Posterior epidural migration of herniated lumbar disc fragment: a literature review

Posterior migration of lumbar disc herniation: A case report

Posterior epidural migration of herniated lumbar disc fragments is a rare pathological entity. This can lead to major neurological deficits. Here, we present a rare case of sequestrated lumbar disc fragment migration into the epidural space. A 49-year-old-man presented with severe low back pain and weakness of the long extensor muscle of the hallux. MRI of the lumbar spine revealed posterior epidural lesion at the L4-L5 level. The disc fragment was isointense on T1 and T2-weighted Images (WI). The mass lesion was removed after decompressive laminectomy. Pathological investigation revealed an intervertebral disc fragment. The patient's condition improved postoperatively.

Case 310: Posterior Epidural Migration of a Lumbar Disk Herniation

HISTORY

A 49-year-old man presented with right foot drop, bilateral cruralgia mainly on the left side, and genital and perianal hypoesthesia, which started suddenly 12 days before. After onset of symptoms, the patient also experienced an accidental fall at home, resulting in a left fibular fracture, which was treated with reduction and with seven-hole plate Synthes Locking Compression Plate at the orthopedic clinic. The neurologic examination showed paresthesias on the posterior aspect of both thighs and crural regions that was worse on the left side, hypoesthesia in the L5 root region on the right side, and right foot drop. There was no urinary retention or fecal incontinence. The patient denied past surgery, back trauma, heavy manual labor, hypermobility, or any other remarkable medical history. The patient was afebrile. Laboratory results on the 1st day of hospitalization showed increased C-reactive protein level (0.62 mg/dL; reference range, 0.0-0.5 mg/dL), elevated erythrocyte sedimentation rate (60 mm/h; reference range, 0-20 mm/h), and increased aspartate transaminase (38 U/L [0.63 μkat/L]; reference range, 0-31 U/L [0-0.52 μkat/L]), alanine transaminase (70 U/L [1.17 μkat/L]; reference range, 0-31 U/L [0-0.52 μkat/L]), and high lymphocyte (4.55 × 103/mL; reference range, [1.0-3.0] ×103/mL), and neutrophil (8.79 × 103/mL; reference range, [2.0-7.0] × 103/mL) levels. Absence of coagulopathy was demonstrated by normal coagulation values (international normalized ratio, 1.19; reference value, 0.80-1.25; activated partial thromboplastin time ratio, 0.88 second; reference range, 0.79-1.27 seconds). Electroneurography showed marked hypoevocable F response in the right tibia. Electromyography indicated severe reduction of muscle recruitment pertaining to right L4, L5, and S1 nerve territory and, to a lesser extent, of muscles pertaining to L3 territory bilaterally in the absence of spontaneous denervation. Unenhanced CT and contrast-enhanced MRI of the lumbosacral spine were performed.

Endplate role in the degenerative disc disease: A brief review

The degenerative disease of the intervertebral disc is nowadays an important health problem, which has still not been understood and solved adequately. The vertebral endplate is regarded as one of the vital elements in the structure of the intervertebral disc. Its constituent cells, the chondrocytes in the endplate, may also be involved in the process of the intervertebral disc degeneration and their role is central both under physiological and pathological conditions. They main functions include a role in homeostasis of the extracellular environment of the intervertebral disc, metabolic support and nutrition of the discal nucleus and annulus beneath and the preservation of the extracellular matrix. Therefore, it is understandable that the cells in the endplate have been in the centre of research from several viewpoints, such as development, degeneration and growth, reparation and remodelling, as well as treatment strategies. In this article, we briefly review the importance of vertebral endplate, which are often overlooked, in the intervertebral disc degeneration.

Posterior and anterior epidural and intradural migration of the sequestered intervertebral disc: Three cases and review of the literature

Context: Dorsal migration of the sequestered lumbar intervertebral disc is an unusual and underrecognized pattern of lumbar disc herniation associated with pain and neurological deficit.Findings: Three patients presented with lower limb- and low back pain. MR imaging showed intracanalicular mass lesions with compression of the spinal cord and allowed precise localization of lesions in the extradural or intradural space. Diagnosis was straightforward for the patients with the posterior and anterior epidural disc fragments, whereas various differential diagnostic considerations were entertained for the patient with the intradural mass lesion. All patients underwent surgical removal of the sequestered disc fragments, and recovered full motosensory function. Surgical repair of the dura mater due to CSF leak was required for the patient with intradural disc herniation.Conclusion/clinical relevance: Posterior and anterior epidural, and intradural disc migration may manifest with clinical symptoms indistinguishable from those associated with non-sequestered lumbar disc hernias. Missed, migrated disc fragments can be implicated as a cause of low back pain, radiculopathy or cauda equina syndrome, especially in the absence of visible disc herniation. A high index of suspicion needs to be maintained in those cases with unexplained and persistent symptoms and/or no obvious disc herniation on MR images.

Posterior epidural intervertebral disc migration and sequestration: A systematic review

Posterior epidural intervertebral disc migration and sequestration (PEIMS) is a rare and debilitating complication of degenerative disc disease. Radiological differential diagnosis is often challenging, complicating the accurate planning of appropriate treatment strategies. We systematically reviewed the literature on PEIMS, focusing on clinical-radiological features and available treatments. PubMed, Scopus, Web of Science, and Cochrane were searched to include studies reporting clinical data of patients with PEIMS. Clinical characteristics, treatment strategies, and functional outcomes were analyzed. We included 82 studies comprising 157 patients. Median age was 54 years (range, 19-91). PEIMSs occurred spontaneously (49.7%) or acutely in patients with underlying progressive degenerative disc disease (50.3%). The most common symptoms were lower-back pain (77.1%) and radiculopathy (66.2%), mainly involving the L5 nerve root (43.8%). PEIMSs were mostly detected at MRI (93%) and/or CT (7%), frequently located in the lumbar spine (81.5%). Median maximum PEIMS diameter was 2.4 cm (range, 1.2-5.0). Surgical debulking was completed in 150 patients (95.5%), sometimes coupled with decompressive laminectomy (65%) or hemilaminectomy (19.1%). Median follow-up time was 3 months (range, 0.5-36.0). Post-treatment symptomatic improvement was reported in 153 patients (97.5%), with total recovery in 118 (75.2%). All 7 patients (4.5%) who received conservative non-surgical management had total clinical recovery at ≤ 3 months follow-ups. PEIMS is a challenging entity that may severely quality-of-life in patients with degenerative disc disease. Surgical removal represents the gold standard to improve patient's functional status. Spine fusion and conservative strategies proved to be effective in some cases.

Posterior epidural migration of lumbar disc fragment: Case reports and literature review

INTRODUCTION

Posterior epidural migration of lumbar disc fragment (PEMLDF) is a very rare condition that may lead to a serious neurological deficit such as cauda equina syndrome. Magnetic resonance imaging (MRI) findings can often result in cases of PEMLDF being misdiagnosed as extradural masses of other origin or epidural hematomas. In this study, we reported four additional cases of PEMLDF and reviewed the relevant literature.

PATIENT CONCERNS

We present four patients with PEMLDF. The mean age of the patients was 53.5 years. Two patients suffered from cauda equine syndrome, and the other two patients complained of radiculopathy.

DIAGNOSIS

The MRI findings in each case showed masses with slightly high signal intensity in T2-weighted images, as well as heterogenous and peripheral rim enhancement after contrast enhancement. In some patients there was a tract-like enhancement extending from the outer aspect of the disc to the posterolateral epidural space. A definitive diagnosis was made intraoperatively.

INTERVENTIONS

We performed laminectomy and discectomy in all patients.

OUTCOMES

The PEMLDF patients with radiculopathy had no complaints of weakness or pain after surgery. Both patients with cauda equine syndrome showed a total recovery post-surgery.

CONCLUSIONS

Early diagnosis and treatment via laminectomy and discectomy is critical to achieving the best postoperative outcomes. Understanding the patient's history, recognizing the similar signal intensity of the mass and intervertebral disc on MRI scans, and looking for peripheral rim enhancement, are the keys to the correct diagnosis of PEMLDF.

Posterior epidural sequestrated disc presenting with contralateral radiculopathy: a very rare case

INTRODUCTION

Posterior epidural sequestrated disc is a fairly uncommon condition. We report a case of an unusual presentation of posterior epidural migration with contralateral symptoms. We emphasize a high index of suspicion for early recognition and treatment to promote a good neurological recovery.

CASE PRESENTATION

A 58-year-old man with a history of severe back pain for 1 week developed sudden right leg weakness while walking. Neurological examination revealed motor and sensory impairments of the right lower extremities (positive right straight leg raising test, right tibialis anterior grade 2/5, right extensor hallucis longus grade 1/5, decreased pinprick sensation of L4-5 dermatome right side) according to the Standards for Neurological Classification of Spinal Cord Injury as Asia Impairment Scale D. Magnetic resonance images showed an acute disc herniation at L4-5 on the left side, cranially migrated and sequestrated to the posterior epidural area, causing severe compression to the cauda equina in the thecal sac. The patient was successfully treated with surgery (transforaminal lumbar interbody fusion) on an urgent basis. We saw significant neurological recovery on the first day after surgery. Motor power recovery was achieved with a minor deficit at 4 weeks. At the follow-up examination at 3 months, the patient had no residual neurological deficits as Asia Impairment Scale E.

DISCUSSION

Posterior epidural sequestrated disc with contralateral radiculopathy is very rare. This case brings a new presentation of posterior epidural sequestrated disc. To our knowledge, this is the first report of a case with an unusual presentation of contralateral radiculopathy.

Case of anterolateral migration of herniated cervical disc fragment mimicking a spinal meningioma

Background:

Before the introduction of high-resolution MR, few disc fragments were misdiagnosed as meningiomas.

Case Description:

A 63-year-old female presented with a 6-month history of mild to moderate pain in the left arm, weakness 4/5 in the left arm C5-C6 distribution, and a loss of the left biceps reflex response. Although the MR study was read as showing a C5-C6 level probable spinal meningioma, this proved to be a sequestrated disc fragment at surgery.

Conclusion:

Rarely, cervical disc herniations may be misdiagnosed on MR studies as spinal meningiomas.

Hyperacute onset of adjacent segment disease with dorsally migrated herniated nucleus pulposus causing cauda equina syndrome: a case report

PURPOSE

To report the first case of hyperacute onset of adjacent segmental disease (ASD) with dorsally migrated herniated nucleus pulposus (HNP) causing cauda equina syndrome.

METHODS

A 55-year-old female complained of lower back pain with radiating pain in both lower extremities that had not responded to conservative treatment over the previous six months. Plain radiographs and magnetic resonance imaging (MRI) findings revealed degenerative spondylolisthesis with spinal stenosis at L3-4, L4-5, and a slight bulging disc at L2-3. The patient underwent decompressive total laminectomy and posterior fusion at L3-4 and L4-5. The stenotic symptoms improved significantly after surgery, and she was then discharged on postoperative day 7.

RESULTS

However, the patient visited the emergency department four days after discharge (postoperative day 11) complaining of sudden onset of bilateral lower extremity weakness and voiding and defecation difficulties. The follow-up MRI showed dorsally migrated huge HNP and a detached posterior longitudinal ligament (PLL) at L2-3, which was diagnosed as hyperacute onset of ASD causing cauda equina syndrome. The patient underwent an emergency second operation consisting of partial laminectomy at L2-3 with removal of the dorsally migrated huge HNP. After the second operation, the symptoms of cauda equina syndrome improved. One year after the second operation, the patient is doing well without recurrence of symptoms.

CONCLUSIONS

Our case showed that hyperacute onset of ASD with dorsally migrated huge HNP can cause cauda equina syndrome, even within 2 weeks after lumbar fusion surgery. Therefore, a high index of suspicion, timely diagnosis, and surgical treatment are needed to avoid the catastrophic neurologic complications in similar extremely rare cases.