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Calcified lumbar disc protrusion in an adolescent
Surg Neurol 1985;24:661-2
661
Calcified Lumbar Disc Protrusion in an A d o l e s c e n t Fabio Reale, M.D., and Domenico
Gambacorta,
M.D.
Department of Neurosurgery, Siena Hospital, Siena, Italy
Reale F, Gambacorta D. Calcified lumbar disc protrusion in an adolescent. Surg Neurol 1985;24:661-2. The case of an adolescent operated on for a calcified lumbar disc protrusion is reported. The literature reviewed shows the rarity of this condition. Moreover, the comparison of our case with similar ones shows that it is extremely peculiar. KEYWORDS: Calcified intervertebral disc; Lumbar spine; Sciatica; Adolescence
Lumbar disc protrusion is rarely found in patients under the age of 18 [ 1 - 8 , 1 1 - 1 4 ] . Still rarer is the finding that the prolapsed portion of the disc has calcified [6,9,10]. The observation and the successful surgical treatment of a 16-year-old patient with this condition led us to report the case. We discuss the syndrome with special reference to the clinical and pathogenetic differences between the adolescent and the adult presentation, and the findings that make our case decidedly unusual. Case Report
A male patient, aged 16 years, was admitted to the Neurosurgery Division of Siena Hospital in N o v e m b e r 1984 with a 6-week history of low back pain without injury. The pain had gradually radiated to the posterior aspect of the left thigh and calf, confining the patient to bed. Neurologic examination showed a very positive straightleg-raising test on the left and slightly less on the right, slight hypotrophy of the left thigh, mild hypestesia of the lateral aspect of the left thigh and leg, markedly reduced dorsiflexion of the left foot and toes and slightly reduced flexion of the thigh on the pelvis, and no knee jerks on either side but normal ankle jerks. Laboratory tests, including phosphorus-calcium metabolism, were noncontributory. Plain x-ray films of the lumbosacral spine revealed nothing noteworthy. A computed to-
Address requests for reprints to: FabioReale, M.D., Via S. Benedetto
41, 53100 Siena, Italy. © 1985by ElsevierSciencePublishingCo., Inc.
mography (CT) scan of the spine revealed at the L4-5 interspace a large herniated disc protrusion in the midline with calcified margin (Figure 1). Laminectomy of L-4 was performed and revealed narrowing o f the canal. Retraction o f the fifth lumbar nerve root revealed a large and extremely hard prolapsed disc at the L4-5 interspace. The calcified material was removed piecemeal, first from the left and then from the right, using rongeur forceps where needed. Both the pain and the neurologic signs receded rapidly during the postoperative course. Within 10 days after operation the reflexes were normal and there was only a hint of dorsiflexion deficit in the left foot. After 3 months only minimal hypertrophy of the left thigh remained and the rest of the neurologic examination showed no abnormalities.
Discussion
Lumbar disc prolapse is an infrequent finding in children and adolescents, accounting for 1 % - 3 % o f all operations for a prolapsed disc [1,4,5,7,11]. Calcification of the prolapsed portion is extremely rare, only 98 cases having been reported up to 1969, o f which only five were lumbar [ 10]. Since then, there have been four cases reported by Hayem in 1972 [10], four (including one lumbar) by Mainzer in 1973 [9], and one by Mougenot in 1979 [10]. Although we do not claim that our search through the literature was exhaustive, we think it safe to say that not many more than 100 cases o f calcified disc in adolescents have been reported, and o f these, fewer than 10 were lumbosacral. Undoubtedly, CT scanning greatly facilitates diagnosis o f the condition: it reveals calcifications not visible on plain x-ray films o f the spine, as in our case. Calcified prolapsed discs are reported more frequently in adults than in young patients [10], though no precise data as to frequency are provided in the literature. The two syndromes are quite different, both anatomopathologically and clinically. In children and in adolescents it is the nucleus polposus that calcifies, whereas in adults it is mainly the anulus fibrosus [9,10]. In the young, moreover, the condition is described as resolving completely in 2 - 3 weeks without surgery, even when there is a myelographic block [6,9,10]. In adults, on the other hand, there is often 0090-3019/85/$3.30
662
Surg Neurol 1985;24:661-2
Reale and Gambacorta
tebral space very likely ruled out this dysmorphic pathology. In addition to being very rare, our case is extremely peculiar. In fact, its pathogenetic pattern (calcification of the anulus fibrosus), signs and symptoms (prevalence of neurologic signs over symptoms), and treatment (severity and progression of neurologic signs necessitating surgery, which resolved the problem), all features usually found in an adult, presented in an adolescent without any other signs of abnormality (as, for example, in the phosphorus-calcium metabolism). It was as if a personal predisposition of the disc vascularization [9] repeated microtraumas [4,10,13], subclinical septic processes of the disc [5,9,10], or a combination of these factors had prematurely "aged" that intervertebral disc.
References I, Borgersen SE, Vang PS. Herniation of the lumbar intervertebral disk in children and adolescents. Acta Orthop Stand 1974; 45:540-9.
Figure 1. Computed tomography scan of the L4-5 interspace: medial intervertebral disc protrusion with calcified margin.
need for surgical treatment, partly because the clinical signs definitely prevail over the symptoms; whereas, as most investigators point out [ 1,3,5,6,13], in prolapse of discs in the young there are few or no neurologic signs, pain and limitation of lower back motion being the principal complaints. An alternative etiopathogenesis to bear in mind is posterior dislocation of vertebral epiphysis, which is described (though very rarely) as the cause of symptoms similar to those of disc protrusion [6,8]. In our case, however, the plain x-ray films of the spine revealed no bone defect of the vertebral margin; the CT scan showing a crescentic calcification argued strongly for a protruding calcified anulus rather than for a bony ridge from the vertebra; and, finally, the operative finding that the hard calcified protrusion continued into the interver-
2. Bradford DS, Garcia A. Herniations of the lumbar intervertebral disk in children and adolescents. JAMA 1969;210:2045-5 I. 3. Bulos S. Herniated intervertebral lumbar disc in the teenager. J Bone Joint Surg 1973;55B:273-8. 4. DeOrio JK, Bianco AJ. Lumbar disc excision in children and adolescents. J Bone Joint Surg 1982;64A:991-6. 5. Fisher RG, Saunders RL. Lumbar disc protrusion in children. J Neurosurg 1981;54:480-3. 6. Garrido E, Humphreys RP, Hendrick EB, Hoffman HJ. Lumbar disc disease in children. Neurosurgery 1978;2:22-5. 7. Key JA. Intervertebral-disc lesions in children and adolescents. J Bone Joint Surg 1950;32A:97-102. 8. Lowrey JJ. Dislocated lumbar vertebral epiphysis in adolescent children. Report of three cases. J Neurosurg 1973;38:232-4. 9. Mainzer F. Herniation of the nucleus pulposus. A rare complication of intervertebral-disk calcification in children. Radiology 1973;107:167-70. 10. Mougenot JF, Pernin J, Herve J. Un cas de calcification d'un disque intervertebral avec hernie. Sem Hop Paris 1979;55:1445-8. 11. Nelson CL, Janecki CJ, Gildenberg PL, Sava G. Disk protrusions in the young. Clin Orthop 1972;88:142-50. 12. Quattrini M, La Terra F. Ernia del disco in et~ pediatrica: osservazione di un caso. Chir Organi Mov 1981;66:447-9. 13. Rugtveit A, Juvenile lumbar disc herniations. Acta Orthop Scand 1966;37:348-56. 14. Webb JH, Svien HJ, Kennedy RLJ. Protruded lumbar intervertebral disks in children. JAMA 1954;154:1 153-4.
661
Calcified Lumbar Disc Protrusion in an A d o l e s c e n t Fabio Reale, M.D., and Domenico
Gambacorta,
M.D.
Department of Neurosurgery, Siena Hospital, Siena, Italy
Reale F, Gambacorta D. Calcified lumbar disc protrusion in an adolescent. Surg Neurol 1985;24:661-2. The case of an adolescent operated on for a calcified lumbar disc protrusion is reported. The literature reviewed shows the rarity of this condition. Moreover, the comparison of our case with similar ones shows that it is extremely peculiar. KEYWORDS: Calcified intervertebral disc; Lumbar spine; Sciatica; Adolescence
Lumbar disc protrusion is rarely found in patients under the age of 18 [ 1 - 8 , 1 1 - 1 4 ] . Still rarer is the finding that the prolapsed portion of the disc has calcified [6,9,10]. The observation and the successful surgical treatment of a 16-year-old patient with this condition led us to report the case. We discuss the syndrome with special reference to the clinical and pathogenetic differences between the adolescent and the adult presentation, and the findings that make our case decidedly unusual. Case Report
A male patient, aged 16 years, was admitted to the Neurosurgery Division of Siena Hospital in N o v e m b e r 1984 with a 6-week history of low back pain without injury. The pain had gradually radiated to the posterior aspect of the left thigh and calf, confining the patient to bed. Neurologic examination showed a very positive straightleg-raising test on the left and slightly less on the right, slight hypotrophy of the left thigh, mild hypestesia of the lateral aspect of the left thigh and leg, markedly reduced dorsiflexion of the left foot and toes and slightly reduced flexion of the thigh on the pelvis, and no knee jerks on either side but normal ankle jerks. Laboratory tests, including phosphorus-calcium metabolism, were noncontributory. Plain x-ray films of the lumbosacral spine revealed nothing noteworthy. A computed to-
Address requests for reprints to: FabioReale, M.D., Via S. Benedetto
41, 53100 Siena, Italy. © 1985by ElsevierSciencePublishingCo., Inc.
mography (CT) scan of the spine revealed at the L4-5 interspace a large herniated disc protrusion in the midline with calcified margin (Figure 1). Laminectomy of L-4 was performed and revealed narrowing o f the canal. Retraction o f the fifth lumbar nerve root revealed a large and extremely hard prolapsed disc at the L4-5 interspace. The calcified material was removed piecemeal, first from the left and then from the right, using rongeur forceps where needed. Both the pain and the neurologic signs receded rapidly during the postoperative course. Within 10 days after operation the reflexes were normal and there was only a hint of dorsiflexion deficit in the left foot. After 3 months only minimal hypertrophy of the left thigh remained and the rest of the neurologic examination showed no abnormalities.
Discussion
Lumbar disc prolapse is an infrequent finding in children and adolescents, accounting for 1 % - 3 % o f all operations for a prolapsed disc [1,4,5,7,11]. Calcification of the prolapsed portion is extremely rare, only 98 cases having been reported up to 1969, o f which only five were lumbar [ 10]. Since then, there have been four cases reported by Hayem in 1972 [10], four (including one lumbar) by Mainzer in 1973 [9], and one by Mougenot in 1979 [10]. Although we do not claim that our search through the literature was exhaustive, we think it safe to say that not many more than 100 cases o f calcified disc in adolescents have been reported, and o f these, fewer than 10 were lumbosacral. Undoubtedly, CT scanning greatly facilitates diagnosis o f the condition: it reveals calcifications not visible on plain x-ray films o f the spine, as in our case. Calcified prolapsed discs are reported more frequently in adults than in young patients [10], though no precise data as to frequency are provided in the literature. The two syndromes are quite different, both anatomopathologically and clinically. In children and in adolescents it is the nucleus polposus that calcifies, whereas in adults it is mainly the anulus fibrosus [9,10]. In the young, moreover, the condition is described as resolving completely in 2 - 3 weeks without surgery, even when there is a myelographic block [6,9,10]. In adults, on the other hand, there is often 0090-3019/85/$3.30
662
Surg Neurol 1985;24:661-2
Reale and Gambacorta
tebral space very likely ruled out this dysmorphic pathology. In addition to being very rare, our case is extremely peculiar. In fact, its pathogenetic pattern (calcification of the anulus fibrosus), signs and symptoms (prevalence of neurologic signs over symptoms), and treatment (severity and progression of neurologic signs necessitating surgery, which resolved the problem), all features usually found in an adult, presented in an adolescent without any other signs of abnormality (as, for example, in the phosphorus-calcium metabolism). It was as if a personal predisposition of the disc vascularization [9] repeated microtraumas [4,10,13], subclinical septic processes of the disc [5,9,10], or a combination of these factors had prematurely "aged" that intervertebral disc.
References I, Borgersen SE, Vang PS. Herniation of the lumbar intervertebral disk in children and adolescents. Acta Orthop Stand 1974; 45:540-9.
Figure 1. Computed tomography scan of the L4-5 interspace: medial intervertebral disc protrusion with calcified margin.
need for surgical treatment, partly because the clinical signs definitely prevail over the symptoms; whereas, as most investigators point out [ 1,3,5,6,13], in prolapse of discs in the young there are few or no neurologic signs, pain and limitation of lower back motion being the principal complaints. An alternative etiopathogenesis to bear in mind is posterior dislocation of vertebral epiphysis, which is described (though very rarely) as the cause of symptoms similar to those of disc protrusion [6,8]. In our case, however, the plain x-ray films of the spine revealed no bone defect of the vertebral margin; the CT scan showing a crescentic calcification argued strongly for a protruding calcified anulus rather than for a bony ridge from the vertebra; and, finally, the operative finding that the hard calcified protrusion continued into the interver-
2. Bradford DS, Garcia A. Herniations of the lumbar intervertebral disk in children and adolescents. JAMA 1969;210:2045-5 I. 3. Bulos S. Herniated intervertebral lumbar disc in the teenager. J Bone Joint Surg 1973;55B:273-8. 4. DeOrio JK, Bianco AJ. Lumbar disc excision in children and adolescents. J Bone Joint Surg 1982;64A:991-6. 5. Fisher RG, Saunders RL. Lumbar disc protrusion in children. J Neurosurg 1981;54:480-3. 6. Garrido E, Humphreys RP, Hendrick EB, Hoffman HJ. Lumbar disc disease in children. Neurosurgery 1978;2:22-5. 7. Key JA. Intervertebral-disc lesions in children and adolescents. J Bone Joint Surg 1950;32A:97-102. 8. Lowrey JJ. Dislocated lumbar vertebral epiphysis in adolescent children. Report of three cases. J Neurosurg 1973;38:232-4. 9. Mainzer F. Herniation of the nucleus pulposus. A rare complication of intervertebral-disk calcification in children. Radiology 1973;107:167-70. 10. Mougenot JF, Pernin J, Herve J. Un cas de calcification d'un disque intervertebral avec hernie. Sem Hop Paris 1979;55:1445-8. 11. Nelson CL, Janecki CJ, Gildenberg PL, Sava G. Disk protrusions in the young. Clin Orthop 1972;88:142-50. 12. Quattrini M, La Terra F. Ernia del disco in et~ pediatrica: osservazione di un caso. Chir Organi Mov 1981;66:447-9. 13. Rugtveit A, Juvenile lumbar disc herniations. Acta Orthop Scand 1966;37:348-56. 14. Webb JH, Svien HJ, Kennedy RLJ. Protruded lumbar intervertebral disks in children. JAMA 1954;154:1 153-4.