- Pars Advanced and Minimally Invasive Medical Manners Research Center, Iran University of Medical Sciences, Tehran, Iran
Pars Advanced and Minimally Invasive Medical Manners Research Center, Iran University of Medical Sciences, Tehran, Iran
DOI:10.25259/SNI-34-2019Copyright: © 2019 Surgical Neurology International This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-Share Alike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.
How to cite this article: Abolfazl Rahimizadeh, Amir Hossein Zohrevand, Nima Mohseni Kabir, Naser Asgari. T1–T2 disc herniation: Report of four cases and review of the literature. 24-Apr-2019;10:56
How to cite this URL: Abolfazl Rahimizadeh, Amir Hossein Zohrevand, Nima Mohseni Kabir, Naser Asgari. T1–T2 disc herniation: Report of four cases and review of the literature. 24-Apr-2019;10:56. Available from: http://surgicalneurologyint.com/surgicalint-articles/9301/
Background:Symptomatic T1–T2 disc herniations are rare and, in most cases, are located posterolaterally. Posterior approaches may utilize transfacet pedicle-sparing techniques, while the less frequent central/anterolateral discs may warrant anterior surgery.
Case Description:Here, we reviewed four cases of symptomatic T1–T2 disc herniations; two patients were paraparetic due to central discs and underwent anterior surgery utilizing a cage construct. The latter two cases had posterolateral discs contributing to a Brown-Sequard syndrome and radiculopathy, respectively; one patient required a transfacet pedicle-sparing procedure, while the second case was managed conservatively. All surgically treated patients recovered fully.
Conclusions:We reviewed 4 cervical T1–T2 disc herniations; two central/anterolateral lesions warranting anterior surgical approaches/cages, and 2 lateral discs treated with a posterolateral transfacet, pedicle-sparing procedure and no surgery respectively. Follow-up magnetic resonance studies documented full resolution for the patient with radiculopathy and a posterolateral disc.
Keywords: Disc herniation, spontaneous resolution, sternal splitting approach, T1–T2 disc space, thoracic disc, upper thoracic disc herniation
Thoracic disc herniations make up 0.25%–0.75% of all disc ruptures.[
In this article, we reviewed these 32 prior cases of T1–T2 disc herniations and added our four cases. We focused on the clinical presentation, e.g. T1–T2 myelopathy and/or radiculopathy, magnetic resonance (MR) localization (anterior/anterolateral/lateral posterior), and optimal surgical management.
Cases 1 and 2
The four cases of T1–T2 discs included two females and two males who ranged in the age group from 36 to 67 years (average: 47 years). Two females aged 67 and 48 years presented with acute cord infarction and paraparesis, respectively; the modified Japanese Orthopaedic Association (JOA) score for thoracic myelopathy (maximum 11) was 6 and the second patient was 7 [
(a) T2-weighted sagittal image demonstrating a disc herniation at T1–T2 level with considerable cord compression. (b) Axial view showing the central location of the disc. (c) Manubrium line and cervicothoracic (CT) angle on T2-weight magnetic resonance imaging (MRI): manubrium line intersects T2 vertebral body near to T2–T3 disc, CT angle is about 38°. (d) Chest X-ray showing that T1–T2 disc space is far enough above biclavicular line. (e) Showing removal of the sequestrated disc fragment. (f) After placement of peek cage, note brachiocephalic vein at lower border of the scene. (g) Post-operative CT AP X-ray: shows the cage in T1–T2 disc space. (f) Postoperative T1-weighted MRI, at 3-year follow-up, note clearance of the cord. (i) Postoperative T2-weighted MRI demonstrates the cage in T1–T2 interspace.
(a) T2-weighted sagittal magnetic resonance imaging (MRI) of the second case showing a hard disc at T1–T2 level. (b) The disc space is a little bit above the manubrium line and cervicothoracic (CT) angle is 27°. (c) Reconstructed sagittal computed tomography (CT) scan of the CT region showing T1–T2 hard disc, indicating that the compression, also note that CT angle is 10°. (d) Chest X-ray shows that T1–T2 disc is a few mm above the manubrium. (e) Intraoperative clearance of the disc space from both hard disc and osteophytes. (f) After placement of a large cage. (g) Plain CT radiograph showing that the cage is located at bicalvicular line. (h) Postoperative T2-weighted MRI: showing appropriate decompression of the spinal cord at T1–T2 level.
Cases 3 and 4
Cases 3 and 4, respectively exhibited, a Brown-Sequard syndrome and radiculopathy alone. For the former patient, cervicothoracic MRI showed a left centro-laterally disc at the T1–T2 level. This was excised utilizing a transfacet pedicle-sparing left-sided approach with left-sided T1–T3 pedicle screw fixation to avoid instability [
(a) T2-weighted sagittal magnetic resonance imaging (MRI) shows T1–T2 disc herniation. (b) Sagittal cervical fat saturated MRI shows the same. (c) Axial T2-weighted MRI shows a hyperintense disc on the left side. (d) Three-dimensional cervical computed tomography (CT) scan shows T1–T2 and T3 screw rod fixation on the left side. (e) Axial CT scan shows a pedicle screw in an upper thoracic vertebra.
(a) T2-weighted sagittal magnetic resonance imaging shows a T1–T2 extruded disc migrated up. (b) Axial view shows the posterolaterally located disc is on the left side. (c) T2-weighted sagittal image shows complete resolution of the disc at 5-month follow-up. (d) Axial T2-weighted axial view also confirms disappearance of the disc.
The surgically treated patients all markedly recovered over an average of 3.87 years’ follow-up (range: 6 months–7 years). Postoperative MR imaging (MRI) studies in the first two patients showed adequate cord decompression following placement of T1–T2 anterior interbody cages [Figures
Frequency of T1–T2 discs
Symptomatic disc herniation in the upper thoracic spine from T1 to T4 is rare, with most occurring at T1–T2 levels[
Diagnosis of T1–T2 discs and therapeutic intervention
MRI best documents soft T1–T2 thoracic discs, while computed tomography is typically optimal for calcified herniations.
Conservative versus surgical treatment for T1–T2 discs
Conservative treatments are appropriate for T1–T2 discs resulting in just mild radiculopathy (e.g. posterolateral discs) and, in some cases, spontaneously resolved (2 of 36 cases).
Surgery for T1–T2 posterolateral herniated discs may require transfacet pedicle-sparing decompression with pedicle screw fixation.[
T1–T2 thoracic disc herniations are an extremely rare, and optimal results depend on the central and centrolateral location of the discs and the operative/nonoperative choices were made based on the clinical presentation.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understand that her name and initial will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
1. Abbott KH, Retter RH. Protrusions of thoracic intervertebral disks. Neurology. 1956. 6: 1-10
2. Alberico AM, Sahni KS, Hall JA, Young HF. High thoracic disc herniation. Neurosurgery. 1986. 19: 449-51
3. Arseni C, Nash F. Thoracic intervertebral disc protrusion:A clinical study. J Neurosurg. 1960. 17: 418-30
4. Bransford R, Zhang F, Bellabarba C, Konodi M, Chapman JR. Early experience treating thoracic disc herniations using a modified transfacet pedicle-sparing decompression and fusion. J Neurosurg Spine. 2010. 12: 221-31
5. Caner H, Kilinçoglu BF, Benli S, Altinörs N, Bavbek M. Magnetic resonance image findings and surgical considerations in T1-2 disc herniation. Can J Neurol Sci. 2003. 30: 152-4
6. Carson J, Gumpert J, Jefferson A. Diagnosis and treatment of thoracic intervertebral disc protrusions. J Neurol Neurosurg Psychiatry. 1971. 34: 68-77
7. Gelch MM. Herniated thoracic disc at T1-2 level associated with horner's syndrome. Case report. J Neurosurg. 1978. 48: 128-30
8. Gille O, Razafimahandry HJ, Söderlund C, Gangnet N, Vital JM. T1-T2 disc herniation:Two cases. Rev Chir Orthop Reparatrice Appar Mot. 2006. 92: 715-8
9. Gokcen HB, Erdogan S, Gumussuyu G, Ozturk S, Ozturk C. A rare case of T1-2 thoracic disc herniation mimicking cervical radiculopathy. Int J Spine Surg. 2017. 11: 30-
10. Hamlyn PJ, Zeital T, King TT. Protrusion of the first thoracic disk. Surg Neurol. 1991. 35: 329-31
11. Hammon WM. Extruded upper thoracic disc causing horner's syndrome:Report of a case. Med Ann Dist Columbia. 1968. 37: 541-2
12. Hann EC. Experience with ruptured T1-T2 discs. J Indiana State Med Assoc. 1980. 73: 598-9
13. Horwitz NH, Whitcomb BB, Reilly FG. Ruptured thoracic discs. Yale J Biol Med. 1955. 28: 322-30
14. Kanno H, Aizawa T, Tanaka Y, Hoshikawa T, Ozawa H, Itoi E. T1 radiculopathy caused by intervertebral disc herniation:Symptomatic and neurological features. J Orthop Sci. 2009. 14: 103-6
15. Keachie K, Shahlaie K, Muizelaar JP. Upper thoracic spine arthroplasty via the anterior approach. J Neurosurg Spine. 2010. 13: 240-5
16. Kumar R, Buckley TF. First thoracic disc protrusion. Spine (Phila Pa 1976). 1986. 11: 499-501
17. Kuzma SA, Doberstein ST, Rushlow DR. Postfixed brachial plexus radiculopathy due to thoracic disc herniation in a collegiate wrestler:A case report. J Athl Train. 2013. 48: 710-5
18. Lloyd TV, Johnson JC, Paul DJ, Hunt W. Horner's syndrome secondary to herniated disc at T1--T2. AJR Am J Roentgenol. 1980. 134: 184-5
19. Logue V. Thoracic intervertebral disc prolapse with spinal cord compression. J Neurol Neurosurg Psychiatry. 1952. 15: 227-41
20. Luk KD, Cheung KM, Leong JC. Anterior approach to the cervicothoracic junction by unilateral or bilateral manubriotomy. A report of five cases. J Bone Joint Surg Am. 2002. 84-A: 1013-7
21. Morgan H, Abood C. Disc herniation at T1-2. Report of four cases and literature review. J Neurosurg. 1998. 88: 148-50
22. Mulier S, Debois V. Thoracic disc herniations:Transthoracic, lateral, or posterolateral approach?A review. Surg Neurol. 1998. 49: 599-606
23. Mulpuri K, LeBlanc JG, Reilly CW, Poskitt KJ, Choit RL, Sahajpal V. Sternal split approach to the cervicothoracic junction in children. Spine (Phila Pa 1976). 2005. 30: E305-10
24. Nakahara S, Sato T. First thoracic disc herniation with myelopathy. Eur Spine J. 1995. 4: 366-7
25. Negovetić L, Cerina V, Sajko T, Glavić Z. Intradural disc herniation at the T1-T2 level. Croat Med J. 2001. 42: 193-5
26. Patterson RH. Arbit E. A surgical approach through the pedicle to protruded thoracic discs. J Neurosurg. 1978. 48: 768-72
27. Rahimizadeh A, Saghri M. Spontaneous resolution of sequestrated lumbar disc herniation:A prospective cohort study. J Glob Spine J. 2016. 6: s-0036
28. Rahimizadeh A. Thoracic disc herniation:20 years experience in 82 cases. J Glob Spine J. 2016. 6: s-0036
29. Rossitti S, Stephensen H, Ekholm S, von Essen C. The anterior approach to high thoracic (T1-T2) disc herniation. Br J Neurosurg. 1993. 7: 189-92
30. Sekhar LN, Jannetta PJ. Thoracic disc herniation:Operative approaches and results. Neurosurgery. 1983. 12: 303-5
31. Sharan AD, Przybylski GJ, Tartaglino L. Approaching the upper thoracic vertebrae without sternotomy or thoracotomy:A radiographic analysis with clinical application. Spine (Phila Pa 1976). 2000. 25: 910-6
32. Son ES, Lee SH, Park SY, Kim KT, Kang CH, Cho SW. Surgical treatment of t1-2 disc herniation with t1 radiculopathy:A case report with review of the literature. Asian Spine J. 2012. 6: 199-202
33. Spacey K, Zaidan A, Khazim R, Dannawi Z. Horner's syndrome secondary to intervertebral disc herniation at the level of T1-2. BMJ Case Rep. 2014. 2014:
34. Stillerman CB, Chen TC, Couldwell WT, Zhang W, Weiss MH. Experience in the surgical management of 82 symptomatic herniated thoracic discs and review of the literature. J Neurosurg. 1998. 88: 623-33
35. Svien HJ, Karavitis AL. Multiple protrusions of intervertebral disks in the upper thoracic region:Report of case. Proc Staff Meet Mayo Clin. 1954. 29: 375-8
36. Takagi H, Kawaguchi Y, Kanamori M, Abe Y, Kimura T. T1-2 disc herniation following an en bloc cervical laminoplasty. J Orthop Sci. 2002. 7: 495-7
37. Winter RB, Siebert R. Herniated thoracic disc at T1-T2 with paraparesis. Transthoracic excision and fusion, case report with 4-year follow-up. Spine (Phila Pa 1976). 1993. 18: 782-4