title: Two-level disc herniation in the cervical and thoracic spine presenting with spastic paresis in the lower extremities without clinical symptoms or signs in the upper extremities.
abstract: BACKGROUND
  There is no report in the literature of two-level disc herniation in the cervical and thoracic spine presenting with spastic paresis/paralysis exclusively in the bilateral lower extremities.
  
  
  OBJECTIVE
  To identify the clinical characteristics of specific myelopathy resulting from C6-C7 disc herniation through a case with spastic paresis in the lower extremities without upper extremities symptoms due to separate disc herniation in the cervical and thoracic spine, which was surgically removed in two stages.
  
  
  METHODS
  A case report.
  
  
  METHODS
  A 48-year-old man developed a gait disturbance as well as weakness and numbness in the lower extremities. Thoracic magnetic resonance imaging (MRI) showed a T11-T12 disc herniation, which was removed under the surgical microscope through a minimally invasive posterior approach. He improved, but 2 months after surgery developed recurrent numbness and spasticity. On this occasion, no evidence of recurrence of the thoracic disc herniation could be identified, but cervical MRI demonstrated a compressed spinal cord at the C6-C7 level. The patient had no neurological findings in the upper extremities. The herniated disc at C6-C7 was removed under the surgical microscope with laminoplasty.
  
  
  RESULTS
  The symptoms gradually improved after surgery. At the present time, 2 years and 9 months after the initial operation, the patient had a stable gait and was able to work.
  
  
  CONCLUSIONS
  Our experience suggests that in the diagnosis of patients with spastic paresis and sensory disturbances in the lower extremities, spinal cord compression should be explored by imaging studies not only in the thoracic spine but also in the cervical spine, especially at the C6-C7 level, even if the symptoms and abnormal neurological findings are absent in the upper extremities.
authors.affiliation: Department of Orthopedic Surgery, Kansai Medical University, Osaka, Japan. sasaik@takii.kmu.ac.jp
authors.forename: Kunihiko
authors.initials: K
authors.lastname: Sasai
authors.forename: Takashi
authors.initials: T
authors.lastname: Adachi
authors.forename: Kouki
authors.initials: K
authors.lastname: Togano
authors.forename: Ei
authors.initials: E
authors.lastname: Wakabayashi
authors.forename: Hiroyuki
authors.initials: H
authors.lastname: Ohnari
authors.forename: Hirokazu
authors.initials: H
authors.lastname: Iida
mesh_terms: D001132:Arm; D002574:Cervical Vertebrae; D003951:Diagnostic Errors; D005500:Follow-Up Studies; D006801:Humans; D007405:Intervertebral Disc Displacement / Q000175:diagnosis* / Q000601:surgery*; D018499:Linear Energy Transfer; D008297:Male; D008875:Middle Aged; D020336:Paraparesis, Spastic / Q000175:diagnosis*; D013904:Thoracic Vertebrae; D016896:Treatment Outcome