Cervical Thecal Sac Indentation at C3–C4

Cervical thecal sac indentation at C3–C4 refers to a condition in which a structure—most commonly an intervertebral disc protrusion or osteophyte—presses against the front (ventral) aspect of the dural sac (the thecal sac) at the level of the third and fourth cervical vertebrae. This indentation can narrow the space available for the spinal cord and its protective cerebrospinal fluid (CSF), potentially causing symptoms ranging from neck pain to neurological deficits.

---

 Anatomy of the Cervical Thecal Sac

Structure & Location

The thecal sac is a tubular sheath of dura mater that encloses the spinal cord and the CSF. In the cervical region, it lies within the vertebral canal formed by the vertebral bodies anteriorly and the vertebral arches posteriorly. At the C3–C4 level, the thecal sac surrounds spinal cord segments supplying the neck and upper limb musculature Wikipedia.

Origin & Insertion

• Origin: The thecal sac begins at the foramen magnum at the base of the skull, where the dura mater of the brain falls inward to surround the spinal cord.

• Termination (“Insertion”): It tapers at the level of the second sacral vertebra (S2), forming the filum terminale, which anchors the spinal cord to the coccyx Wikipedia.

Blood Supply

• Arterial: The anterior and paired posterior spinal arteries (branches of the vertebral arteries) supply the spinal cord and dural sac. Radicular (segmental) arteries, such as the cervical radicular branches, reinforce this supply at each vertebral level ScienceDirectOrthobullets.

• Venous: The internal vertebral (epidural) venous plexus drains blood from the dura and epidural space back into segmental veins that exit via intervertebral foramina.

Nerve Supply

• The outer dura (thecal sac) receives sensory fibers from the sinuvertebral (recurrent meningeal) nerves, which arise from the cervical nerve roots. These fibers transmit pain and proprioceptive signals when the dura or adjacent structures are irritated ScienceDirectTeachMeAnatomy.

Key Functions

1. Protection: Encases the spinal cord and nerve roots, shielding them from mechanical injury.

2. CSF Containment: Holds cerebrospinal fluid, which cushions the cord and maintains nutrient/waste exchange.

3. Shock Absorption: The CSF buffer reduces impact forces transmitted through the spine.

4. Barrier Function: Limits the spread of infection and confines intrathecal drug delivery.

5. Durable Sheath: Forms root sleeves around exiting nerves, guiding them safely through the spinal canal.

6. Anchoring: Via the filum terminale, it secures the spinal cord’s position within the canal ScienceDirectWikipedia.

Indentation of the thecal sac at C3–C4 occurs when an anterior structure—most often a bulging or herniated disc, osteophyte complex, or ligamentous hypertrophy—protrudes into the spinal canal and presses on the dural sac, partially obliterating the CSF space without necessarily overtly compressing the spinal cord itself RadiopaediaRadiopaedia.

---

Types of Indentation

Indentations can be classified by etiology and severity:

• By Cause:

  • Disc Protrusion (bulge or herniation)

  • Osteophyte Complex (bone spur from spondylosis)

  • Ligamentum Flavum Hypertrophy

  • Epidural Masses (abscess, tumor)

• By Severity:

  • Mild: Minimal effacement of CSF rim

  • Moderate: Partial CSF effacement with slight cord deformation

  • Severe: Significant CSF loss with cord compression

---

Causes

1. Degenerative Disc Disease – age-related disc dehydration and bulging Cleveland Clinic

2. Cervical Spondylosis – osteophyte formation from facet/joint degeneration Radiopaedia

3. Herniated Cervical Disc – nucleus pulposus extrudes posteriorly RadiopaediaRadiopaedia

4. Posterior Longitudinal Ligament Thickening

5. Ligamentum Flavum Hypertrophy

6. Traumatic Disc Injury – sudden loading causing disc tear

7. Epidural Hematoma – bleeding into epidural space after trauma

8. Epidural Abscess – infection forming pus collection

9. Neoplastic Lesions – meningioma or metastatic tumors

10. Congenital Spinal Canal Narrowing

11. Rheumatoid Arthritis – pannus formation at facet joints

12. Ossification of Ligaments (OPLL)

13. Posterior Disc Osteophyte Complex Practo

14. Facet Joint Cysts

15. Calcified Disc Fragments

16. Spinal Synovial Cysts

17. Paget’s Disease of Bone – abnormal bone remodeling

18. Gouty Tophi deposition in ligaments

19. Metabolic Bone Disease – e.g., hyperparathyroidism

20. Iatrogenic Changes – post-surgical scarring or instrumentation

---

Symptoms

1. Neck Pain – often the first sign

2. Stiffness – reduced range of motion

3. Occipital Headache

4. Shoulder Pain/Radiation

5. Arm Numbness or Tingling

6. Upper Limb Weakness

7. Hand Grip Weakness

8. Clumsiness – dropping objects

9. Gait Disturbance – imbalance

10. Hyperreflexia – brisk reflexes below lesion level

11. Lhermitte’s Sign – electric-shock sensation on neck flexion

12. Sensory Level – diminished sensation below C4

13. Muscle Spasms

14. Fatigue – from chronic pain

15. Sleep Disturbance

16. Bowel/Bladder Dysfunction – in severe cases

17. Spasticity

18. Cervical Myelopathy Signs

19. Torticollis – head tilting

20. Autonomic Symptoms – e.g., sweating changes

---

Diagnostic Tests

1. Plain X-Ray (AP & Lateral) – alignment, osteophytes

2. MRI of Cervical Spine – gold standard for soft tissues RadiopaediaRadiopaedia

3. CT Scan – bony detail, calcification

4. CT Myelogram – dye outlines thecal sac

5. Flexion/Extension X-Rays – dynamic instability

6. Electromyography (EMG) – nerve conduction

7. Nerve Conduction Studies (NCS)

8. Somatosensory Evoked Potentials (SSEPs)

9. Motor Evoked Potentials (MEPs)

10. Ultrasound – limited, for soft-tissue masses

11. Blood Tests – infection markers (ESR, CRP)

12. Bone Scan – for metastases or infection

13. Discography – provocative disc testing

14. CSF Analysis – if infection suspected

15. Facet Joint Blocks – diagnostic pain relief

16. Selective Nerve Root Blocks

17. Vertebral Artery Doppler – vascular assessment

18. CT-Guided Biopsy – tissue diagnosis

19. Positional MRI – weight-bearing changes

20. Functional Outcome Scores (e.g., Neck Disability Index)

---

Non-Pharmacological Treatments

1. Physical Therapy – posture and strengthening Physiopedia

2. Cervical Traction

3. Heat/Cold Therapy

4. TENS (Transcutaneous Electrical Nerve Stimulation)

5. Acupuncture

6. Chiropractic Adjustment (with caution)

7. Massage Therapy

8. Ergonomic Assessment

9. Postural Training

10. Flexion-Extension Exercises

11. Isometric Neck Exercises

12. Core Stabilization

13. Pilates for Neck Support

14. Yoga (Neck-friendly poses)

15. McKenzie Method

16. Alexander Technique

17. Mindfulness & Relaxation

18. Biofeedback

19. Aquatic Therapy

20. Prolotherapy

21. Laser Therapy

22. Ultrasound Therapy

23. Dry Needling

24. Cervical Collar (short-term)

25. Postural Bracing

26. Weight Management

27. Smoking Cessation

28. Ergonomic Pillow/Mattress

29. Nutritional Counseling

30. Education on Activity Modification

---

Drugs

1. NSAIDs (e.g., ibuprofen, naproxen)

2. Acetaminophen

3. Muscle Relaxants (e.g., cyclobenzaprine)

4. Oral Corticosteroids (short course)

5. Neuropathic Pain Agents (gabapentin, pregabalin)

6. Tricyclic Antidepressants (amitriptyline)

7. Selective Serotonin Reuptake Inhibitors (duloxetine)

8. Opioids (short-term, e.g., tramadol)

9. Epidural Steroid Injection

10. Facet Joint Injection

11. Selective Nerve Root Block

12. Botulinum Toxin (for spasm)

13. Calcitonin (for osteoporotic spurs)

14. Bisphosphonates (if bone-related)

15. Disease-Modifying Antirheumatic Drugs (for RA)

16. Antibiotics (for epidural abscess)

17. Antifungals (rare fungal infections)

18. Anticoagulants (if hematoma risk low)

19. Intrathecal Analgesics (ziconotide)

20. IVIG (for autoimmune causes)

---

Surgical Treatments

1. Anterior Cervical Discectomy & Fusion (ACDF) RadiopaediaRadiopaedia

2. Cervical Disc Arthroplasty (disc replacement)

3. Posterior Cervical Laminectomy

4. Laminoplasty

5. Foraminotomy (nerve root decompression)

6. Corpectomy (vertebral body removal)

7. Posterior Instrumentation & Fusion

8. Endoscopic Decompression

9. Microsurgical Resection (for tumors)

10. Epidural Abscess Drainage

---

Prevention Strategies

1. Maintain Good Posture

2. Regular Neck-Strengthening Exercises

3. Ergonomic Workstation Setup

4. Proper Lifting Techniques

5. Avoid Prolonged Neck Flexion

6. Stay Active & Fit

7. Quit Smoking (improves disc health)

8. Weight Control

9. Early Management of Neck Pain

10. Annual Spine Health Check-Ups

---

When to See a Doctor

• Persistent or Worsening Neck Pain: Despite 4–6 weeks of conservative care

• Neurological Signs: Numbness, tingling, or weakness in arms/hands

• Balance Issues or Gait Changes

• Loss of Bladder/Bowel Control (medical emergency)

• High Fever with Neck Pain (possible infection)

• Severe Trauma History

---

Frequently Asked Questions

1. What exactly is a thecal sac?
   It’s the dura mater sheath around the spinal cord holding CSF Wikipedia.

2. Can minimal indentation cause symptoms?
   Yes—some patients feel pain or tingling even with mild CSF effacement.

3. How is indentation diagnosed?
   MRI is the best test to see disc bulges indenting the thecal sac Radiopaedia.

4. Is surgery always needed?
   No—many cases improve with physical therapy and medications.

5. What risks come with surgery?
   Potential nerve injury, infection, or fusion-related stiffness.

6. Can I prevent this indentation?
   Good posture, regular exercise, and ergonomics help reduce risk.

7. How long is recovery after ACDF?
   Typically 6–12 weeks for fusion stability.

8. Will my neck be stiff after fusion?
   Some loss of motion at fused levels, but adjacent levels adapt.

9. Are there non-fusion surgical options?
   Yes—disc arthroplasty preserves motion in selected patients.

10. What if I have an epidural abscess?
    Urgent drainage plus antibiotics is required.

11. Is physical therapy safe with indentation?
    Yes—therapists tailor exercises to avoid exacerbating pressure.

12. Can you work with this condition?
    Many patients continue work after proper treatment.

13. Are injections helpful?
    Epidural steroids can relieve inflammation and pain temporarily.

14. When should I seek emergency care?
    If you have sudden weakness, loss of coordination, or bladder issues.

15. Does smoking affect my risk?
    Yes—smoking accelerates disc degeneration and impairs healing.

Indentation of the cervical thecal sac at C3–C4 is a multifactorial condition that can range from asymptomatic imaging findings to severe spinal cord impingement with neurological deficits. A clear understanding of anatomy, causes, symptoms, and evidence-based interventions—both conservative and surgical—empowers patients and clinicians to achieve optimal outcomes. Early recognition, appropriate imaging, and a tailored treatment plan ensure the best chance for pain relief, neurological recovery, and prevention of long-term disability.

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.

PDF Document For This Disease Conditions

References