Ventral dural nociception as a pain generator in thoracic disc herniation: a case report with anatomical correlation

Dear Editor, Thoracic disc herniation (TDH) may present with isolated axial pain without neurological deficits, making diagnosis and mechanistic attribution challenging. Although discogenic and radicular mechanisms are commonly considered, accumulating neuroanatomical evidence suggests that the spinal dura mater itself may function as a pain-sensitive structure. We report a case of TDH in which clinical features, imaging findings, and immediate postoperative response strongly suggest ventral dural nociception as the primary pain generator. TDH accounts for less than 1% of all disc herniations and often presents with nonspecific symptoms. When neurological deficits are absent, isolated axial thoracic pain is frequently attributed to musculoskeletal or discogenic causes, leading to diagnostic uncertainty. Cyriax originally proposed the concept of “dural pain,” postulating that localized mechanical stress on the spinal dura could produce deep midline spinal pain.1 However, this concept has historically been overshadowed by disc-centric and radicular theories. Modern neuroanatomical studies have revived interest in the dura mater as a pain-sensitive structure. Groen and colleagues demonstrated abundant sensory fibers within the spinal dura.2 Yamada et al. showed that dorsal root ganglion (DRG)–derived sensory afferents, including substance P– and CGRP-positive nociceptive fibers, innervate both the dura mater and the posterior longitudinal ligament (PLL).3,4 These findings support a segmental organization of dural sensory innervation and challenge earlier misconceptions of dominant longitudinal sympathetic convergence.