An unusual cause for chronic right-sided abdominal pain: answer

Abstract

MRI of the spine (Fig. 1 of Images in Neuroscience: Question) demonstrated a calcified lesion at T6/T7 causing marked cord compression, consistent with a large disc prolapse. The disc extrusion was eccentric to the right with the compressed cord displaced to the left. Localised cord signal abnormality was present on T2-weighted images. CT scan of the thoracic spine (Fig. 1 of Images in Neuroscience: Question) demonstrated calcification with a broad dural base anteriorly, extending superiorly behind the T6 vertebral body and intradurally. There were moderate degenerative changes within the T6/T7 intervertebral disc. The major differential diagnosis was considered to be a calcified meningioma. Surgery was subsequently performed through a T6/T7 laminectomy, wider on the right than the left. The calcified mass was confirmed to be intradural, and the dura was opened just right of the midline. An ultrasonic bone curette was used to resect the mass. Histopathology revealed mature hyaline cartilage, without evidence of atypia or malignancy. Thoracic disc prolapse is uncommon, with reported incidences between 0.15% to 4% of all symptomatic disc prolapses [1,2]. The most common level of prolapse is T11/T12, and calcification occurs in 65% of patients [2]. Presentations are varied, ranging from chronic pain to an acute myelopathy in 4% of patients [3]. The most common complaint is that of back pain, with or without a radicular component. Abdominal and groin pain are a rare but recognised entity and diagnosis of a thoracic disc prolapse in these patients usually follows multiple non-invasive and invasive procedures such as endoscopy and laparoscopy [1,3–7].The mechanism of abdominal pain is unclear. Visceral and somatic afferent fibres are attributed to different spinal locations and there is no relationship between visceral afferents and dermatome level, although the lower thoracic nerves (T8–T12) appear to be most commonly involved with patients who present with abdominal pain [1,4–6]. Surgery remains themainstay of treatment for symptomatic thoracic disc prolapse with rapid surgical decompression of patients with acute myelopathy frequently leading to neurological recovery