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Case Report

T1-T2 Disk Herniation PresentingWith Horner Syndrome: A CaseReport With Literary Review

Abstract

Horner syndrome or oculosympathetic paresis is caused by

interruption of the sympathetic nerve supply to the face and eye

that manifests as facial anhidrosis, blepharoptosis, and miosis.

This sympathetic pathway begins in the hypothalamus and

synapses in the intermediolateral gray substance of the spinal

cord at C8-T2 levels making it susceptible to disruption via a high

thoracic intervertebral disk herniation. We present a rare case of a

patient with T1-T2 intervertebral disk herniation and Horner

syndromewhowas treated surgically. After confirming thediagnosis

with MRI, the patient was treated with standard posterior approach

with laminoforaminotomy and diskectomy. Although posterior

approach surgery is most commonly used for laminectomy and/or

foraminotomy, successful anterior approaches to upper thoracic

lesions are valid as well. Our patient had resolution of his back pain,

paresthesias, and grip weakness at 6weeks postoperatively, but his

Horner syndromepersisted at latest follow-up. Patientswith cervical

radiculopathy symptoms and physical examination findings

consistent with Horner syndrome should be evaluated with a MRI

that includes the upper thoracic spine. An accurate diagnosis and

timely surgical intervention may provide the patient the best chance

for regression of symptoms and a satisfactory outcome.

Intervertebral thoracic disk hernia-tion is rare. After literature review,

39 cases of T1-2 disk herniation werediscovered.1 Only seven of these casespresented with an associated Hornersyndrome (Table 1). T1-2 disk herni-ation diagnosis is often delayedbecause of its prevalence and misdi-agnosis. Symptoms characteristic ofT1 disk herniation can often overlapwith other maladies. Specifically, T1nerve root compression presents withspecific signs and symptoms. Corre-

lating history, examination, andimaging will guide toward a successfuldiagnosis. We present a patient withthoracic disk herniation and Hornersyndrome who was treated surgically.Informed consent to present the dataconcerning the case for publicationwas obtained by the patient.

Case

A 29-year-old surgical resident pre-sented to the emergency department

Daniel Possley, DO

S. Brandon Luczak, MD

Andrew Angus, MD

David Montgomery, MD

From the Department of OrthopaedicSpine Surgery (Dr. Possley),Department of Orthopaedic Surgery(Dr. Luczak), Department of GeneralSurgery (Dr. Angus), and Departmentof Orthopaedic Spine Surgery(Dr. Montgomery), Beaumont Health,Royal Oak, MI.

Correspondence to Dr. Luczak:Stephen.Luczak@beaumont.org

None of the following authors or anyimmediate family member hasreceived anything of value from or hasstock or stock options held in acommercial company or institutionrelated directly or indirectly to thesubject of this article: Dr. Possley,Dr. Luczak, Dr. Angus, andDr. Montgomery.

JAAOS Glob Res Rev 2018;2:e016

DOI: 10.5435/JAAOSGlobal-D-18-00016

Copyright © 2018 The Authors.Published by Wolters Kluwer Health,Inc. on behalf of the AmericanAcademy of OrthopaedicSurgeons.This is an open accessarticle distributed under the CreativeCommons Attribution License 4.0(CCBY), which permits unrestricteduse, distribution, and reproduction inany medium, provided the originalwork is properly cited.

complaining of acute onset left peri-scapular back pain, along with pro-gressive left medial forearm andfourth and fifth digit numbness withgrip weakness of the left hand. Thesymptoms began as dull back pain,which the patient initially attributedto a muscle strain, but progressivelyworsened throughouta24-hourperiod.Physical examination revealed pain inthe left upper paraspinal and scapularregion radiating to the left shoulderwith mild improvement of the painwith abduction of the left shoulderabove thehead.Therewas adecreasedsensation noted along the left medialforearm and hypothenar region. Leftupper extremity motor was 5/5 in allmyotomes except 4/5 finger abduc-tion. New left-sided partial ptosis and

pupillary miosis were found on facialexamination (Figure 1, A). Althoughanhydrosis was not explicitly tested,Horner syndrome was strongly sus-pected. Reflex examination was 2/4in C 6, 7, and 8 roots. Hoffman’s signwas negative. Given the neurologicfindings on examination, a cervicaland thoracic MRI was obtainedwhich revealed T1-T2 left paracentraldisk extrusion with mild superiormigration and left intraforaminalextension causing moderate left lat-eral recess stenosis and abutment ofthe left T1 nerve root (Figure 2). Thepatient was then discharged from theemergency center with oral methyl-prednisolone and follow-up with anorthopaedic spine surgeon. At hisfollow-up appointment, there was

no improvement of his symptoms;therefore, the decision was made tointervene surgically given his persistentpain, weakness, andHorner syndrome.Surgery was done 8 days from the

onset of symptoms. A standard pos-terior approach with laminofor-aminotomy and diskectomy wasdone. On postoperative day 1, thepatient reported improvement in hisleft-sided radiating back pains, par-tial return of sensation along the leftmedial forearm, and hand with somemild persistent paresthesias.At 1-weekpostoperatively, he had near completeimprovement in his left-hand strengthwith mild forearm paresthesias andpersistent ptosis and miosis of the lefteye. Sixweeks after surgery, the patienthad complete resolution of his left-hand weakness and paresthesias, zeroback pain, and some significant im-provement in the ptosis and miosis(Figure 1, B). At 9 months postoper-atively, the patient continued to bepain free with full strength and intactsensation. A very subtle ptosis andmiosis remained.

Discussion

Historically, symptomatic thoracicdisk herniation occurred with a fre-quency of 2 to 3/1,000 cases of diskherniation.2 This is likely even lessfrequent with the advent of MRI usein diagnosis. Patients with upperextremity radicular pain/paresthesiasare often sent for radiographs andMRI. Cervical radiographs are notusually clinically useful because ofthe difficulty in visualizing throughthe shoulders. The T1-T2 interspaceis not fully visualized on a cervicalMRI; therefore, a thoracic MRI scancan be helpful. CT can be used tocomplementMRI in cases of thoracicdisk herniations. This study candistinguish calcified disk herniations,which may lead to modified treatmentstrategies and surgical approach.3 TheT1 nerve root supplies the ulnar nerve

Table 1

Signs and Symptoms of a T1-T2 Herniated Nucleus Pulposis in theLiterature (n = 21)

Signs and Symptoms No. of cases (%)

Radiating pain (on the medial aspect of the arm and4th, 5th fingers)

18 (86)

Axial pain (on the neck and scapular area) 17 (81)

Sensory deficit (T1 dermatome) 15 (71)Motor deficit (intrinsic muscles of hand) 14 (67)

Horner syndrome 7 (33)Chest pain 5 (24)

Myelopathy 3 (14)

Reproduced with permission from Son ES, Lee SH, Park SY, Kim KT, Kang CH, Cho SW:Surgical treatment of t1-2 disk herniation with t1 radiculopathy: A case report with review of theliterature. Asian Spine J 2012;6:199-202

Figure 1

A, Clinical photograph of the patient preoperative with ptosis and miosis of theleft eye. B, Clinical photograph of the patient 6 weeks postoperative with slightlyimproved but persistent ptosis and miosis of the left eye.

T1-T2 Disk Herniation Presenting With Horner Syndrome

2 Journal of the American Academy of Orthopaedic Surgeons

with C8 at a root level, the medialpectoral, medial brachial cutaneous,the medial antebrachial cutaneousnerves at a cord level, and the firstintercostal nerve. Delineating thelocation of nerve compression beginswith assessing sites of peripheralcompression with physical examina-tion. Tests such as Tinel sign atcarpal/cubital tunnel, elbow flexiontest, ulnar nerve compression test,Phalen test, and/or Durkan test arehelpful. Causes of T1 nerve rootcompression has been summarizedin the literature (Table 2). C8 andT1 nerve roots compromise both theulnar and median nerve root; there-fore, precise examination of theseroots is necessary. Dermatomal pat-terns for C8 and T1 radiculopathycan be difficult to discern on exami-nation because they can mimic pe-ripheral nerve pathology such ascubital and/or Guyon tunnel syn-drome.7 Motor deficits of C8 com-pression are reflected as weaknessin hand intrinsic muscles, fingerflexion, and some finger abduction.Weakness with finger abduction re-sults from C8 radiculopathy and/orperipheral ulnar nerve entrapment.The C8 nerve root innervates theextensor indicus and abductor pol-licis brevis from the radial andmediannerves, respectively, in addition tofinger flexion (ulnar nerve). C8 rootpathology will result in weakness inall three of these muscles with manualmuscle testing. T1 motor root in-nervates the flexor digitorum super-ficialis, flexor pollicis longus, flexorpollicis longus, flexor digitorum pro-fundus, lumbricals, interossei, and thepectoralis major.Differentiating motor function

from theC8-T1 nerve roots and ulnarnerve pathology can be assessed withmotor testing. All but five intrinsichand muscles are innervated by theulnar nerve; abductor pollicus brevis,flexor pollicis brevis, opponens pol-licis, and lateral lumbricals. By spe-cifically examining these fivemuscles,

one can differentiate between cubitaltunnel syndrome, which leaves theirmotor strength intact, and C8-T1radiculopathy.A working differential diagnosis

can guide management. Horner syn-drome with associated T1 weaknessand paresthesias is representative ofmany etiologies (Table 2). This clin-ical condition can commonly be aconsequence of cervical sympatheticchain injury, which runs along thelateral aspect of the vertebral body.Horner syndrome or oculosympa-

thetic paresis is evident because of

interruption of sympathetic nervesupply to the eye, which consists of a3-neuron pathway. The arc begins inthe hypothalamus and synapses in theintermediolateral gray substance atC8-T2 levels (ciliospinal center ofbudge). The preganglionic fibers thenexit the spinal cord and enter thecervical sympathetic chain. The fibersascend and synapse at the superiorcervical ganglia at the level of thebifurcation of the common carotidartery (C3-C4). Shortly after thepostganglionic fibers leave the supe-rior cervical ganglion, vasomotor

Figure 2

T2 sagittal and axial MR images with T1-T2 disk herniation (arrows).

Table 2

Causes of Horner Syndrome

Nerve sheath tumor

Mediastinal massLesion of the primary neuronPreganglionic neuron injury (brain stem stroke, tumor, or syrinx)4

Trauma to the brachial plexusTumors (ie, Pancoast) or infection of the lung apex5

Lesion of the postganglionic neuronDissecting carotid aneurysm6

Carotid artery ischemiaMigraine

Middle cranial fossa neoplasm

Daniel Possley, DO, et al

November 2018, Vol 2, No 11

and sudomotor fibers branch off totravel along external carotid artery toinnervate the blood vessels and sweatglands of the face. The rest of thepostganglionic fibers travel alongthe internal carotid artery and enterthe cavernous sinus. The oculo-sympathetic pathway then joins theophthalmic division of the fifth cranialnerve (V1) and travels into the orbit

through the superior orbital fissure toprovide innervation to the iris dilatormuscle andMueller’s muscle; a smallsmooth muscle in the eyelid respon-sible for a minor portion of upperlid elevation and lower lid retrac-tion. Disk herniation at T1/T2 cancompress the preganglionic fibers ofthe oculosympathetic pathway caus-ing the classic Horner syndrome pre-

sentation of enopthalmos, miosis,blepharoptosis, and facial anhid-rosis5,8,9 (Figure 3).Surgical approaches to thoracic

disk herniations correlatewith patientanatomy, location of nerve root com-pression, and surgeon familiarity.While the anterior approach tends tobe a more familiar approach to mostspine surgeons, certain anatomic re-strictions may limit its use for T1-T2.Posterior approach surgery has mostcommonly been used for laminectomyand/or foraminotomy.1,5,11-13 Ade-quate disk access of more central diskherniations may not be accomplishedwithout excessive facet resectionleading to hypermobility. SuccessfulSmith-Robinson approaches to T1-T2have been achieved, whereas partialsternotomy has been used in oth-ers.9,14 Thoracic disk herniations canbe approached posteriorly when littleto no retraction of the spinal cord isnecessary for disk access. Central diskherniations or those that compromiseup to 50% across the disk space areoften approached through an anteriorapproach as effective decompressioncannot be completed from a posterioronly approach. With this technique,there is no retraction of the neuralelements, no sacrifice of the nerveroots, and the pedicles are spared.15

When considering anterior surgery,identify the level of the clavicles, ster-num, and breast tissue in relation tothe upper thoracic levels for ade-quate preoperative planning. Anteriorapproaches are useful, but more in-volved. A modified anterior approachto the cervicothoracic junction withclavicle resection16 or combined cer-vicothoracic approach for diskectomyhas proven useful as well.14,17

Overall outcomes for T1 disk her-niations treated surgically are favor-able. Most studies report improvementin pain and neurologic dysfunction,but Horner syndrome can be refrac-tory to surgical decompression.12,18

Similarly, our patient at 6 weekspostoperative had resolution of his

Figure 3

Drawing showing the anatomy of the oculosympathetic pathway. Sympatheticfibers in the posterolateral hypothalamus pass through the lateral brain stemand synapse at the ciliospinal Center of Budge in the intermediolateral graysubstance of the spinal cord at C8 to T2. Preganglionic sympathetic neuronsexit the spinal cord and ascend up the carotid sheath to the superior cervicalganglion at the level of the bifurcation of the common carotid artery. Shortlyafter the postganglionic fibers leave the superior cervical ganglion, vasomotorand sudomotor fibers branch off to travel along the external carotid artery toinnervate the blood vessels and sweat glands of the face. The rest of thepostganglionic fibers travel along the internal carotid artery and enter thecavernous sinus. The oculosympathetic pathway then joins the ophthalmicdivision of the fifth cranial nerve (V1) and travels into the orbit through thesuperior orbital fissure to provide innervation to the pupil dilator muscle andMueller’s muscles; small smooth muscles in the eyelid responsible for a minorportion of upper lid elevation and lower lid retraction. a = artery, n = nerve.10(Reproduced with permission from Glaser J: Neuro-Ophthalmology, ed 1.Hagerstown, MD, Harper & Row, 1978.)

T1-T2 Disk Herniation Presenting With Horner Syndrome

4 Journal of the American Academy of Orthopaedic Surgeons

pain, motor, and sensory deficits butpersistent Horner syndrome at ninemonths postoperatively.Patients with cervical radiculopathy

symptoms and physical examinationfindings consistent with Horner syn-drome should be evaluated with aMRI that includes the upper tho-racic spine. An accurate diagnosisand timely surgical intervention mayprovide the patient the best chance forregression of symptoms and a satis-factory outcome.

References

1. Son ES, Lee SH, Park SY, Kim KT, KangCH, Cho SW: Surgical treatment of t1-2disc herniation with t1 radiculopathy: Acase report with review of the literature.Asian Spine J 2012;6:199-202.

2. Love JG, Kiefer EJ: Root pain and paraplegiadue to protrusions of thoracic intervertebraldisks. J Neurosurg 1950;7:62-69.

3. Arts MP, Bartels RH: Anterior or posteriorapproach of thoracic disc herniation? Acomparative cohort of mini-transthoracicversus transpedicular discectomies. Spine J2014;14:1654-1662.

4. Krasnianski M, Georgiadis D, Grehl H,Lindner A: Correlation of clinical andmagnetic resonance imaging findings inpatients with brainstem infarction.Fortschr Neurol Psychiatr 2001;69:236-241.

5. Lloyd TV, Johnson JC, Paul DJ, Hunt W:Horner’s syndrome secondary to herniateddisc at T1-T2. AJR Am J Roentgenol 1980;134:184-185.

6. Biousse V, Touboul PJ, D’Anglejan-Chatillon J, Levy C, Schaison M,Bousser MG: Ophthalmologicmanifestations of internal carotid arterydissection. Am J Ophthalmol 1998;126:565-577.

7. Stillerman CB, Chen TC, Couldwell WT,Zhang W, Weiss MH: Experience in thesurgical management of 82 symptomaticherniated thoracic discs and review ofthe literature. J Neurosurg 1998;88:623-633.

8. Maloney WF, Younge BR, Moyer NJ:Evaluation of the causes and accuracy ofpharmacologic localization in Horner’ssyndrome. Am J Ophthalmol 1980;90:394-402.

9. Gelch MM: Herniated thoracic disc at T1-2level associated with Horner’s syndrome:Case report. J Neurosurg 1978;48:128-130.

10. Glaser J. Neuro-Ophthalmology, ed 1.Hagerstown, MD, Harper & Row, 1978.

11. Svien HJ, Karavitis AL: Multipleprotrusions of intervertebral disks in theupper thoracic region: Report of case.Proc Staff Meet Mayo Clin 1954;29:375-378.

12. Morgan H, Abood C: Disc herniationat T1-2: Report of four cases andliterature review. J Neurosurg 1998;88:148-150.

13. Love JG, Schorn VG: Thoracic-diskprotrusions. JAMA 1965;191:627-631.

14. Rossitti S, Stephensen H, Ekholm S, vonEssen C: The anterior approach to highthoracic (T1-T2) disc herniation. Br JNeurosurg 1993;7:189-192.

15. Bransford RJ, Zhang F, Bellabarba C, LeeMJ. Treating thoracic-disc herniations: Dowe always have to go anteriorly? EvidBased Spine Care J 2010;1:21-28.

16. Kurz LT, Pursel SE, Herkowitz HN.Modified anterior approach to thecervicothoracic junction. Spine (Phila Pa1976) 1991;16(10 suppl):S542-S547.

17. Micheli LJ, Hood RW: Anterior exposureof the cervicothoracic spine using acombined cervical and thoracic approach. JBone Joint Surg Am 1983;65:992-997.

18. Kanno H, Aizawa T, Tanaka Y, et al: T1radiculopathy caused by intervertebraldisc herniation: Symptomatic andneurological features. J Orthop Sci 2009;14:103-106.

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