Cervical spine disc herniation at C2-C3 level: Study of a Clinical Observation and Literature Review - PDF Document

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  1. Romanian Neurosurgery (2015) XXIX 4: 459 - 464 459 DOI: 10.1515/romneu-2015-0061 Cervical spine disc herniation at C2-C3 level: Study of a Clinical Observation and Literature Review Dominique N'Dri Oka1, Fulbert Kouakou2, Yacouba Haro3, Souleymane Sarki3 1Associate Neurosurgery Professor, 2Professor assistant (anatomist) 3Neurosurgery Resident Physician Department of Medical Sciences of Abidjan, University Félix Houphouet Boigny Neurosurgery, University teaching Hospital of Yopougon (Abidjan Ivory Coast) Abstract: Cervical C2-C3 herniated disc is rare. It is characterized by its clinical polymorphism. Several surgical approaches have been described for the discectomy of a herniated disc. This work aims at discussing through personal observations and literature review clinical semiology and surgical treatment. Key words: C2-C3 herniated disc/ clinical presentation / surgical treatment sitting position for long periods. Then, the patient found out about her hands being weak when making gestures and trying to grasp, predominantly on the right-hand side. No spine trauma history was found during history taking. Clinical examination found a distal brachial paresis affecting C8 and T1 roots with a motor deficit on a side at 3/5 left and 2/5 right. Deep tendon reflexes were normal in all limbs. There was no sign of a pyramidal syndrome. MRI and CT scan of the spine revealed a posterior medial C2-C3 herniated disc lateralized to the right, compressing the cervical spinal cord and the thecal sac (Figures 1 and 2). Introduction The cervical herniated disc is common especially in the C5-C6 and C6-C7 lower segment; as for the C2-C3 segment, it occurs in the elderly and results in common clinical symptomatology. Its management remain delicate. Indeed, as it is difficult to perform the C2-C3 disc exposure, this makes it difficult to carry out exeresis, and leads to an obsession for surgeons. We are hereby reporting a case of C2-C3 herniated disc in a young patient. diagnosis and Clinical Presentation A 34-year-old patient complained of neck pain associated with distal weakness in upper limbs, located in fingers. This clinical history started a month ago with a neck pain (torticollis) felt when in

  2. 460 N'Dri Oka et al Cervical spine disc herniation at C2-C3 level A A B B Figure 1 - TDM axial section showing a posterior median C2-C3. And axial MRI sequence showing the C2-C3 disc herniation Figure 2 - T2 sagittal MRI sequence (A) showing C2C3 disk herniation and (B) post-operative control showing the freedom of the dural sheath and highlighting the cage in place within the disc space C2-C3

  3. Romanian Neurosurgery (2015) XXIX 4: 459 - 464 461 DOI: 10.1515/romneu-2015-0061 A Figure 4 - Peroperative view Surgical technique The incision primarily chosen was right anterolateral and pre-sternocleidomastoid. The procedure was fluoroscopy and surgical microscope. Under general anaesthesia and naso tracheal intubation, the patient was installed in the supine position, head on a headrest, hyperextension and turned to the left at 45°, a block under the shoulders, arms along the body. After rigorous asepsis, a C2C3 level fluoroscopy tracking, then the front edge of the sterno-mastoid tracking by palpation was performed. The incision was made from a curved line with dorsal concavity along the anterior edge of the right sterno-mastoid muscle towards the right mastoid. (Figure 3) After separating the platysma muscle, we performed a gradual dissection to the upper performed under B Figure 3 - CT scan in front of view(A) and sagittal view after removing (A) C2-C3 disk herniation and (B) post-operative control highlighting the cage in place within the disc space C2-C3 muscle fluoroscopy

  4. 462 N'Dri Oka et al Cervical spine disc herniation at C2-C3 level thyroid artery we ligated. Installing spacers enabled reclination of the sterno- cleido mastoid, homo-hyoid muscles and nervous vascular package outside and inside aerodigestive tracts exposing the anterior longitudinal ligament. A C2-C3 discectomy was performed with an inter- somatic cage set up. At the end of the operation a check through imaging was performed to verify whether the thecal sac was free and the mounting stable (Figures 4, 5, 6 and 7). favouring has been incriminated in our patient. Its late onset, usually in the context of degenerative damage, reflects the diversity of clinical signs, from simple sensory and / or motor radiculopathy to Brown Sequard syndrome or severe myelopathy [1, 3, 5, 11]. The distal brachial paresis noted would be the expression of an incipient myelopathy. In many cases imaging reveals an excluded hernia with retro odontoid migration leading to the issue of differential diagnosis with the masses among which there are metastases, meningiomas, neurolemmomes and synovial cysts [1, 4 ,5 -19]. The simple hernia without migration form is diagnosed early, justifying the brevity of the clinical history of the patient; (Table 1). Several surgical approaches have already been described but there is no consensus as regards the choice of the first one. This is the area around posterior Trans dural [16] and epidural, of the Trans oral odontoidectomy [2], and the anterolateral area. The major limitation of the posterior tract is the risk of neuro-aggressiveness and reduced stability due to non-economic resections of parts of posterior columns of Denis [16, 17,19] The oral trans aggressive and requires occipital cervical fusion; it is indicated in cases of excluded hernia with retro dens migration. Strict lateral approach is very rarely practiced and thus limited to the lateral foraminal hernia [14]. Discussion The C2-C3 herniated disc is very rare [11, 16]. To our knowledge this case represents the thirtieth (30th) case published in the literature [1-12; 15-19] (Table No. 1). Its incidence is estimated at 0.45% [11]. The most frequently affected are C5-C6 and C6-C7 levels. Indeed in the young patient, the cervical spine will recover its maximum mobility in lower segment undergoing more stress during a movement. As senescence occurs, bone remodelling (uncocervicarthrose) and discal remodelling (degeneration) resulting in a fusion of the lower discs, which significantly reduces the mobility of the lower segment and increases the load distribution to the C2-C3 and C3-C4 disc [16]. Therefore, the C2-C3 disc herniation is a condition for the elderly with a mean age of onset at 67 [5, 7] Except for the strain, strenuous activity, repeated lifting of heavy loads [8], no other factor takes place odontoidectomy is

  5. Romanian Neurosurgery (2015) XXIX 4: 459 - 464 463 DOI: 10.1515/romneu-2015-0061 TABLE 1 Review of cases published in literature ACDF: Anterior cervical discectomy + autograft fusion Outcome Number of cases Presentation 1 Location of the disc material C2-C3 level Authors and Year Espersen et al, 1984 Surgical technique Cloward’s technique Jomin et al, 1986 2 C2-C3 level ACDF 2 Myelopathy Retro-odontoïd Posterior transdural 1 improved, 1 stable Rosemberg et al, 1991 1 Myelopathy Retro-odontoïd Posterior transdural Nishizawa et al, 1996 1 Myelopathy Retro-odontoïd Transoral odontoidectomy+C1–C2 fusion Posterior transdural improved Chen and Luis, 1997 3 Myelopathy 2 Retro-odontoïd 1 C2-C3 level C2-C3level all improved Nishizawa et al, 1999 1 Myelopathy ACDF improved Antich et al, 1999 1 Myelopathy Retro-odontoïd Transoral odontoidectomy ACDF Campbell, 2000 8 Myelopathy C2-C3 level 6 improved 2 stable Chen, 2000 1 Myelopathy Retro-odontoïd Far lateral Matsutano et al, 2004 1 C2 Radiculopathy Retro-odontoïd Posterior extradural improved Deshmukh et al, 2004 1 C3 radiculopathy C2-C3 level Anterolateral extradural approach C3 transcorporeal improved Türe et al, 2007 1 Myelopathy C2-C3 level Chan et al, 2009 5 Myelo-radiculopathy C2-C3 Myelo-radiculopathy C2-C3 level C2-C3 level Discectomie antérieure + greffe Anterolateral extradural approach 3 improved, 2 stable Kotil et al, 2011 1 improved N'Dri et al, 2014 The choice of the anterolateral approach in our patient is supported by the initial seat of the compression and the effectiveness of past approaches in cases where the two approaches are possible [13,10]. Indeed a retrospective study conducted in hospitals [7] has confirmed the efficacy of surgical treatment of cervicarthrosic myelopathy decompression in the event of pain and predominant and posterior brachialgia if patients are in bedridden or precarious condition. The deep location of C2-C3 disc, the control of the vertebral artery V2 segment and obesity makes it very difficult to expose the disc and makes its surgery a challenge [11, 13]. Although its anatomy is not different from the other discs, practitioners avoid the introduction of osteosynthesis material at its level [10,16]. Our gesture being limited to discectomy, the intersomatic cage was the best by anterior

  6. 464 N'Dri Oka et al Cervical spine disc herniation at C2-C3 level comparaison des abords antérieur et postérieur. Revue de chirurgie orthopédique 2002; 88: 591-600 8. Haid RW The soft cervical disc: Natural history and management. Cooper PR (ed) Degenerative Disease of the Cervical Spine. AANS Publications, Chicago1993 9 :113-124 9. Tan J1, Zheng Y, Gong L, Liu X, Li J, Du W. Anterior cervical discectomy and interbody fusion by endoscopic approach: a preliminary report. J Neurosurg Spine 8:17– 21, 2008 10. Jomin M, Lesoin F, Lozes G, et al: Herniated cervical discs: Analysis of a series of 230 cases. Acta Neurochir (Wien) 1986;79:107-111, 11. Kotil KT, Se sengoz A. The Management in the C2-C3 Disc Herniations: A Clinical Neurosurgery 2011, 21(1):, 15-21 12. Matsutano A, Nakashima M, Murakami M, Nagashima T . Microsurgical excision of a retro odontoid disc hernia via a far-lateral approach: Successful treatment of a rare cause of myelopathy: case report Neurosurgery 2004; 54(4):1015-8. 13. McAfee PC, Bohlman HH, Riley LH Jr, et al: The anterior retropharyngeal approach to the upper part of the cervical spine. J Bone Joint Surg Am 198769:1371- 1383 14. Murphey F, Simmons JCH, Brunson B: Surgical treatment of laterally ruptured cervical disc: Review of 648 cases, 1939 to 1972. J Neurosurg 1973 38:679-683, 15. Nishizawa S, Ryu H, Yokohama T, Uemura K: Myelopathy caused by retro-odontoid disc hernia: Case report. Neurosurgery 1996;39: 1256-1259 16. Nishizawa S, Yokoyama T, Yokota N, et al: High cervical disc lesions in elderly patients—presentation and surgical approach. Acta Neurochir199910141:119–126, 17.Rosenberg WS, Rosenberg AE, Poletti CE: Cervical disc herniation presenting as a mass lesion posterior to the odontoid process. Report of two cases. J Neurosurg1991 75:954–959 18.Shim CS, Jung T-G, Lee S-H. Transcorporeal approach for disc herniation at the C2-C3 level: a technical case report. Spinal Disord Tech. (22) 6, 459- 462. 19. Türe U, Güçlü B, Naderi S. Anterolateral extradural approach for C2–C3 disc herniation: technical case report. Neurosurg Rev ,2008 3:117-121 anatomy restoration means compatible with spinal stability and satisfactory spinal mobility. Conclusion The C2-C3 herniated disc is very rare and usually occurs in the elderly. When it occurs in young subjects its treatment offers the patient the preservation of mobility, reduction in the degeneration of adjacent segments and a significant clinical improvement. Correspondence N’Dri Oka Dominique E-mail: ndriokad@gmail.com 21 BP 632 Abidjan21 Mobile: 0022546261800 Study. Turkish References 1.Antich PA., Sanjuan AC., Girvent FM., Simó JD. High cervical disc herniation and Brown-Séquard syndrome A case report and review of literature. Journal of bone and joints surgery 1999;( 81-B, )3 2.Campbell SF, Tannenberg AE, Mowat P: Transoral resection of retroodontoid disc sequestration: Case report and review of the literature. J Clin Neurosci 20007:325- 327 3. Chen TY: The clinical presentation of uppermost cervical disc protrusion. Spine 2000 25:439-442 4. Chen TY, Lui T: Retrodental fibrocartilaginous mass. Report of a case. Spine 1997; 22:920-923 5. Deshmukh VR, Harold L. Rekate, Volker K. H. Sonntag. High cervical disc herniation presenting with C- 2 radiculopathy Case report and review of the literature J Neurosurg (Spine 3) 2004;100:303:306 6. Espersen JO, Buhl M, Eriksen EF, et al: Treatment of cervical disc disease using Cloward’s technique. I. General results, effect of different operative methods and complications in 1,106 patients. Acta Neurochir (Wien) 1984 8;70:97-114, 7.Goubier J.N., Benazet J.P., Saillant G. Décompression chirurgicale desmyélopathies cervicarthrosiques: