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MRI of difficult discs. Clin Radiol 2023; 78:201-208. [PMID: 36535826 DOI: 10.1016/j.crad.2022.11.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Revised: 11/12/2022] [Accepted: 11/21/2022] [Indexed: 12/23/2022]
Abstract
Diagnosis of disc herniation is a daily task for radiologists. Although diagnosis is usually straightforward, it may become more difficult due to disc location. Disc herniations in the neural foramen or lateral to it can be overlooked if sagittal images are not obtained far enough laterally, and are often best seen on coronal images. Intradural disc herniations should be recognised preoperatively by their distinctive shape; recognition prepares the surgeon for the need to perform a durotomy and dural repair. Sequestered discs are often lentiform and inconspicuous on sagittal images. They can be missed if axial images are obtained only through the level of the intervertebral disc. Mimics of disc herniation must also be kept in mind when reviewing magnetic resonance imaging (MRI) studies: these include disc osteophyte complex, epidural haematoma, facet joint cyst, and tumours such as meningioma, nerve sheath tumours, and metastases.
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Theodorou DJ, Theodorou SJ, Gelalis ID, Kakitsubata Y. Lumbar Intervertebral Disc and Discovertebral Segment. Part 2: An Imaging Review of Pathologic Conditions With Anatomic Correlation. Cureus 2022; 14:e25733. [PMID: 35812589 PMCID: PMC9262421 DOI: 10.7759/cureus.25733] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/07/2022] [Indexed: 11/24/2022] Open
Abstract
The lumbar intervertebral disc is a complex anatomic structure that can be affected by a number of distinct pathologic processes. Categories of the disease include degenerative changes, subclinical or overt trauma, infectious lesions, inflammatory insults, metabolic disease, and tumors. Abnormalities affecting the intervertebral disc may assume atypical appearances or alterations may as well mimic pathologic processes related to degeneration that can be asymptomatic. Although the imaging findings of degenerative diseases of the vertebral column have been emphasized extensively, the assembly of pathologic conditions associated with the discovertebral segment has not received adequate attention. This manuscript reviews and illustrates a range of abnormalities affecting the discovertebral segment, providing a detailed analysis of postmortem material, in the realm of a close anatomic-imaging correlation. Knowledge of the characteristic morphology and patterns of abnormal conditions affecting the intervertebral disc and discovertebral segment can help radiologists narrow the differential diagnosis in a broad spectrum of disease processes.
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Palmisciano P, Balasubramanian K, Scalia G, Sagoo NS, Haider AS, Bin Alamer O, Chavda V, Chaurasia B, Deora H, Passanisi M, Da Ros V, Giammalva GR, Maugeri R, Iacopino DG, Cicero S, Aoun SG, Umana GE. Posterior epidural intervertebral disc migration and sequestration: A systematic review. J Clin Neurosci 2022; 98:115-126. [PMID: 35152147 DOI: 10.1016/j.jocn.2022.01.039] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2021] [Revised: 01/25/2022] [Accepted: 01/31/2022] [Indexed: 10/19/2022]
Abstract
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.
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Affiliation(s)
- Paolo Palmisciano
- Department of Neurosurgery, Trauma Center, Gamma Knife Center, Cannizzaro Hospital, Catania, Italy
| | | | - Gianluca Scalia
- Department of Neurosurgery, Highly Specialized Hospital and of National Importance "Garibaldi", Catania, Italy
| | - Navraj S Sagoo
- Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Ali S Haider
- Texas A&M University College of Medicine, Houston, TX, USA
| | - Othman Bin Alamer
- King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Vishal Chavda
- Division of Anaesthesia, Sardar Women's Hospital, Ahmedabad, Gujarat, India
| | - Bipin Chaurasia
- Department of Neurosurgery, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh
| | - Harsh Deora
- Department of Neurosurgery, National Institute of Mental Health and Neurosciences, Bangalore, Karnataka, India
| | - Maurizio Passanisi
- Department of Neurosurgery, Trauma Center, Gamma Knife Center, Cannizzaro Hospital, Catania, Italy
| | - Valerio Da Ros
- Department of Biomedicine and Prevention, University Hospital of Rome "Tor Vergata", Rome, Italy
| | - Giuseppe R Giammalva
- Unit of Neurosurgery, Department of Biomedical Neurosciences and Advanced Diagnostics, University of Palermo, Palermo, Italy
| | - Rosario Maugeri
- Unit of Neurosurgery, Department of Biomedical Neurosciences and Advanced Diagnostics, University of Palermo, Palermo, Italy
| | - Domenico G Iacopino
- Unit of Neurosurgery, Department of Biomedical Neurosciences and Advanced Diagnostics, University of Palermo, Palermo, Italy
| | - Salvatore Cicero
- Department of Neurosurgery, Trauma Center, Gamma Knife Center, Cannizzaro Hospital, Catania, Italy
| | - Salah G Aoun
- Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Giuseppe E Umana
- Department of Neurosurgery, Trauma Center, Gamma Knife Center, Cannizzaro Hospital, Catania, Italy.
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Konbaz F, Aleissa SI, Al Helal F, Abaalkhail M, Alrogy W, Bin Dohaim A, Albishi N. Sequestrated Lumbar Disc Herniation Mimicking Spinal Neoplasm. Cureus 2021; 13:e18529. [PMID: 34765331 PMCID: PMC8573969 DOI: 10.7759/cureus.18529] [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] [Accepted: 10/06/2021] [Indexed: 11/26/2022] Open
Abstract
Sequestered disc fragments do not have indistinctive features and often share the clinical and radiological presentation as spinal neoplasms making their diagnosis and treatment a clinical challenge. We report a rare case of sequestered lumbar disc fragment at the level of L2-L3 in a 70-year-old male who presented to the ER complaining of six years' history of low back pain with acute onset lower extremities weakness for six days, associated with right foot drop. He was admitted for tumor workup as the MRI showed diffuse bone high signal intensity throughout the spine with a soft tissue epidural mass at L2/3, causing severe compression on the cauda equina nerve roots. The patient underwent L2-L3 decompression and fixation, mass excision, multiple open biopsies. Soft tissue biopsy of the mass revealed fibrocartilaginous tissue consistent with the intervertebral disc, while the bone biopsy was diagnostic of acute leukemia. The patient was observed postoperatively with unremarkable complications. He did well with physiotherapy, and there was a remarkable improvement of his right lower extremity power reaching 4/5. Our case presented a rare phenomenon in which sequestered disc fragments manifested clinically and radiologically as a spinal neoplasm. Vigilant history taking and physical examination are paramount; a physician should be watchful for any red flags that may warrant further investigation such as in our case.
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Affiliation(s)
- Faisal Konbaz
- Department of Orthopaedic Surgery, King Abdulaziz Medical City, Ministry of National Guard Health Affairs, Riyadh, SAU
| | - Sami I Aleissa
- Department of Orthopaedic Surgery, King Abdulaziz Medical City, Ministry of National Guard Health Affairs, Riyadh, SAU
| | - Fahad Al Helal
- Department of Orthopaedic Surgery, King Abdulaziz Medical City, Ministry of National Guard Health Affairs, Riyadh, SAU
| | - Majed Abaalkhail
- Department of Orthopaedic Surgery, King Abdulaziz Medical City, Ministry of National Guard Health Affairs, Riyadh, SAU
| | - Waleed Alrogy
- Department of Orthopaedic Surgery, King Abdulaziz Medical City, Ministry of National Guard Health Affairs, Riyadh, SAU
| | - Abrar Bin Dohaim
- Department of Medicine, King Saud Bin Abdulaziz University for Health Sciences College of Medicine, Riyadh, SAU
| | - Nasser Albishi
- Department of Pathology, King Abdulaziz Medical City, Ministry of National Guard Health Affairs, Riyadh, SAU
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Kesornsak W, Wasinpongwanich K, Kuansongtham V. Posterior epidural sequestrated disc presenting with contralateral radiculopathy: a very rare case. Spinal Cord Ser Cases 2021; 7:98. [PMID: 34743186 DOI: 10.1038/s41394-021-00460-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Revised: 10/19/2021] [Accepted: 10/26/2021] [Indexed: 11/09/2022] Open
Abstract
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.
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Affiliation(s)
| | - Kanthika Wasinpongwanich
- Spine Institute, Bumrungrad International Hospital, Bangkok, Thailand. .,School of Orthopedics, Institute of Medicine, Suranaree University of Technology, Nakhon Ratchasima, Thailand.
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Chen J, Ni HJ, Xue F, Fan YS, Li XF, Chen XZ, He SS. Upper Lumbar Intradural Disc Herniation: A Rare Case Report and Etiologic Analysis. J Pain Res 2021; 14:1475-1481. [PMID: 34079362 PMCID: PMC8166278 DOI: 10.2147/jpr.s297304] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2021] [Accepted: 04/30/2021] [Indexed: 01/15/2023] Open
Abstract
Background Intradural disc herniation (IDH) is a rare type of disc degeneration that infrequently affects the upper lumbar spine. Pre- and intraoperative diagnosis and surgical management of IDH are challenging. The present case study provides insight into these aspects of upper lumbar IDH and discusses possible mechanisms. Case Description A 63-year-old female with a history of chronic lower back and leg pain presented with an acute lumbar sprain that had occurred 1 month prior. The pain progressed and spread to the front of the left thigh, which affected her ability to lift her leg when ascending/descending stairs. Sagittal gadolinium-enhanced magnetic resonance imaging (MRI) revealed a disc protruding into the ventral dural sac showing a hawk-beak sign, and the posterior edge of the disc annulus and local posterior longitudinal ligament was broken. Total L2 laminectomy was performed, and the dorsal side of the dural sac was exposed and incised to enable exploration of the ventral side of the dura. We found two free fragments protruding into the inner wall of the dura through the left ventral dura mater defect. After carefully and completely removing the mass, we repaired the defect and performed internal fixation. Postoperative pathologic analysis confirmed that the mass was nucleus pulposus tissue from the degenerated disc. The patient’s pain significantly improved after surgery, and she was able to walk normally at the 1-month follow-up. Conclusion Upper lumbar IDH is an extremely rare type of disc degeneration. An enhanced MRI scan can provide diagnostic evidence, but the final diagnosis requires surgical exploration of the path of herniation and pathologic examination of the mass lesion.
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Affiliation(s)
- Jia Chen
- Department of Orthopaedics, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, 200072, People's Republic of China.,Spinal Pain Research Institute, Tongji University School of Medicine, Shanghai, 200072, People's Republic of China
| | - Hai-Jian Ni
- Department of Orthopaedics, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, 200072, People's Republic of China.,Spinal Pain Research Institute, Tongji University School of Medicine, Shanghai, 200072, People's Republic of China
| | - Fei Xue
- Department of Neurosurgery, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, 200072, People's Republic of China
| | - Yun-Shan Fan
- Department of Orthopaedics, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, 200072, People's Republic of China.,Spinal Pain Research Institute, Tongji University School of Medicine, Shanghai, 200072, People's Republic of China
| | - Xi-Fan Li
- Department of Radiology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, 200072, People's Republic of China
| | - Xian-Zhen Chen
- Department of Neurosurgery, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, 200072, People's Republic of China
| | - Shi-Sheng He
- Department of Orthopaedics, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, 200072, People's Republic of China.,Spinal Pain Research Institute, Tongji University School of Medicine, Shanghai, 200072, People's Republic of China
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