What Symptoms Can a C4-C5 Disc Herniation Cause?

A herniated disc at C4-C5 most commonly compresses the C5 nerve root, producing pain that radiates from the neck into the shoulder and upper arm, weakness in the deltoid muscle, and sometimes a diminished biceps reflex. But the symptom picture can range from a dull ache across the top of the shoulder to difficulty lifting your arm, headaches, or even breathing changes, depending on the size and direction of the herniation. Understanding which symptoms trace back to this specific spinal level helps you make sense of what your body is telling you and have a more productive conversation with your doctor.

How a C4-C5 Herniation Creates Symptoms

At the C4-C5 level, a disc that bulges or ruptures can press on the C5 nerve root as it exits the spinal canal. But the type and severity of symptoms depend heavily on which direction the disc material pushes. A lateral (sideways) herniation tends to compress a single nerve root at the edge of the spinal canal, producing the classic arm-and-shoulder pain known as radiculopathy. A median (central) herniation pushes against the spinal cord itself, which can cause a broader set of neurological problems called myelopathy. A paramedian herniation falls somewhere in between, pressing the cord on one side.

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This distinction matters because two people with a C4-C5 herniation can experience wildly different symptoms. One person might have shooting pain down one arm with a weak shoulder, while another might notice clumsy hands and unsteady walking without much arm pain at all. The direction and size of the herniation explain much of that difference.

Pain Patterns From C5 Nerve Root Compression

The C5 nerve root supplies sensation to the outer part of the upper arm, roughly the area covered by a military shoulder patch. When this nerve is compressed at C4-C5, you typically feel pain that starts in the neck and spreads across the top of the shoulder and down the outside of the upper arm. It rarely extends below the elbow. The pain can be sharp and electrical or a deep, persistent ache, and it often worsens when you tilt your head toward the painful side or look upward.

Neck stiffness and muscle spasm usually accompany the arm pain, especially in the early weeks. Some people describe a burning sensation across the shoulder blade on the affected side. Unlike a pulled muscle, this pain tends to follow a specific strip of skin rather than spreading diffusely across the shoulder and back.

Shoulder and Arm Weakness

One of the hallmark signs of C4-C5 disc herniation is weakness in the deltoid muscle, the rounded cap of muscle that sits on top of your shoulder. The deltoid is the primary muscle you use to lift your arm out to the side, so people with C5 nerve compression often notice difficulty raising their arm overhead, reaching for a shelf, or carrying objects at shoulder height. Deltoid paralysis is a well-documented consequence of C4-C5 disc herniation or spondylotic narrowing at that level.

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The biceps muscle, which bends the elbow and helps rotate the forearm, also receives some of its nerve supply from C5. So you may notice that elbow flexion feels weaker on the affected side, or that the biceps reflex (the tap-on-the-elbow test your doctor performs with a small hammer) is sluggish or absent compared to the other arm. Hand grip and finger strength are typically preserved, since those functions rely on lower cervical nerve roots.

Weakness can develop suddenly when a disc herniates acutely or build gradually if the nerve has been compressed by a slowly enlarging bulge or bone spur. In clinical studies, researchers have used specialized nerve-stimulation techniques to assess deltoid recovery after C5 radiculopathy, which underscores how closely this muscle is tied to the C4-C5 level.

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When Shoulder Pain Mimics a Rotator Cuff Tear

Here is where things get tricky for both patients and doctors. Because the C5 nerve root feeds sensation to the shoulder and controls muscles that move it, C4-C5 radiculopathy can feel almost identical to a rotator cuff injury. You might have trouble lifting your arm, pain when reaching behind your back, and tenderness over the shoulder joint. Research has found a statistically significant relationship between herniations at C4-C5 (and C5-C6) and shoulder pathologies including supraspinatus, infraspinatus, and subscapularis problems.

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The overlap is not just coincidental. Some people develop both conditions simultaneously, and it can be genuinely difficult to tell where the neck ends and the shoulder begins as a pain source. Studies examining patients with cervical radiculopathy have found that common shoulder clinical tests like the Hawkins and Neer impingement tests sometimes cannot reliably distinguish between a neck problem and a shoulder problem.

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If you have been treated for a shoulder injury that is not improving, or if your shoulder pain came on alongside neck pain and arm tingling, it is worth considering a cervical spine evaluation. The reverse is also true: some people undergo extensive neck workups when the real culprit is a torn rotator cuff.

Myelopathy Symptoms From Spinal Cord Compression

When a C4-C5 herniation is large enough or centrally directed enough to press on the spinal cord rather than just a nerve root, the symptoms become more diffuse and potentially more serious. Myelopathy at this level can produce clumsiness in the hands, difficulty with fine motor tasks like buttoning a shirt, a sensation of heaviness or stiffness in the legs, and trouble with balance or walking. Some people report feeling as though they are walking on a spongy surface.

These symptoms tend to develop gradually rather than all at once, which makes them easy to dismiss as aging or deconditioning. Unlike radiculopathy, which typically affects one arm, myelopathy can cause problems on both sides of the body because the spinal cord carries signals to everything below the level of compression. Bladder and bowel changes are possible in severe cases, though they are less common at C4-C5 than at lower cervical levels. Myelopathy is the main reason that spinal surgeons monitor central herniations more closely, even when pain is manageable.

Less Common Symptoms You Might Not Expect

A few symptoms associated with C4-C5 problems surprise people because they do not seem like they should have anything to do with the neck.

Breathing Difficulty

The phrenic nerve, which controls the diaphragm, originates primarily from C3, C4, and C5. A large herniation or bone-spur narrowing at C4-C5 can impinge on the nerve fibers that contribute to diaphragm function, occasionally causing paralysis of one side of the diaphragm. This has been documented in case reports where imaging revealed foraminal stenosis at C4-C5 alongside confirmed hemidiaphragmatic paralysis.

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In practice, you would notice unexplained shortness of breath, especially when lying flat, or a feeling that you cannot take a full breath. This is rare, but it is worth mentioning to your doctor if breathing symptoms coincide with neck or shoulder problems, particularly if lung tests come back normal.

Headaches and Vertigo

Compression of the spinal cord at C4-C5 has been linked to headaches as an atypical symptom of degenerative cervical myelopathy. A retrospective study found that headaches were significantly more common in patients with spinal cord compression at the C4-C5 level, while vertigo was associated with compression across C3-C5.

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These symptoms are considered atypical and are sometimes dismissed as unrelated, but the association with specific compression levels suggests a real neurological link. If you have persistent headaches or dizziness that your primary care workup has not explained, spinal cord compression at mid-cervical levels is at least worth considering.

Clinical Tests Your Doctor May Use

A few office-based maneuvers help clinicians determine whether your symptoms originate from the C4-C5 level.

The Spurling test involves extending your neck and tilting your head toward the painful side while the examiner applies gentle downward pressure. This narrows the neural foramen (the bony opening where the nerve root exits) and, if that nerve is being compressed, reproduces or intensifies your arm pain. The test is not very sensitive, catching only about 30% of cases, but it is highly specific: when it does reproduce symptoms, there is roughly a 93% chance that cervical nerve root compression is the cause.

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The Bakody test, also called the shoulder abduction relief test, works in the opposite direction. You raise your affected arm and rest your hand on top of your head. If this position relieves your arm pain, it suggests an extradural compression lesion such as a herniated disc, because lifting the arm takes tension off the compressed nerve root. This test is particularly relevant at the C4 and C5 root levels. Patients with C5 radiculopathy have been noted to show a positive Spurling sign and relief with shoulder abduction.

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Your doctor will also test your biceps reflex, deltoid strength, and skin sensation over the lateral arm. The combination of findings from these physical exam maneuvers often points to the right level before an MRI is even ordered.

Why an MRI Finding Does Not Always Equal a Symptom

One of the most important things to understand about cervical disc herniations is that MRI findings and symptoms do not always line up. Disc bulges, protrusions, and even herniations are frequently found on MRI scans of people who have no neck pain or neurological symptoms at all.

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The numbers are striking. Research on asymptomatic individuals has found that abnormal MRI findings, including disc herniations above the level of a simple bulge, are present in over 80% of people without any neck complaints. One analysis found that the prevalence of disc degeneration in people without symptoms was actually higher than rates reported in some symptomatic populations, which led the authors to question the direct relationship between cervical MRI findings and symptoms.

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This does not mean your MRI is useless. It means that simply having a C4-C5 herniation on your scan does not automatically explain your symptoms. A good clinician matches the MRI findings to the specific nerve root pattern your physical exam reveals. If the herniation is on the left but your symptoms are on the right, or if the MRI shows a mild bulge but you have severe weakness, something else may be going on. The MRI is one piece of the puzzle, not the whole picture.

Can a C4-C5 Herniation Heal on Its Own?

Many people are surprised to learn that herniated cervical discs can spontaneously shrink over time. Documented cases show that cervical disc herniations, including at C4-C5, can regress significantly without surgery. In one case report, a patient with a C4-C5 disc extrusion showed major regression on follow-up MRI after conservative treatment, with symptoms resolving on their own.

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A literature review found that the average time between initial presentation and documented regression of herniated cervical discs on MRI was roughly nine months.

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The leading explanation for why this happens involves the body’s immune response. When disc material pushes outside its normal boundary, the body may treat it as foreign tissue and mount an inflammatory reaction. New blood vessels grow into the area, and immune cells gradually break down and absorb the extruded material. A second proposed mechanism is simple dehydration: the herniated fragment loses water over time and shrinks. A third possibility is that the disc material physically retracts back toward its original position.

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Spontaneous regression is more likely with larger herniations, particularly extrusions and sequestrations where the disc fragment has separated from the parent disc, because these seem to trigger a stronger immune response. Smaller bulges that stay contained may not shrink as readily, but they also tend to cause less severe symptoms. The takeaway is not that you should ignore a symptomatic herniation, but that the passage of time, combined with conservative care, resolves the problem for many people.

Epidural Steroid Injections and Conservative Care

For people whose symptoms are significant but do not include progressive myelopathy or severe weakness, conservative treatment is the usual first step. This typically includes a short period of activity modification, anti-inflammatory medications, physical therapy focused on neck stabilization and posture, and sometimes a cervical collar for comfort in the acute phase.

When pain persists despite these measures, cervical epidural steroid injections are a common next option. In a study of 70 patients with symptomatic cervical disc herniations treated with epidural steroid injections, about 63% experienced enough relief that they did not wish to proceed to surgery. At an average follow-up of 13 months, roughly 65% reported a good or excellent outcome, and 75% said they would try the injections again if symptoms returned.

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Those numbers are encouraging but also show that about a third of patients do not get adequate relief from injections alone. Surgery, typically an anterior cervical discectomy and fusion at C4-C5, becomes a more serious consideration when you have progressive weakness, signs of myelopathy, or pain that remains disabling after several months of conservative treatment. The decision is rarely urgent outside of rapidly worsening neurological deficits, so you usually have time to try non-surgical approaches first.

When Multiple Levels Are Involved

C4-C5 herniations rarely exist in isolation. The cervical spine degenerates as a unit, and it is common to have disc problems at neighboring levels, especially C5-C6 and C3-C4. When multiple levels are involved, the symptom picture becomes harder to parse because you may have overlapping nerve root patterns. A person with herniations at both C4-C5 and C5-C6 might have deltoid weakness from the C5 root and wrist extensor weakness from the C6 root, along with pain that spans from the shoulder to the hand.

Multi-level disease also makes the asymptomatic-findings problem more complex. If your MRI shows herniations at three levels, only one or two may actually be producing symptoms. Electrodiagnostic testing, which measures electrical activity in muscles and nerve conduction speed, can sometimes help pinpoint which level is the active troublemaker. Your clinician’s ability to correlate the physical exam with the imaging is what separates a useful diagnosis from a confusing list of MRI findings.