AIN) and anal squamous intraepithelial neoplasia (ASIL).
Squamous cell carcinoma – Squamous cell cancer is the most common type of anal cancer in the United States. According to the American Cancer Society, it accounts for 9 out of 10 cases. These malignant tumors in the anus are caused by abnormal squamous cells (cells that line most of the anal canal).
Bowen’s disease – This condition, also known as squamous cell carcinoma in situ, is characterized by abnormal cells on anal surface tissue that haven’t invaded deeper layers.
Basal cell carcinoma – Basal cell carcinoma is a type of skin cancer that generally affects skin exposed to the sun. Because of this, it’s a very rare form of anal cancer.
Adenocarcinoma – This is a rare form of cancer that arises from the glands surrounding the anus.
Carcinoma in situ – is early cancer or precancerous cells. They are only on the surface cells of the anal canal. This also may be called Bowen’s disease.
Squamous cell cancer – (carcinoma) forms in the cells that line the anus. This is the most common type of anal cancer.
Adenocarcinomas – develop in the glands around the anus.
Skin cancers, including basal cell and melanoma, often are found when they are in advanced stages.
There are three ways that cancer spreads in the body
Cancer can spread through tissue, the lymph system, and the blood:
Tissue. The cancer spreads from where it began by growing into nearby areas.
Lymph system. The cancer spreads from where it began by getting into the lymph system. The cancer travels through the lymph vessels to other parts of the body.
Blood. The cancer spreads from where it began by getting into the blood. The cancer travels through the blood vessels to other parts of the body.
Cancer may spread from where it began to other parts of the body
When cancer spreads to another part of the body, it is called metastasis. Cancer cells break away from where they began (the primary tumor) and travel through the lymph system or blood.
Lymph system – Cancer gets into the lymph system, travels through the lymph vessels, and forms a tumor (metastatic tumor) in another part of the body.
Blood – Cancer gets into the blood, travels through the blood vessels, and forms a tumor (metastatic tumor) in another part of the body.
The metastatic tumor is the same type of cancer as the primary tumor. For example, if anal cancer spreads to the lung, the cancer cells in the lung are actually anal cancer cells. The disease is metastatic anal cancer, not lung cancer.
Anatomy of Anal Cancer
The anal canal runs from the anal verge (the visible junction between the internal anal canal and hair-bearing keratinized external anal skin) to the anorectal ring (the location in which rectum enters puborectalis sling). The anal canal is approximately 3 to 5 cm in length. The dentate line is the anatomic boundary where mucosa changes from non-keratinized squamous epithelium to colorectal-type columnar mucosa proximally. It divides the upper and lower anal canal. The anal margin, also referred to as perianal skin, is a rim of tissue around the anus encompassed by a 5 cm radius, and it bears true squamous epithelium. Lymphatic drainage of anal cancers depends upon its location relative to the dentate line. Cancers above the dentate line drain to the presacral and internal iliac nodes. Cancers below the dentate line drain to superficial inguinal and femoral nodes.
Causes of Anal Cancer
High grade anal intraepithelial neoplasia (AIN) can be a precursor to anal cancer. AIN can result from an infection with human papillomavirus (HPV), predominantly serotypes 16 and 18. HPV spreads via skin-to-skin contact and sexual intercourse.[rx] Additional risk factors for anal cancer include HIV infection, promiscuous sexual behavior, smoking, chronic immunosuppression not due to HIV, and chronic inflammatory states such as Crohn disease.[rx][rx][rx][rx] HPV vaccines, when given before HPV exposure, reduce the rates of AIN and should be considered in populations at high risk for anal cancer.[rx]
Anal cancer develops when cells grow uncontrollably and form a tumor. Two types of cancer can form in the anus, depending on where the cancer starts.
Squamous cell cancer – The anal canal connects the rectum to the outside of the body. Squamous cells line the canal. These flat cells look like fish scales under the microscope. Most anal cancers are squamous cell carcinomas because they develop from squamous cells.
Adenocarcinoma: The point where the anal canal meets the rectum is called the transitional zone. It has squamous cells and glandular cells. Glandular cells produce mucus, which helps the stool pass through the anus smoothly. Adenocarcinoma can also develop from the glandular cells in the anus. Around 3–9% of anal cancers are of this type.
Risk factors
The risk factors for anal cancer include:
HPV – There is growing evidence that some types of HPV increase the risk of various cancers. Researchers have linked the presence of HPV16 to various cancers, including cervical cancer and some head and neck cancers.
Other cancers – People who have had another HPV-linked cancer seem to have a higher risk of anal cancer. For females, these include vaginal or cervical cancer, or a history of precancerous cells in the cervix. Males who have had penile cancer have a higher risk, also.
HIV – People with HIV have a higher risk of developing anal cancer than people without the virus.
Reduced immunity – People with a suppressed immune system have a higher risk. The immune system can be weaker in people with AIDS and those who take medications following a transplant.
Sexual activity – Having multiple sex partners can increase the risk, as this increases the chance of exposure to HPV.
Sex – Anal cancer is more common in females than in males. However, among African Americans, it is more common among males up to the age of 60 years, after which it is more likely to affect females.
Age – As people get older, their chances of developing anal cancer increase.
Smoking – Smokers have a significantly higher risk of several cancers, including anal cancer. Quitting may lower the risk.
Symptoms of Anal Cancer
Bleeding from anus/rectum, especially during bowel movements.
Having a lump or pain in the area.
Itching (also known as pruritus).
Seeing a change in bowel movements, such as frequency or consistency of the stools.
Leaking stool.
Feeling like you constantly need to have a bowel movement.
bleeding from the bottom (rectal bleeding)
itching and pain around the anus
small lumps around the anus
a discharge of mucus from the anus
loss of bowel control (bowel incontinence)
Bleeding from the anus
Pain or pressure in your anal area
Itching around your anus
Fluid leaking from your anus
Narrower stools or other changes in your bowel movements
A lump or swelling near your anus
Swollen lymph nodes in your anal or groin area
Diagnosis of Anal Cancer
Clinical presentation can include bleeding (45%), pain (30%), pruritus, perianal mass, fecal urgency, or change in the stool caliber.[rx] Locally advanced tumors may have the above symptoms as well as mucous discharge, lower extremity edema, or non-healing perianal wounds. Systemic metastasis of squamous cell anal cancer occurs in less than 10% of cases at presentation.[rx] The liver and lungs are the most common site of distant spread, and clinical presentation of metastatic disease is dependent upon location and tumor burden.
Physical exam and health history – An exam of the body to check general signs of health, including checking for signs of disease, such as lumps or anything else that seems unusual. A history of the patient’s health habits and past illnesses and treatments will also be taken.
Digital rectal examination (DRE) – An exam of the anus and rectum. The doctor or nurse inserts a lubricated, gloved finger into the lower part of the rectum to feel for lumps or anything else that seems unusual.
Anoscopy – An exam of the anus and lower rectum using a short, lighted tube called an anoscope.
Proctoscopy – A procedure to look inside the rectum and anus to check for abnormal areas, using a proctoscope. A proctoscope is a thin, tube-like instrument with a light and a lens for viewing the inside of the rectum and anus. It may also have a tool to remove tissue samples, which are checked under a microscope for signs of cancer.
Endo-anal or endorectal ultrasound – A procedure in which an ultrasound transducer (probe) is inserted into the anus or rectum and used to bounce high-energy sound waves (ultrasound) off internal tissues or organs and make echoes. The echoes form a picture of body tissues called a sonogram.
Biopsy – The removal of cells or tissues so they can be viewed under a microscope by a pathologist to check for signs of cancer. If an abnormal area is seen during the anoscopy, a biopsy may be done at that time.
Anal electromyography (EMG) – This test determines if nerve damage is the reason why the anal sphincters are not working properly. It also examines the coordination between the rectum and anal muscles.
Anal manometry – This test studies the strength of the anal sphincter muscles. A short, thin tube, inserted up into the anus and rectum, is used to measure the sphincter tightness.
Anal ultrasound – This test helps evaluate the shape and structure of the anal sphincter muscles and surrounding tissue. In this test, a small probe is inserted up into the anus and rectum to take images of the sphincters.
Pudendal nerve terminal motor latency test – This test measures the function of the pudendal nerves, which are involved in bowel control.
Proctography (also called defecography) – This test is done in the radiology department. In this test, an X-ray video is taken that shows how well the rectum is functioning. The video shows how much stool the rectum can hold, how well the rectum holds the stool, and how well the rectum releases the stool.
Colonoscopy – A procedure to look inside the rectum and colon for polyps (small pieces of bulging tissue), abnormal areas, or cancer. A colonoscope is a thin, tube-like instrument with a light and a lens for viewing. It may also have a tool to remove polyps or tissue samples, which are checked under a microscope for signs of cancer.
Reverse transcription-polymerase chain reaction (RT–PCR) test – A laboratory test in which the amount of a genetic substance called mRNA made by a specific gene is measured. An enzyme called reverse transcriptase is used to convert a specific piece of RNA into a matching piece of DNA, which can be amplified (made in large numbers) by another enzyme called DNA polymerase. The amplified DNA copies help tell whether a specific mRNA is being made by a gene. RT–PCR can be used to check the activation of certain genes that may indicate the presence of rectal prolapse cells. This test may be used to look for certain changes in a gene or chromosome, which may help diagnose rectal prolapse.
Immunohistochemistry – A laboratory test that uses antibodies to check for certain antigens (markers) in a sample of a patient’s tissue. The antibodies are usually linked to an enzyme or a fluorescent dye. After the antibodies bind to a specific antigen in the tissue sample, the enzyme or dye is activated, and the antigen can then be seen under a microscope. This type of test is used to help diagnose cancer and to help tell one type of cancer from another type of cancer.
Carcinoembryonic antigen (CEA) assay – A test that measures the level of CEA in the blood. CEA is released into the bloodstream from both rectal prolapse and normal cells. When found in higher than normal amounts, it can be a sign of rectal prolapse or other conditions.
Anorectal manometry – measures and assesses the anal sphincter (internal and external) and rectal pressure and its function. This method is used to evaluate patients with fecal incontinence and constipation. It can directly measure the luminal pressure, including the high-pressure zone, resting pressure, squeezing pressure, rectal sensation/compliance, and the anorectal inhibitory reflex.[rx]
Defecating proctography/Defecography – A study using X-ray imaging to evaluate anatomic defects of the anorectal region and function of the puborectalis muscle. A contrast filled paste gets initially introduced to the rectum, and the patient is instructed to defecate in a series of stages (relaxation, contraction, tensing of the abdomen, and evacuation).[rx]
Balloon capacity and compliance test – Evaluates the function of the rectum using a device (plastic catheter with a latex balloon attached), which is inserted into the rectum and gradually filled with warm water. During this process, the volume and pressure are measured.[rx]
Balloon evacuation study – This test is similar to the balloon capacity and compliance test in which a catheter with a small balloon gets inserted into the rectum and filled with water. Different volumes of water get loaded inside the balloon, and the patient is instructed to evacuate the balloon. This procedure is done to evaluate the opening of the anal canal and to assess the relaxation of the pelvic floor.[rx]
Pudendal nerve terminal motor latency – A probe designed to stimulate and record nerve activity is placed on the physician’s gloved finger, which is then inserted into the rectum to measure pudendal nerve activity (latency to contraction of the anal sphincter muscle). The pudendal nerve innervates the anal sphincter muscles; therefore, this test can be used to assess any injury to that nerve.
Electromyography – A test to measure the ability of the puborectalis muscle and sphincter muscles to relax properly. An electrode is placed inside the rectum, and the activity of these muscles gets evaluated throughout a series of stages (relaxation, contraction, and evacuation).[rx]
Endoanal Ultrasonography – The use of ultrasound imaging to examine rectal lesions, defects, or injuries to the surrounding tissues.[rx]
Suction rectal biopsy – Gold standard for the diagnosis of Hirschsprung disease. A biopsy is taken two cm above the dentate line, and the absence of ganglion cells on histology confirms the diagnosis. Hypertrophic nerve fibers may be present in addition to this finding.[rx]
Contrast enema – Used as one of the diagnostic methods for Hirschsprung disease. Useful for localization of the aganglionic segment by looking for a narrowed rectum. Diagnostic confirmation is via a rectal biopsy.[rx]
CT scan (CAT scan) – A procedure that makes a series of detailed pictures of areas inside the body, such as the abdomen, pelvis, or chest, taken from different angles. The pictures are made by a computer linked to an x-ray machine. A dye may be injected into a vein or swallowed to help the organs or tissues show up more clearly. This procedure is also called computed tomography, computerized tomography, or computerized axial tomography.
Chest x-ray – An x-ray of the organs and bones inside the chest. An x-ray is a type of energy beam that can go through the body and onto film, making a picture of areas inside the body.
MRI (magnetic resonance imaging) – A procedure that uses a magnet, radio waves, and a computer to make a series of detailed pictures of areas inside the body. This procedure is also called nuclear magnetic resonance imaging (NMRI).
PET scan (positron emission tomography scan) – A procedure to find malignant tumor cells in the body. A small amount of radioactive glucose (sugar) is injected into a vein. The PET scanner rotates around the body and makes a picture of where glucose is being used in the body. Malignant tumor cells show up brighter in the picture because they are more active and take up more glucose than normal cells do.
Pelvic exam – An exam of the vagina, cervix, uterus, fallopian tubes, ovaries, and rectum. A speculum is inserted into the vagina and the doctor or nurse looks at the vagina and cervix for signs of disease. A Pap test of the cervix is usually done. The doctor or nurse also inserts one or two lubricated, gloved fingers of one hand into the vagina and places the other hand over the lower abdomen to feel the size, shape, and position of the uterus and ovaries. The doctor or nurse also inserts a lubricated, gloved finger into the rectum to feel for lumps or abnormal areas.
Treatment of Anal Cancer
Activity – Typically, the child is encouraged to walk around as soon as possible.
Diet – Patients are started on liquids after their surgery then advanced to a general diet.
Antibiotics – To help prevent or treat an infection caused by bacteria.
Anti-nausea medicine – To control vomiting (throwing up).
Pain medicine – Pain medicine can include acetaminophen (Tylenol®), ibuprofen (Motrin®), or narcotics. These medicines can be given by vein or by mouth.
Stool softeners – Polyethylene glycol (Miralax), Docusate (Colace) or senna are among the medications used to avoid straining after surgery.
Certain factors affect the prognosis (chance of recovery) and treatment options.
The prognosis depends on the following:
The size of the tumor.
Whether the cancer has spread to the lymph nodes.
The treatment options depend on the following:
The stage of the cancer.
Where the tumor is in the anus.
Whether the patient has human immunodeficiency virus (HIV).
Whether cancer remains after initial treatment or has recurred.
Stages of Anal Cancer
KEY POINTS
After anal cancer has been diagnosed, tests are done to find out if cancer cells have spread within the anus or to other parts of the body.
There are three ways that cancer spreads in the body.
Cancer may spread from where it began to other parts of the body.
The following stages are used for anal cancer:
Stage 0
Stage I
Stage II
Stage III
Stage IV
Anal cancer can recur (come back) after it has been treated.
After anal cancer has been diagnosed, tests are done to find out if cancer cells have spread within the anus or to other parts of the body.
The process used to find out if cancer has spread within the anus or to other parts of the body is called staging. The information gathered from this staging process determines the stage of the disease. It is important to know the stage in order to plan treatment. The following tests may be used in the staging process:
The following stages are used for anal cancer:
Stage 0
In stage 0, abnormal cells are found in the mucosa (innermost layer) of the anus. These abnormal cells may become cancer and spread into nearby normal tissue. Stage 0 is also called high-grade squamous intraepithelial lesion (HSIL).
ENLARGETumor sizes are often measured in centimeters (cm) or inches. Common food items that can be used to show tumor size in cm include: a pea (1 cm), a peanut (2 cm), a grape (3 cm), a walnut (4 cm), a lime (5 cm or 2 inches), an egg (6 cm), a peach (7 cm), and a grapefruit (10 cm or 4 inches).
Stage I
In stage I, cancer has formed and the tumor is 2 centimeters or smaller.
Stage II
Stage II anal cancer is divided into stages IIA and IIB.
In stage IIA, the tumor is larger than 2 centimeters but not larger than 5 centimeters.
In stage IIB, the tumor is larger than 5 centimeters.
Stage III
Stage III anal cancer is divided into stages IIIA, IIIB, and IIIC.
In stage IIIA, the tumor is 5 centimeters or smaller and has spread to lymph nodes near the anus or groin.
In stage IIIB, the tumor is any size and has spread to nearby organs, such as the vagina, urethra, or bladder. Cancer has not spread to lymph nodes.
In stage IIIC, the tumor is any size and may have spread to nearby organs. Cancer has spread to lymph nodes near the anus or groin.
Stage IV
In stage IV, the tumor is any size. Cancer may have spread to lymph nodes or nearby organs and has spread to other parts of the body, such as the liver or lungs.
Anal cancer can recur (come back) after it has been treated.
The cancer may come back in the anus or other parts of the body, such as the liver or lungs.
Treatment of Anal Cancer
There are different types of treatment for patients with anal cancer.
Three types of standard treatment are used:
Surgery
Radiation therapy
Chemotherapy
New types of treatment are being tested in clinical trials.
Radiosensitizers
Immunotherapy
Treatment for anal cancer may cause side effects.
Patients may want to think about taking part in a clinical trial.
Patients can enter clinical trials before, during, or after starting their cancer treatment.
Follow-up tests may be needed.
There are different types of treatment for patients with anal cancer.
Different types of treatments are available for patients with anal cancer. Some treatments are standard (the currently used treatment), and some are being tested in clinical trials. A treatment clinical trial is a research study meant to help improve current treatments or obtain information on new treatments for patients with cancer. When clinical trials show that a new treatment is better than the standard treatment, the new treatment may become the standard treatment. Patients may want to think about taking part in a clinical trial. Some clinical trials are open only to patients who have not started treatment.
Three types of standard treatment are used:
Surgery
Local resection – A surgical procedure in which the tumor is cut from the anus along with some of the healthy tissue around it. Local resection may be used if the cancer is small and has not spread. This procedure may save the sphincter muscles so the patient can still control bowel movements. Tumors that form in the lower part of the anus can often be removed with local resection.
Abdominoperineal resection – A surgical procedure in which the anus, the rectum, and part of the sigmoid colon are removed through an incision made in the abdomen. The doctor sews the end of the intestine to an opening, called a stoma, made in the surface of the abdomen so body waste can be collected in a disposable bag outside of the body. This is called a colostomy. Lymph nodes that contain cancer may also be removed during this operation. This procedure is used only for cancer that remains or comes back after treatment with radiation therapy and chemotherapy.
Resection of the colon with colostomy. Part of the colon containing the cancer and nearby healthy tissue are removed, a stoma is created, and a colostomy bag is attached to the stoma.
Radiation therapy
Radiation therapy is a cancer treatment that uses high-energy x-rays or other types of radiation to kill cancer cells or keep them from growing. There are two types of radiation therapy:
External radiation therapy uses a machine outside the body to send radiation toward the area of the body with cancer.
Internal radiation therapy uses a radioactive substance sealed in needles, seeds, wires, or catheters that are placed directly into or near the cancer.
The way the radiation therapy is given depends on the type and stage of the cancer being treated. External and internal radiation therapy are used to treat anal cancer.
Chemotherapy
Chemotherapy is a cancer treatment that uses drugs to stop the growth of cancer cells, either by killing the cells or by stopping the cells from dividing. When chemotherapy is taken by mouth or injected into a vein or muscle, the drugs enter the bloodstream and can reach cancer cells throughout the body (systemic chemotherapy).
New types of treatment are being tested in clinical trials.
This summary section describes treatments that are being studied in clinical trials. It may not mention every new treatment being studied. Information about clinical trials is available from the NCI website.
Radiosensitizers
Radiosensitizers are drugs that make tumor cells more sensitive to radiation therapy. Combining radiation therapy with radiosensitizers may kill more tumor cells.
Immunotherapy
Immunotherapy is a treatment that uses the patient’s immune system to fight cancer. Substances made by the body or made in a laboratory are used to boost, direct, or restore the body’s natural defenses against cancer. This type of cancer treatment is also called biotherapy or biologic therapy.
Immune checkpoint inhibitor therapy is a type of immunotherapy.
Immune checkpoint inhibitor therapy: PD-1 is a protein on the surface of T cells that helps keep the body’s immune responses in check. When PD-1 attaches to another protein called PDL-1 on a cancer cell, it stops the T cell from killing the cancer cell. PD-1 inhibitors attach to PDL-1 and allow the T cells to kill cancer cells. Pembrolizumab and nivolumab are types of immune checkpoint inhibitors.
Immune checkpoint inhibitor. Checkpoint proteins, such as PD-L1 on tumor cells and PD-1 on T cells, help keep immune responses in check. The binding of PD-L1 to PD-1 keeps T cells from killing tumor cells in the body (left panel). Blocking the binding of PD-L1 to PD-1 with an immune checkpoint inhibitor (anti-PD-L1 or anti-PD-1) allows the T cells to kill tumor cells (right panel).
Immunotherapy uses the body’s immune system to fight cancer. This animation explains one type of immunotherapy that uses immune checkpoint inhibitors to treat cancer.
Treatment for anal cancer may cause side effects.
For information about side effects caused by treatment for cancer, see our Side Effects page.
Patients may want to think about taking part in a clinical trial.
For some patients, taking part in a clinical trial may be the best treatment choice. Clinical trials are part of the cancer research process. Clinical trials are done to find out if new cancer treatments are safe and effective or better than the standard treatment.
Many of today’s standard treatments for cancer are based on earlier clinical trials. Patients who take part in a clinical trial may receive the standard treatment or be among the first to receive a new treatment.
Patients who take part in clinical trials also help improve the way cancer will be treated in the future. Even when clinical trials do not lead to effective new treatments, they often answer important questions and help move research forward.
Patients can enter clinical trials before, during, or after starting their cancer treatment.
Some clinical trials only include patients who have not yet received treatment. Other trials test treatments for patients whose cancer has not gotten better. There are also clinical trials that test new ways to stop cancer from recurring (coming back) or reduce the side effects of cancer treatment.
Clinical trials are taking place in many parts of the country. Information about clinical trials supported by NCI can be found on NCI’s clinical trials search webpage. Clinical trials supported by other organizations can be found on the ClinicalTrials.gov website.
Treatment of Stage 0 (Carcinoma in Situ)
For information about the treatments listed below, see the Treatment Option Overview section.
Use our clinical trial search to find NCI-supported cancer clinical trials that are accepting patients. You can search for trials based on the type of cancer, the age of the patient, and where the trials are being done.
Treatment of Stages I, II, and III Anal Cancer
For information about the treatments listed below,
Treatment of stage I, stage II, and stage III anal cancer may include the following:
Local resection for tumors of the skin around the outside of the anus and tumors inside the anal opening that do not involve the anal sphincter.
External-beam radiation therapy with chemotherapy.
Radiation therapy alone.
Abdominoperineal resection, if cancer remains or comes back after treatment with radiation therapy and chemotherapy. Other options may include treatment with additional chemoradiation therapy, chemotherapy alone, or immunotherapy.
Patients who have had treatment that saves the sphincter muscles may receive follow-up exams every 3 months for the first 2 years, including rectal exams with endoscopy and biopsy, as needed to check for recurrence.
Use our clinical trial search to find NCI-supported cancer clinical trials that are accepting patients. You can search for trials based on the type of cancer, the age of the patient, and where the trials are being done. General information about clinical trials is also available.
Treatment of Stage IV Anal Cancer
For information about the treatments listed below, see the Treatment Option Overview section.
Treatment of stage IV anal cancer may include the following:
Palliative surgery to relieve symptoms and improve the quality of life.
Palliative radiation therapy.
Palliative chemotherapy with or without radiation therapy.
A clinical trial of immune checkpoint inhibitors.
A clinical trial of new treatment options.
Tumors of the Anal Margin
Anal margin cancers are more commonly diagnosed at an earlier stage and therefore tend to have a better prognosis. Management of very early stage anal margin cancer is best by wide local excision or radiotherapy alone, similar to management of skin cancer.[rx] The recommended radiation dose in these cases is between 60 to 65 Gy in 6 to 7 weeks. More advanced disease of the anal margin is treated similarly to anal canal cancers.
Tumors of the Anal Canal
The traditional management of tumors of the anal canal was via an abdominoperineal resection (APR) resulting in a permanent colostomy. Since the 1980s, there has been a paradigm shift for nonsurgical organ-preserving treatment, and modern management consists of concurrent chemoradiation. While there are no randomized trials comparing APR with chemoradiation, superior colostomy-free survival rates with equivalent survival have established chemoradiation as the preferred modality of treatment.[rx] Current radiation techniques involve intensity-modulated radiation therapy (IMRT) to a minimum dose of 45 Gy via conventional fractionation. Concurrent chemotherapy includes a combination of mitomycin C (MMC), 5FU, capecitabine, or cisplatin.
Suitability for Definitive Treatment
Performance status must be a consideration when determining a patient’s suitability for definitive treatment. Poor performance status may preclude adherence to conventional chemoradiation. Upfront APR may also be indicated if the patient has bowel incontinence or fistula present at baseline. Other relative reasons that may preclude definitive treatment include prior pelvic radiotherapy or surgery and any underlying medical, psychiatric, and/or social concerns.[rx]
HIV/AIDS Patients
People living with HIV have a 15 to 35-fold increase in anal cancer incidence.[rx] There is evidence that they have higher local relapse rates and higher rates of acute skin toxicity although there are no observable differences in complete response rates or 5-year OS.[rx] HIV-positive patients should continue on antiretroviral therapy throughout chemoradiation. Patients living with HIV should also be evaluated by their CD4 count, making appropriate chemotherapy adjustments to limit hematologic toxicity. Although concerns for increased hematological toxicity may exist in the HIV positive patient, standard MMC/ 5FU is the preferred chemotherapeutic regimen with superior outcomes when compared to cisplatin-based chemotherapy. In the setting of poorly controlled HIV with high viral load, >10000 copies, or very low CD4 count with significant concerns for hematologic toxicity, cisplatin-based chemotherapy is acceptable.
Surgical Oncology
Historically, APR was the standard of care for anal cancers, resulting in permanent colostomies. General principles for APR are similar to those of distal rectal cancer, which incorporate meticulous total mesorectal excision (TME) and removal of the distal colon, rectum, and anal sphincter complex using both anterior abdominal and perineal incisions. APR alone yields a poor 5-year overall survival rate of 50% and local recurrence rates of 30%.[rx] In an effort to reduce the rates of local recurrence, Nigro et al.[rx] pioneered a neoadjuvant regimen consisting of chemotherapy and radiation. In his report of 28 patients, 80% experienced a complete pathologic response. These promising results led to multiple randomized clinical trials of anal cancer to validate definitive chemoradiation as primary treatment of anal cancer. Therefore, the role of APR in the modern era is predominantly reserved for salvage treatment or patients with dysfunctional anal sphincter at diagnosis. Adenocarcinomas of the anal canal may also receive treatment with organ preservation.[rx]
Local excision with wide margins may be an alternative to chemoradiation in select patients with T1N0M0 anal canal cancers, as long as sphincter function can is preservable. However, the cure rates are markedly lower: 60% at 5 years, with local recurrence rates of 40%.[rx][rx] Therefore, local excision alone should be reserved for unique circumstances such as a patient with poor performance status and/or significant comorbidities.[rx]
Radiation Oncology
Radiation Alone
The efficacy of external beam radiation therapy (EBRT) alone in patients with anal cancer has undergone extensive study. In Taboul et al.,[rx] local control for primary tumors < 4 cm was 90% at 10 years, whereas it was 65% for primary tumors > 4 cm. Overall, 57% of patients maintained normal anal function. Newmen et al.[rx] reported similar results for radiation alone, in which they found that the probability of local control was related to the T stage. Overall, 74% of patients maintained a functional anus. Very few studies have reported on the efficacy of brachytherapy alone. James et al.[rx] used interstitial radiotherapy as primary treatment and found a 64% local control for tumors < 5 cm diameter at presentation.
Radiation Alone vs. Chemoradiation
After the Nigro protocol demonstrated a high rate of complete pathologic response to neoadjuvant chemoradiation, there was the development of multiple randomized clinical trials to validate definitive chemoradiation as primary treatment of anal cancer. Concurrent chemotherapy and radiation yield results superior to those of radiation alone or surgery alone. The two most prominent trials comparing radiation alone to chemoradiation include ACT I and EORTC 22861. The ACT I trial randomized patients to radiation alone vs. chemoradiation with 5FU/MMC. Results indicated improved 3-yr local control with chemoradiation vs radiation alone (64% vs 41%, p < 0.001).[rx] A recently published follow-up study on these patients demonstrates a persistent local control benefit after 13 years, with an absolute risk of locoregional recurrence reduced by 25%.[rx] Their results were similar to EORTC 22896, with the same randomization, which showed a 5-yr local control improvement from 50% to 68% (p = 0.02) with chemoradiation. Similarly, patients had an improved colostomy-free survival rate with chemoradiation.[rx]
Radiation Dose and Technique
The optimal dose and fractionation of radiation have yet to be fully elucidated. A minimum dose of at least 45 Gy is the current recommendation. One study showed that T1 lesions had effective treatment with a dose of 50 to 60 Gy.[rx] Several studies suggest that dose escalation results in higher local control rates.[rx][rx] However, the ACCORD 03 trial did not see a benefit in colostomy-free survival or complete response with higher boost doses of radiation up to 70 Gy.[rx] Therefore, conventional doses between 50.4 to 59.4 Gy are acceptable reserving doses at the higher end of the spectrum for bulkier disease.
Techniques associated with radiation therapy have evolved with the utilization of intensity-modulated radiation therapy (IMRT). This inverse planning method of external beam radiotherapy (EBRT) increases the therapeutic ratio by increasing conformal dose to the target structures while reducing dose to surrounding normal tissue.[rx] IMRT is clinically associated with decreased acute toxicity when compared to historical outcomes. RTOG 0529 is a phase II study evaluating patients with anal cancer treated with IMRT chemoradiation. T2N0 patients received treatment with a simultaneous integrated boost (SIB) plan prescribing 50.4 Gy to the primary tumor and 42 Gy to elective nodes in 28 fractions. T3-4N0 patients received treatment with a SIB plan delivering 54 Gy to the primary tumor and 45 Gy to elective nodes in 30 fractions. Positive nodes < 3 cm were treated to 50.4 Gy in 30 fractions, whereas nodes >=3cm were treated to 54 Gy in the same 30 fractions. Although the primary endpoint, reducing grade 2+ acute GI/GU toxicity by 15% compared to RTOG 9811, was not met, there was significant sparing of grade 2+ hematologic and grade 3+ dermatologic and GI toxicity.[rx] It is important to note that quality control and technical aspects of IMRT are challenging and conformal radiation therapy requires training in target volume contouring as demonstrated in RTOG 0529 by the number of plans failing central review. Various contouring atlases are available, including RTOG 0529, Myerson et al., and Ng et al.[rx][rx][rx]
Dose Constraints
The main purpose of dose constraints is to limit the acute and long-term toxicities associated with radiation to the pelvis when using IMRT. RTOG 0529 limited small and large bowel to V45 Gy < 20 cc, V35 Gy < 150 cc, and V30 Gy < 200 cc. This resulted in acute grade 2+ GI adverse events of 73% and acute grade 3+ GI adverse events of 21%. The same study limited bladder dose to V50 Gy <= 5%, V40 Gy <= 35%, and V35 Gy <= 50%. These constraints limited acute grade 2+ GU adverse events to 15% and acute grade 3+ GU adverse events to 2%.[rx] The overall rate of late GI grade 2+ adverse events was 10% and late GU grade 2+ adverse events was 4%.[rx]
Nodal Metastases
Lymph node positivity portends a poor prognosis and correlates with worse survival and colostomy rates.[rx] Radiation alone controls 70% of involved inguinal nodes, whereas chemoradiation controls 90% of involved inguinal nodes.[rx] Therefore, it is important to include mesenteric, iliac, and inguinal lymph nodes within the radiation fields.[rx][rx][rx]
Salvage Treatment
Despite the effectiveness of chemoradiation as definitive management, reports exist of locoregional failure rates of 10 to 30%.[rx][rx] Progressive or recurrent disease after definitive chemoradiation requires APR for salvage. Mullen et a.l[37] reported an actuarial 5-yr survival rate of 64% in 31 patients after radical salvage surgery. This study also showed that dose > 55 Gy as part of the initial chemoradiation regimen results in a better prognosis after radical salvage surgery.
Medical Oncology
MMC
RTOG 87-04 demonstrated a benefit to chemoradiation with MMC and 5FU vs. chemoradiation with 5FU alone.[rx] This study showed an improvement in 5-yr LC from 64% to 83% as well as a decreased colostomy rate from 22% to 9% (p = 0.002) with the addition of MMC.
Capecitabine
Capecitabine is an acceptable alternative to 5FU in the treatment of colon and rectal cancer with fewer hematologic toxicities, and it has therefore merited consideration as an alternative to 5FU in chemoradiation regimens for anal cancer. Although data for this regimen are limited, multiple retrospective studies have shown adequate LC, OS, and colostomy-free survival with this group of patients.[rx][rx]
Cisplatin
Cisplatin as a substitute for MMC has undergone evaluation in multiple phase II studies showing promising results for chemoradiation with 5FU and cisplatin.[rx][rx] Fewer hematologic and other toxicities are evident with cisplatin relative to MMC. The ACT II trial compared cisplatin with MMC and looked at the effect of additional maintenance chemotherapy following definitive chemoradiation. In this study, patients were randomly assigned to 5FU/MMC or 5FU/cisplatin with 50.4 Gy concurrent radiation. Each patient then underwent a second randomization receiving two cycles of maintenance therapy with 5FU and cisplatin vs. no maintenance therapy. There was no difference among any arm of the study, and because it was not a non-inferiority trial, they concluded that 5FU and MMC should remain the standard of care.[rx] Also, this trial confirmed that assessment for treatment response should not commence prior to 26 weeks unless there is a clear progression of the disease.[rx] RTOG 9811 was a two-arm trial evaluating the utilization of cisplatin as a replacement for MMC. Induction cisplatin plus concurrent chemoradiation with cisplatin/5FU was compared to the standard of concurrent chemoradiation with 5FU/MMC. Results were inferior in the cisplatin/5FU arm as compared to standard chemoradiation with 5FU/MMC.[rx] The use of induction cisplatin in this study may have confounded the results, because of the delay in the completion of therapy. The cisplatin arm resulted in worse 5-yr OS (70.7% vs 78.3%, p = 0.026), DFS (57.8% vs 67.8%, p = 0.006), and colostomy-free survival (65% vs 71.9%, p = 0.05) compared to the MMC arm.[rx] Chemoradiation with trimodal therapy including 5FU, MMC, and cisplatin was studied in a phase II trial, but found to be too toxic.[rx] Taken together, these studies support 5FU and MMC remaining the standard of care in concurrent chemoradiation with the possibility of using 5FU/cisplatin in the rare patient at high risk for excessive hematologic toxicity from MMC.
Induction
According to ACCORD 03, induction chemotherapy with 5FU and cisplatin offers no benefit in survival, complete response, or colostomy-free survival.[rx] This trial had two randomizations, one that looked at higher boost doses of radiation (as discussed previously), and the other evaluated two cycles of induction chemotherapy with 5FU/cisplatin vs. no induction chemotherapy. Additionally, RTOG 9811 as discussed above, demonstrated a detriment in OS, DFS, and colostomy-free survival with induction cisplatin.[rx]
Metastatic
First-line treatment of metastatic anal cancer includes a fluoropyrimidine-based regimen plus cisplatin. Additional regimens may include carboplatin plus paclitaxel or mFOLFOX. Second-line systemic therapies may include the anti-PD-1 antibody nivolumab, which has a 17% response rate in the KEYNOTE-028 study.[rx] Palliative radiation should be a consideration for symptomatic metastases, and chemoradiation may be an option for local control of bulky primary disease
Staging
Several clinical staging systems have been used in the past. The TNM (tumor, nodes, metastases) classification system developed by the American Joint Committee on Cancer (AJCC) is the most widely accepted classification system. TNM staging may use a combination of physical examination, positron emission tomography (PET), magnetic resonance imaging (MRI), and/or computed tomography (CT) to identify the primary tumor, involved nodes, and metastatic disease if present.[rx] If there is discordant or indeterminate imaging, pathologic staging with a sentinel lymph node biopsy may be an option.[rx] Unlike other GI malignancies, anal cancer T-stage is based primarily on tumor size rather than depth of invasion. A major change in the revision from AJCC 7th to 8th edition staging is with nodal staging. Previously lymph node staging was denoted as N1, N2, or N3 based on the location of regional nodes, which has undergone revision to a more straightforward N0-N1 designation based on the presence of lymph nodes. The N1 category now subdivides into N1a, N1b, and N1c based on the location of the nodes. This change is due to long-term outcomes of RTOG 98-11, demonstrating overall survival is impacted primarily by nodal positivity rather than the location of regional nodes.[rx]
AJCC 8th Edition:
Primary Tumor (T)
TX: Primary tumor not assessed
T0: No evidence of primary tumor
Tis: High-grade squamous intraepithelial lesion
T1: Tumor 2 cm or less
T2: Tumor more than 2 cm but not more than 5 cm
T3: Tumor more than 5 cm
T4: Tumor of any size that invades adjacent organ(s) including vagina, urethra, or bladder
Regional Lymph Nodes (N)
NX: Regional lymph nodes cannot be assessed
N0: No regional lymph node metastasis
N1: Regional lymph node metastasis present
N1a: Metastasis in inguinal, mesorectal, or internal iliac lymph nodes
N1b: Metastasis in external iliac lymph nodes
N1c: Metastasis in external iliac with any N1a nodes
Distant Metastasis (M)
M0: No distant metastasis
M1: Distant Metastasis
Anatomic Stage/Prognostic Groups:
Stage 0: Tis N0 M0
Stage I: T1 N0 M0
Stage IIA: T2 N0 M0
Stage IIB: T3 N0 M0
Stage IIIA: T1-2 N1 M0
Stage IIIB: T4 N0 M0
Stage IIIC: T3-4 N1 M0
Stage IV: Any T Any N M1
The following are risk factors for anal cancer:
Anal HPV infection
Being infected with human papillomavirus (HPV) is the main risk factor for anal cancer. Being infected with HPV can lead to squamous cell carcinoma of the anus, the most common type of anal cancer. About nine out of every ten cases of anal cancer are found in patients with anal HPV infection.
Patients with healthy immune systems are usually able to fight HPV infections. Patients with weakened immune systems who are infected with HPV have a higher risk of anal cancer.
Certain medical conditions
History of cervical, vaginal, or vulvar cancer
Cervical cancer, vaginal cancer, and vulvar cancer are related to HPV infection. Women who have had cervical, vaginal, or vulvar cancer have a higher risk of anal cancer.
HIV infection/AIDS
Being infected with human immunodeficiency virus (HIV) is a strong risk factor for anal cancer. HIV is the cause of acquired immunodeficiency syndrome (AIDS). HIV weakens the body’s immune system and its ability to fight infection. HPV infection of the anus is common among patients who are HIV-positive.
The risk of anal cancer is higher in men who are HIV-positive and have sex with men compared with men who are HIV-negative and have sex with men. Women who are HIV-positive also have an increased risk of anal cancer compared with women who are HIV-negative.
Studies show that intravenous drug use or cigarette smoking may further increase the risk of anal cancer in patients who are HIV-positive.
Immunosuppression
Immunosuppression is a condition that weakens the body’s immune system and its ability to fight infections and other diseases. Chronic (long-term) immunosuppression may increase the risk of anal cancer because it lowers the body’s ability to fight HPV infection.
Patients who have an organ transplant and receive immunosuppressive medicine to prevent organ rejection have an increased risk of anal cancer.
Having an autoimmune disorder such as Crohn disease or psoriasis may increase the risk of anal cancer. It is not clear if the increased risk is due to the autoimmune condition, the treatment for the condition, or a combination of both.
Certain sexual practices
The following sexual practices increase the risk of anal cancer because they increase the chance of being infected with HPV:
Having receptive anal intercourse (anal sex).
Having many sexual partners.
Sex between men.
Men and women who have a history of anal warts or other sexually transmitted diseases also have an increased risk of anal cancer.
Cigarette smoking
Studies show that cigarette smoking increases the risk of anal cancer. Studies also show that current smokers have a higher risk of anal cancer than smokers who have quit or people who have never smoked.
The following protective factor decreases the risk of anal cancer:
HPV vaccine
The human papillomavirus (HPV) vaccine is used to prevent anal cancer, cervical cancer, vulvar cancer, and vaginal cancer caused by HPV. It is also used to prevent lesions caused by HPV that may become cancer in the future.
Studies show that being vaccinated against HPV lowers the risk of anal cancer. The vaccine may work best when it is given before a person is exposed to HPV.
It is not clear if the following protective factor decreases the risk of anal cancer:
Condom use
It is not known if the use of condoms protects against anal HPV infection. This is because not enough studies have been done to prove this.
Cancer prevention clinical trials are used to study ways to prevent cancer.
Cancer prevention clinical trials are used to study ways to lower the risk of developing certain types of cancer. Some cancer prevention trials are conducted with healthy people who have not had cancer but who have an increased risk for cancer. Other prevention trials are conducted with people who have had cancer and are trying to prevent another cancer of the same type or to lower their chance of developing a new type of cancer. Other trials are done with healthy volunteers who are not known to have any risk factors for cancer.
The purpose of some cancer prevention clinical trials is to find out whether actions people take can prevent cancer. These may include eating fruits and vegetables, exercising, quitting smoking, or taking certain medicines, vitamins, minerals, or food supplements.
Coping with anal cancer
Many people feel worried, depressed, and stressed when dealing with cancer. Getting treatment for cancer can be hard on your mind and body. Keep talking with your healthcare team about any problems or concerns you may have. Work together to ease the effect of cancer and its symptoms on your daily life.
Here are tips:
Talk with your family or friends.
Ask your healthcare team or social worker for help.
Speak with a counselor.
Talk with a spiritual advisor, such as a minister or rabbi.
Ask your healthcare team about medicines for depression or anxiety.
Keep socially active.
Join a cancer support group.
Cancer treatment is also hard on the body. To help yourself stay healthier, try to:
Eat a healthy diet, with a focus on high-protein foods.
Drink plenty of water, fruit juices, and other liquids.
Keep physically active.
Rest as much as needed.
Talk with your healthcare team about ways to manage treatment side effects.
Take your medicines as directed by your team.
When should I call my healthcare provider?
Your healthcare provider will talk with you about when to call. You may be told to call if you have any of the below:
New symptoms or symptoms that get worse
Signs of an infection, such as a fever
Side effects of treatment that affect your daily function or don’t get better with treatment
Ask your healthcare provider what signs to watch for, and when to call. Know how to get help after office hours and on weekends and holidays.
Next steps
Tips to help you get the most from a visit to your healthcare provider:
Know the reason for your visit and what you want to happen.
Before your visit, write down questions you want answered.
Bring someone with you to help you ask questions and remember what your provider tells you.
At the visit, write down the name of a new diagnosis, and any new medicines, treatments, or tests. Also write down any new instructions your provider gives you.
Know why a new medicine or treatment is prescribed, and how it will help you. Also know what the side effects are.
Ask if your condition can be treated in other ways.
Know why a test or procedure is recommended and what the results could mean.
Know what to expect if you do not take the medicine or have the test or procedure.
If you have a follow-up appointment, write down the date, time, and purpose for that visit.
Know how you can contact your provider if you have questions.
What Is Anusitis?/Anusitis may happen secondary to ulcerative colitis (UC), Chronic Radiation Proctitis, Proctopathy (CRP), or Diversion Proctitis (DP). Infectious causes include Clostridium difficile, enteric infections (Campylobacter, Shigella, Escherichia coli, Salmonella, and amebiasis), and STI’s (Gonorrhea, Chlamydia, Syphilis, HSV, Lymphogranuloma venereum, chancroid, CMV, HPV).[rx] Other causes include ischemia, vasculitis, toxins as hydrogen peroxide enemas or medication side effects. The most common cause of anusitis is diet, as with excess citrus, coffee, cola, beer, garlic, spices, and sauces. Diarrhea noted after intake of laxatives as in preparation for colonoscopy is noted to cause anusitis and stress may be another etiologic factor.
Anusitis is a disorder that involves inflammation of the anal canal. People often mistake anusitis for hemorrhoids. Inflammatory bowel disease, infections, and chronic diarrhea can cause anusitis. However, the most common cause is a diet that contains a lot of acidic or spicy foods, such as coffee, citrus, and spices.
Causes of Anusitis
There are lots of possible causes. See the separate leaflets linked to each condition below for more detail. These are just some of the possible causes:
Skin conditions
There are a number of skin conditions which may affect the skin around the anus and cause itch. For example:
Eczema.
Psoriasis.
Lichen sclerosis.
Lichen planus.
Seborrhoeic dermatitis.
An allergic or irritant dermatitis. Dermatitis means inflammation of the skin. This may be caused by:
Excess sweat and moisture around the anus. Young children who may not wipe themselves properly, adults with sweaty jobs and adults with a lot of hair round their anus may be especially prone to this.
Excess cleaning of the anal area.
Some soaps, perfumes, creams, or ointments, or the dye in some toilet tissue, may irritate (sensitise) the skin around the anus in some people. You may be ‘allergic’ to one or more of the ingredients in these products.
Skin conditions cause about half of all cases of secondary pruritus ani.
Infections
Thrush and fungal infections are caused by germs that thrive in moist, warm, airless areas, such as around the anus. Thrush is more common in people with diabetes.
Threadworms are a very common cause in children. Up to 4 in 10 children in the UK have threadworms at some stage. Threadworms live in the gut and lay eggs around the anus which cause itch. Children may pass them on to adults in the same home. Consider this cause particularly if there is more than one person in the home with an itchy bottom. Also, with threadworms, the itch is mainly at night.
Other infections such as scabies, infections with germs (bacteria), herpes infection, anal warts and some other sexually transmitted infections can cause itch around the anus. You are likely to have other symptoms too such as a rash, lump or discharge.
Conditions affecting the anus
These include:
Anal fissure. This is a small crack in the anal skin. It is usually painful as well as itchy.
Piles (hemorrhoids).
A tumor of the anus or lower gut (bowel and rectum) is a rare cause of an itch around the anus.
Some diseases
Generalized itch, which may seem more intense around the anus at times, maybe caused by some diseases. For example:
Lymphoma
Certain liver diseases
Iron-deficiency anemia
Thyroid gland problems
Diabetes
With these conditions you are likely to be unwell with other symptoms.
Some foods
When certain foods are not fully digested, they may irritate the skin around the anus after you have gone to the toilet to pass stools. These include:
Citrus fruits.
Grapes.
Tomatoes.
Spices and chilli peppers.
Large amounts of beer.
Milk.
Caffeine – in coffee, tea or cola.
Some medicines
Some antibiotics can lead to diarrhoea. Passing lots of diarrhoea can irritate the anal skin and cause an itchy bottom.
If you are taking steroid medication or other medicines that can weaken your immune system, you are at increased risk of developing skin infections which may affect the skin around the anus.
Other medicines such as colchicine (for gout) and peppermint oil (for wind and bloating) may cause an itchy bottom as a side-effect.
Medicines that are put on to the skin near the anus to treat problems such as haemorrhoids may irritate the anal skin and cause a type of dermatitis.
Diagnosis Of Anusitis
Physical exam and history – An exam of the body to check general signs of health, including checking for signs of disease, such as lumps or anything else that seems unusual. A history of the patient’s health habits and past illnesses and treatments will also be taken.
Blood tests – These can detect blood loss or infections.
Stool test – You may be asked to collect a stool sample for testing. A stool test may help determine if your proctitis is caused by a bacterial infection.
Scope exam of the last portion of your colon – During this test (flexible sigmoidoscopy), your doctor uses a slender, flexible, lighted tube to examine the last part of your colon (sigmoid), as well as the rectum. During the procedure, your doctor can also take small samples of tissue (biopsy) for laboratory analysis.
Scope exam of your entire colon – This test (colonoscopy) allows your doctor to view your entire colon using a thin, flexible, lighted tube with an attached camera. Your doctor can also take a biopsy during this test.
Tests for sexually transmitted infections – These tests involve obtaining a sample of discharge from your anus or from the tube that drains urine from your bladder (urethra).
Digital anus exam (DRE) – An exam of the anus. The doctor or nurse inserts a lubricated, gloved finger into the lower part of the rectum to feel for lumps or anything else that seems unusual. In women, the vagina may also be examined.
Biopsy – The removal of cells or tissues so they can be viewed under a microscope to check for signs of the anus. Anus tissue that is removed during the biopsy may be checked to see if the patient is likely to have the gene mutation that causes HNPCC. This may help to plan treatment.
Treatment of Anusitis
The following treatment is available for anusitis
Antibiotic – Gonococcal proctitis is treated with ceftriaxone 250 mg intramuscular one time plus azithromycin 1 gram oral one time.
An alternative regimen is cefixime 400 mg -moral one time plus doxycycline 100 mg oral twice daily for seven days.mChlamydia is treated with azithromycin.
Doxycycline – erythromycin, ofloxacin, or Levofloxacin may be used as an alternative regimen.
LGV – has treated with doxycycline 100 mg twice daily for 21 days.
Erythromycin or azithromycin – may be used as alternative regimens for the same period of 21 days.
Herpes proctitis – is treated with acyclovir 400 mg oral three times daily or valacyclovir 1 gram twice daily or famciclovir 250 mg three times daily for 7 to 10 days. The course of treatment may be extended if no complete healing is achieved by the end of the 10-day course of treatment.[rx][rx]
For patients with mild to moderate UP, guidelines from American College of Gastroenterology (ACG) and American Gastroenterological Association (AGA) recommend
Rectal 5-Aminosalicylic Acid (5-ASA) – mesalamine rather than oral mesalamine. Suppositories are more effective than enemas. For induction of remission, the dose is 1 g/day and this is to be continued at the same dose to maintain remission.
Anus therapy – In cases of intolerance, refractoriness, hypersensitivity to mesalamine suppositories, inability to retain rectal therapy, rectal corticosteroid therapy is suggested for induction of remission rather than no therapy, despite the superiority of rectal 5-ASA over rectal steroids.
Corticosteroids – are not recommended and are not effective in the maintenance of remission secondary to side effects and long-term complications. Up to 46% of patients with UP may develop extensive colitis. This should be especially suspected in patients refractory to topical treatment and follow-up is recommended.[rx][rx]
UP is treated with topical mesalazine – in the form of suppositories, enemas, foams, and gels in severe cases combined with oral mesalazine with topical steroids or systemic corticosteroids in more severe cases.
In steroid-resistant cases – the addition of cyclosporine or immunomodulators; thiopurines as azathioprine (AZA) and 6-mercaptopurine (6-MP) is considered. Other options include anti-TNF-α (infliximab, adalimumab, and golimumab), anti-integrin antibodies as vedolizumab, and certolizumab, or oral tacrolimus.[rx][rx]
A particular treatment may be advised by a doctor or pharmacist. For example
You may be advised to use a steroid cream for a short while if there is eczema (dermatitis) around the anus.
An antifungal cream will clear fungal infections and thrush.
Antibiotics may help with certain other types of infection.
Anal conditions such as piles (haemorrhoids) or anal fissure may need treatment.
A medicine can clear threadworms if they are the cause.
This is a common situation. The following tips often help to stop the itch
Avoid any potential irritants
Stop using scented soaps, talcum powder, bubble bath, perfume, etc, near your anus.
Use plain, non-colored toilet tissue. Wipe your anus gently after passing stools (feces).
If any foods or medicines could be causing the itch, try avoiding for a while the foods and drinks listed above (such as fruits and tomatoes). If you take laxatives regularly, some of your stool may be leaking on to your anal skin.
Pay special attention to hygiene around your anus
Wash your anus after going to the toilet to pass stools. The aim is to clear any remnant of stool which may irritate the skin. Also, wash your anus at bedtime.
When washing around your anus, it is best to use water only. If you use soap, use bland non-scented soap.
When you are not at home, use a moistened cloth or a special moistened tissue to clean your anus. You can buy moistened tissues from pharmacies. Avoid scented or perfumed versions.
Have a bath or shower daily. If possible, wash your anus with water only. If you use soap around your anus, rinse well.
Change your underwear daily.
Avoid excessive moisture around your anus
After washing, dry around your anus properly by patting gently (rather than rubbing) with a soft towel. Even better, use a hairdryer, especially if your anal skin is hairy.
Do not put on underwear until your anus is fully dry.
Wear loose cotton underwear (not nylon). Avoid wearing tight-fitting trousers. If possible, do not sit for long periods and try not to get too hot. The aim is to allow air to get to your anus as much as possible and to avoid getting too sweaty.
If you sweat and moisture gathers around your anus, put a cotton tissue in your underwear to absorb the moisture.
Consider the ‘itch-scratch cycle
Scratching can make the itch worse – which makes you want to scratch more, etc.
As much as possible, try not to scratch. This is especially difficult at night when the itch tends to be worse while you are trying to get to sleep.
You may also scratch in your sleep without realising. To help this:
Keep your fingernails short to limit any damage done to the skin by scratching.
Consider wearing cotton gloves at night to prevent sharp scratching with fingernails.
An antihistamine medicine that makes you drowsy may be worth a try at bedtime. Your doctor will advise.
Your doctor may advise a short course of a cream or ointment
A bland soothing ointment may be recommended to use after going to the toilet and at bedtime. There are many to choose from. (However, remember an ingredient of an ointment may sometimes cause sensitivity and itch around the anus.) You should not use a cream such as this for longer than two weeks unless you are advised otherwise by your doctor.
A short course (up to 14 days but no more) of a mild steroid cream may ease symptoms if there is inflammation of your anal skin. Steroids reduce inflammation (but should not normally be used on infected skin).
Anusitis may happen secondary to ulcerative colitis (UC), Chronic Radiation Proctitis, Proctopathy (CRP), or Diversion Proctitis (DP). Infectious causes include Clostridium difficile, enteric infections (Campylobacter, Shigella, Escherichia coli, Salmonella, and amebiasis), and STI’s (Gonorrhea, Chlamydia, Syphilis, HSV, Lymphogranuloma venereum, chancroid, CMV, HPV).[rx] Other causes include ischemia, vasculitis, toxins as hydrogen peroxide enemas or medication side effects. The most common cause of anusitis is diet, as with excess citrus, coffee, cola, beer, garlic, spices, and sauces. Diarrhea noted after intake of laxatives as in preparation for colonoscopy is noted to cause anusitis and stress may be another etiologic factor.
Anusitis is a disorder that involves inflammation of the anal canal. People often mistake anusitis for hemorrhoids. Inflammatory bowel disease, infections, and chronic diarrhea can cause anusitis. However, the most common cause is a diet that contains a lot of acidic or spicy foods, such as coffee, citrus, and spices.
Causes of Anusitis
There are lots of possible causes. See the separate leaflets linked to each condition below for more detail. These are just some of the possible causes:
Skin conditions
There are a number of skin conditions which may affect the skin around the anus and cause itch. For example:
Eczema.
Psoriasis.
Lichen sclerosis.
Lichen planus.
Seborrhoeic dermatitis.
An allergic or irritant dermatitis. Dermatitis means inflammation of the skin. This may be caused by:
Excess sweat and moisture around the anus. Young children who may not wipe themselves properly, adults with sweaty jobs and adults with a lot of hair round their anus may be especially prone to this.
Excess cleaning of the anal area.
Some soaps, perfumes, creams, or ointments, or the dye in some toilet tissue, may irritate (sensitise) the skin around the anus in some people. You may be ‘allergic’ to one or more of the ingredients in these products.
Skin conditions cause about half of all cases of secondary pruritus ani.
Infections
Thrush and fungal infections are caused by germs that thrive in moist, warm, airless areas, such as around the anus. Thrush is more common in people with diabetes.
Threadworms are a very common cause in children. Up to 4 in 10 children in the UK have threadworms at some stage. Threadworms live in the gut and lay eggs around the anus which cause itch. Children may pass them on to adults in the same home. Consider this cause particularly if there is more than one person in the home with an itchy bottom. Also, with threadworms, the itch is mainly at night.
Other infections such as scabies, infections with germs (bacteria), herpes infection, anal warts and some other sexually transmitted infections can cause itch around the anus. You are likely to have other symptoms too such as a rash, lump or discharge.
Conditions affecting the anus
These include:
Anal fissure. This is a small crack in the anal skin. It is usually painful as well as itchy.
Piles (hemorrhoids).
A tumor of the anus or lower gut (bowel and rectum) is a rare cause of an itch around the anus.
Some diseases
Generalized itch, which may seem more intense around the anus at times, maybe caused by some diseases. For example:
Lymphoma
Certain liver diseases
Iron-deficiency anemia
Thyroid gland problems
Diabetes
With these conditions you are likely to be unwell with other symptoms.
Some foods
When certain foods are not fully digested, they may irritate the skin around the anus after you have gone to the toilet to pass stools. These include:
Citrus fruits.
Grapes.
Tomatoes.
Spices and chilli peppers.
Large amounts of beer.
Milk.
Caffeine – in coffee, tea or cola.
Some medicines
Some antibiotics can lead to diarrhoea. Passing lots of diarrhoea can irritate the anal skin and cause an itchy bottom.
If you are taking steroid medication or other medicines that can weaken your immune system, you are at increased risk of developing skin infections which may affect the skin around the anus.
Other medicines such as colchicine (for gout) and peppermint oil (for wind and bloating) may cause an itchy bottom as a side-effect.
Medicines that are put on to the skin near the anus to treat problems such as haemorrhoids may irritate the anal skin and cause a type of dermatitis.
Diagnosis Of Anusitis
Physical exam and history – An exam of the body to check general signs of health, including checking for signs of disease, such as lumps or anything else that seems unusual. A history of the patient’s health habits and past illnesses and treatments will also be taken.
Blood tests – These can detect blood loss or infections.
Stool test – You may be asked to collect a stool sample for testing. A stool test may help determine if your proctitis is caused by a bacterial infection.
Scope exam of the last portion of your colon – During this test (flexible sigmoidoscopy), your doctor uses a slender, flexible, lighted tube to examine the last part of your colon (sigmoid), as well as the rectum. During the procedure, your doctor can also take small samples of tissue (biopsy) for laboratory analysis.
Scope exam of your entire colon – This test (colonoscopy) allows your doctor to view your entire colon using a thin, flexible, lighted tube with an attached camera. Your doctor can also take a biopsy during this test.
Tests for sexually transmitted infections – These tests involve obtaining a sample of discharge from your anus or from the tube that drains urine from your bladder (urethra).
Digital anus exam (DRE) – An exam of the anus. The doctor or nurse inserts a lubricated, gloved finger into the lower part of the rectum to feel for lumps or anything else that seems unusual. In women, the vagina may also be examined.
Biopsy – The removal of cells or tissues so they can be viewed under a microscope to check for signs of the anus. Anus tissue that is removed during the biopsy may be checked to see if the patient is likely to have the gene mutation that causes HNPCC. This may help to plan treatment.
Treatment of Anusitis
The following treatment is available for anusitis
Antibiotic – Gonococcal proctitis is treated with ceftriaxone 250 mg intramuscular one time plus azithromycin 1 gram oral one time.
An alternative regimen is cefixime 400 mg -moral one time plus doxycycline 100 mg oral twice daily for seven days.mChlamydia is treated with azithromycin.
Doxycycline – erythromycin, ofloxacin, or Levofloxacin may be used as an alternative regimen.
LGV – has treated with doxycycline 100 mg twice daily for 21 days.
Erythromycin or azithromycin – may be used as alternative regimens for the same period of 21 days.
Herpes proctitis – is treated with acyclovir 400 mg oral three times daily or valacyclovir 1 gram twice daily or famciclovir 250 mg three times daily for 7 to 10 days. The course of treatment may be extended if no complete healing is achieved by the end of the 10-day course of treatment.[rx][rx]
For patients with mild to moderate UP, guidelines from American College of Gastroenterology (ACG) and American Gastroenterological Association (AGA) recommend
Rectal 5-Aminosalicylic Acid (5-ASA) – mesalamine rather than oral mesalamine. Suppositories are more effective than enemas. For induction of remission, the dose is 1 g/day and this is to be continued at the same dose to maintain remission.
Anus therapy – In cases of intolerance, refractoriness, hypersensitivity to mesalamine suppositories, inability to retain rectal therapy, rectal corticosteroid therapy is suggested for induction of remission rather than no therapy, despite the superiority of rectal 5-ASA over rectal steroids.
Corticosteroids – are not recommended and are not effective in the maintenance of remission secondary to side effects and long-term complications. Up to 46% of patients with UP may develop extensive colitis. This should be especially suspected in patients refractory to topical treatment and follow-up is recommended.[rx][rx]
UP is treated with topical mesalazine – in the form of suppositories, enemas, foams, and gels in severe cases combined with oral mesalazine with topical steroids or systemic corticosteroids in more severe cases.
In steroid-resistant cases – the addition of cyclosporine or immunomodulators; thiopurines as azathioprine (AZA) and 6-mercaptopurine (6-MP) is considered. Other options include anti-TNF-α (infliximab, adalimumab, and golimumab), anti-integrin antibodies as vedolizumab, and certolizumab, or oral tacrolimus.[rx][rx]
A particular treatment may be advised by a doctor or pharmacist. For example
You may be advised to use a steroid cream for a short while if there is eczema (dermatitis) around the anus.
An antifungal cream will clear fungal infections and thrush.
Antibiotics may help with certain other types of infection.
Anal conditions such as piles (haemorrhoids) or anal fissure may need treatment.
A medicine can clear threadworms if they are the cause.
This is a common situation. The following tips often help to stop the itch
Avoid any potential irritants
Stop using scented soaps, talcum powder, bubble bath, perfume, etc, near your anus.
Use plain, non-colored toilet tissue. Wipe your anus gently after passing stools (feces).
If any foods or medicines could be causing the itch, try avoiding for a while the foods and drinks listed above (such as fruits and tomatoes). If you take laxatives regularly, some of your stool may be leaking on to your anal skin.
Pay special attention to hygiene around your anus
Wash your anus after going to the toilet to pass stools. The aim is to clear any remnant of stool which may irritate the skin. Also, wash your anus at bedtime.
When washing around your anus, it is best to use water only. If you use soap, use bland non-scented soap.
When you are not at home, use a moistened cloth or a special moistened tissue to clean your anus. You can buy moistened tissues from pharmacies. Avoid scented or perfumed versions.
Have a bath or shower daily. If possible, wash your anus with water only. If you use soap around your anus, rinse well.
Change your underwear daily.
Avoid excessive moisture around your anus
After washing, dry around your anus properly by patting gently (rather than rubbing) with a soft towel. Even better, use a hairdryer, especially if your anal skin is hairy.
Do not put on underwear until your anus is fully dry.
Wear loose cotton underwear (not nylon). Avoid wearing tight-fitting trousers. If possible, do not sit for long periods and try not to get too hot. The aim is to allow air to get to your anus as much as possible and to avoid getting too sweaty.
If you sweat and moisture gathers around your anus, put a cotton tissue in your underwear to absorb the moisture.
Consider the ‘itch-scratch cycle
Scratching can make the itch worse – which makes you want to scratch more, etc.
As much as possible, try not to scratch. This is especially difficult at night when the itch tends to be worse while you are trying to get to sleep.
You may also scratch in your sleep without realising. To help this:
Keep your fingernails short to limit any damage done to the skin by scratching.
Consider wearing cotton gloves at night to prevent sharp scratching with fingernails.
An antihistamine medicine that makes you drowsy may be worth a try at bedtime. Your doctor will advise.
Your doctor may advise a short course of a cream or ointment
A bland soothing ointment may be recommended to use after going to the toilet and at bedtime. There are many to choose from. (However, remember an ingredient of an ointment may sometimes cause sensitivity and itch around the anus.) You should not use a cream such as this for longer than two weeks unless you are advised otherwise by your doctor.
A short course (up to 14 days but no more) of a mild steroid cream may ease symptoms if there is inflammation of your anal skin. Steroids reduce inflammation (but should not normally be used on infected skin).
Inflammation of Rectum mucosa, distal to the rectosigmoid junction, within 18 cm of the anal verge. It can be acute or chronic. Anusitis is inflammation of the lining of the anal canal. Anusitis is a common disorder that is rarely diagnosed and is often misdiagnosed as hemorrhoids.
Proctitis refers to inflammation of the rectum, a diagnosis made by endoscopic evaluation. Symptoms of proctitis include rectal bleeding, urgency, tenesmus, diarrhea or constipation, and occasionally rectal pain. The causes of proctitis include infection, medication, ischemia, radiation, and ulcerative proctitis. Ulcerative proctitis is an important and increasingly common subcategory of ulcerative colitis (UC) in which inflammation is limited to the rectum.
Types of Proctitis
Proctitis and anusitis may happen secondary to ulcerative colitis (UC),
Chronic Radiation Proctitis
Proctopathy (CRP)
Diversion Proctitis (DP)
Gonorrhea (Gonococcal proctitis) – This is the most common cause. Strongly associated with anal intercourse. Symptoms include soreness, itching, bloody or pus-like discharge, or diarrhea. Other rectal problems that may be present are anal warts, anal tears, fistulas, and hemorrhoids.
Chlamydia (chlamydia proctitis) – Accounts for twenty percent of cases. People may show no symptoms, mild symptoms, or severe symptoms. Mild symptoms include rectal pain with bowel movements, rectal discharge, and cramping. With severe cases, people may have discharge containing blood or pus, severe rectal pain, and diarrhea. Some people have rectal strictures, a narrowing of the rectal passageway.
Herpes Simplex Virus 1 and 2 (herpes proctitis) – Symptoms may include multiple vesicles that rupture to form ulcers, tenesmus, rectal pain, discharge, hematochezia. The disease may run its natural course of exacerbations and remissions but is usually more prolonged and severe in patients with immunodeficiency disorders. Presentations may resemble dermatitis or decubitus ulcers in debilitated, bedridden patients. A secondary bacterial infection may be present.
Syphilis (syphilitic proctitis)
The symptoms are similar to other causes of infectious proctitis; rectal pain, discharge, and spasms during bowel movements, but some people may have no symptoms. Syphilis occurs in three stages.
The primary stage – One painless sore, less than an inch across, with raised borders found at the site of sexual contact, and during acute stages of infection, the lymph nodes in the groin become diseased, firm, and rubbery.
The secondary stage – A contagious diffuse rash that may appear over the entire body, particularly on the hands and feet.
The third stage – occurs late in the course of syphilis and affects mostly the heart and nervous system.
Causes of Inflammation of Rectum
Infectious causes – include Clostridium difficile, enteric infections (Campylobacter, Shigella, Escherichia coli, Salmonella, and amebiasis), and STI’s (Gonorrhea, Chlamydia, Syphilis, HSV, Lymphogranuloma venereum, chancroid, CMV, HPV).[rx]
Causes include ischemia vasculitis – toxins as hydrogen peroxide enemas or medication side effects. The most common cause of anusitis is diet, as with excess citrus, coffee, cola, beer, garlic, spices, and sauces. Diarrhea noted after intake of laxatives as in preparation for colonoscopy is noted to cause anusitis and stress may be another etiologic factor.
Inflammatory bowel disease – About 30% of people with inflammatory bowel disease (Crohn’s disease or ulcerative colitis) have inflammation of the rectum.
Infections – Sexually transmitted infections, spread particularly by people who engage in anal intercourse, can result in proctitis. Sexually transmitted infections that can cause proctitis include gonorrhea, genital herpes and chlamydia. Infections associated with foodborne illness, such as salmonella, shigella and campylobacter infections, also can cause proctitis.
Radiation therapy for cancer – Radiation therapy directed at your rectum or nearby areas, such as the prostate, can cause rectal inflammation. Radiation proctitis can begin during radiation treatment and last for a few months after treatment. Or it can occur years after treatment.
Antibiotics – Sometimes antibiotics used to treat an infection can kill helpful bacteria in the bowels, allowing the harmful Clostridium difficile bacteria to grow in the rectum.
Diversion proctitis – Proctitis can occur in people following some types of colon surgery in which the passage of stool is diverted from the rectum to a surgically created opening (stoma).
Food protein-induced proctitis – This can occur in infants who drink either cow’s milk- or soy-based formula. Infants breastfed by mothers who eat dairy products also may develop proctitis.
Eosinophilic proctitis – This condition occurs when a type of white blood cell (eosinophil) builds up in the lining of the rectum. Eosinophilic proctitis affects only children younger than 2.
Unsafe sex – Practices that increase your risk of a sexually transmitted infection (STI) can increase your risk of proctitis. Your risk of contracting an STI increases if you have multiple sex partners, don’t use condoms and have sex with a partner who has an STI.
Inflammatory bowel diseases – Having an inflammatory bowel disease (Crohn’s disease or ulcerative colitis ) increases your risk of proctitis.
Radiation therapy for cancer – Radiation therapy directed at or near your rectum (such as for rectal, ovarian or prostate cancer) increases your risk of proctitis.
Physical exam and history – An exam of the body to check general signs of health, including checking for signs of disease, such as lumps or anything else that seems unusual. A history of the patient’s health habits and past illnesses and treatments will also be taken.
Blood tests – These can detect blood loss or infections.
Stool test – You may be asked to collect a stool sample for testing. A stool test may help determine if your proctitis is caused by a bacterial infection.
Scope exam of the last portion of your colon – During this test (flexible sigmoidoscopy), your doctor uses a slender, flexible, lighted tube to examine the last part of your colon (sigmoid), as well as the rectum. During the procedure, your doctor can also take small samples of tissue (biopsy) for laboratory analysis.
Scope exam of your entire colon – This test (colonoscopy) allows your doctor to view your entire colon using a thin, flexible, lighted tube with an attached camera. Your doctor can also take a biopsy during this test.
Tests for sexually transmitted infections – These tests involve obtaining a sample of discharge from your rectum or from the tube that drains urine from your bladder (urethra).
Digital rectal exam (DRE) – An exam of the rectum. The doctor or nurse inserts a lubricated, gloved finger into the lower part of the rectum to feel for lumps or anything else that seems unusual. In women, the vagina may also be examined.
Colonoscopy – A procedure to look inside the rectum and colon for polyps (small pieces of bulging tissue), abnormal areas, or cancer. A colonoscope is a thin, tube-like instrument with a light and a lens for viewing. It may also have a tool to remove polyps or tissue samples, which are checked under a microscope for signs of cancer.
Biopsy – The removal of cells or tissues so they can be viewed under a microscope to check for signs of cancer. Tumor tissue that is removed during the biopsy may be checked to see if the patient is likely to have the gene mutation that causes HNPCC. This may help to plan treatment. The following tests may be used:
Reverse transcription-polymerase chain reaction (RT–PCR) test – A laboratory test in which the amount of a genetic substance called mRNA made by a specific gene is measured. An enzyme called reverse transcriptase is used to convert a specific piece of RNA into a matching piece of DNA, which can be amplified (made in large numbers) by another enzyme called DNA polymerase. The amplified DNA copies help tell whether a specific mRNA is being made by a gene. RT–PCR can be used to check the activation of certain genes that may indicate the presence of cancer cells. This test may be used to look for certain changes in a gene or chromosome, which may help diagnose cancer.
Immunohistochemistry – A laboratory test that uses antibodies to check for certain antigens (markers) in a sample of a patient’s tissue. The antibodies are usually linked to an enzyme or a fluorescent dye. After the antibodies bind to a specific antigen in the tissue sample, the enzyme or dye is activated, and the antigen can then be seen under a microscope. This type of test is used to help diagnose cancer and to help tell one type of cancer from another type of cancer.
Carcinoembryonic antigen (CEA) assay – A test that measures the level of CEA in the blood. CEA is released into the bloodstream from both cancer cells and normal cells. When found in higher than normal amounts, it can be a sign of rectal cancer or other conditions.
Anorectal manometry – measures and assesses the anal sphincter (internal and external) and rectal pressure and its function. This method is used to evaluate patients with fecal incontinence and constipation. It can directly measure the luminal pressure, including the high-pressure zone, resting pressure, squeezing pressure, rectal sensation/compliance, and the anorectal inhibitory reflex.[rx]
Defecating proctography/Defecography – A study using X-ray imaging to evaluate anatomic defects of the anorectal region and function of the puborectalis muscle. A contrast filled paste gets initially introduced to the rectum, and the patient is instructed to defecate in a series of stages (relaxation, contraction, tensing of the abdomen, and evacuation).[rx]
Balloon capacity and compliance test – Evaluates the function of the rectum using a device (plastic catheter with a latex balloon attached), which is inserted into the rectum and gradually filled with warm water. During this process, the volume and pressure are measured.[rx]
Balloon evacuation study – This test is similar to the balloon capacity and compliance test in which a catheter with a small balloon gets inserted into the rectum and filled with water. Different volumes of water get loaded inside the balloon, and the patient is instructed to evacuate the balloon. This procedure is done to evaluate the opening of the anal canal and to assess the relaxation of the pelvic floor.[rx]
Pudendal nerve terminal motor latency – A probe designed to stimulate and record nerve activity is placed on the physician’s gloved finger, which is then inserted into the rectum to measure pudendal nerve activity (latency to contraction of the anal sphincter muscle). The pudendal nerve innervates the anal sphincter muscles; therefore, this test can be used to assess any injury to that nerve.
Electromyography – A test to measure the ability of the puborectalis muscle and sphincter muscles to relax properly. An electrode is placed inside the rectum, and the activity of these muscles gets evaluated throughout a series of stages (relaxation, contraction, and evacuation).[rx]
Endoanal Ultrasonography – The use of ultrasound imaging to examine rectal lesions, defects, or injuries to the surrounding tissues.[rx]
Suction rectal biopsy – Gold standard for the diagnosis of Hirschsprung disease. A biopsy is taken two cm above the dentate line, and the absence of ganglion cells on histology confirms the diagnosis. Hypertrophic nerve fibers may be present in addition to this finding.[rx]
Contrast enema – Used as one of the diagnostic methods for Hirschsprung disease. Useful for localization of the aganglionic segment by looking for a narrowed rectum. Diagnostic confirmation is via a rectal biopsy.[rx]
Treatment of Inflammation of Rectum
When the presentation is consistent with acute proctitis in patients with receptive anal intercourse, therapy should be initiated while awaiting results of laboratory tests. Partners of patients with STI’s should be evaluated and patients should refrain from sexual intercourse until they are treated.
Antibiotic – Gonococcal proctitis is treated with ceftriaxone 250 mg intramuscular one time plus azithromycin 1 gram oral one time.
An alternative regimen is cefixime 400 mg -moral one time plus doxycycline 100 mg oral twice daily for seven days.mChlamydia is treated with azithromycin.
Doxycycline – erythromycin, ofloxacin, or Levofloxacin may be used as an alternative regimen.
LGV – has treated with doxycycline 100 mg twice daily for 21 days.
Erythromycin or azithromycin – may be used as alternative regimens for the same period of 21 days.
Herpes proctitis – is treated with acyclovir 400 mg oral three times daily or valacyclovir 1 gram twice daily or famciclovir 250 mg three times daily for 7 to 10 days. The course of treatment may be extended if no complete healing is achieved by the end of the 10-day course of treatment.[rx][rx]
For patients with mild to moderate UP, guidelines from American College of Gastroenterology (ACG) and American Gastroenterological Association (AGA) recommend
Rectal 5-Aminosalicylic Acid (5-ASA) – mesalamine rather than oral mesalamine. Suppositories are more effective than enemas. For induction of remission, the dose is 1 g/day and this is to be continued at the same dose to maintain remission.
Rectal therapy – In cases of intolerance, refractoriness, hypersensitivity to mesalamine suppositories, inability to retain rectal therapy, rectal corticosteroid therapy is suggested for induction of remission rather than no therapy, despite the superiority of rectal 5-ASA over rectal steroids.
Corticosteroids – are not recommended and are not effective in the maintenance of remission secondary to side effects and long-term complications. Up to 46% of patients with UP may develop extensive colitis. This should be especially suspected in patients refractory to topical treatment and follow-up is recommended.[rx][rx]
UP is treated with topical mesalazine – in the form of suppositories, enemas, foams, and gels in severe cases combined with oral mesalazine with topical steroids or systemic corticosteroids in more severe cases.
In steroid-resistant cases – the addition of cyclosporine or immunomodulators; thiopurines as azathioprine (AZA) and 6-mercaptopurine (6-MP) is considered. Other options include anti-TNF-α (infliximab, adalimumab, and golimumab), anti-integrin antibodies as vedolizumab, and certolizumab, or oral tacrolimus.[rx][rx]
For CRP, topical
Sucralfate enema – is the best available treatment. For DP, topical short-chain fatty acids (SCFAs) enemas, topical 5-ASA, or topical steroids are used.
In patients with intractable symptoms – despite intensive therapy or complications including strictures, fistulas, and persistent bleeding, colostomy, ileostomy, proctectomy or proctocolectomy with ileal pouch-anal anastomosis (IPAA) may be considered.
The application of a cold – retaining probe to the anal canal may give relief to anusitis patients as well as diet change and better handling of stress.[rx]
Injury
Proctitis due to injury, such as anal sex or anal play, requires the person to stop the activity that is responsible for the inflammation. The doctor may also prescribe or recommend medications to treat pain and relieve diarrhea, if necessary.
The National Institute of Diabetes and Digestive and Kidney Diseases note that healing from injury in the rectum usually takes 4–6 weeks.
Radiation therapy
Proctitis from radiation therapy is common. As a 2015 study notes, close to 75% of people who have radiation therapy in the pelvis will develop acute proctitis symptoms, while 20% may experience chronic, long lasting symptoms.
Doctors will treat radiation proctitis on a case-by-case basis. If the person has mild symptoms of proctitis due to radiation therapy, they may need no treatment, and the symptoms may clear up on their own.
In some cases, doctors may use corticosteroid enemas to help with severe symptoms or pain. These medications reduce inflammation in the rectum.
A doctor may also recommend other medications, such as sucralfate, which is a drug that is primarily for the treatment of ulcers but which may help with symptoms.
Inflammatory bowel disease
Inflammatory bowel disease is a more long-term cause of proctitis, and people with this condition will require consistent treatment to control the symptoms.
There is no cure for inflammatory bowel disease, so the treatment goal is to keep inflammation in check, prevent flare-ups, and put the body in remission.
To achieve these goals, doctors may recommend several different types of drugs, including:
Corticosteroids
Corticosteroids in different forms may help reduce immune system activity in the area to decrease inflammation. These include steroids such as:
hydrocortisone
prednisone
methylprednisolone
budesonide
Immunomodulators
Immunomodulators reduce the overall activity in the immune system. As autoimmune factors often seem to play a role in chronic disorders such as Crohn’s disease, this treatment often helps reduce and manage symptoms.
Common immunomodulators include:
methotrexate
cyclosporine
6-mercaptopurine
azathioprine
Aminosalicylates
Aminosalicylates, also called 5-ASA drugs, help control inflammation. These include:
mesalamine
balsalazide
olsalazine
sulfasalazine
Prevention of Proctitis
Prevention of proctitis begins with addressing the high-risk sexual behaviors that you may engage in. Sexually safe behaviors include using protection such as the condom, knowing your sexual partner and history, and avoiding anal intercourse. You must use safe sex practices, such as condoms, if you engage in high-risk sexual behaviors such as these:
Having multiple sexual partners (or changing sexual partners)
A previous history of any sexually transmitted disease
Having a partner with a past history of any STD
Having a partner with an unknown sexual history
Using drugs or alcohol (these may increase the likelihood of unsafe sexual practices)
Having a partner who is an IV drug user
Bisexual or homosexual partners
Anal intercourse (Anal sex with a condom decreases the risk of proctitis by STDs, but you can still get proctitis from anal trauma)
Having unprotected intercourse (sex without the use of a condom) with an unknown partner
Outlook for Proctitis
In most cases, anal/rectal problems like proctitis go away with treatment.
Because most cases of proctitis are caused by sexually transmitted infections, antibiotics may be needed.
Proctitis caused by other conditions, such as radiation therapy, ulcerative colitis, and Crohn’s disease, may last a long time. You may need long-term therapy. Symptoms may return from time to time (in relapse or flare-up).
In certain instances, where medications are not effective, you may need surgery to remove the diseased part of your gastrointestinal tract. There can be complications as a result of proctitis, especially if it goes untreated. Some complications include severe bleeding, anemia, ulcers, and fistulas.
Fistulas may occur in many parts of the body. Women typically may get recto-vaginal fistulas in which a tube grows to connect the rectum to the vagina. Both men and women may get anal fistulas, which connect the rectum to the skin. These fistulas can also become infected and cause complications themselves.
What Is Proctitis?/Proctitis is inflammation of the rectal mucosa, distal to the rectosigmoid junction, within 18 cm of the anal verge. It can be acute or chronic. Anusitis is inflammation of the lining of the anal canal. Anusitis is a common disorder that is rarely diagnosed and is often misdiagnosed as hemorrhoids.
Proctitis refers to inflammation of the rectum, a diagnosis made by endoscopic evaluation. Symptoms of proctitis include rectal bleeding, urgency, tenesmus, diarrhea or constipation, and occasionally rectal pain. The causes of proctitis include infection, medication, ischemia, radiation, and ulcerative proctitis. Ulcerative proctitis is an important and increasingly common subcategory of ulcerative colitis (UC) in which inflammation is limited to the rectum.
Types of Proctitis
Proctitis and anusitis may happen secondary to ulcerative colitis (UC),
Chronic Radiation Proctitis
Proctopathy (CRP)
Diversion Proctitis (DP)
Gonorrhea (Gonococcal proctitis) – This is the most common cause. Strongly associated with anal intercourse. Symptoms include soreness, itching, bloody or pus-like discharge, or diarrhea. Other rectal problems that may be present are anal warts, anal tears, fistulas, and hemorrhoids.
Chlamydia (chlamydia proctitis) – Accounts for twenty percent of cases. People may show no symptoms, mild symptoms, or severe symptoms. Mild symptoms include rectal pain with bowel movements, rectal discharge, and cramping. With severe cases, people may have discharge containing blood or pus, severe rectal pain, and diarrhea. Some people have rectal strictures, a narrowing of the rectal passageway.
Herpes Simplex Virus 1 and 2 (herpes proctitis) – Symptoms may include multiple vesicles that rupture to form ulcers, tenesmus, rectal pain, discharge, hematochezia. The disease may run its natural course of exacerbations and remissions but is usually more prolonged and severe in patients with immunodeficiency disorders. Presentations may resemble dermatitis or decubitus ulcers in debilitated, bedridden patients. A secondary bacterial infection may be present.
Syphilis (syphilitic proctitis)
The symptoms are similar to other causes of infectious proctitis; rectal pain, discharge, and spasms during bowel movements, but some people may have no symptoms. Syphilis occurs in three stages.
The primary stage – One painless sore, less than an inch across, with raised borders found at the site of sexual contact, and during acute stages of infection, the lymph nodes in the groin become diseased, firm, and rubbery.
The secondary stage – A contagious diffuse rash that may appear over the entire body, particularly on the hands and feet.
The third stage – occurs late in the course of syphilis and affects mostly the heart and nervous system.
Causes of Proctitis
Infectious causes – include Clostridium difficile, enteric infections (Campylobacter, Shigella, Escherichia coli, Salmonella, and amebiasis), and STI’s (Gonorrhea, Chlamydia, Syphilis, HSV, Lymphogranuloma venereum, chancroid, CMV, HPV).[rx]
Causes include ischemia vasculitis – toxins as hydrogen peroxide enemas or medication side effects. The most common cause of anusitis is diet, as with excess citrus, coffee, cola, beer, garlic, spices, and sauces. Diarrhea noted after intake of laxatives as in preparation for colonoscopy is noted to cause anusitis and stress may be another etiologic factor.
Inflammatory bowel disease – About 30% of people with inflammatory bowel disease (Crohn’s disease or ulcerative colitis) have inflammation of the rectum.
Infections – Sexually transmitted infections, spread particularly by people who engage in anal intercourse, can result in proctitis. Sexually transmitted infections that can cause proctitis include gonorrhea, genital herpes and chlamydia. Infections associated with foodborne illness, such as salmonella, shigella and campylobacter infections, also can cause proctitis.
Radiation therapy for cancer – Radiation therapy directed at your rectum or nearby areas, such as the prostate, can cause rectal inflammation. Radiation proctitis can begin during radiation treatment and last for a few months after treatment. Or it can occur years after treatment.
Antibiotics – Sometimes antibiotics used to treat an infection can kill helpful bacteria in the bowels, allowing the harmful Clostridium difficile bacteria to grow in the rectum.
Diversion proctitis – Proctitis can occur in people following some types of colon surgery in which the passage of stool is diverted from the rectum to a surgically created opening (stoma).
Food protein-induced proctitis – This can occur in infants who drink either cow’s milk- or soy-based formula. Infants breastfed by mothers who eat dairy products also may develop proctitis.
Eosinophilic proctitis – This condition occurs when a type of white blood cell (eosinophil) builds up in the lining of the rectum. Eosinophilic proctitis affects only children younger than 2.
Unsafe sex – Practices that increase your risk of a sexually transmitted infection (STI) can increase your risk of proctitis. Your risk of contracting an STI increases if you have multiple sex partners, don’t use condoms and have sex with a partner who has an STI.
Inflammatory bowel diseases – Having an inflammatory bowel disease (Crohn’s disease or ulcerative colitis ) increases your risk of proctitis.
Radiation therapy for cancer – Radiation therapy directed at or near your rectum (such as for rectal, ovarian or prostate cancer) increases your risk of proctitis.
Physical exam and history – An exam of the body to check general signs of health, including checking for signs of disease, such as lumps or anything else that seems unusual. A history of the patient’s health habits and past illnesses and treatments will also be taken.
Blood tests – These can detect blood loss or infections.
Stool test – You may be asked to collect a stool sample for testing. A stool test may help determine if your proctitis is caused by a bacterial infection.
Scope exam of the last portion of your colon – During this test (flexible sigmoidoscopy), your doctor uses a slender, flexible, lighted tube to examine the last part of your colon (sigmoid), as well as the rectum. During the procedure, your doctor can also take small samples of tissue (biopsy) for laboratory analysis.
Scope exam of your entire colon – This test (colonoscopy) allows your doctor to view your entire colon using a thin, flexible, lighted tube with an attached camera. Your doctor can also take a biopsy during this test.
Tests for sexually transmitted infections – These tests involve obtaining a sample of discharge from your rectum or from the tube that drains urine from your bladder (urethra).
Digital rectal exam (DRE) – An exam of the rectum. The doctor or nurse inserts a lubricated, gloved finger into the lower part of the rectum to feel for lumps or anything else that seems unusual. In women, the vagina may also be examined.
Colonoscopy – A procedure to look inside the rectum and colon for polyps (small pieces of bulging tissue), abnormal areas, or cancer. A colonoscope is a thin, tube-like instrument with a light and a lens for viewing. It may also have a tool to remove polyps or tissue samples, which are checked under a microscope for signs of cancer.
Biopsy – The removal of cells or tissues so they can be viewed under a microscope to check for signs of cancer. Tumor tissue that is removed during the biopsy may be checked to see if the patient is likely to have the gene mutation that causes HNPCC. This may help to plan treatment. The following tests may be used:
Reverse transcription-polymerase chain reaction (RT–PCR) test – A laboratory test in which the amount of a genetic substance called mRNA made by a specific gene is measured. An enzyme called reverse transcriptase is used to convert a specific piece of RNA into a matching piece of DNA, which can be amplified (made in large numbers) by another enzyme called DNA polymerase. The amplified DNA copies help tell whether a specific mRNA is being made by a gene. RT–PCR can be used to check the activation of certain genes that may indicate the presence of cancer cells. This test may be used to look for certain changes in a gene or chromosome, which may help diagnose cancer.
Immunohistochemistry – A laboratory test that uses antibodies to check for certain antigens (markers) in a sample of a patient’s tissue. The antibodies are usually linked to an enzyme or a fluorescent dye. After the antibodies bind to a specific antigen in the tissue sample, the enzyme or dye is activated, and the antigen can then be seen under a microscope. This type of test is used to help diagnose cancer and to help tell one type of cancer from another type of cancer.
Carcinoembryonic antigen (CEA) assay – A test that measures the level of CEA in the blood. CEA is released into the bloodstream from both cancer cells and normal cells. When found in higher than normal amounts, it can be a sign of rectal cancer or other conditions.
Anorectal manometry – measures and assesses the anal sphincter (internal and external) and rectal pressure and its function. This method is used to evaluate patients with fecal incontinence and constipation. It can directly measure the luminal pressure, including the high-pressure zone, resting pressure, squeezing pressure, rectal sensation/compliance, and the anorectal inhibitory reflex.[rx]
Defecating proctography/Defecography – A study using X-ray imaging to evaluate anatomic defects of the anorectal region and function of the puborectalis muscle. A contrast filled paste gets initially introduced to the rectum, and the patient is instructed to defecate in a series of stages (relaxation, contraction, tensing of the abdomen, and evacuation).[rx]
Balloon capacity and compliance test – Evaluates the function of the rectum using a device (plastic catheter with a latex balloon attached), which is inserted into the rectum and gradually filled with warm water. During this process, the volume and pressure are measured.[rx]
Balloon evacuation study – This test is similar to the balloon capacity and compliance test in which a catheter with a small balloon gets inserted into the rectum and filled with water. Different volumes of water get loaded inside the balloon, and the patient is instructed to evacuate the balloon. This procedure is done to evaluate the opening of the anal canal and to assess the relaxation of the pelvic floor.[rx]
Pudendal nerve terminal motor latency – A probe designed to stimulate and record nerve activity is placed on the physician’s gloved finger, which is then inserted into the rectum to measure pudendal nerve activity (latency to contraction of the anal sphincter muscle). The pudendal nerve innervates the anal sphincter muscles; therefore, this test can be used to assess any injury to that nerve.
Electromyography – A test to measure the ability of the puborectalis muscle and sphincter muscles to relax properly. An electrode is placed inside the rectum, and the activity of these muscles gets evaluated throughout a series of stages (relaxation, contraction, and evacuation).[rx]
Endoanal Ultrasonography – The use of ultrasound imaging to examine rectal lesions, defects, or injuries to the surrounding tissues.[rx]
Suction rectal biopsy – Gold standard for the diagnosis of Hirschsprung disease. A biopsy is taken two cm above the dentate line, and the absence of ganglion cells on histology confirms the diagnosis. Hypertrophic nerve fibers may be present in addition to this finding.[rx]
Contrast enema – Used as one of the diagnostic methods for Hirschsprung disease. Useful for localization of the aganglionic segment by looking for a narrowed rectum. Diagnostic confirmation is via a rectal biopsy.[rx]
Treatment of Proctitis
When the presentation is consistent with acute proctitis in patients with receptive anal intercourse, therapy should be initiated while awaiting results of laboratory tests. Partners of patients with STI’s should be evaluated and patients should refrain from sexual intercourse until they are treated.
Antibiotic – Gonococcal proctitis is treated with ceftriaxone 250 mg intramuscular one time plus azithromycin 1 gram oral one time.
An alternative regimen is cefixime 400 mg -moral one time plus doxycycline 100 mg oral twice daily for seven days.mChlamydia is treated with azithromycin.
Doxycycline – erythromycin, ofloxacin, or Levofloxacin may be used as an alternative regimen.
LGV – has treated with doxycycline 100 mg twice daily for 21 days.
Erythromycin or azithromycin – may be used as alternative regimens for the same period of 21 days.
Herpes proctitis – is treated with acyclovir 400 mg oral three times daily or valacyclovir 1 gram twice daily or famciclovir 250 mg three times daily for 7 to 10 days. The course of treatment may be extended if no complete healing is achieved by the end of the 10-day course of treatment.[rx][rx]
For patients with mild to moderate UP, guidelines from American College of Gastroenterology (ACG) and American Gastroenterological Association (AGA) recommend
Rectal 5-Aminosalicylic Acid (5-ASA) – mesalamine rather than oral mesalamine. Suppositories are more effective than enemas. For induction of remission, the dose is 1 g/day and this is to be continued at the same dose to maintain remission.
Rectal therapy – In cases of intolerance, refractoriness, hypersensitivity to mesalamine suppositories, inability to retain rectal therapy, rectal corticosteroid therapy is suggested for induction of remission rather than no therapy, despite the superiority of rectal 5-ASA over rectal steroids.
Corticosteroids – are not recommended and are not effective in the maintenance of remission secondary to side effects and long-term complications. Up to 46% of patients with UP may develop extensive colitis. This should be especially suspected in patients refractory to topical treatment and follow-up is recommended.[rx][rx]
UP is treated with topical mesalazine – in the form of suppositories, enemas, foams, and gels in severe cases combined with oral mesalazine with topical steroids or systemic corticosteroids in more severe cases.
In steroid-resistant cases – the addition of cyclosporine or immunomodulators; thiopurines as azathioprine (AZA) and 6-mercaptopurine (6-MP) is considered. Other options include anti-TNF-α (infliximab, adalimumab, and golimumab), anti-integrin antibodies as vedolizumab, and certolizumab, or oral tacrolimus.[rx][rx]
For CRP, topical
Sucralfate enema – is the best available treatment. For DP, topical short-chain fatty acids (SCFAs) enemas, topical 5-ASA, or topical steroids are used.
In patients with intractable symptoms – despite intensive therapy or complications including strictures, fistulas, and persistent bleeding, colostomy, ileostomy, proctectomy or proctocolectomy with ileal pouch-anal anastomosis (IPAA) may be considered.
The application of a cold – retaining probe to the anal canal may give relief to anusitis patients as well as diet change and better handling of stress.[rx]
Injury
Proctitis due to injury, such as anal sex or anal play, requires the person to stop the activity that is responsible for the inflammation. The doctor may also prescribe or recommend medications to treat pain and relieve diarrhea, if necessary.
The National Institute of Diabetes and Digestive and Kidney Diseases note that healing from injury in the rectum usually takes 4–6 weeks.
Radiation therapy
Proctitis from radiation therapy is common. As a 2015 study notes, close to 75% of people who have radiation therapy in the pelvis will develop acute proctitis symptoms, while 20% may experience chronic, long lasting symptoms.
Doctors will treat radiation proctitis on a case-by-case basis. If the person has mild symptoms of proctitis due to radiation therapy, they may need no treatment, and the symptoms may clear up on their own.
In some cases, doctors may use corticosteroid enemas to help with severe symptoms or pain. These medications reduce inflammation in the rectum.
A doctor may also recommend other medications, such as sucralfate, which is a drug that is primarily for the treatment of ulcers but which may help with symptoms.
Inflammatory bowel disease
Inflammatory bowel disease is a more long-term cause of proctitis, and people with this condition will require consistent treatment to control the symptoms.
There is no cure for inflammatory bowel disease, so the treatment goal is to keep inflammation in check, prevent flare-ups, and put the body in remission.
To achieve these goals, doctors may recommend several different types of drugs, including:
Corticosteroids
Corticosteroids in different forms may help reduce immune system activity in the area to decrease inflammation. These include steroids such as:
hydrocortisone
prednisone
methylprednisolone
budesonide
Immunomodulators
Immunomodulators reduce the overall activity in the immune system. As autoimmune factors often seem to play a role in chronic disorders such as Crohn’s disease, this treatment often helps reduce and manage symptoms.
Common immunomodulators include:
methotrexate
cyclosporine
6-mercaptopurine
azathioprine
Aminosalicylates
Aminosalicylates, also called 5-ASA drugs, help control inflammation. These include:
mesalamine
balsalazide
olsalazine
sulfasalazine
Prevention of Proctitis
Prevention of proctitis begins with addressing the high-risk sexual behaviors that you may engage in. Sexually safe behaviors include using protection such as the condom, knowing your sexual partner and history, and avoiding anal intercourse. You must use safe sex practices, such as condoms, if you engage in high-risk sexual behaviors such as these:
Having multiple sexual partners (or changing sexual partners)
A previous history of any sexually transmitted disease
Having a partner with a past history of any STD
Having a partner with an unknown sexual history
Using drugs or alcohol (these may increase the likelihood of unsafe sexual practices)
Having a partner who is an IV drug user
Bisexual or homosexual partners
Anal intercourse (Anal sex with a condom decreases the risk of proctitis by STDs, but you can still get proctitis from anal trauma)
Having unprotected intercourse (sex without the use of a condom) with an unknown partner
Outlook for Proctitis
In most cases, anal/rectal problems like proctitis go away with treatment.
Because most cases of proctitis are caused by sexually transmitted infections, antibiotics may be needed.
Proctitis caused by other conditions, such as radiation therapy, ulcerative colitis, and Crohn’s disease, may last a long time. You may need long-term therapy. Symptoms may return from time to time (in relapse or flare-up).
In certain instances, where medications are not effective, you may need surgery to remove the diseased part of your gastrointestinal tract. There can be complications as a result of proctitis, especially if it goes untreated. Some complications include severe bleeding, anemia, ulcers, and fistulas.
Fistulas may occur in many parts of the body. Women typically may get recto-vaginal fistulas in which a tube grows to connect the rectum to the vagina. Both men and women may get anal fistulas, which connect the rectum to the skin. These fistulas can also become infected and cause complications themselves.
Proctitis is inflammation of the rectal mucosa, distal to the rectosigmoid junction, within 18 cm of the anal verge. It can be acute or chronic. Anusitis is inflammation of the lining of the anal canal. Anusitis is a common disorder that is rarely diagnosed and is often misdiagnosed as hemorrhoids.
Proctitis refers to inflammation of the rectum, a diagnosis made by endoscopic evaluation. Symptoms of proctitis include rectal bleeding, urgency, tenesmus, diarrhea or constipation, and occasionally rectal pain. The causes of proctitis include infection, medication, ischemia, radiation, and ulcerative proctitis. Ulcerative proctitis is an important and increasingly common subcategory of ulcerative colitis (UC) in which inflammation is limited to the rectum.
Types of Proctitis
Proctitis and anusitis may happen secondary to ulcerative colitis (UC),
Chronic Radiation Proctitis
Proctopathy (CRP)
Diversion Proctitis (DP)
Gonorrhea (Gonococcal proctitis) – This is the most common cause. Strongly associated with anal intercourse. Symptoms include soreness, itching, bloody or pus-like discharge, or diarrhea. Other rectal problems that may be present are anal warts, anal tears, fistulas, and hemorrhoids.
Chlamydia (chlamydia proctitis) – Accounts for twenty percent of cases. People may show no symptoms, mild symptoms, or severe symptoms. Mild symptoms include rectal pain with bowel movements, rectal discharge, and cramping. With severe cases, people may have discharge containing blood or pus, severe rectal pain, and diarrhea. Some people have rectal strictures, a narrowing of the rectal passageway.
Herpes Simplex Virus 1 and 2 (herpes proctitis) – Symptoms may include multiple vesicles that rupture to form ulcers, tenesmus, rectal pain, discharge, hematochezia. The disease may run its natural course of exacerbations and remissions but is usually more prolonged and severe in patients with immunodeficiency disorders. Presentations may resemble dermatitis or decubitus ulcers in debilitated, bedridden patients. A secondary bacterial infection may be present.
Syphilis (syphilitic proctitis)
The symptoms are similar to other causes of infectious proctitis; rectal pain, discharge, and spasms during bowel movements, but some people may have no symptoms. Syphilis occurs in three stages.
The primary stage – One painless sore, less than an inch across, with raised borders found at the site of sexual contact, and during acute stages of infection, the lymph nodes in the groin become diseased, firm, and rubbery.
The secondary stage – A contagious diffuse rash that may appear over the entire body, particularly on the hands and feet.
The third stage – occurs late in the course of syphilis and affects mostly the heart and nervous system.
Causes of Proctitis
Infectious causes – include Clostridium difficile, enteric infections (Campylobacter, Shigella, Escherichia coli, Salmonella, and amebiasis), and STI’s (Gonorrhea, Chlamydia, Syphilis, HSV, Lymphogranuloma venereum, chancroid, CMV, HPV).[rx]
Causes include ischemia vasculitis – toxins as hydrogen peroxide enemas or medication side effects. The most common cause of anusitis is diet, as with excess citrus, coffee, cola, beer, garlic, spices, and sauces. Diarrhea noted after intake of laxatives as in preparation for colonoscopy is noted to cause anusitis and stress may be another etiologic factor.
Inflammatory bowel disease – About 30% of people with inflammatory bowel disease (Crohn’s disease or ulcerative colitis) have inflammation of the rectum.
Infections – Sexually transmitted infections, spread particularly by people who engage in anal intercourse, can result in proctitis. Sexually transmitted infections that can cause proctitis include gonorrhea, genital herpes and chlamydia. Infections associated with foodborne illness, such as salmonella, shigella and campylobacter infections, also can cause proctitis.
Radiation therapy for cancer – Radiation therapy directed at your rectum or nearby areas, such as the prostate, can cause rectal inflammation. Radiation proctitis can begin during radiation treatment and last for a few months after treatment. Or it can occur years after treatment.
Antibiotics – Sometimes antibiotics used to treat an infection can kill helpful bacteria in the bowels, allowing the harmful Clostridium difficile bacteria to grow in the rectum.
Diversion proctitis – Proctitis can occur in people following some types of colon surgery in which the passage of stool is diverted from the rectum to a surgically created opening (stoma).
Food protein-induced proctitis – This can occur in infants who drink either cow’s milk- or soy-based formula. Infants breastfed by mothers who eat dairy products also may develop proctitis.
Eosinophilic proctitis – This condition occurs when a type of white blood cell (eosinophil) builds up in the lining of the rectum. Eosinophilic proctitis affects only children younger than 2.
Unsafe sex – Practices that increase your risk of a sexually transmitted infection (STI) can increase your risk of proctitis. Your risk of contracting an STI increases if you have multiple sex partners, don’t use condoms and have sex with a partner who has an STI.
Inflammatory bowel diseases – Having an inflammatory bowel disease (Crohn’s disease or ulcerative colitis ) increases your risk of proctitis.
Radiation therapy for cancer – Radiation therapy directed at or near your rectum (such as for rectal, ovarian or prostate cancer) increases your risk of proctitis.
Physical exam and history – An exam of the body to check general signs of health, including checking for signs of disease, such as lumps or anything else that seems unusual. A history of the patient’s health habits and past illnesses and treatments will also be taken.
Blood tests – These can detect blood loss or infections.
Stool test – You may be asked to collect a stool sample for testing. A stool test may help determine if your proctitis is caused by a bacterial infection.
Scope exam of the last portion of your colon – During this test (flexible sigmoidoscopy), your doctor uses a slender, flexible, lighted tube to examine the last part of your colon (sigmoid), as well as the rectum. During the procedure, your doctor can also take small samples of tissue (biopsy) for laboratory analysis.
Scope exam of your entire colon – This test (colonoscopy) allows your doctor to view your entire colon using a thin, flexible, lighted tube with an attached camera. Your doctor can also take a biopsy during this test.
Tests for sexually transmitted infections – These tests involve obtaining a sample of discharge from your rectum or from the tube that drains urine from your bladder (urethra).
Digital rectal exam (DRE) – An exam of the rectum. The doctor or nurse inserts a lubricated, gloved finger into the lower part of the rectum to feel for lumps or anything else that seems unusual. In women, the vagina may also be examined.
Colonoscopy – A procedure to look inside the rectum and colon for polyps (small pieces of bulging tissue), abnormal areas, or cancer. A colonoscope is a thin, tube-like instrument with a light and a lens for viewing. It may also have a tool to remove polyps or tissue samples, which are checked under a microscope for signs of cancer.
Biopsy – The removal of cells or tissues so they can be viewed under a microscope to check for signs of cancer. Tumor tissue that is removed during the biopsy may be checked to see if the patient is likely to have the gene mutation that causes HNPCC. This may help to plan treatment. The following tests may be used:
Reverse transcription-polymerase chain reaction (RT–PCR) test – A laboratory test in which the amount of a genetic substance called mRNA made by a specific gene is measured. An enzyme called reverse transcriptase is used to convert a specific piece of RNA into a matching piece of DNA, which can be amplified (made in large numbers) by another enzyme called DNA polymerase. The amplified DNA copies help tell whether a specific mRNA is being made by a gene. RT–PCR can be used to check the activation of certain genes that may indicate the presence of cancer cells. This test may be used to look for certain changes in a gene or chromosome, which may help diagnose cancer.
Immunohistochemistry – A laboratory test that uses antibodies to check for certain antigens (markers) in a sample of a patient’s tissue. The antibodies are usually linked to an enzyme or a fluorescent dye. After the antibodies bind to a specific antigen in the tissue sample, the enzyme or dye is activated, and the antigen can then be seen under a microscope. This type of test is used to help diagnose cancer and to help tell one type of cancer from another type of cancer.
Carcinoembryonic antigen (CEA) assay – A test that measures the level of CEA in the blood. CEA is released into the bloodstream from both cancer cells and normal cells. When found in higher than normal amounts, it can be a sign of rectal cancer or other conditions.
Anorectal manometry – measures and assesses the anal sphincter (internal and external) and rectal pressure and its function. This method is used to evaluate patients with fecal incontinence and constipation. It can directly measure the luminal pressure, including the high-pressure zone, resting pressure, squeezing pressure, rectal sensation/compliance, and the anorectal inhibitory reflex.[rx]
Defecating proctography/Defecography – A study using X-ray imaging to evaluate anatomic defects of the anorectal region and function of the puborectalis muscle. A contrast filled paste gets initially introduced to the rectum, and the patient is instructed to defecate in a series of stages (relaxation, contraction, tensing of the abdomen, and evacuation).[rx]
Balloon capacity and compliance test – Evaluates the function of the rectum using a device (plastic catheter with a latex balloon attached), which is inserted into the rectum and gradually filled with warm water. During this process, the volume and pressure are measured.[rx]
Balloon evacuation study – This test is similar to the balloon capacity and compliance test in which a catheter with a small balloon gets inserted into the rectum and filled with water. Different volumes of water get loaded inside the balloon, and the patient is instructed to evacuate the balloon. This procedure is done to evaluate the opening of the anal canal and to assess the relaxation of the pelvic floor.[rx]
Pudendal nerve terminal motor latency – A probe designed to stimulate and record nerve activity is placed on the physician’s gloved finger, which is then inserted into the rectum to measure pudendal nerve activity (latency to contraction of the anal sphincter muscle). The pudendal nerve innervates the anal sphincter muscles; therefore, this test can be used to assess any injury to that nerve.
Electromyography – A test to measure the ability of the puborectalis muscle and sphincter muscles to relax properly. An electrode is placed inside the rectum, and the activity of these muscles gets evaluated throughout a series of stages (relaxation, contraction, and evacuation).[rx]
Endoanal Ultrasonography – The use of ultrasound imaging to examine rectal lesions, defects, or injuries to the surrounding tissues.[rx]
Suction rectal biopsy – Gold standard for the diagnosis of Hirschsprung disease. A biopsy is taken two cm above the dentate line, and the absence of ganglion cells on histology confirms the diagnosis. Hypertrophic nerve fibers may be present in addition to this finding.[rx]
Contrast enema – Used as one of the diagnostic methods for Hirschsprung disease. Useful for localization of the aganglionic segment by looking for a narrowed rectum. Diagnostic confirmation is via a rectal biopsy.[rx]
Treatment of Proctitis
When the presentation is consistent with acute proctitis in patients with receptive anal intercourse, therapy should be initiated while awaiting results of laboratory tests. Partners of patients with STI’s should be evaluated and patients should refrain from sexual intercourse until they are treated.
Antibiotic – Gonococcal proctitis is treated with ceftriaxone 250 mg intramuscular one time plus azithromycin 1 gram oral one time.
An alternative regimen is cefixime 400 mg -moral one time plus doxycycline 100 mg oral twice daily for seven days.mChlamydia is treated with azithromycin.
Doxycycline – erythromycin, ofloxacin, or Levofloxacin may be used as an alternative regimen.
LGV – has treated with doxycycline 100 mg twice daily for 21 days.
Erythromycin or azithromycin – may be used as alternative regimens for the same period of 21 days.
Herpes proctitis – is treated with acyclovir 400 mg oral three times daily or valacyclovir 1 gram twice daily or famciclovir 250 mg three times daily for 7 to 10 days. The course of treatment may be extended if no complete healing is achieved by the end of the 10-day course of treatment.[rx][rx]
For patients with mild to moderate UP, guidelines from American College of Gastroenterology (ACG) and American Gastroenterological Association (AGA) recommend
Rectal 5-Aminosalicylic Acid (5-ASA) – mesalamine rather than oral mesalamine. Suppositories are more effective than enemas. For induction of remission, the dose is 1 g/day and this is to be continued at the same dose to maintain remission.
Rectal therapy – In cases of intolerance, refractoriness, hypersensitivity to mesalamine suppositories, inability to retain rectal therapy, rectal corticosteroid therapy is suggested for induction of remission rather than no therapy, despite the superiority of rectal 5-ASA over rectal steroids.
Corticosteroids – are not recommended and are not effective in the maintenance of remission secondary to side effects and long-term complications. Up to 46% of patients with UP may develop extensive colitis. This should be especially suspected in patients refractory to topical treatment and follow-up is recommended.[rx][rx]
UP is treated with topical mesalazine – in the form of suppositories, enemas, foams, and gels in severe cases combined with oral mesalazine with topical steroids or systemic corticosteroids in more severe cases.
In steroid-resistant cases – the addition of cyclosporine or immunomodulators; thiopurines as azathioprine (AZA) and 6-mercaptopurine (6-MP) is considered. Other options include anti-TNF-α (infliximab, adalimumab, and golimumab), anti-integrin antibodies as vedolizumab, and certolizumab, or oral tacrolimus.[rx][rx]
For CRP, topical
Sucralfate enema – is the best available treatment. For DP, topical short-chain fatty acids (SCFAs) enemas, topical 5-ASA, or topical steroids are used.
In patients with intractable symptoms – despite intensive therapy or complications including strictures, fistulas, and persistent bleeding, colostomy, ileostomy, proctectomy or proctocolectomy with ileal pouch-anal anastomosis (IPAA) may be considered.
The application of a cold – retaining probe to the anal canal may give relief to anusitis patients as well as diet change and better handling of stress.[rx]
Injury
Proctitis due to injury, such as anal sex or anal play, requires the person to stop the activity that is responsible for the inflammation. The doctor may also prescribe or recommend medications to treat pain and relieve diarrhea, if necessary.
The National Institute of Diabetes and Digestive and Kidney Diseases note that healing from injury in the rectum usually takes 4–6 weeks.
Radiation therapy
Proctitis from radiation therapy is common. As a 2015 study notes, close to 75% of people who have radiation therapy in the pelvis will develop acute proctitis symptoms, while 20% may experience chronic, long lasting symptoms.
Doctors will treat radiation proctitis on a case-by-case basis. If the person has mild symptoms of proctitis due to radiation therapy, they may need no treatment, and the symptoms may clear up on their own.
In some cases, doctors may use corticosteroid enemas to help with severe symptoms or pain. These medications reduce inflammation in the rectum.
A doctor may also recommend other medications, such as sucralfate, which is a drug that is primarily for the treatment of ulcers but which may help with symptoms.
Inflammatory bowel disease
Inflammatory bowel disease is a more long-term cause of proctitis, and people with this condition will require consistent treatment to control the symptoms.
There is no cure for inflammatory bowel disease, so the treatment goal is to keep inflammation in check, prevent flare-ups, and put the body in remission.
To achieve these goals, doctors may recommend several different types of drugs, including:
Corticosteroids
Corticosteroids in different forms may help reduce immune system activity in the area to decrease inflammation. These include steroids such as:
hydrocortisone
prednisone
methylprednisolone
budesonide
Immunomodulators
Immunomodulators reduce the overall activity in the immune system. As autoimmune factors often seem to play a role in chronic disorders such as Crohn’s disease, this treatment often helps reduce and manage symptoms.
Common immunomodulators include:
methotrexate
cyclosporine
6-mercaptopurine
azathioprine
Aminosalicylates
Aminosalicylates, also called 5-ASA drugs, help control inflammation. These include:
mesalamine
balsalazide
olsalazine
sulfasalazine
Prevention of Proctitis
Prevention of proctitis begins with addressing the high-risk sexual behaviors that you may engage in. Sexually safe behaviors include using protection such as the condom, knowing your sexual partner and history, and avoiding anal intercourse. You must use safe sex practices, such as condoms, if you engage in high-risk sexual behaviors such as these:
Having multiple sexual partners (or changing sexual partners)
A previous history of any sexually transmitted disease
Having a partner with a past history of any STD
Having a partner with an unknown sexual history
Using drugs or alcohol (these may increase the likelihood of unsafe sexual practices)
Having a partner who is an IV drug user
Bisexual or homosexual partners
Anal intercourse (Anal sex with a condom decreases the risk of proctitis by STDs, but you can still get proctitis from anal trauma)
Having unprotected intercourse (sex without the use of a condom) with an unknown partner
Outlook for Proctitis
In most cases, anal/rectal problems like proctitis go away with treatment.
Because most cases of proctitis are caused by sexually transmitted infections, antibiotics may be needed.
Proctitis caused by other conditions, such as radiation therapy, ulcerative colitis, and Crohn’s disease, may last a long time. You may need long-term therapy. Symptoms may return from time to time (in relapse or flare-up).
In certain instances, where medications are not effective, you may need surgery to remove the diseased part of your gastrointestinal tract. There can be complications as a result of proctitis, especially if it goes untreated. Some complications include severe bleeding, anemia, ulcers, and fistulas.
Fistulas may occur in many parts of the body. Women typically may get recto-vaginal fistulas in which a tube grows to connect the rectum to the vagina. Both men and women may get anal fistulas, which connect the rectum to the skin. These fistulas can also become infected and cause complications themselves.
