Neurology India Medknow Publications on behalf of the Neurological Society of India ISSN: 0028-3886 EISSN: 1998-4022 Vol. 59, Num. 4, 2011, pp. 627-628

Neurology India, Vol. 59, No. 4, July-August, 2011, pp. 627-628

Letter to Editor

Thoracic disc herniation with affection of the anterior spinothalamic tract: A case report and review of literature

Marcel A Gloyer¹, Dieter Cadosch², Norbert Galldiks³, Oliver P Gautschi⁴

¹ Department of Surgery, State Hospital Winterthur, Winterthur,
² Department of Surgery, State Hospital Winterthur, Winterthur; Division of Trauma Surgery, University Hospital of Zurich, Zurich, Switzerland,
³ Department of Neurology, University of Cologne, Cologne, Germany,
⁴ Department of Neurosurgery, University Hospital of Geneva, and Faculty of Medicine, University of Geneva, Geneva, Switzerland,
Correspondence Address: Oliver P Gautschi, Department of Neurosurgery, University Hospital of Geneva, and Faculty of Medicine, University of Geneva, Geneva, Switzerland, oliver.gautschi@hcuge.ch

Date of Submission: 16-Mar-2011
Date of Decision: 17-Mar-2011
Date of Acceptance: 17-Mar-2011

Code Number: ni11186

PMID: 21891949

DOI: 10.4103/0028-3886.84353

Sir,

Symptomatic disc herniation at the thoracic level is rare and the common clinical manifestations include Brown-Séquard-Syndrome (BSS), radicular pain, back pain, long tract signs, spasticity and bowel or bladder dysfunction. We report a rare presentation of isolated lesion of anterior spinothalmic tract in a patient with thoracic disc herniation.

A 49-year-old man presented with acute onset radiating lower back pain in his left foot immediately after lifting a heavy duty. The pain was treated symptomatically and the patient was able to continue his work. Four days later, he noticed a sensory loss for temperature and pain on his left leg and the left abdominal wall. Neurological examination revealed impairment of sensation of temperature and pain below T8 level on the left side with intact tactile sensation and bilaterally absent Achilles tendon reflex. The remaining neurological examination was normal. Tibial somatosensory evoked potential (SEP) studies revealed slightly increased cortical latencies. Magnetic resonance imaging (MRI) showed multisegmental disc herniations between thoracic vertebra 5/6, 6/7 and 7/8 in mediolateral direction on the right side and dislocation of the spinal cord [Figure - 1] and [Figure - 2]. At the level of T6, the T2-MRI revealed a hyperintense lesion of the spinal cord. The cerebral MRI did not show any pathology. Surgical treatment was discussed, however, not performed because the patient was in favor of a conservative treatment. During the course of the disease, neurological symptoms remained unchanged and he suffered from bilaterally radiating lower back pain in bottom and thigh. An extended conservative treatment was initiated.

Herniations of the thoracic disc are much less common than those of the cervical and lumbar spine and account for 0.2-3% with a mean of 0.7% of all herniated discs. Thoracic disc herniation is predominantly a disease of middle age, about 80% patients are between the third and fifth decade with a male predominance, 60%. ^[1] Two large case series found trauma to play an etiological role in about 25% of the cases. However, in the series by Russell et al. in men less than 40 years, 53% had trauma whereas all others had only 17%, suggesting that younger men represent a distinct group in whom trauma is a significant risk factor. ^[2] In thoracic herniations there is a higher incidence of central or centrolateral herniated discs. ^[1] The most common level was between T11 and 12 (26%), and in 75% the thoracic disc herniated below T8 vertebra. The possible mechanism for predilection in the lower thoracic spine is due to increased mobility and torsion stresses in this area. ^[1]

Clinical manifestations of thoracic disc herniations may vary. The most common symptom is pain (60%) followed by sensory disturbances. Bladder involvement as an initial symptom has been reported in only 2% of the cases. Pain with associated sensory deficits has been reported in about half of the patients. In a further review, pain was the main complaint. ^[1] Young et al. reported that back pain in 27% of patients and the other common symptom in this series was motor weakness. ^[3] Sensory disturbances, which had not been specified, were noted in 11% of patients. BSS presentation was observed in 7% of patients. A complete manifestation of BSS is very rare, most often the BSS presentation is incomplete. The pathogenesis of BSS is supposed to be due to ipsilateral compression of the spinal cord and associated spinal cord ischemia due to the unilateral compression of the radicular artery arising from the anterior spinal artery. An isolated lesion of the anterior spinothalamic tract due to a herniated thoracic disc is a rare clinical condition. The main clinical features are a contralateral loss of pain and temperature sensation below the level of the lesion, but with preserved touch and vibration sensation due to the sparing of the dorsal column. To the best of our knowledge, a thoracic disc herniation has previously not been reported as a cause of an isolated lesion of the anterior spinothalamic tract. Our patient illustrates that clinicians should be aware of this rare clinical manifestation as the presenting feature of thoracic disc herniation.

References

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