Upper thoracic disc herniation followed by acutely progressing paraplegia

ABSTRACT STUDY DESIGN: Case report. OBJECTIVE: To report a rare thoracic intervertebral disc herniation followed by acutely progressing paraplegia. SETTING: Spinal Injuries Center, Fukuoka,

Japan. METHOD: A 37-year-old man presented with sudden severe backache and acutely progressing motor impairments of both lower extremities after antecedent backache lasting about 5 days.

Neurological examination showed analgesia and hypoesthesia below the T4 dermatome level, dysesthesia to pinprick below right inguinal level, and severe motor impairments of the lower

extremities (Frankel classification C). Magnetic resonance (MR) imaging demonstrated spinal cord compression due to a postero-laterally existing epidural mass at the T2–T3 level. After

laminectomy at the T2–T3 level, the sequestrated disc material was detected and excised as one piece through the right side of the dura. The excised herniated mass had a ring-like form and

was thought to originate from the annulus fibrosis. RESULT: After the emergency surgery, he had complete relief from the backache and control of both lower extremities recovered gradually.

At 4 weeks after the emergent operation, motor power of both lower extremities recovered almost completely. He was able to walk without any assistance. MR imaging study after surgery did not

reveal the sequestrated mass, except for a mild disc bulging at the T2–T3 level. CONCLUSION: Accurate diagnosis of acute symptomatic thoracic disc herniation is occasionally difficult.

However, timely and successful surgery could result in complete symptom relief and satisfactory results. SIMILAR CONTENT BEING VIEWED BY OTHERS POSTERIOR EPIDURAL SEQUESTRATED DISC

PRESENTING WITH CONTRALATERAL RADICULOPATHY: A VERY RARE CASE Article 06 November 2021 SPINAL CORD DISORDER DUE TO SPINAL EPIDURAL ABSCESS SECONDARY TO THORACIC FACET JOINT SEPTIC

ARTHRITIS—A RARE CASE WITH A SURPRISING EVOLUTION Article 19 November 2020 NATURAL HISTORY AND SURGICAL OUTCOMES OF IDIOPATHIC SPINAL CORD HERNIATION Article 28 June 2023 INTRODUCTION

Thoracic disc herniations are rare compared with herniations at cervical or lumbar disc levels, and they are mainly located at a lower thoracic level.1 When it does occur, symptomatic

thoracic disc herniation is a slowly progressive disease.2 To our knowledge, acutely developing disc herniation at the upper thoracic level has not been previously reported in the English

literature. We describe a case of the upper thoracic disc herniation (T2–T3) with rapidly progressing paraplegia due to a dorsally sequestrated herniated disc, which could be successfully

removed by posterior surgery. CASE REPORT PRESENTATION A previously healthy 37-year-old man (height: 177 cm, weight: 100 kg) presented with a sudden backache and motor impairments of both

lower extremities after antecedent backache lasting for about 5 days. He did not report any previous trauma. Motor impairments of both lower extremities deteriorated gradually, and about 3 h

after the onset of the motor impairments, he could not stand without assistance. He was admitted to another hospital and magnetic resonance (MR) imaging study of the whole spine was

performed, revealing compression of the thoracic spinal cord at the T2–T3 level. At 6 h after the onset of motor impairments, he was transferred to our hospital. EXAMINATION On physical

examination, there was tenderness in the upper part of the back. He did not have fever. On neurological examination, hyperreflexia of both lower extremities was observed and both Babinski

reflexes were positive. He had analgesia and hypoesthesia below the T4 dermatome level, dysesthesia to pin prick below the right inguinal level, and motor impairments of both lower

extremities. Motor functions were assessed in five key muscles in the lower extremities, based on the international American Spinal Injury Association (ASIA) scale (Table 1). Anal wink was

lacking and anal tone was flaccid but anal sphincter motion was preserved (Frankel classification C). Motor and sensory examination of both upper extremities was normal. MR imaging revealed

the localized compression of the thoracic spinal cord at T2–T3 level (Figure 1). Axial MR imaging showed the mass was located postero-laterally and compressed the dural sac. MR imaging with

gadolinium showed slight enhancement of the lesion. Plain X-ray and computerized tomography (CT) of thoracic spine showed no calcification in any intervertebral disc. OPERATION MR imaging

showed the mass was located postero-laterally in the spinal canal and the spinal cord was compressed mainly from the posterior site. Acute idiopathic epidural hematoma, abscess or thoracic

disc herniation could be suspected from the primary clinical and imaging diagnosis. Posterior surgery was thus performed to remove the mass. After laminectomy of T2–T3, hematoma or abscess

could not be detected in the epidural space. However, the terminal end of the sequestrated disc could be detected. The sequestrated disc materials were excised successfully through the right

side of the dura without any damage to it. The extracted herniated mass was a ring-like form and thought to originate from the annulus fibrosis (Figure 2). POSTOPERATIVE COURSE Soon after

the emergency surgery, he had complete relief of his backache. He could stand up without aid on the second postoperative day and he started walking with assistance on the fifth postoperative

day. At 4 weeks after the operation, motor power of both lower extremities had recovered almost completely. He was able to walk without assistance. Sensation also recovered except mild

hypoesthesia below the right inguinal level and he could control his bladder-rectal function well. At 2 months after the operation, he had no complaints in activities in daily living

(Frankel classification E). MR imaging study after surgery did not show a sequestrated mass, but only mild disc bulging at the T2–T3 level. There was no residual spinal cord compression

(Figure 3). DISCUSSION The incidence of symptomatic thoracic disc herniation has been reported to be one per million per year and occurs in only 0.25–0.75% of all intervertebral disc

herniations.1 Our present case, is especially unique in that the upper thoracic disc herniation resulted in acutely progressing paraplegia, and the herniated mass which migrated posteriorly

in the spinal canal, was successfully excised by posterior surgery without fusion. The rarity of thoracic disc herniation probably results from the fact that the thoracic vertebrae are

mechanically stabilized by the rib head joints and, as a result, they avoid dynamic stress.3 Our review of the literature showed that the symptoms of thoracic disc herniation were mainly

_backache_, slowly progressive myelopathy, thoracic nerve radiculopathy and bladder dysfunction.2, 4, 5, 6 Some cases in which acute paraplegia developed from thoracic disc herniations have

been reported;7, 8 however, the present case is unique in that the sequestrated disc migrated posteriorly in the high thoracic spinal canal toward the dorsal side of the dura. The majority

of thoracic disc herniations have been reported to be of the posterior or postero-lateral bulged type.2 Furthermore, some authors had reported that thoracic disc herniation was mostly

associated with radiological calcification of the disc.9, 10, 11 In our case, however, preoperative X-ray, CT scans and macroscopic examination of the herniated disc showed no calcification.

One report in which the thoracic disc herniation was sequestrated to the postero-lateral side of spinal canal could be found.12 In the reported case, X-ray and CT examination showed no

calcification of the herniated disc, similar to our patient. There have been several reports about the surgical procedures for thoracic disc herniations. Stillerman _et al_2 reported four

surgical approaches for thoracic disc herniations: (1) transthoracic, (2) transfacet pedicle-sparing, (3) lateral extracavitary, and (4) transpedicular approaches. Some authors reported that

anterior or antero-lateral discectomy may be the simplest and most effective method for disc excision and relief of spinal cord.4, 13, 14 Furthermore, Vanichkachorn and Vaccaro6 reported

that posterior laminectomy was controversial for the treatment of symptomatic thoracic disc protrusions and recommended that the operative procedure must be chosen carefully among the

anterior, lateral and posterior approaches. The avoidance of the posterior approach might be related to the fact that posterior laminectomy of the thoracic spine characterized by kyphosis

would not successfully lead to decompression of the spinal cord compressed by posterior bulged disc and, furthermore, the spinal cord could be easily damaged when performing disc removal via

posterior laminectomy. In the present case, however, axial MR imaging showed that the mass was located postero-laterally and compressed the dural sac mainly from the posterior site, and

acute idiopathic epidural hematoma or abscess also could be suspected from the primary clinical and imaging diagnosis, therefore posterior surgery was performed. After laminectomy at the

T2–T3 level, the terminal end of the herniated disc material could be detected in the epidural space, so we were able to perform an excision easily, without any damage to the dura. In the

present case, paraplegia developed after antecedent backache lasting several days. The pathogenesis of this thoracic disc herniation could, therefore, be speculated as follows: Preceding

intrinsic disc degeneration due to obesity (height: 177 cm, weight: 100 kg) caused disc budging, then rapid and momentary rise of the intra-discal pressure due to body twisting, etc,

occurred and, as a result, annulus fibrosis ruptured the posterior longitudinal ligament and migrated posteriorly in the spinal canal. Generally, characteristic neurological patterns for

symptomatic thoracic disc herniation are lacking and the localization of pain induced by thoracic disc herniation is sometimes ambiguous. For these reasons, accurate diagnosis of symptomatic

thoracic disc herniation has been reported to be considerably difficult. These facts can lead to delay in diagnosis, which may result in progressive neurological impairments. Previous

reports have shown, however, that postoperative results of acutely developing thoracic disc herniation are generally satisfactory.15 Therefore, appropriate diagnosis and earlier treatment

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from intradural thoracic disc herniation. Case report. _J Neurosurg_ 2003; 98: 282–284. PubMed  Google Scholar  Download references AUTHOR INFORMATION AUTHORS AND AFFILIATIONS * Department

of Orthopaedic Surgery, Japan Labour, Health and Welfare Organization, Spinal Injuries Center, Iizuka-shi, Fukuoka, Japan S Sasaki, K Kaji & K Shiba Authors * S Sasaki View author

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Shiba, K. Upper thoracic disc herniation followed by acutely progressing paraplegia. _Spinal Cord_ 43, 741–745 (2005). https://doi.org/10.1038/sj.sc.3101781 Download citation * Published: 05

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disc herniation * acutely progressing paraplegia * upper thoracic