Thecal Sac Indentation Cervical Region

Dr. Tracy L. Ansay, MD - Spine and Neurosurgery Dr. Tracy L. Ansay, MD - Spine and Neurosurgery
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Degenerative Bones, Joints, and Spine Care (A - Z)

Cervical thecal sac indentation occurs when structures—like a bulging disc or bone spur—press into the dural sac in the neck (cervical) portion of the spine, causing it to flatten or “dent.” It is also called thecal sac effacement or encroachment. While mild indentation may cause no symptoms, more severe compression can pinch nerve roots or the spinal cord itself, leading to pain, numbness, or even weakness Spine InfoSpine Info.

Anatomy of the Cervical Thecal Sac

Structure and Location

The thecal sac is a tubular sheath made of dura mater (the tough outer meningeal layer) that surrounds the spinal cord and cerebrospinal fluid (CSF). In the cervical spine, it lies inside the bony spinal canal formed by the vertebral bodies in front and the laminae behind Wikipedia.

Origin and Insertion

  • Origin: At the base of the skull (foramen magnum), where the dura mater envelops the brain and transitions into the spinal dura

  • Insertion: It tapers at about the second sacral vertebra, blending into the filum terminale that anchors the spinal cord Wikipedia.

Blood Supply

Tiny meningeal branches from the vertebral arteries and ascending cervical arteries penetrate the dura to nourish the thecal sac. These vessels also help remove waste from the CSF space Wikipedia.

Nerve Supply

The outer layer of the dura is sensitive to pain. It is innervated by the sinuvertebral nerves (branches of the spinal nerves), which relay discomfort when the sac is stretched or compressed Wikipedia.

Six Key Functions

  1. Protection: Shields the spinal cord and nerve roots from direct impact.

  2. CSF Containment: Holds cerebrospinal fluid for nutrient exchange and waste removal.

  3. Buoyancy: CSF suspension reduces the effective weight of the spinal cord.

  4. Shock Absorption: Fluid cushion dampens sudden movements or blows.

  5. Anchoring: Maintains proper alignment of the spinal cord within the canal.

  6. Drug Delivery Conduit: Allows medications (e.g., intrathecal injections) to diffuse around neural tissues.

Classification and Types of Indentation

Indentations can be classified by:

  • Location:

    • Ventral (front) indentation (e.g., by osteophytes)

    • Dorsal (back) indentation (e.g., by ligamentum flavum thickening)

    • Lateral recess indentation (side channels)

  • Severity:

    • Mild (<25% flattening)

    • Moderate (25–50%)

    • Severe (>50%)

  • Shape:

    • Focal (spot) vs. Broad-based (widespread)

  • Etiology:

    • Disc-related vs. Bone-related vs. Soft-tissue vs. Mass lesions

Causes of Cervical Thecal Sac Indentation

Any condition that narrows the spinal canal can indent the thecal sac. Common causes include: Spine Info

  1. Herniated (slipped) cervical disc

  2. Degenerative disc disease

  3. Ligamentum flavum hypertrophy (thickened posterior ligament)

  4. Osteophyte (bone spur) formation on vertebral bodies

  5. Cervical spondylosis (general wear-and-tear)

  6. Cervical spinal stenosis (canal narrowing)

  7. Spondylolisthesis (vertebral slippage)

  8. Synovial cysts in facet joints

  9. Spinal tumors (meningioma, metastasis)

  10. Epidural abscess (infection)

  11. Epidural hematoma (bleeding)

  12. Rheumatoid pannus (inflammatory tissue)

  13. Traumatic fractures or dislocations

  14. Congenital canal narrowing (developmental)

  15. Arachnoiditis (arachnoid membrane scarring)

  16. Dural arteriovenous fistula

  17. Tuberculosis (Pott’s disease of the spine)

  18. Paget’s disease (bone remodeling)

  19. Calcium pyrophosphate deposition (CPPD) arthropathy

  20. Post-surgical scar tissue (epidural fibrosis)

Symptoms

Symptoms depend on how much the sac—and underlying nerves—are compressed Spine Info:

  1. Neck pain (local ache)

  2. Stiffness, reduced range of motion

  3. Radiating shoulder pain

  4. Arm or hand numbness

  5. Tingling (“pins and needles”)

  6. Muscle weakness in arms or hands

  7. Hand clumsiness or loss of dexterity

  8. Grip strength reduction

  9. Balance problems or unsteady gait

  10. Leg weakness or spasticity (if severe)

  11. Hyperreflexia (overactive reflexes)

  12. Lhermitte’s sign (electric shock sensation down spine)

  13. Gait ataxia (walking difficulty)

  14. Bladder urgency or retention

  15. Bowel dysfunction

  16. Sexual dysfunction

  17. Headaches (cervicogenic)

  18. Dizziness or vertigo

  19. Fatigue from chronic pain

  20. Sleep disturbances (due to pain)

Diagnostic Tests

Accurate diagnosis combines clinical exam with imaging and electrophysiology Spine Info:

  1. Magnetic resonance imaging (MRI)

  2. Computed tomography (CT) scan

  3. X-rays (plain films)

  4. Flexion-extension X-rays (dynamic views)

  5. CT myelogram (contrast dye)

  6. Discography (contrast into disc)

  7. Electromyography (EMG)

  8. Nerve conduction study (NCS)

  9. Somatosensory evoked potentials (SSEPs)

  10. Motor evoked potentials (MEPs)

  11. Bone scan (for tumors/infection)

  12. Ultrasound (for guided injections)

  13. Blood tests (ESR, CRP for inflammation)

  14. White blood cell count (infection)

  15. Tumor markers (if malignancy suspected)

  16. Cerebrospinal fluid (CSF) analysis (via lumbar puncture)

  17. Vertebral artery angiography (rare vascular causes)

  18. Dynamic MRI (positional imaging)

  19. Kinematic CT (motion-based CT)

  20. Ultrasound Doppler (vascular flow in epidural space)

Non-Pharmacological Treatments

Conservative care is first-line for mild to moderate indentation:

  1. Physical therapy (neck stabilization exercises)

  2. Cervical traction (mechanical or over-door)

  3. Heat therapy (warm packs)

  4. Cold therapy (ice packs)

  5. Posture correction training

  6. Ergonomic workstation setup

  7. Cervical pillows (supportive sleeping)

  8. Soft cervical collar (temporary support)

  9. Yoga (neck-friendly poses)

  10. Pilates (core strengthening)

  11. Manual therapy (gentle mobilization)

  12. Chiropractic adjustments (if appropriate)

  13. Massage therapy (muscle relaxation)

  14. Transcutaneous electrical nerve stimulation (TENS)

  15. Ultrasound therapy (deep heat)

  16. Dry needling or acupuncture

  17. Mindfulness meditation (pain coping)

  18. Tai chi (balance, gentle movement)

  19. Aquatic therapy (low-impact exercise)

  20. Postural taping (Kinesio tape)

  21. Ergonomic driving posture

  22. Weighted cervical exercises

  23. Scapular stabilization exercises

  24. Diaphragmatic breathing exercises

  25. Activity modification (avoid aggravators)

  26. Graded exercise programs

  27. Core strengthening routines

  28. Nutritional counseling (anti-inflammatory diet)

  29. Weight management programs

  30. Smoking cessation support

Medications

When needed, drugs help relieve pain and reduce inflammation Spine Info:

  1. Acetaminophen (paracetamol)

  2. Ibuprofen (NSAID)

  3. Naproxen (NSAID)

  4. Diclofenac (NSAID)

  5. Celecoxib (COX-2 inhibitor)

  6. Aspirin (NSAID)

  7. Cyclobenzaprine (muscle relaxant)

  8. Tizanidine (muscle relaxant)

  9. Baclofen (muscle relaxant)

  10. Prednisone (oral steroid)

  11. Methylprednisolone (oral steroid)

  12. Gabapentin (neuropathic pain)

  13. Pregabalin (neuropathic pain)

  14. Duloxetine (SNRI antidepressant)

  15. Amitriptyline (TCA antidepressant)

  16. Tramadol (weak opioid)

  17. Codeine (opioid)

  18. Lidocaine patches (topical)

  19. Capsaicin cream (topical)

  20. Epidural steroid injection (ESI)

Surgical Treatments

Reserved for severe or refractory cases Spine Info:

  1. Anterior cervical discectomy and fusion (ACDF)

  2. Posterior cervical laminectomy

  3. Cervical laminoplasty

  4. Posterior cervical fusion

  5. Artificial disc replacement (ADR)

  6. Foraminotomy (nerve root decompression)

  7. Corpectomy (vertebral body removal)

  8. Microdiscectomy (minimally invasive)

  9. Tumor resection (if mass present)

  10. Epidural hematoma evacuation

Preventive Measures

Simple steps can lower your risk:

  1. Maintain good posture (sitting/standing)

  2. Use an ergonomic workstation

  3. Perform daily neck stretches

  4. Strengthen neck and core muscles

  5. Lift objects with proper technique

  6. Keep a healthy weight

  7. Ensure good sleeping posture and pillow support

  8. Take frequent breaks during screen time

  9. Avoid smoking (reduces disc health)

  10. Stay active with low-impact exercise

When to See a Doctor

Seek medical attention if you experience:

  • Persistent or worsening neck pain lasting >6 weeks

  • Progressive numbness, tingling, or weakness in arms/hands

  • Difficulty walking, balance problems, or falls

  • Bladder or bowel control changes

  • Fever, chills, or unexplained weight loss (infection/tumor warning signs)

 

Frequently Asked Questions

1. What is cervical thecal sac indentation?
It’s when a structure in your neck, such as a herniated disc or bone spur, pushes into the thecal sac—the dura mater tube that holds your spinal cord and fluid—causing it to deform on scans like MRI. WikipediaRadiopaedia

2. What symptoms should I look for?
You might feel neck pain, arm numbness or tingling, hand weakness, balance issues, or even bowel/bladder changes if it’s severe. Myelopathic signs like overactive reflexes (hyperreflexia) or spasticity can also occur. WikipediaWikipedia

3. How is it diagnosed?
Your doctor will review your symptoms and do a neurological exam (reflexes, strength, sensation). Imaging—especially MRI—is the best way to see thecal sac indentation, often supplemented by CT, CT myelography, or nerve studies (EMG/NCV). WikipediaRadiopaedia

4. What causes it?
Most often, age-related wear and tear like degenerative disc disease, spondylosis (arthritis), herniated discs, or ligament thickening leads to canal narrowing and thecal sac indentation. Less common causes include tumors, infections, or trauma. RadiopaediaRadiopaedia

5. Can it be treated without surgery?
Yes. Many people find relief with physical therapy, posture correction, traction, heat/cold, TENS, acupuncture, and targeted neck exercises before considering surgery. Mayo ClinicWikipedia

6. What medicines are used?
Pills like NSAIDs (ibuprofen, naproxen), acetaminophen, muscle relaxants (cyclobenzaprine, baclofen), neuropathic agents (gabapentin, pregabalin), antidepressants (duloxetine), and sometimes short-term steroids or epidural steroid shots help reduce pain and inflammation. WikipediaWeill Cornell Medicine

7. What are the risks of surgery?
As with any neck operation, there’s risk of infection, bleeding, nerve injury, implant failure, or adjacent segment disease (wear at neighboring levels). Most patients improve, but recovery can vary. WikipediaRadiopaedia

8. How long is recovery after surgery?
Typically you’ll wear a soft collar briefly, stay in hospital 1–3 days, then do physical therapy for 6–12 weeks. Bone fusion (if done) can take 3–6 months to solidify. Verywell HealthWikipedia

9. Can exercise help?
Absolutely. Neck stabilization, core strengthening, stretching, and low-impact aerobics (walking, swimming) improve function and may slow progression. Always follow a guided program. Mayo ClinicPhysical Therapy Specialists

10. Are there lifestyle changes to prevent it?
Yes—stay active, keep good posture, maintain healthy weight, use ergonomic workstations, avoid smoking, and get enough calcium and vitamin D. NIAMS

11. Is it a serious condition?
It can be if it causes spinal cord compression (myelopathy), leading to lasting weakness or bladder/bowel issues. Mild cases may only cause neck pain. WikipediaRadiopaedia

12. Can it heal on its own?
Mild indentation often remains stable or improves slightly with conservative treatment, but the underlying wear-and-tear usually doesn’t fully reverse without intervention. WikipediaPatient Care at NYU Langone Health

13. When should I see a doctor?
See a doctor for persistent neck pain, new arm or leg weakness, balance loss, or any changes in bladder/bowel function. Early care can prevent permanent nerve damage. Mayo ClinicWikipedia

14. Will it get worse over time?
Without management, age-related changes may progress slowly. Good treatment (therapy, lifestyle) can slow or halt that progression in many cases. WikipediaWikipedia

15. Can I work with this condition?
Most people can continue working with proper ergonomics, breaks, and therapeutic exercises. Severe myelopathy may require job modifications until decompression is achieved. Mayo Clinic

Disclaimer: Each person’s journey is unique, treatment plan, life style, food habit, hormonal condition, immune system, chronic disease condition, geological location, weather and previous medical  history is also unique. So always seek the best advice from a qualified medical professional or health care provider before trying any treatments to ensure to find out the best plan for you. This guide is for general information and educational purposes only. Regular check-ups and awareness can help to manage and prevent complications associated with these diseases conditions. If you or someone are suffering from this disease condition bookmark this website or share with someone who might find it useful! Boost your knowledge and stay ahead in your health journey. We always try to ensure that the content is regularly updated to reflect the latest medical research and treatment options. Thank you for giving your valuable time to read the article.

The article is written by Team Rxharun and reviewed by the Rx Editorial Board Members

Last Updated: May 02, 2025.

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References

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