Introduction
Cervical disc herniation is generally caused by degeneration of the cervical vertebrae. Symptomatic cervical disc herniation is a common cause of radiculopathy, and there is a clear peak incidence in the fourth and fifth decades [
1]. Because disc degeneration advances with age, the development of a symptomatic herniated cervical disc before the age of 20 is extremely rare. All of the sporadically reported cases with cervical disc herniation before the age of 20 had underlying disease, such as Klippel-Feil syndrome (KFS) [
2]. To the best of our knowledge, symptomatic cervical disc herniation occurring in teenaged patients without underlying disease has not been previously reported in the English literature. We report herein two cases of symptomatic cervical disc herniation with no trauma or underlying disease in teenaged patients.
Discussion
Cervical disc herniation, a well-known cause of cervical myelopathy and radiculopathy, is more common in men and often occurs in those 40 to 60 years of age, with an average age of around 50 years. C5-C6 is frequently involved in the case of cervical myelopathy, whereas C6-C7 is more common in radiculopathy [
5]. In both cases presented, C4-C5 was the affected level, with deltoid muscle strength of 2 and difficulty in arm lifting (using the positive drop-arm sign). Since C4-C5 is the level with the greatest rotation and lateral flexion movement among the middle and lower cervical vertebrae [
6], and since mobility of the cervical vertebrae tends to decrease with advancing age [
7], it is possible that this level was affected due to the tendency for C4-C5 to be vulnerable to loading in young people with no degeneration.
There have been scattered reports of cervical disc herniation occurring in young people [
2,
8,
9]. However, all of the previously reported cases had underlying disease, that is, a complication of intervertebral disc calcification or KFS [
2]. Samartzis
et al. [
2] reported a 16-year-old KFS boy with occipitalization of C1 and fusion of C2-C3, and C4-T1 showed cervical disc herniation at his hypermobile segment of C3-C4. In an extensive search of the literature, there were no reports of symptomatic cervical disc herniation occurring in teenaged patients without underlying disease. In this regard, the two cases presented here are extremely rare.
In general, cervical disc herniation responds well to conservative treatment. Saal
et al. reported that herniated cervical disc with radiculopathy was successfully managed in 93% of the patients with nonoperative management, including relative rest, cervical collar, analgesic medicine, traction, and physical training [
10]. The authors described that no patients had progressive neurological loss or reached a neurological catastrophe. However, the timing of the surgical intervention for the patient with motor deficit is still unclear. The patient in Case 1 underwent surgical decompression because there were no signs of improvement in motor and sensory function after two weeks of conservative treatment. Posterior decompression was selected rather than ventral decompression and fusion. The advantages of foraminotomy are to preserve the motion segment and to minimize the future risk of adjacent segment disorder for this younger age. Another advantage is to reduce the period of postoperative management in contrast with the latter procedure.
Cervical disc herniation is known to resolve spontaneously in the same way as lumbar disc herniation [
11]. In Case 2, the herniation was enhanced on an MRI scan after Gd-DTPA administration, indicating that spontaneous resolution could be anticipated, and muscle strength improved within a week after admission. Therefore, surgery was not indicated, and a favorable outcome was obtained with conservative treatment.
In both cases, a favorable outcome was achieved by conventional treatments for cervical disc herniation, but differences in pathology compared with the common middle-aged onset of this disorder remain a question for future investigation.
Conclusion
Although extremely rare, symptomatic cervical disc herniations may occur even in the younger population under the age of 20 without any trauma or underlying disease. Favorable outcomes can be achieved by conventional treatments for cervical disc herniation.
Consent
Case 1: Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.
Case 2: Written informed consent was obtained from the patient’s legal guardian for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.
Competing interests
The authors declare that they have no competing interests.
Authors’ contributions
Surgery was performed by TA, TS, and EA. TA, NM, and EA were the major contributors in writing the manuscript. MH and TK analyzed and interpreted the patient data. EA and YS supervised the whole work. All authors read and approved the final manuscript.