The Journal of Bone & Joint Surgery

The Journal of Bone & Joint Surgery, Volume 86, Issue 7

Scientific Articles | July 01, 2004

The Natural History of Cervical Disc Calcification in Children

Li-Yang Dai, MD, PhD¹; Hua Ye, MD²; Qi-Rong Qian, MD, PhD³

¹ Department of Orthopaedic Surgery, Xinhua Hospital, Shanghai Second Medical University, 1665 Kongjiang Road, Shanghai 200092, China. E-mail address: lydai@etang.com
² Department of Radiology, Changhai Hospital, 174 Changhai Road, Shanghai 200003, China
³ Department of Orthopaedic Surgery, Changzheng Hospital, 415 Fengyang Road, Shanghai 200003, China

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The authors did not receive grants or outside funding in support of their research or preparation of this manuscript. They did not receive payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated.

Investigation performed at the Department of Orthopaedic Surgery, Xinhua Hospital, Shanghai, and the Department of Orthopaedic Surgery, Changzheng Hospital, Shanghai, China

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J Bone Joint Surg Am, 2004 Jul 01;86(7):1467-1472

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Abstract

Background: Calcification of cervical intervertebral discs is uncommon in children. The cases of approximately 200 children have been reported in the literature. The objective of the present study was to examine the natural history of this condition.

Methods: Seventeen consecutive children, ten boys and seven girls, with calcified cervical intervertebral discs were included in the study. The mean age at diagnosis was 7.7 years. Three children had had a fever, and two had a history of trauma. All of the children complained of neck pain except one who was asymptomatic and was identified by chance. On radiographs, the calcification was seen within the central part of the cervical intervertebral discs. All children had treatment of the symptoms, and they were then followed periodically until the disappearance of both the symptoms and the calcific deposits.

Results: The children were followed for a mean of five years, and all had a complete disappearance of both the symptoms and the calcification. None had recurrent symptoms or calcifications. The average time to resolution of the symptoms and the calcifications was 34.3 days (range, seventeen to 173 days) and fifteen months (range, three to sixty months), respectively. With the numbers available, factors such as age, level of disc calcification, severity of symptoms, and degree of spinal canal compromise were not related to the time of resolution.

Conclusions: Cervical disc calcification in children is a self-limiting condition with an excellent prognosis. Even if clinical symptoms due to nerve-root or spinal cord compression are present, conservative therapy produces satisfactory results. Therefore, nerve-root or spinal cord compression by a calcified cervical disc should not be considered an absolute indication for surgical intervention.

Level of Evidence: Prognostic study, Level IV (case series). See Instructions to Authors for a complete description of levels of evidence.

Figures in this Article

Calcification of intervertebral discs is common in adults^1,2. It has been implicated in the degenerative process of the spine^3,4, but usually no clinical symptoms are evident. In contrast, calcified intervertebral discs rarely occur in children, and symptomatic discs most commonly involve the lower cervical region^5,6. Since the condition was first documented, as far as we know, by Lyon⁷ and Weens⁸, it has not been reported frequently in the literature. The cases of approximately 200 children with calcified intervertebral discs have been published⁹. It may be an incidental finding, or it may be associated with a distinct clinical syndrome and, rarely, with a neurological deficit^10-12. Conservative treatment is usually effective^13,14, but surgical intervention has been reported for some patients with a progressive neurological deficit^{2,12,13,15-21}.

We present the cases of seventeen children with symptomatic or asymptomatic cervical disc calcification. The objective of this study was to examine its natural history and to identify associated factors.

Materials and Methods

Materials and Methods | Results | Discussion | Appendix | References

Between 1984 and 2000, seventeen consecutive children with cervical disc calcification were seen in our hospitals. There were ten boys and seven girls. The mean age at diagnosis was 7.7 years (range, five to thirteen years) (see Appendix). Fifteen children had single-level involvement of the cervical spine, and two children had two-level involvement of the cervical spine or both cervical and thoracic spine involvement.

Three children had recently had a fever, but it had subsided five to seven days before they were referred to our hospitals. None of them had a temperature that was >38°C, and the symptoms lasted for less than three days. Although none of them had been seen by a physician at the time, antipyretics were administered to two of them by their parents.

Two children had had a neck injury three days and 1.7 years prior to the onset of symptoms. Sixteen children complained of neck pain, and one, who had been identified by chance, was asymptomatic. Five children had neurologic symptoms involving the upper extremities. Two children had weakness of the biceps muscle, and one of the two children also had weakness of flexion of the ring and small fingers. Three children had arm numbness, which corresponds to the expected anatomic distribution region of spinal cord compression. The muscle weakness was evaluated according to the grading system for muscle strength from the Medical Research Council²², and all three patients had grade 3 of 5. The numbness was defined as objective sensory loss (light touch). No involvement of the lower extremities was identified.

Anteroposterior and lateral radiographs of the cervical spine demonstrated dense, oval-shaped disc calcification involving most of the disc space of the cervical spine in all patients (Fig. 1). Computed tomography was performed in eleven patients and confirmed dense calcification of the nucleus pulposus (Fig. 2). Magnetic resonance imaging of the cervical spine was performed in seven patients. Disc calcification was demonstrated as a low signal intensity on both T1 and T2-weighted images (Fig. 3).

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Fig. 1: A seven-year-old boy (Case 8 in the Appendix) was admitted to our hospital with pain and a stiff neck. A lateral radiograph showed calcification of the disc space between C2 and C3.

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Fig. 2: A five-year-old boy (Case 13 in the Appendix) was seen with neck pain, torticollis, and arm pain. There had been numbness radiating down the forearm into the thumb, index, and long fingers. Computed tomography revealed a calcified disc herniated into the spinal canal with canal compromise of 60%.

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Fig. 3: A ten-year-old girl (Case 12 in the Appendix) had neck pain, torticollis, arm pain, and numbness on the medial aspect of the forearm extending to the long finger. The T1-weighted magnetic resonance image demonstrated low signal intensity of the calcified discs between T1 and T2 and between C7 and T1. The spinal canal compromise at C7-T1 was 50%.

Treatment included analgesia, traction, and/or a cervical collar until the patients became asymptomatic. They were followed for a mean of five years (range, two to nine years). For the one patient without any symptoms, a cervical collar was used for only three weeks. All children were evaluated at two weeks, three months, six months, and one year after treatment and were followed annually thereafter. Institutional review board approval was obtained at each institution before the study was initiated.

The time interval until the disappearance of both the symptoms and the calcific deposits was recorded. Age, gender, level of disc calcification, severity of symptoms, and degree of spinal canal compromise were analyzed. The severity of the symptoms was graded, with grade 0 indicating no symptoms; grade 1, mild pain and no need for medication; grade 2, moderate pain and the need for occasional medication; grade 3, severe pain and the need for constant medication; and grade 4, neurologic deficit of the upper extremities. Five children had grade-4 symptoms; three, grade-3; six, grade-2; two, grade-1; and one child, grade-0 symptoms. All five patients with grade-4 symptoms had severe pain and needed constant medication. The degree of spinal canal compromise was defined as a percentage that was calculated by dividing the smallest sagittal diameter of the spinal canal at the level of disc herniation by the mean sagittal diameter at adjacent levels cephalad and caudad to the herniated disc as seen on computed tomography scans or magnetic resonance images. The mean spinal canal compromise was 17% (range, 0% to 64%). For the two patients with two-level involvement, the level was arbitrarily defined as the one adjacent to the middle portion of the cervical spine. Therefore, the level was defined as C3-C4 for patients with C2-C3 and C3-C4 involvement, and as C7-T1 for those with C7-T1 and T1-T2 involvement.

Statistical Analysis

The correlations between parameters and the time to disappearance of both the symptoms and the calcific deposits were calculated with a t test, one-way analysis of variance, and linear regression analysis. Results were considered to be significant when the p value was <0.05.

Results

Materials and Methods | Results | Discussion | Appendix | References

Both the symptoms and the calcific deposits completely disappeared in all patients (Figs. 4-A, 4-B, 4-D). No patient had recurrent symptoms or calcifications. The mean time to resolution of the symptoms was 34.3 days (range, seventeen to 173 days). The mean time to resolution of calcification was fifteen months (range, three to sixty months).

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Figs. 4-A through 4-D: A twelve-year-old girl (Case 14 in the Appendix) with cervical disc calcification between C3 and C4. She had mild neck pain (a grade-1 symptom). The findings on the neurological examination were normal. Fig. 4-A Plain radiograph showing a calcified disc of C3-C4 herniated into the canal and substantially wedged vertebral body of C4.

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Fig. 4-B: T2-weighted magnetic resonance image showing a low signal intensity in the spinal canal. The extent of spinal canal compromise was 64%. Fig. 4-C The symptoms disappeared completely seventeen days after treatment. Partial disappearance of the calcific deposits was noted four months later.

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Fig. 4-D: Complete disappearance of the calcific deposits three years later.

With the numbers available, factors such as age (r = 0.147 or 0.152), gender (t = 0.735 or 1.469), level of disc calcification (F = 0.544 or 1.042), severity of symptoms (r = 0.345 or —0.286), and degree of spinal canal compromise (r = —0.178 or 0.067) were not significantly related to the time of resolution of either the symptoms or the calcification (p > 0.05). There was also no significant correlation (r = 0.098, p > 0.05) between the time of resolution of the symptoms and the calcification.

Discussion

Materials and Methods | Results | Discussion | Appendix | References

The etiology of cervical disc calcification in children remains obscure; however, it is likely different from the degenerative calcification seen in adults. Trauma has often been implicated as a predisposing factor since disc calcification in some children was preceded by trauma^{5,12,14,18,23}. However, preexisting disc calcification was also identified in some children^6,8,24, and most patients have no history of injury. Furthermore, disc calcification in newborns has been reported²⁵. Thus, it is difficult to determine the relationship between trauma and disc calcification in children. Some authors^5,6,8 have postulated an inflammatory or infectious mechanism, supported by the evidence that these patients often have an increased erythrocyte sedimentation rate, an elevated white blood-cell count, and an elevated C-reactive protein level¹⁵. Five children in the current series underwent laboratory evaluation, and three of them had an increased white blood-cell count and/or an elevated erythrocyte sedimentation rate. In our opinion, the clinical and radiographic features of disc calcification in children are entirely different from discitis. None of the children in this series received any antibiotic therapy, and all reported satisfactory improvement.

The clinical spectrum of disc calcification varies. In children, calcified discs are most commonly found in the cervical spine, whereas the thoracic area is rarely involved^25,26 and the lumbar spine is almost never involved^4,9. Multiple disc involvement has also been reported²⁷. Most patients have local symptoms, and some may have a fever. Three patients in this series had a fever, but none had a temperature of >38°C. Rechtman et al.²⁴ classified the clinical symptoms as "disappearing," "dormant," and "silent" types. In general, the symptoms persist for days to weeks; symptoms lasting longer than several weeks are rarely documented^5,6,28. In the current study, no patient had symptoms that persisted beyond six months.

The most frequent problem with disc calcification is recognition. The calcified discs are usually seen radiographically as a dense round or oval mass within the nucleus pulposus. Computed tomography or magnetic resonance imaging can demonstrate an associated disc herniation²³. The calcification has been described as having a diminished signal intensity on magnetic resonance images^11,23, although hyperintense discs on the T1-weighted image are associated with calcification^29,30. We believe that plain radiographs are sufficient to assess disc calcification in children, and additional investigation with imaging may be recommended only for those with a neurological deficit³¹. Wong et al. noted the persistence of a freckle of calcification after the complete disappearance of symptoms¹⁴. All of the patients in this series experienced complete disappearance of the calcific deposits.

The severity of the symptoms is often not correlated with the radiographic findings^23,32, and the calcification may be only an incidental finding^9,24. It has been generally accepted that disc calcification in children is self-limiting and has an excellent prognosis. However, herniation of calcified discs occasionally leads to acute nerve-root or spinal cord compression. Although conservative treatment has been recommended for those with radiculopathy or myelopathy, anterior discectomy with or without arthrodesis^{2,12,13,15-21} has been performed for a few patients with intractable pain and a progressive neurological deficit. In our study, treatment of the symptoms was effective even for the patients with neural compression. Six patients had spinal canal compromise because of herniation of the calcified disc. None of these patients experienced deterioration of neurological function, and none underwent surgery. Therefore, we believe that surgical intervention for the treatment of nerve-root or spinal cord compression by a calcified cervical disc is rarely indicated.

To our knowledge, the present report is the largest series of cervical disc calcifications in children to date, yet no factor was found to be related to the natural history of the disease process. One reason may be that the size of the sample included in this study is still not large enough to attain significance. Further investigation is required to better define the natural history of this condition in children.

Appendix

Materials and Methods | Results | Discussion | Appendix | References

A table showing clinical data on all seventeen patients is available with the electronic versions of this article, on our web site at (go to the article citation and click on "Supplementary Material") and on our quarterly CD-ROM (call our subscription department, at 781-449-9780, to order the CD-ROM).

References

Materials and Methods | Results | Discussion | Appendix | References

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Topics

intervertebral disc of cervical vertebra ; calcification ; intervertebral disk calcification

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Li-Yang Dai, Hua Ye, Qi-Rong Qian; The Natural History of Cervical Disc Calcification in Children. The Journal of Bone & Joint Surgery. 2004 Jul;86(7):1467-1472.

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