Rare case of Dorsal discD10 – D11

Vinod NaneriaGirish Yeotikar

Arjun WadhwaniChoithram Hospital & Research Centre,

Indore, India

Case summary

• A 40 years old male, a regular visitor of gym.• Complaint of sudden weakness & parasthesia in

whole right lower limb while doing weight lifting in Gym.

• He was immediately made to lay down on a bench.

• Gradual massage of the limb was done.• Within 15 minutes he gradually regain the control

on the limb.

Case summary

• Out of fear – he attended the hospital for check up.

• Clinically:• Spine had stiffness, with limited flexion.• Paraspinal rigidity was there.• SLRT was negative.• No obvious neuro-vascular deficit was

observed.

Case summary

• Hearing his abnormal history, • Anxious but educated patient.• A MRI was done.• There was a disc extrusion at D10 – D11.• The extruded fragment was on left side.

December 2014

December 2014

December 2014

Treatment

• Since patient had already improved,• He was treated conservatively.• Observation,• Precautions,• Instructions to report S.O.S.• Follow up MRI was done March 2015• Complete absorption of fragmant.

March 2015

March 2015

D10 – D11

March 2015

D11

March 2015

March 2015

Review Literature

• Neurosurgical FocusThe Pathophysiology of Thoracic Disc DiseaseJames Mcinerney, MD, and Perry A. Ball, MD, Section of Neurosurgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire.Neurosurg Focus. 2000;9(4)

Review Literature Incidence & Site:

• Thoracic disc herniation accounts for 0.15 - 4.4% of all disc herniation.

• 75 % of all thoracic disc problems occur below T8, with a peak of 26% at T11-12.

• The upper thoracic spine (T1-5) is the region least often affected, with only 6% of all thoracic disc herniation occurring here.

• To date, a total of 31 cases of T1-2 disc herniation have been reported in the literature.

Review Literature

• Analysis of population studies suggests that the overall incidence of thoracic disc herniations is approximately 1 per 1,000,000 patient years.

• The majority of thoracic herniations have been noted to be central or centrolateral, with a minority of herniations truly lateral.

Review Literature

• Calcification is reported to occur in 30 to 70% of cases of thoracic disc herniations,

• The cause of this phenomenon remains unclear.

• Calcification is an important consideration, however, because approximately 5 to 10% of calcified discs are associated with intradural extension.

Patho-physiology

• The decrease in matrix water is due to decrease in the overall amount of proteoglycans as well as a change in the ratio of chondroitin sulfate to keratin sulfate.

• Keratin sulfate, with only one net negative charge, tends to increase as compared with chondroitin sulfate, which has two.

Patho-physiology

• Because KS attracts fewer small cations, the osmotic gradient into the disc is decreased and subsequently the overall water content is reduced as well.

• With decreased water content, the disc loses height and some ability to expand.

Patho-physiology

• As a result, more of the load is borne by the annulus fibrosus. This, in turn, increases the likelihood of injury to the annulus and the overall rate of its degeneration.

• The disc's ability to expand does not begin to decrease until the fourth decade.

Patho-physiology

• Thoracic disc prolapse peak during the fourth and fifth decades of life.

• It is at this time that the intervertebral discs experience a slight decrease in nuclear expansion, causing increased stress on the annulus fibrosus, and the decreased elasticity of the annulus makes it more susceptible to injury.

Patho-physiology

• An increase in annular tears coupled with a persistently expansile nucleus then results in a higher incidence of disc herniation.

• This would be especially true for active individuals who place additional loads on the spine.

Brown CW, Deffer PA Jr, Akmakjian J, et al:The natural history of thoracic disc herniation.

Spine 17(Suppl):S97–S102, 1992• Brown, et al.,

• Retrospectively reviewed data obtained in 55 patients with 72 thoracic disc herniation.

• 15 (27%) of these patients eventually required surgery, due to myelopathy.

• The vast majority of patients, however, did not require surgery and have continued to perform activities of daily living, including vigorous sports activities.•

• There was no correlation between radiographic depiction and the patient’s symptoms.

operative treatment of thoracic discs

• Posterior approach – – Transpedicular, – Transfacetal, – Posterolateral approach modified

costotransversectomy, • lateral extracavitary; • Anterolateral approach - transthoracic; • Thoracoscopic approach

Treatment options

• Thoracic herniated disc surgery is reserved for cases of:

• Myelopathy, • Progressive lower extremity weakness, and • Intolerable radicular pain that does not get

better with non-surgical treatments.

References• Adams MA, Hutton WC: Prolapsed intervertebral

disc. A hyperflexion injury. Spine 7:184-191, 1982• Adams P, Muir H: Qualitative changes with age of

proteoglycans in human lumbar discs. Ann Rheum Dis 35:289-296, 1976 Neurosurg. Focus / Volume 9 / October, 2000 Pathophysiology of thoracic disc disease 7

• Arce CA, Dohrmann GJ: Thoracic disc herniation. Improved diagnosis with computed tomographic scanning and a review of the literature. Surg Neurol 23:356-361, 1985

References• Awwad EE, Martin DS, Smith KR Jr, et al:

Asymptomatic versus symptomatic herniated thoracic discs: their frequency and characteristics as detected by computed tomography after myelography. Neurosurgery 28:180-186, 1991

• Ball PA, Benzel EC: Pathology of disc degeneration, in Menezes AH, Sonntag VKH (eds): Principles of Spinal Surgery. New York: McGraw-Hill, 1996, pp 507-516

References• Benzel EC: Biomechanics of Spine Stabilization:

Principles and Clinical Practice. New York: McGraw-Hill, 1995

• Brown CW, Deffer PA Jr, Akmakjian J, et al: The natural history of thoracic disc herniation. Spine 17 (Suppl 6):S97-S102, 1992

• Compere EL, Cloward RB: Origin, anatomy, physiology, and pathology of the intervertebral disc. Instruct Lect Am Acad Orthop Surg 18:15-20, 1961

• DePalma AF, Rothman RH: The Intervetebral Disc. Philadelphia: WB Saunders, 1970

References

• Fisher CM: Painful states: a neurological commentary. Clin Neurosurg 31:32-53, 1983

• Hirsch C, et al: The anatomical basis for low back pain. Studies on the presence of sensory nerve endings in ligamentous, capsular and intervertebral disc structuresin the human lumbar spine. Acta Orthop Scand 33:1-17, 1963

References• Hitselberger WE, Witten RM: Abnormal

myelograms in asymptomatic patients. J Neurosurg 28:204-206, 1968

• Holm S, Maroudas A, Urban JP, et al: Nutrition of the intervertebral disc: solute transport and metabolism. Connect Tissue Res 8:101-119, 1981

• Kramer J, Schleberger R, Hedtmann A, et al: Intervertebral Disk Diseases: Causes, Diagnosis, Treatment, and Prophylaxis, ed 2. Stuttgart: Thieme, 1990

References• Moore K: The Developing Human: Clinically

Oriented Embryology, ed 4. Philadelphia: WB Saunders, 1988, pp 334-340

• Nachemson A, Lewin T, Maroudas A, et al: In vitro diffusion of dye through the end-plates and annulus fibrosus of human intervertebral discs. Acta Orthop Scand 41:589-607, 1970

• Smyth M, Wright V: Sciatica and the intrvertebral disc: an experimental study. J Bone Joint Surg (Am) 40:1401-1418, 1958

References• Stillerman CB, Chen TC, Couldwell WT, et al:

Experience in the surgical management of 82 symptomatic herniated thoracic discs and review of the literature. J Neurosurg 88:623-633, 1998

• Stryer L: Biochemistry, ed 3. New York: WH Freeman, 1988, pp 261-281

• White AA III, Panjabi MM: Clinical Biomechanics of the Spine. Philadelphia: Lippincott, 1990

DISCLAIMER • Information contained and transmitted by this presentation is based

on personal experience and collection of cases at Choithram Hospital & Research centre, Indore, India.

• It is intended for use only by the students of orthopaedic surgery. • Views and opinion expressed in this presentation are personal. • Depending upon the x-rays and clinical presentations viewers can

make their own opinion. • For any confusion please contact the sole author for clarification.• Every body is allowed to copy or download and use the material best

suited to him. • We not responsible for any controversies arise out of this

presentation. For any correction or suggestion please contact naneria@yahoo.com