Novel Strategy of Ventral Dural Repair for Idiopathic Thoracic Spinal Cord Herniation: Report of Outcomes and Review of Techniques

Unveiling the Current Understanding of Idiopathic Spinal Cord Herniation: A Systematic Review

Background

Idiopathic spinal cord herniation (ISCH) is a rare condition that is characterized by ventral herniation of the spinal cord through a defect in the dura mater into the epidural space, with no identifiable cause. ISCH is frequently underdiagnosed, and the information available in case reports is limited. To provide an overview of the clinical manifestations and diagnosis of this condition, this study aims to conduct a review of reported cases of ISCH.

Methods

A literature review was carried out using seven databases. The search was conducted using the keywords "Idiopathic spinal cord herniation" OR "Idiopathic Ventral Spinal Cord Herniation" AND "Case report" OR "case series."

Results

A total of 92 relevant papers reporting 224 cases, besides the index case, were determined. Of the cases, 58.5% were females and the mean age was 50.7 (SD 13.2) years. Symptoms, diagnoses, and outcomes were similar between genders. The most common clinical signs included motor symptoms (82.6%), instability (61.3%), hypoesthesia (59.2%), and disturbance of thermal sensitivity (47.3%). Brown-Séquard syndrome was observed in 27.2% of the cases, and surgical treatment was employed in 89.7% of the cases.

Conclusions

ISCH is a pathology that is principally treated with surgical approach. This study provides valuable insights into the clinical manifestations and diagnosis of ISCH, which can aid in the early recognition and treatment of this rare condition.

Idiopathic Ventral Spinal Cord Hernia-A Single-Center Case Series of 11 Patients

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.

A unique case of pure lateral spinal cord herniation

BACKGROUND

Spinal cord herniation (SCH) remains a challenging diagnosis for neuroradiologists and may require treatment challenging for neurosurgeons. Most cord herniations are usually found at anterior thoracic levels.

CLINICAL PRESENTATION

A 28-year-old woman presented at our department with a 7-year history of progressive myelopathy. MR analysis showed a displacement of the spinal cord in a lateral thoracic dural defect. The herniated cord was released using a microscope and the patient significantly recovered 6 months after surgery.

CONCLUSION

We present a unique case of pure lateral SCH. In the light of reviewed literature and operative findings, the underlying pathophysiological mechanisms are discussed.

Single-centre study comparing surgically and conservatively treated patients with spinal cord herniation and review of the literature

Introduction

Spinal cord herniation (SCH) is a rare cause of progressive myelopathy and Brown-Séquard-Syndrome.

Research question

Evaluation of functional outcome after SCH treatment compared to conservatively treated patients.

Material and methods

We retrospectively analysed functional outcome in SCH patients treated between 2009 and 2020. We conducted a systematic search using PubMed, MEDLINE and EMBASE to perform a pooled analysis in SCH patients.

Results

Our hospital cohort included 17 patients of which 9 were treated surgically. Mean age was 51.9 years, 58.8% of the patients were female. In 4/9 patients (44.4%) the neurological state remained stable after surgery. Four patients improved (44.4%) and one deteriorated after surgery (11.1%). Conservatively treated patients had a higher deterioration rate on follow-up with 3/8 patients deteriorating (37.5%). In our pooled analysis, 109/145 (75.2%) of patients improved, 32/145 (22.1%) remained stable and 4/145 patients deteriorated (2.8%). Among the available data of nine cohorts, mean recovery rate measured by the JOA score was 36.6% (SD 14.4). In our pooled multivariable model lower preoperative JOA score was associated with worse functional outcome (OR 0.86, 95%CI 0.74–0.99, p ​= ​.04).

Discussion and conclusion

Our data shows that patients who are treated surgically have a higher improvement rate and acceptable perioperative morbidity compared to conservatively treated patients. Lower preoperative JOA score decreases chances of improved functional outcome on follow-up. We therefore advocate early surgery for symptomatic patients. Wait and see appears outdated due to progressive impairment and decreased chances of recovery. However, it is still an option in asymptomatic incidental SCH patients.

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Evaluation of 17 patients with myelon herniation, 9 undergoing surgical treatment, 8 choosing conservative treatment.

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In the surgically treated group, 44.4% improved after surgery compared to none in the conservative group.

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11.1% deteriorated in the surgically treated compared to 37.5% in the conservatively treated group.

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Surgically treated patients have a higher improvement rate.

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Lower preoperative JOA score is associated with less improvement advocating early surgery in symptomatic patients.

Intradural extraarachnoid sutureless technique combined with laminoplasty for indirect repair of ventral dural defects in spontaneous intracranial hypotension: technical note and case series

BACKGROUND

There is a significant variance in surgical treatment strategies of ventral cerebrospinal fluid (CSF) leaks causing spontaneous intracranial hypotension (SIH). Posterior approaches might represent a preferable alternative to the more invasive anterior and lateral routes, as long as the spinal cord is not exposed to harmful manipulation. The aim of this technical note is to report and illustrate a new surgical technique using an intradural extraarachnoid sutureless technique via laminoplasty for indirect repair of ventral CSF leaks causing intractable SIH symptoms.

METHODS

The surgical technique is described in a step by step fashion. Between May 2018 and May 2020, five patients with ventral spinal CSF leaks were operated on, utilizing this technique. All dural defects were located at the level of the thoracic spine. A retrospective review on demographic and radiological findings, symptoms, outcome, and follow-up was performed.

RESULTS

The intra- and postoperative course was uneventful in all patients with no surgery-related complications. Three patients recovered completely at discharge, while neurological symptoms significantly improved in two patients. A postoperative MRI of the spine was obtained for all patients, demonstrating regressive signs of CSF leak.

CONCLUSION

Based on the presented case series, this intradural extraarachnoid sutureless technique combined with laminoplasty seems to be a safe and effective option for indirect repair of ventral dural defects in SIH. In our opinion, it represents a valid alternative to traditional more aggressive approaches.

Late-Onset Post-Traumatic Spinal Cord Herniation as a Rare and Overlooked Cause of Late Neurologic Deterioration After Penetrating Injury to the Thoracic Spine: A Case Report and Review of the Literature

BACKGROUND AND CASE DESCRIPTION

We report a case of an 18-year-old patient who presented with late progressive deterioration of neurologic condition 8 weeks after a penetrating injury to the back. Investigations revealed a dorsally located post-traumatic spinal cord herniation. Urgent exploration, decompression, and repair were performed. We reviewed the literature and found only 19 similar cases previously reported. Pathophysiology and presentations were variable and even poorly understood.

CONCLUSIONS

Late-onset post-traumatic spinal cord herniation is a potentially curable cause of neurologic deterioration after spinal trauma and should be considered in all cases with late neurologic deterioration after spinal trauma.