Cervical Disc Sequestration at the C1–C2

Cervical disc sequestration at the C1–C2 level refers to a rare condition in which a fragment of intervertebral disc material completely breaks away (sequestrates) and migrates within the spinal canal at the level of the first (atlas) and second (axis) cervical vertebrae. This free fragment can compress the spinal cord or nerve roots, leading to pain, neurologic symptoms, and, in severe cases, myelopathy. Disc sequestration is distinguished from other herniation types—protrusion and extrusion—by the complete detachment of disc material from its parent disc Verywell Health.

Anatomy of the Atlantoaxial Region

Structure & Location

• Atlas (C1): The ring-shaped first cervical vertebra supports the skull and lacks a vertebral body and spinous process, forming the atlanto-occipital joint with the occipital condyles Physiopedia.

• Axis (C2): The second cervical vertebra features the odontoid process (dens), which projects upward to articulate with C1, forming the atlantoaxial joint and allowing head rotation Physiopedia.

• Intervertebral Disc: Unlike other cervical levels, there is no true fibrocartilaginous disc between C1 and C2. Instead, a synovial joint and specialized ligaments (alar, transverse) maintain stability NCBI.

Origin & Insertion of Ligaments

• Transverse Ligament of Atlas: Originates from the medial aspects of the lateral masses of C1 and inserts behind the dens of C2, preventing anterior displacement of the atlas.

• Alar Ligaments: Extend from the sides of the dens to the medial occipital condyles, limiting rotation and side bending of the head.

Blood Supply

• Vertebral Arteries: Ascend through the transverse foramina of C6 to C1, curve posteromedially to enter the foramen magnum, supplying the brainstem and posterior brain Kenhub.

• Venous Plexus: A network of veins around the vertebrae drains into the internal vertebral venous plexus.

Nerve Supply

• C1 Nerve Root: Exits above C1, primarily motor, supplying suboccipital muscles.

• C2 Nerve Root: Exits between C1–C2, contributing to the greater occipital nerve, which transmits sensation from the posterior scalp.

Functions of the Atlantoaxial Complex

1. Head Rotation: Approximately 50% of cervical rotation occurs here.

2. Flexion/Extension Stabilization: Works with C0–C1 joint to nod the head.

3. Protection of Neural Elements: Shields the spinal cord and C2 nerve roots.

4. Load Transmission: Bears axial loads from the head.

5. Proprioception: Ligaments convey head position sense.

6. Vascular Conduit: Allows passage of vertebral arteries to the brain NCBIKenhub.

Classification of Disc Sequestration

1. General Herniation Categories:

   • Protrusion: Disc bulges without annulus tear.

   • Extrusion: Nucleus pulposus breaches the annulus but remains attached.

   • Sequestration: Free fragment separates completely Verywell Health.

2. Sequestration Localization (Manabe & Tateishi):

   • Anterior Sequestrum: On anterior dural surface.

   • Lateral Sequestrum (Radicular): Compresses nerve root.

   • Lateral (Drop Attack): Causes vertebrobasilar symptoms.

   • Posterior Sequestrum: On posterior dural sac PMC.

Causes

Disc sequestration arises when disc integrity is compromised. Common Causes:

1. Age-related Degeneration

2. Repetitive Microtrauma

3. Heavy Lifting & Bending

4. Direct Cervical Impact

5. Sudden Twisting Injuries

6. Falls onto Head/Neck

7. Whiplash from Motor Vehicle Crashes

8. High-impact Sports

9. Occupational Strain (e.g., construction)

10. Prolonged Poor Posture

11. Smoking (disc nutrition impairment)

12. Obesity (increased axial load)

13. Genetic Predisposition

14. Inflammatory Conditions (e.g., rheumatoid arthritis)

15. Osteoporosis (vertebral brittleness)

16. Previous Cervical Surgery

17. Connective Tissue Disorders

18. Diskitis or Infection Weakening Disc

19. Tumor Infiltration Weaken Disc

20. Congenital Spinal Anomalies

These factors compromise the annulus fibrosus, allowing nucleus pulposus to migrate and fragment QI SpineSpine-health.

Symptoms

Sequestrated fragments at C1–C2 may cause:

1. Severe Neck Pain

2. Occipital Headaches

3. Radiating Pain to Shoulders/Arms

4. Upper Limb Numbness/Tingling

5. Weakness in Arm Muscles

6. Gait Disturbance/Myelopathy

7. Loss of Fine Motor Skills

8. Dizziness/Vertigo

9. Facial Sensory Changes

10. Bowel or Bladder Dysfunction

11. Dysphagia (difficulty swallowing)

12. Respiratory Difficulty

13. Spasms of Neck Muscles

14. Reflex Changes (hyperreflexia)

15. Positive Hoffmann’s Sign

16. Positive Lhermitte’s Sign

17. Ataxic Gait

18. Drop Attacks (sudden collapse)

19. Torticollis (neck tilt)

20. Radiographic Incidental Findings

Symptoms result from nerve root irritation or spinal cord compression QI SpineSpine-health.

Diagnostic Tests

A thorough workup includes imaging and clinical exams:

1. Magnetic Resonance Imaging (MRI) – Gold standard for soft tissue detail Spine-health.

2. Computed Tomography (CT) Scan – Excellent bone detail.

3. X-Ray (Neutral, Flexion/Extension) – Instability assessment.

4. Myelography – CSF space outline.

5. Electromyography (EMG) – Nerve conduction, root involvement Clínic Barcelona.

6. Nerve Conduction Studies (NCS)

7. Discography – Provocative injection under imaging.

8. Spurling’s Test – Foraminal compression test Physiopedia.

9. Lhermitte’s Sign – Neck flexion electric shock sensation.

10. Reflex Testing – Hyperreflexia suggests myelopathy.

11. Sensory Examination – Pinprick, vibration.

12. Motor Strength Testing

13. Babinski Sign – Upper motor neuron lesion.

14. Hoffmann’s Reflex – UMN sign.

15. Gait Analysis

16. Somatosensory Evoked Potentials (SSEP)

17. Cervical Spine Ultrasound – For dynamic assessment.

18. Blood Tests – Rule out infection/inflammatory markers Medscape.

19. CT Angiography – Vascular involvement.

20. Kinematic MRI – Under motion stress.

Non-Pharmacological Treatments

1. Activity Modification (avoid aggravating movements)

2. Cervical Collar (short-term immobilization)

3. Therapeutic Ultrasound

4. Heat Therapy

5. Cold Packs

6. Transcutaneous Electrical Nerve Stimulation (TENS)

7. Manual Therapy/Chiropractic Mobilization

8. Traction (mechanical/home) Medscape.

9. Targeted Physical Therapy (strengthening/stretching) AAFP.

10. Yoga/Pilates for Neck Stability

11. Posture Training

12. Ergonomic Workstation Setup

13. Alexander Technique

14. Acupuncture

15. Massage Therapy

16. Dry Needling

17. Hydrotherapy

18. Core Stabilization Exercises

19. Balance Training

20. Proprioceptive Neuromuscular Facilitation (PNF)

21. Myofascial Release

22. Biofeedback

23. Sensory Re-education

24. Patient Education Programs

25. Weight Management

26. Smoking Cessation

27. Nutritional Support (anti-inflammatory diet)

28. Mindfulness/Relaxation Techniques

29. Psychological Counseling for Chronic Pain

30. Aquatic Therapy

These approaches aim to reduce pain, improve function, and prevent recurrence AAFPPMC.

Drug Treatments

These medications target pain, inflammation, muscle spasm, and neuropathic components AAFPPMC.

Surgical Options

1. Anterior Cervical Discectomy and Fusion (ACDF)

2. Posterior Cervical Discectomy

3. Cervical Microdiscectomy

4. Anterior Cervical Corpectomy

5. Laminectomy

6. Laminoplasty

7. Foraminotomy

8. Artificial Disc Replacement

9. Endoscopic Cervical Discectomy

10. Posterior Decompression with Instrumentation

Surgery is indicated for progressive neurologic deficit, myelopathy, or intractable pain after conservative therapy Spine.

Preventive Measures

1. Maintain Good Posture

2. Regular Neck-Strengthening Exercises

3. Ergonomic Workstation

4. Avoid Prolonged Neck Flexion

5. Use Proper Lifting Techniques

6. Stay Hydrated

7. Quit Smoking

8. Healthy Body Weight

9. Warm-up Before Physical Activity

10. Periodic Ergonomic Breaks

Preventive strategies reduce disc stress and degeneration QI Spine.

When to See a Doctor

• Severe or Worsening Pain not relieved by rest or medications.

• Neurological Symptoms: Numbness, weakness, gait disturbance.

• Red-Flag Signs: Bowel/bladder dysfunction, sudden collapse (“drop attack”), myelopathic signs (hyperreflexia).

• Persistent Symptoms beyond 6 weeks of conservative care.

Early evaluation ensures timely diagnosis and management to prevent permanent injury QI Spine.

FAQs

1. What is cervical disc sequestration?
   It’s when a piece of the spinal disc completely detaches and can press on nerves or the spinal cord in the neck Verywell Health.

2. How common is sequestration at C1–C2?
   Extremely rare, as there is no true disc between C1 and C2; reported cases involve migrated fragments from lower levels NCBI.

3. What symptoms should raise concern?
   Intense neck pain with limb weakness, sensory loss, or bladder/bowel changes warrants urgent care Spine-health.

4. Is MRI always necessary?
   Yes, MRI provides optimal detail of soft tissues and disc fragments Spine-health.

5. Can conservative care resolve sequestration?
   Some fragments may shrink over time with therapy, but surgery is often required if neurological signs are present Medscape.

6. What are non-surgical options?
   Physical therapy, traction, heat/cold packs, and ergonomic training are first-line treatments AAFP.

7. When is surgery recommended?
   Intractable pain, progressive weakness, or myelopathy despite 6–12 weeks of conservative therapy Spine.

8. What risks are associated with surgery?
   Infection, nerve injury, failed fusion, adjacent segment disease.

9. How long is recovery after ACDF?
   Typically 6–12 weeks for fusion; return to light activity in days.

10. Can disc sequestration recur?
    Yes, recurrence rates after surgery can be up to 25% in some series QI Spine.

11. Are there non-drug pain relief aids?
    TENS units, acupuncture, and massage can help manage symptoms AAFP.

12. Does weight affect recurrence?
    Obesity increases spinal load and recurrence risk.

13. What lifestyle changes help prevent recurrence?
    Core strengthening, posture correction, ergonomic adjustments.

14. Is discography safe?
    It carries risks of infection and disc damage; used selectively Clínic Barcelona.

15. Can children develop disc sequestration?
    Rare; usually linked to severe trauma or congenital anomalies.

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

Last Updated: May 01, 2025.

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