Herein, we report on an inferior migration of an intervertebral disc C6-7 to the cervicothoracic junction manifesting as acute paraplegia. The patient showed a remarkable recovery after the surgery. The diagnostic dilemma and management difficulties of such an entity are briefly discussed

Amit Mahore

Monit Agarwal

Raghvendra Ramdasi

Vishakha Tikeykar

Asian Spine Journal

PubMed

Directory of Open Access Journals

Cervical disc migrationAsian Spine Journal 449Copyright Ⓒ 2015 by Korean Society of Spine SurgeryThis is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/)which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.Asian Spine Journal • pISSN 1976-1902 eISSN 1976-7846 • www.asianspinejournal.orgReceived May 25, 2014; Revised Jul 3, 2014; Accepted Jul 18, 2014Corresponding author: Raghvendra RamdasiDepartment of Neurosurgery, King Edward VII Memorial Hospital, Parel, Mumbai-400012, India Tel: +91-22-24129884, Fax: +91-22-24143435, E-mail: drraghavr@gmail.com Migrated Disc at Cervicothoracic Junction Presenting as Acute Paraplegia Amit Mahore1, Monit Agarwal1, Raghvendra Ramdasi1, Vishakha Tikeykar2    1Department of Neurosurgery, King Edward Memorial Hospital and Seth Gordhandas Sunderdas Medical College, Mumbai, India2Department of Pathology, Bombay Hospital Institute of Medical Sciences and Research, Mumbai, India    Herein, we report on an inferior migration of an intervertebral disc C6–7 to the cervicothoracic junction manifesting as acute paraple-gia. The patient showed a remarkable recovery after the surgery. The diagnostic dilemma and management difficulties of such an entity are briefly discussed.Keywords: Cervical disc prolapse; Disc herniation; Cervico thoracic junction; Disc migrationCase Report Asian Spine J 2015;9(3):449-451  •  http://dx.doi.org/10.4184/asj.2015.9.3. 49ASJAsian Spine JournalIntroductionHerniated discs at the cervicothoracic junction demand attending surgeons to keep eyes open vigilant. A single level disc herniation at the C7–T1 levels is unusual and is often incorrectly diagnosed because of unusual neurologi-cal findings and suboptimal imaging studies [1-4]. Herein we present a case of a migrated C6–7 disc causing a spinal cord compression at C7–T1 resulting into an acute com-pressive myelopathy.Case ReportA 70-year-old smoker was admitted with acute onset se-vere interscapular pain and paraplegia following a bout of cough. The patient was on treatment for coronary artery disease. The clinical examination revealed spatic paraple-gia, weak grips with relatively preserved proprioception and sense of vibration. A provisional diagnosis of aortic dissection was made by the emergency physician, but an aortic angiography failed to show any abnormality. The magnetic resonance imaging (MRI) of the spine revealed a midline ventral epidural lesion at C7–T1 level, isoin-tense to cord in both T1 and T2 (Fig. 1A–C). C7–T1 disc space and posterior longitudinal ligament were observed as undisturbed. However, the height of the C6–7 disc was significantly lesser than normal (Fig. 1D) with minimal disc material lying behind the C7 vertebral body sugges-tive of a migrated C6–7 disc (Fig. 1B). During operation, the lesion was located in the epidural space of C7–T1. The operation was done using the anterior approach through the C7–T1 disc space .The annulus fibrosus and the poste-rior longitudinal ligament behind the C7–T1 disc was in-tact. The diagnosis of the disc material was histologically confirmed (Fig. 2). The patient showed a dramatic and progressive recovery in postoperative period. At 2 years follow-up, the patient had a normal neurological status.  DiscussionIn the cervical spine, most herniated masses penetrate the deep layer of the posterior longitudinal ligament in the Amit Mahore et al.450 Asian Spine J 2015;9(3):449-451middle, where the posterior inter vertebral space is wid-est. Most of the median penetrations end up in paramedi-an or lateral herniation, whereas paramedian penetrations lead to a lateral herniation through oblique courses. The narrow space of the Luschka joint may prevent fragments from penetrating laterally [1,4]. At C7–T1, where there are no Luschka joints, lateral penetration is observed. Thus, a centrally placed and herniated disc mass at C7–T1 remains a rare event and intriguing even whilst consider-ing the possibility of migrated C6–7 disc [1,4]. The compression can involve not only the neural ele-ments themselves, but also the blood vessels that supply Fig. 1. Magnetic resonance imaging of spine-sagital precontrast T2-weigted (A), post-contrast T1-weighted (B), and (C) axial T2-weighted  images showing midline ventral epidural lesion behind C7–T1 level with inflammatory reaction and compressive myelopathy. (D) Presents a digital X-ray of the cervical spine showing a normal disc height at the level of C7–T1, whereas the disc space height is reduced at C6–C7 level.A BCDFig. 2. (A) Photomicrograph (H&E, ×40) showing degenerated nucleus pulposus composed of irregualar fibrillar matrix. (B) Photo-micrograph (H&E, ×40) showing calcification of the cartilage cells and the surrounding matrix.BACervical disc migrationAsian Spine Journal 451them. The most vulnerable vessel is the anterior spinal artery. Patients with a partial spinal cord transaction syn-drome are often first thought to have multiple sclerosis or spinal cord tumor until the correct diagnosis is revealed by a MRI and then confirmed at surgery [1,3,4].Anterior approaches to the cervicothoracic junction are difficult during a spinal surgery because the opera-tive area is narrow. The manubrium, the clavicles and the slope of the vertebral bodies obstruct the view of the surgeon. The vascular and neural structures of the supe-rior mediastinum limit the surgical approach. Posterior approaches are advocated at C7–T1 level as radicular symptoms occur more often than myelopathic symptoms [2]. But an anterior approach is ideal in a central disc pro-lapse. Understanding the site and characteristic course of the herniation can guide in choosing the approach and thus achieving a complete removal of the herniated mass. Retrospectively, we infer our case as a case of inferiorly migrated C6–7 intervertebral disc causing an anterior cervical cord syndrome.Our case is of significance for more than one reason. It clearly demonstrates an acutely large migrated cervical disc. Additionally, it emphasizes the fact that it may clini-cally mimic an aortic dissection in elderly patients if lo-cated at the cervicothoracic junction. It also suggests that such patients have an excellent clinical outcome if they were early operated via anterior approach.A migrated disc at the cervicothoracic junction may be a diagnostic dilemma. The vigilant study of adjacent levels may help to clinch the diagnosis.Conflict of InterestNo potential conflict of interest relevant to this article was reported.References1. Manabe S, Tateishi A. Epidural migration of extruded cervical disc and its surgical treatment. Spine (Phila Pa 1976) 1986;11:873-8.2. Ozer AF, Kaner T, Sasani M, Oktenoglu T, Cosar M. Anterior approach to disc herniation with modified anterior microforaminotomy at C7-T2: technical note. Spine (Phila Pa 1976) 2009;34:1879-83.3. Post NH, Cooper PR, Frempong-Boadu AK, Costa ME. Unique features of herniated discs at the cervi-cothoracic junction: clinical presentation, imaging, operative management, and outcome after anterior decompressive operation in 10 patients. Neurosur-gery 2006;58:497-501.4. Yamazaki S, Kokubun S, Ishii Y, Tanaka Y. Courses of cervical disc herniation causing myelopathy or radicu-lopathy: an analysis based on computed tomographic discograms. Spine (Phila Pa 1976) 2003;28:1171-5.

Migrated Disc at Cervicothoracic Junction Presenting as Acute Paraplegia

http://www.asianspinejournal.org/upload/pdf/asj-9-449.pdf

Migrated Disc at Cervicothoracic Junction Presenting as Acute Paraplegia

Abstract

Similar works

Full text

Available Versions

Directory of Open Access Journals