Neuroradiology 9, 223--225 (1975) © by Springer-Verlag 1975
Protrusion of Calcified Cervical Discs into the Spinal Canal in Children A Report of two Cases S. Cronqvist and W. Mortensson D e p a r t m e n t of Diagnostic Radiology, University Hospital, Lund, Sweden Received: March 10, 1975 Summary. The occurrence of calcified discs with large calcified masses protruding into the spinal canal in two children is reported. The discs affected h a d increased height in the acute stage. Air myelogram, performed in one case with muscular weakness in the h a n d demonstrated compression of the spinal cord. The condition improved on conservative treatment without sequelae in both cases.
Protrusion von verkalkten zervikalen Bandscheiben in den Spinalkanal bei Kindern. Fallbeschreibung yon 2 Patienten Zusammen]assung. Es handelt sich u m eine Fallbeschreibung mit Besprechung der neurologischen und neuroradiolo-
gischen Zeichen von 2 Kindern, bei denen eine grol3e verkalkte Bandscheibe in den Spinalkanal ragte.
Protrusion de disques cervicaux calcifies dans le canal rachidien chez Pen]ant Rdsum~. L'auteur d6crit deux cas d'hernie discale cervicale calcifi6e chez l'enfant.
There are many reports in the literature about calcified cervical intervertebral discs in children [2, 3], but there are very few on herniation of such calcified cervical discs [1, 2, 4] and these concern single cases. A prolapse of a calcified disc dorsally into the spinal canal was observed in the upper thoracic region of a 12 year old boy by Peck [5]. This caused slight spinal cord compression, revealed by myelography. Although occasionally asymptomatic, acute torticollis, pain in the neck and local tenderness usually cause the patients to visit the hospital. Slight fever and elevated sedimentation rate (ESR) are often found. The symptoms usually disappear in a week or two. Neurological signs are very rare. But in Peck's case the deep tendon reflexes were more active in the lower limbs than in the upper and there was an incomplete sensory defect to pin prick and light touch below the costal margin bilaterally. Recent trauma to the neck is also frequently reported to have occurred. This paper concerns the appearance of hernation into the cervical spinal canal of calcified discs in two children. Case 1. A 8 year old girl was suddenly struck by pain and stiffness in the cervicothoracic region during a period of cold weather in November 1973. She improved gradually during the following 6 weeks then had an acute episode of non-radiating pain in the neck with limitation of movement, appearing in connection
with a cold and sore throat. On admission to hospital she had fever (39 ° C), increased ESR (25 mm), normal alkaline serum phosphatase (490 I.U.) and no neurological symptoms. Roentgen examination on 28.12. 73 disclosed extensive calcification in the intervertebral disc at C 6_ ~, protruding into the spinal canal in the midline (Fig. l a and b). There was no vertebral fracture. The height of the disc was somewhat increased. There was also calcification in the second thoracic disc. The patient improved gradually. On roentgen examination on 2 8 . 8 . 7 4 no calcification was to be seen in the cervical spine. All discs were then of normal height. The calcification in the thoracic intervertebral disc was unchanged. Case 2. A 9 year old girl fell backwards while skating on 2 7 . 1 . 7 2 . After that she felt pain in the interscapular region and on admission to the hospital on 10. 2 . 7 2 she had torticollis, tenderness over the upper thoracic spine and pain in the neck when trying to turn her head but no radiation of the pain. There was some muscular weakness in the right hand as compared with the left but no other neurological signs. There was no fever and ESR was normal. Roentgen examination of the cervical spine on 11.2. 72 showed extensive calcification in the intervertebral disc C6_7 protruding into the spinal canal (Fig. 2a and b). The disc had slightly increased thickness. The anterior part of vertebrae C6 and C7 were
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S. Cronqvist and W. Mortensson: Protrusion of Calcified Cervical Discs in Children
deformed, probably as a sequela to earlier injuries. Roentgen examination on 2 9 . 2 . 7 2 showed unchanged conditions.
Fig. 1 a and b. Case I. Roentgen examination of the cervical spine on 4. 1.74 in lateral and oblique projections. The intervertebral disc C6_ ~ has increased thickness compared with the adjacent discs. It is partly calcified and there is a large calcified mass protruding into the spinal canal. In addition there is calcification in the second thoracic intervertebral disc
Myelography was performed on 18.2. 72 demonstrating a large extradural mass at the level of the disc C6_7 protruding into the anterior part of the subarachnoid space with compression of the spinal cord (Fig. 3).
Fig. 3. Case 2. Myelography performed on 18.2.72. The soft mass bulging into the spinaI canal is substantially larger than the calcified part. It causes a marked compression on the cervical cord
The patient was treated with mild analgesics and gradually improved. The muscle strength of the right hand returned and exceeded that of the left hand within a month from the onset of symptoms (the patient was right handed). On 19. 8 . 7 2 the patient was completely free of symptoms, the calcified disc herniation had shrunk substantially and the deformity of the anterior part of the 6th and the 7th cervical vertebra had increased as a sign of further compression. The disc now had normal height. No further examination was performed.
Discussion Fig. 2 a and b. Case 2. Roentgen examination of the cervical spine on 29.2.72, lateral and oblique projections. The intervertebral disc C~_ r has a slightly increased thickness, most marked dorsally. There is calcification in the disc and calcified masses protrude into the spinal canal. Anterior part of C~ and C 7are deformed, probably as a result of earlier injuries
The etiology of the condition is obscure. Probably it is induced by mechanical trauma and/or infection. Some authors consider that, in addition, a primary congenital defect in the disc substance is also a pre-
S. Cronqvist and W. Mortensson: Protrusion of Calcified Cervical Discs in Children requisite. Sandstr6m [6] was of the opinion that the disease is akin to peritendinitis calcarea and Newton [4] considered that the calcifications localized ventrally to a calcified disc to be located in the prevertebral tendons. In the case reported by Peck operation was performed. A rupture of the annulus was noted and the herniated material "consisted of amorphous calcific material similar to that seen in peritendinitis calcarea of the supraspinatus tendon". The present two cases do not add any further information as to the etiology of the condition. The patients illustrate however, the possibility of intraspinal herniation with cord compression but in spite of this, the prognosis is favourable. It is to be noted that in the acute stage the height of the affected discs was increased but had returned to normal at a later examination. Attention should also be called to the fact that the same clinical symptoms are relatively often seen in children without any demonstrable disc calcification. This suggests that in these conditions, as in our two cases with calcification, there is a common etiological factor.
225
The result in our two cases speaks in favour of conservative treatment without acute surgical intervention.
References 1. Bjelkhagen, I., Gladnikoff, H.: Calcified disc protrusion in children. Acta Radiol. 48, 151-- 155 (1957) 2. K~Steles, Gy., Danko, J.: Bandscheibenverkalkungen der Halswirbelsiiule im Kindesalter. Z. Kinderchirurg. 12, 487--492 (1973) 3. Lindberg, T.: Intervertebral calcinosis in childhood. Ann. paediat. 201, 173-- 184 (1963) 4. Newton, Th.: Cervical intervertebral disc calcification in children. J. Bone Jt. Surg. 40--A, 107--113 (1958) 5. Peck Jr, F.: A calcified thoracic intervertebral disc with herniation and spinal cord compression in a child. Case report. J. Neurosurg. 14, 105-- 109 (1957) 6. Sandstr/Sm, C.: Calcification of the intervertebral discs and the relation between various types of calcifications in the soft tissues of the body. Acta radiol. 36, 217--233 (1951) Dr. Sten Cronqvist Neuroradiological Dept. Lasarettet i Lund S--22185 Lund Sweden
Protrusion of Calcified Cervical Discs into the Spinal Canal in Children A Report of two Cases S. Cronqvist and W. Mortensson D e p a r t m e n t of Diagnostic Radiology, University Hospital, Lund, Sweden Received: March 10, 1975 Summary. The occurrence of calcified discs with large calcified masses protruding into the spinal canal in two children is reported. The discs affected h a d increased height in the acute stage. Air myelogram, performed in one case with muscular weakness in the h a n d demonstrated compression of the spinal cord. The condition improved on conservative treatment without sequelae in both cases.
Protrusion von verkalkten zervikalen Bandscheiben in den Spinalkanal bei Kindern. Fallbeschreibung yon 2 Patienten Zusammen]assung. Es handelt sich u m eine Fallbeschreibung mit Besprechung der neurologischen und neuroradiolo-
gischen Zeichen von 2 Kindern, bei denen eine grol3e verkalkte Bandscheibe in den Spinalkanal ragte.
Protrusion de disques cervicaux calcifies dans le canal rachidien chez Pen]ant Rdsum~. L'auteur d6crit deux cas d'hernie discale cervicale calcifi6e chez l'enfant.
There are many reports in the literature about calcified cervical intervertebral discs in children [2, 3], but there are very few on herniation of such calcified cervical discs [1, 2, 4] and these concern single cases. A prolapse of a calcified disc dorsally into the spinal canal was observed in the upper thoracic region of a 12 year old boy by Peck [5]. This caused slight spinal cord compression, revealed by myelography. Although occasionally asymptomatic, acute torticollis, pain in the neck and local tenderness usually cause the patients to visit the hospital. Slight fever and elevated sedimentation rate (ESR) are often found. The symptoms usually disappear in a week or two. Neurological signs are very rare. But in Peck's case the deep tendon reflexes were more active in the lower limbs than in the upper and there was an incomplete sensory defect to pin prick and light touch below the costal margin bilaterally. Recent trauma to the neck is also frequently reported to have occurred. This paper concerns the appearance of hernation into the cervical spinal canal of calcified discs in two children. Case 1. A 8 year old girl was suddenly struck by pain and stiffness in the cervicothoracic region during a period of cold weather in November 1973. She improved gradually during the following 6 weeks then had an acute episode of non-radiating pain in the neck with limitation of movement, appearing in connection
with a cold and sore throat. On admission to hospital she had fever (39 ° C), increased ESR (25 mm), normal alkaline serum phosphatase (490 I.U.) and no neurological symptoms. Roentgen examination on 28.12. 73 disclosed extensive calcification in the intervertebral disc at C 6_ ~, protruding into the spinal canal in the midline (Fig. l a and b). There was no vertebral fracture. The height of the disc was somewhat increased. There was also calcification in the second thoracic disc. The patient improved gradually. On roentgen examination on 2 8 . 8 . 7 4 no calcification was to be seen in the cervical spine. All discs were then of normal height. The calcification in the thoracic intervertebral disc was unchanged. Case 2. A 9 year old girl fell backwards while skating on 2 7 . 1 . 7 2 . After that she felt pain in the interscapular region and on admission to the hospital on 10. 2 . 7 2 she had torticollis, tenderness over the upper thoracic spine and pain in the neck when trying to turn her head but no radiation of the pain. There was some muscular weakness in the right hand as compared with the left but no other neurological signs. There was no fever and ESR was normal. Roentgen examination of the cervical spine on 11.2. 72 showed extensive calcification in the intervertebral disc C6_7 protruding into the spinal canal (Fig. 2a and b). The disc had slightly increased thickness. The anterior part of vertebrae C6 and C7 were
224
S. Cronqvist and W. Mortensson: Protrusion of Calcified Cervical Discs in Children
deformed, probably as a sequela to earlier injuries. Roentgen examination on 2 9 . 2 . 7 2 showed unchanged conditions.
Fig. 1 a and b. Case I. Roentgen examination of the cervical spine on 4. 1.74 in lateral and oblique projections. The intervertebral disc C6_ ~ has increased thickness compared with the adjacent discs. It is partly calcified and there is a large calcified mass protruding into the spinal canal. In addition there is calcification in the second thoracic intervertebral disc
Myelography was performed on 18.2. 72 demonstrating a large extradural mass at the level of the disc C6_7 protruding into the anterior part of the subarachnoid space with compression of the spinal cord (Fig. 3).
Fig. 3. Case 2. Myelography performed on 18.2.72. The soft mass bulging into the spinaI canal is substantially larger than the calcified part. It causes a marked compression on the cervical cord
The patient was treated with mild analgesics and gradually improved. The muscle strength of the right hand returned and exceeded that of the left hand within a month from the onset of symptoms (the patient was right handed). On 19. 8 . 7 2 the patient was completely free of symptoms, the calcified disc herniation had shrunk substantially and the deformity of the anterior part of the 6th and the 7th cervical vertebra had increased as a sign of further compression. The disc now had normal height. No further examination was performed.
Discussion Fig. 2 a and b. Case 2. Roentgen examination of the cervical spine on 29.2.72, lateral and oblique projections. The intervertebral disc C~_ r has a slightly increased thickness, most marked dorsally. There is calcification in the disc and calcified masses protrude into the spinal canal. Anterior part of C~ and C 7are deformed, probably as a result of earlier injuries
The etiology of the condition is obscure. Probably it is induced by mechanical trauma and/or infection. Some authors consider that, in addition, a primary congenital defect in the disc substance is also a pre-
S. Cronqvist and W. Mortensson: Protrusion of Calcified Cervical Discs in Children requisite. Sandstr6m [6] was of the opinion that the disease is akin to peritendinitis calcarea and Newton [4] considered that the calcifications localized ventrally to a calcified disc to be located in the prevertebral tendons. In the case reported by Peck operation was performed. A rupture of the annulus was noted and the herniated material "consisted of amorphous calcific material similar to that seen in peritendinitis calcarea of the supraspinatus tendon". The present two cases do not add any further information as to the etiology of the condition. The patients illustrate however, the possibility of intraspinal herniation with cord compression but in spite of this, the prognosis is favourable. It is to be noted that in the acute stage the height of the affected discs was increased but had returned to normal at a later examination. Attention should also be called to the fact that the same clinical symptoms are relatively often seen in children without any demonstrable disc calcification. This suggests that in these conditions, as in our two cases with calcification, there is a common etiological factor.
225
The result in our two cases speaks in favour of conservative treatment without acute surgical intervention.
References 1. Bjelkhagen, I., Gladnikoff, H.: Calcified disc protrusion in children. Acta Radiol. 48, 151-- 155 (1957) 2. K~Steles, Gy., Danko, J.: Bandscheibenverkalkungen der Halswirbelsiiule im Kindesalter. Z. Kinderchirurg. 12, 487--492 (1973) 3. Lindberg, T.: Intervertebral calcinosis in childhood. Ann. paediat. 201, 173-- 184 (1963) 4. Newton, Th.: Cervical intervertebral disc calcification in children. J. Bone Jt. Surg. 40--A, 107--113 (1958) 5. Peck Jr, F.: A calcified thoracic intervertebral disc with herniation and spinal cord compression in a child. Case report. J. Neurosurg. 14, 105-- 109 (1957) 6. Sandstr/Sm, C.: Calcification of the intervertebral discs and the relation between various types of calcifications in the soft tissues of the body. Acta radiol. 36, 217--233 (1951) Dr. Sten Cronqvist Neuroradiological Dept. Lasarettet i Lund S--22185 Lund Sweden
