Clinical Presentation, Diagnosis, and Surgical Treatment of Spontaneous Cervical Intradural Disc Herniations: A Review of the Literature

Objective

Spontaneous cervical intradural disc herniation (IDH) is a rare occurrence with limited and disparate information available regarding its presentation, diagnosis, and treatment. However, its accurate detection is vital for planning surgical treatment. In this review of the literature, we collected data from all cervical IDHs described to date. Particular attention was paid to diagnostic findings, surgical approach, and causation for cervical IDH, especially at the cervicothoracic junction.

Methods

A review for cases of cervical IDH was performed via the following search criteria: (“neck”[MeSH Terms] OR “neck”[All Fields] OR “cervical”[All Fields]) AND intradural[All Fields] AND disc[All Fields]. Thirty-seven cases of cervical disc herniation were identified. Demographic variables identified included age, sex, cervical level of herniation, history of associated cervical trauma, presence of Brown-Séquard syndrome, Horner syndrome, and other neurologic findings, radiographic findings, direction of surgical approach, and postoperative outcomes.

Results

A total of 37 cases of cervical IDH were identified. Most of the cases occurred at the lower levels of the cervical spine, with 35.1% at the C5–C6 level, followed by 24.3% at C6–C7, and lower still at other levels. Of the patients reviewed, 44.4% had a previous history of trauma before manifestation of symptom, with the majority being spontaneous IDH with no previous history of trauma or spine surgery. Brown-Séquard syndrome was present in 43.2% of the patients, whereas 10.8% of patients experienced Horner syndrome. The most common presentations of IDH included quadriplegia, finger/gait ataxia, radiculopathy, and nuchal pain. The degree of neurologic recovery was not associated with patient age. Most of the cervical IDHs in the literature were treated surgically via an anterior approach, but a larger portion of patients who underwent a posterior approach had improved recovery.

Conclusions

Cervical IDH is a rare event, with this review of the literature outlining the clinical and radiographic parameters of its presentation as well as comparing common surgical strategies for treatment. We outline theories underlying the development of cervical IDH and argue for a posterior surgical approach in which the disc herniation is sequestrated with migration.

Introduction

Intradural disc herniation (IDH) is a rare occurrence, particularly in the cervical spine. Since Dandy's first description of lumbar IDH in 1942, there has been more than 100 cases of IDH in the lumbar spine described.1, 2 In comparison, our review of the current literature found only 37 cervical IDH cases reported to date. Marega³ reported the first ever case of cervical IDH in 1968 followed by Dürig and Zdrojewski⁴ in 1977, with both discs surgically treated via a posterior approach. Most cervical IDHs occur at the level of C5–C6 and C6–C7, where neck movement is believed to exert the greatest tension on the posterior longitudinal ligament (PLL).5, 6, 7 Despite most cases occurring in the lower cervical spine, there has only been one case of IDH reported at the cervicothoracic junction, as described by Woischneck et al. in 2009.⁸ In this paper, we report another rare case of IDH at the level of C7–T1, increasing the number of cervical IDH cases to 38. We review all reported cervical IDH cases and explore the surgical approaches to these uncommon lesions. Based on our patient experience, we postulate the time course of development of these lesions.