Correspondence

Cervical-Disk Herniation

N Engl J Med 1998; 339:852-853September 17, 1998

Article

To the Editor:

In the May 7 issue, Drs. Ansari and Rockswold described the case of a 46-year-old woman with signs and symptoms of cervical myelopathy.1 A magnetic resonance image (MRI) was featured that showed multiple disk herniations from C3 to C7, causing multiple levels of spinal cord compression. A cervical myelogram showed a myelographic block at the junction of C4 and C5. On the basis of the clinical and radiographic evidence, an anterior cervical diskectomy and fusion were performed at C4–C5, with apparently excellent resolution of symptoms.

Although we agree with the authors' attempt to localize the lesion at one level and therefore minimize the surgical intervention, we find it difficult to come to the same diagnostic conclusions on the basis of the available information. Our interpretation of this patient's MRI is that there was multifocal cervical stenosis with nearly identical pathology at all four affected levels. The authors apparently relied on the myelographic block at the junction of C4 and C5 as evidence that the lesion was at that level. However, with a caudal injection of an intrathecal contrast agent and a blockage of dye flow at C4–C5, an accurate assessment of the C3–C4 level on the basis of this myelogram is precluded. From what can be ascertained from the MRI, the protrusion of the disk at C3–C4 caused as severe a spinal cord compression as that at C4–C5. In addition, there is some evidence that in patients with multilevel spondylosis, surgical decompression and fusion at one level may hasten degeneration at the adjacent levels and cause the recurrence of symptoms. Furthermore, four months is an inadequate period of follow-up to determine the true long-term success of this procedure.

Our interpretation of this case is that the patient had a congenitally stenotic spinal canal with superimposed cervical spondylosis. The patient presented with myelopathic symptoms and was treated with a single-level fusion, despite having considerable stenosis at three other levels. We feel that it would have been prudent and effective to treat all four abnormal levels with a cervical laminaplasty or laminectomy. This procedure would also have treated the patient without seriously altering the biomechanics of the spine and thus would have provided long-term protection from recurrent stenosis and myelopathy at all the levels of spinal cord compression.

J. Patrick Johnson, M.D.
Jeffery E. Masciopinto, M.D.
University of California, Los Angeles, Los Angeles, CA 90095

1 References

1. 1

   Ansari A, Rockswold G. Cervical-disk herniation. N Engl J Med 1998;338:1358-1358
   Full Text | Web of Science | Medline

To the Editor:

The images of cervical-disk herniation remind us of a patient with a similar condition whom we recently treated. Earlier this year, a healthy 49-year-old man with no history of cervical spine disease arrived at a crowded movie theater just before a showing of Titanic. Although forced to choose a seat in the second row, uncomfortably near the screen, he tolerated the movie well.

Two days afterward, however, he noted paresthesias in both hands and intermittent weakness in the right hand. Sneezing provoked a radicular shocklike sensation extending to both arms. He consulted a neurologist. The neurologic examination was completely normal, but an MRI showed acute anterior disk herniation at C5–C6, with 40 percent spinal stenosis and mild degenerative disease of the cervical spine. No other abnormalities were seen. The patient underwent an anterior diskectomy at C5–C6 and fusion with the use of a bone graft and is now asymptomatic.

Asymptomatic cervical spondylosis is exceedingly common.1 We hypothesize that the extended period of cervical hyperextension required by our patient's second-row seat in the movie theater unmasked preexisting subclinical disease, although coincidence can never be ruled out. Nontraumatic hyperextension of the neck has been previously reported to cause cervical-disk herniation in subjects with asymptomatic cervical spondylosis and spinal stenosis,2 as well as other complications.3

John G. Sotos, M.D.
Healtheon, Santa Clara, CA 95054

Kevin W. Olden, M.D.
University of California, San Francisco, San Francisco, CA 94117

3 References

1. 1

   Gore DR, Sepic SB, Gardner GM. Roentgenographic findings of the cervical spine in asymptomatic people. Spine 1986;11:521-524
   CrossRef | Web of Science | Medline

2. 2

   Whiteson JH, Panaro N, Ahn JH, Firooznia H. Tetraparesis following dental extraction: case report and discussion of preventive measures for cervical spinal hyperextension injury. J Spinal Cord Med 1997;20:422-425
   Medline

3. 3

   Weintraub MI. Stroke after visit to the hairdresser. Lancet 1997;350:1777-1778
   CrossRef | Web of Science | Medline

Author/Editor Response

The authors reply:

To the Editor: Drs. Johnson and Masciopinto are correct that the MRI reveals multilevel cervical-disk protrusions. However, a cervical myelogram and computed tomography revealed the disk herniation at C4–C5 to be the one causing cord compression (Figure 1Figure 1Myelogram Showing Cervical-Disk Herniation at C4–C5 (Arrows).).

In our experience, MRIs tend to exaggerate the degree of spinal stenosis. Because adjacent levels become symptomatic only infrequently, our approach is to decompress symptomatic levels only. On the basis of this rationale, a single-level decompression at C4–C5 was carried out. Our patient returned to her previous employment rapidly and continues to be in excellent health, more than 2 1/2 years after surgery.

Azam Ansari, M.D.
Gaylan Rockswold, M.D., Ph.D.
Abbott Northwestern Hospital, Minneapolis, MN 55407