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Jesse CM, Gallus M, Beck J, Ulrich CT, Seidel K, Piechowiak E, Dobrocky T, Häni L, Schär RT, Raabe A. Idiopathic Ventral Spinal Cord Hernia-A Single-Center Case Series of 11 Patients. Oper Neurosurg (Hagerstown) 2023; 24:268-275. [PMID: 36701551 PMCID: PMC9904192 DOI: 10.1227/ons.0000000000000507] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2022] [Accepted: 09/07/2022] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND Idiopathic spinal cord herniations (ISCH) are rare defects of the ventromedial or mediolateral dura mater with herniation of the spinal cord through the defect with approximately 350 described cases worldwide. Patients usually become symptomatic with motor or sensory neurological deficits and gait disturbances. OBJECTIVE To describe characteristic symptoms and clinical findings and to evaluate the postoperative course and outcomes of ISCH. METHODS We present a single-center data analysis of a case series of 11 consecutive patients who were diagnosed with ISCH and underwent surgery in our department between 2009 and 2021. RESULTS All herniations were located in the thoracic spine between T2 and T9. In most cases, gait ataxia and dysesthesia led to further workup and subsequently to the diagnosis of ISCH. A "far-enough" posterior-lateral surgical approach, hemilaminectomy or laminectomy with a transdural approach, was performed under intraoperative neurophysiological monitoring which was followed by adhesiolysis, repositioning of the spinal cord and sealing using a dura patch. After surgery, clinical symptoms improved in 9 of 11 patients (81.8%), while only 1 patient experienced deterioration of symptoms (9.1%) and 1 patient remained equal (9.1%). The median preoperative McCormick grade was 3 (±0.70), while the median postoperative grade was 2 (±0.98) ( P = .0047). CONCLUSION In our case series of ISCH, we found that in most patients, neurological deficits improved postoperatively. This indicates that surgery in ISCH should not be delayed in symptomatic patients.
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Affiliation(s)
- Christopher Marvin Jesse
- Department of Neurosurgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Marco Gallus
- Department of Neurosurgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Department of Neurosurgery, University Hospital Muenster, Münster, Germany
| | - Jürgen Beck
- Department of Neurosurgery, Medical Center—University of Freiburg, Freiburg, Germany;
| | | | - Kathleen Seidel
- Department of Neurosurgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Eike Piechowiak
- Institute of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Tomas Dobrocky
- Institute of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Levin Häni
- Department of Neurosurgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Ralph T. Schär
- Department of Neurosurgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Andreas Raabe
- Department of Neurosurgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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Idiopathic spinal cord herniation at the cervicothoracic junction level presenting with unilateral sensory symptoms. Clin Neurol Neurosurg 2022; 224:107526. [PMID: 36442311 DOI: 10.1016/j.clineuro.2022.107526] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Revised: 11/11/2022] [Accepted: 11/13/2022] [Indexed: 11/16/2022]
Abstract
Idiopathic spinal cord herniation (ISCH) most commonly occurs through a ventral dural defect at the midthoracic levels with a predilection to affect middle-aged females. It can have various presentations, the most common of which are Brown-Séquard syndrome and spastic paraparesis. Due to its rarity in clinical practice, the diagnosis of ISCH can be challenging to physicians unfamiliar with this entity. We report an exceedingly rare case of ISCH at the C7-T1 intervertebral disc level in a 44-year-old male presenting with eight months of isolated unilateral sensory symptoms. The diagnosis was made based on the findings on the patient's magnetic resonance imaging of the spinal cord, including the presence of an extradural cerebrospinal fluid collection. Surgical reduction of the herniated segment and patching of the dural defect resulted in a remarkable clinical improvement beginning in the immediate postoperative period. Follow-up MRIs showed no sign of reherniation, and the patient remained asymptomatic after one year of follow-up. Early diagnosis and surgical intervention led to an excellent early outcome in this case. However, long-term follow-up is necessary to monitor for reherniation and relapse of the symptoms in ISCH patients.
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Buntting CS, Ham Y, Teng KX, Dimou J, Gauden AJ, Nair G. Scalpel sign: Dorsal thoracic arachnoid web, thoracic arachnoid cyst and ventral cord herniation. Radiol Case Rep 2022; 17:3564-3569. [PMID: 35923346 PMCID: PMC9340144 DOI: 10.1016/j.radcr.2022.06.100] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2022] [Revised: 06/26/2022] [Accepted: 06/29/2022] [Indexed: 12/01/2022] Open
Abstract
The “Scalpel sign” is a radiological sign which can be identified on magnetic resonance imaging and indicates dorsal compression of the spinal cord [1]. Prior descriptions of a “Scalpel sign” have been reported in the literature and the awareness and identification of this pathognomonic sign may aid in the rapid diagnosis and treatment of patients with dorsal arachnoid web, dorsal arachnoid cyst or ventral cord herniation. We describe 3 cases which highlight these rare conditions for which this sign is pathognomonic and summarize the pertinent literature related to these disorders [1,2].
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Affiliation(s)
| | - Yeji Ham
- Royal Melbourne Hospital, 300 Grattan Street, Parkville, 3050, Victoria, Australia
| | - Ken X Teng
- Royal Melbourne Hospital, 300 Grattan Street, Parkville, 3050, Victoria, Australia
| | - James Dimou
- Royal Melbourne Hospital, 300 Grattan Street, Parkville, 3050, Victoria, Australia
| | - Andrew J Gauden
- Royal Melbourne Hospital, 300 Grattan Street, Parkville, 3050, Victoria, Australia
| | - Girish Nair
- Royal Melbourne Hospital, 300 Grattan Street, Parkville, 3050, Victoria, Australia
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Yang C, Lin G, Zhang J, Yang J, Xie J. Case Report: Idiopathic Spinal Cord Herniation: An Overlooked and Frequently Misdiagnosed Entity. Front Surg 2022; 9:905038. [PMID: 35711698 PMCID: PMC9195413 DOI: 10.3389/fsurg.2022.905038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2022] [Accepted: 05/05/2022] [Indexed: 11/29/2022] Open
Abstract
Background Idiopathic spinal cord herniation is an extremely rare entity that is characterized by protrusion of the spinal cord through a defect in the ventral dura. Due to the paucity of enough clinical evidence, the treatment and prognosis of idiopathic spinal cord herniation are still elusive. Herein, we reported a case of idiopathic spinal cord herniation occurring at the C7–T1 levels that was treated by surgical reduction. Case description A 44-year-old Chinese woman presented with a 5-year history of numbness and weakness in the bilateral lower limbs. Spinal magnetic resonance imaging demonstrated ventral displacement of the spinal cord at the C7–T1 levels, and there seemed to be a cuneiform space-occupying lesion dorsal to the spinal cord. A diagnosis of the spinal intradural extramedullary tumor was suspected. An exploratory operation was performed via a posterior midline approach. Intraoperatively, we found a defect in the ventral dura through which the spinal cord herniated to the epidural space. After the herniated parenchyma was returned, an artificial dura matter was used to repair the defect. The postoperative course was uneventful. After a 3-month follow-up, the lower-extremity weakness was significantly improved, and there was no recurrence of the spinal cord herniation. Conclusion Preoperative diagnosis of idiopathic spinal cord herniation is exceedingly challenging. Surgical reduction of the herniated spinal cord with the repair of the dural defect is an effective approach for the treatment of this rare disorder, and the surgical outcome is favorable.
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Wilson TA, Kumar RPP, Omosor E. Thoracic ventral spinal cord herniation with progressive myelopathy - A case report and review of the literature. Surg Neurol Int 2021; 12:382. [PMID: 34513149 PMCID: PMC8422540 DOI: 10.25259/sni_496_2021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Accepted: 06/30/2021] [Indexed: 11/04/2022] Open
Abstract
Background Idiopathic spinal cord herniation (ISCH) is a rare, underrecognized, and often misdiagnosed entity of unclear pathogenesis that typically presents as a slowly progressive thoracic myelopathy. There are less than 200 such cases reported in the literature. ISCH diagnosis and treatment are often delayed contributing to greater fixed neurological deficits, often leading to costly, unnecessary imaging studies, and inappropriate surgery. Case Description Here, a 48-year-old female presented with trauma-induced ISCH characterized by gradually worsening lower extremity myelopathy. Conclusion Idiopathic spinal cord herniation (ISCH) is rare, often underdiagnosed posttraumatic myelopathy that, when accurately diagnosed and treated, can result in good outcomes.
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Affiliation(s)
- Taylor Anne Wilson
- Department of Neurosurgery, Loma Linda University Medical Center, Loma Linda, California, United States
| | | | - Emmanuel Omosor
- Department of Neurosurgery, School of Medicine, Loma Linda University School of Medicine, Loma Linda, California, United States
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Jensen M, Zygourakis C. Commentary: Transdural Spinal Cord Herniation: An Exceptional Complication of Thoracoscopic Discectomy: 2-Dimensional Operative Video. Oper Neurosurg (Hagerstown) 2021; 21:E49-E50. [PMID: 33825873 DOI: 10.1093/ons/opab083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Accepted: 01/31/2021] [Indexed: 11/14/2022] Open
Affiliation(s)
- Michael Jensen
- Department of Neurosurgery, Stanford University, Stanford, California, USA
| | - Corinna Zygourakis
- Department of Neurosurgery, Stanford University, Stanford, California, USA
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Bhatia K, Madhavan A, Coutinho C, Mathur S. Idiopathic spinal cord herniation. Clin Radiol 2020; 75:721-729. [PMID: 32499121 DOI: 10.1016/j.crad.2020.04.013] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2019] [Accepted: 04/28/2020] [Indexed: 11/28/2022]
Abstract
Idiopathic spinal cord herniation is a rare but important and increasingly recognised cause of myelopathy seen in the thoracic spine. The factors that contribute to the aetiology of the condition and of the dural defect through which the cord herniates remain under debate. We discuss the clinical features and proposed pathophysiology of the condition, and illustrate key imaging findings on MRI, fluoroscopy and computed tomography (CT) myelography to establish the diagnosis, and discuss relevant differential diagnoses. Awareness and recognition of the condition is key as surgical intervention can improve outcomes for patients.
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Affiliation(s)
- K Bhatia
- Department of Neuroradiology, Lancashire Teaching Hospitals NHS Trust, Sharoe Green Lane, Preston, PR2 9HT, UK.
| | - A Madhavan
- Department of Neuroradiology, Lancashire Teaching Hospitals NHS Trust, Sharoe Green Lane, Preston, PR2 9HT, UK
| | - C Coutinho
- Department of Neuroradiology, Lancashire Teaching Hospitals NHS Trust, Sharoe Green Lane, Preston, PR2 9HT, UK
| | - S Mathur
- Department of Neuroradiology, Lancashire Teaching Hospitals NHS Trust, Sharoe Green Lane, Preston, PR2 9HT, UK.
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Iunes EA, Barletta EA, Suzuki FS, Barba Belsuzarri TA, de Araújo Paz D, Veiga de Castro Sparapani F, Onishi FJ, Cavalheiro S, Salati T, de Meldau Benites V, Riechelmann G, Joaquim AF. Idiopathic Ventral Spinal Cord Herniation: Video Report and Systematic Review. World Neurosurg 2020; 139:592-602. [PMID: 32376383 DOI: 10.1016/j.wneu.2020.04.190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2020] [Revised: 04/23/2020] [Accepted: 04/24/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Idiopathic ventral spinal cord herniation (ISCH) is a rare disease; however, it is an important differential diagnosis. Its treatment presents some controversies. CASE DESCRIPTION We report on a 55-year-old woman who had been presenting with relevant back pain and leg weakness for the past 3 years and urinary incontinence for the past 3 months. Clinical examination disclosed paresis on the right inferior limb and right foot, as well as a T6-level painful hypoesthesia. Magnetic resonance imaging disclosed a T4/T5 ISCH. The patient underwent surgical decompression. During the procedure, we opened the arachnoid and cut the dentate ligaments of the spine, which considerably improved the mobility and safety of the procedure. In the early follow-up, our patient presented a partial improvement regarding the paresis grades and hypoesthesia pain relief on the left side. A video showing the surgical procedure and case evolution is presented. We also assembled literature reviews to compare our case with others. ISCH is becoming a more recognized cause of progressive thoracic myelopathy. However, this condition is still frequently misdiagnosed. Magnetic resonance imaging is the key for diagnosis. The objective of surgical treatment is to prevent myelopathy progression. The technique presented in this report is an appropriate surgical option, once it is a safer way to identify and treat the defect. The neurologic condition usually improves greatly after surgical treatment, especially when the patient presents positive predictive factors. CONCLUSIONS ISCH is being more recognized. The technique presented is an appropriate surgical option.
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Affiliation(s)
- Eduardo Augusto Iunes
- Federal University of São Paulo, Medical School, Neurosurgery Department, São Paulo, Brazil
| | - Enrico Affonso Barletta
- Medical School, Post Graduation Program, Pontifical Catholic University of Campinas, São Paulo, Brazil.
| | - Fernando Seiji Suzuki
- Federal University of São Paulo, Medical School, Neurosurgery Department, São Paulo, Brazil
| | - Telmo Augusto Barba Belsuzarri
- Neurosurgery Department, Medical School, Post Graduation Program, Pontifical Catholic University of Campinas, São Paulo, Brazil
| | - Daniel de Araújo Paz
- Federal University of São Paulo, Medical School, Neurosurgery Department, São Paulo, Brazil
| | | | - Franz Jooji Onishi
- Federal University of São Paulo, Medical School, Neurosurgery Department, São Paulo, Brazil
| | - Sergio Cavalheiro
- Federal University of São Paulo, Medical School, Neurosurgery Department, São Paulo, Brazil
| | - Thiago Salati
- Federal University of São Paulo, Medical School, Neurosurgery Department, São Paulo, Brazil
| | | | - Guilherme Riechelmann
- Federal University of São Paulo, Medical School, Neurosurgery Department, São Paulo, Brazil
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