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Rairan LG, Henriquez A, Diaz G, Mejía JA, Gomez D, Ramon JF, Hakim EJ. Unveiling the Current Understanding of Idiopathic Spinal Cord Herniation: A Systematic Review. Spine Surg Relat Res 2024; 8:225-234. [PMID: 38868787 PMCID: PMC11165495 DOI: 10.22603/ssrr.2023-0102] [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: 05/11/2023] [Accepted: 08/07/2023] [Indexed: 06/14/2024] Open
Abstract
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.
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Affiliation(s)
- Luis Garcia Rairan
- Department of Neurosurgery, Universidad Nacional de Colombia, Bogotà, Colombia
| | | | - Gustavo Diaz
- Faculty of Medicine, Universidad El Bosque, Bogotá, Colombia
| | | | - Diego Gomez
- Department of Neurosurgery, Fundación Santa Fe, Bogotá, Colombia
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Ifthekar S, Shin S, Lee S, Bae J. Idiopathic spinal cord herniation with postoperative paraplegia-A case report. Clin Case Rep 2023; 11:e8246. [PMID: 38111513 PMCID: PMC10726001 DOI: 10.1002/ccr3.8246] [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: 09/24/2023] [Revised: 10/30/2023] [Accepted: 11/06/2023] [Indexed: 12/20/2023] Open
Abstract
Key clinical message Spinal cord herniation is an uncommon diagnosis. There should be a high index of suspicion to diagnose spinal cord herniation when a patient presents with incomplete neurological deficits. Surgical repair of the hernia can have postoperative complications with new neurological deficits and they should be considered during the treatment. Abstract A 37-year-old male presented with insidious onset upper back pain and altered sensations of pain and temperature over the right half of the body below the nipple for 2 months. MRI of the thoracic spine showed an anterolateral defect (left) at the level of T2-T3 vertebra. The defect was covered by a dural graft and the wound was closed with a drain On the 3rd postoperative day, neurological weakness progressed to paraplegia. Patient was treated by exploration and decompression of the hematoma. The deficits were completely recovered at one-month follow-up. Patients with spinal cord herniation and neurologic deficits when treated timely have good outcomes.
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Affiliation(s)
- Syed Ifthekar
- All Indian Institute of Medical SciencesHyderabadTelanganaIndia
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Kaida M, Hirata H, Noda H, Kishikawa Y, Yoshihara T, Kobayashi T, Tsukamoto M, Mawatari M, Morimoto T. Early detection of idiopathic thoracic ventral spinal cord herniation by using imaging: A case report. Clin Case Rep 2023; 11:e8112. [PMID: 37953892 PMCID: PMC10636536 DOI: 10.1002/ccr3.8112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Revised: 10/10/2023] [Accepted: 10/11/2023] [Indexed: 11/14/2023] Open
Abstract
In middle-aged and older populations, clinicians often suspect lumbar spine disease when the gait is disturbed with lumbar lower extremity numbness, but spinal herniation at the thoracic level may be causal. Early detection, appropriate treatment, and minimization of complications requires understanding of characteristic magnetic resonance imaging findings of herniation.
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Affiliation(s)
- Mana Kaida
- Faculty of MedicineSaga UniversitySagaJapan
| | - Hirohito Hirata
- Department of Orthopedic Surgery, Faculty of MedicineSaga UniversitySagaJapan
| | | | | | - Tomohito Yoshihara
- Department of Orthopedic Surgery, Faculty of MedicineSaga UniversitySagaJapan
| | - Takaomi Kobayashi
- Department of Orthopedic Surgery, Faculty of MedicineSaga UniversitySagaJapan
| | - Masatsugu Tsukamoto
- Department of Orthopedic Surgery, Faculty of MedicineSaga UniversitySagaJapan
| | - Masaaki Mawatari
- Department of Orthopedic Surgery, Faculty of MedicineSaga UniversitySagaJapan
| | - Tadatsugu Morimoto
- Department of Orthopedic Surgery, Faculty of MedicineSaga UniversitySagaJapan
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Hunziker S, Örgel A, Tatagiba M, Adib SD. Case report: A vertebral bone spur as an etiology for spinal cord herniation: case presentation, surgical technique, and review of the literature. Front Surg 2023; 10:1238448. [PMID: 37614664 PMCID: PMC10442939 DOI: 10.3389/fsurg.2023.1238448] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2023] [Accepted: 07/24/2023] [Indexed: 08/25/2023] Open
Abstract
Objective The pathophysiology of idiopathic spinal cord herniation remains unknown. However, several different factors have been postulated, such as congenital causes (ventral dura mater duplication, preexisting pseudomeningocele, or other congenital dural defects), inflammation, remote spinal trauma, or thoracic disc herniation. Herein, the diagnosis and surgical treatment of a patient with spinal cord herniation caused by an intraspinal bone spur is presented along with a relevant literature review. Case presentation A 56-year-old male patient presented with a non-traumatic Brown-Sequard syndrome persisting for over 1 year. A magnetic resonance imaging of the spinal axis revealed a ventral spinal cord displacement in the level of T 6/7. A supplementary thin-sliced computed tomography of the spine revealed a bone spur at the same level. For neurosurgical intervention, T 6 and T 7 laminectomy was performed. The cranial and caudal end of the right paramedian ventral dural defect was visualized and enlarged. Following extradural spinal cord mobilization by denticulate ligament transection, the spinal cord was finally released. The spinal cord was rotated and the ventral closure of the dural defect was performed by continuous suture. The patient recovered from surgery without additional deficits. The patient's postoperative gait, sensory, and motor function deficits improved, and further neurological deterioration was prevented. Conclusion Since the first description of spinal cord herniation by Wortzman et al. in 1974, approximately 260 cases have been reported in the literature. In addition to other causes, intraspinal bone spur is a possible cause of spinal cord herniation.
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Affiliation(s)
- S. Hunziker
- Department of Neurosurgery, University of Tuebingen, Tübingen, Germany
| | - A. Örgel
- Department of Diagnostic and Interventional Neuroradiology, University of Tuebingen, Tübingen, Germany
| | - M. Tatagiba
- Department of Neurosurgery, University of Tuebingen, Tübingen, Germany
| | - S. D. Adib
- Department of Neurosurgery, University of Tuebingen, Tübingen, Germany
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Hirose Y, Nagoshi N, Tsuji O, Kono H, Iida T, Suzuki S, Takahashi Y, Nori S, Yagi M, Matsumoto M, Nakamura M, Watanabe K. Natural history and surgical outcomes of idiopathic spinal cord herniation. Spinal Cord 2023; 61:441-446. [PMID: 37380759 DOI: 10.1038/s41393-023-00904-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2022] [Revised: 06/19/2023] [Accepted: 06/20/2023] [Indexed: 06/30/2023]
Abstract
STUDY DESIGN Retrospective multicenter study. OBJECTIVES Although surgery is frequently selected for the treatment of idiopathic spinal cord herniation (ISCH), its impact on functional outcomes has yet to be fully understood given the limited number of patients in previous studies. This study aims to evaluate the symptomatic history and surgical outcomes of ISCH. SETTING Three institutions in Japan. METHODS A total of 34 subjects with ISCH were retrospectively enrolled and followed up for at least 2 years. Demographic information, imaging findings, and clinical outcomes were collected. Functional status was assessed using the JOA score. RESULTS The types of neurologic deficit were monoparesis, Brown-Sequard, and paraparesis in 5, 17, and 12 cases, with their mean disease duration being 1.2, 4.2, and 5.8 years, respectively. Significant differences in disease duration were observed between the monoparesis and Brown-Sequard groups (p < 0.01) and between the monoparesis and paraparesis groups (p = 0.04). Surgery promoted significantly better recovery rates from baseline. Correlations were observed between age at surgery and recovery rate (p < 0.01) and between disease duration and recovery rate (p = 0.04). The mean recovery rates were 82.6%, 51.6%, and 29.1% in the monoparesis, Brown-Sequard, and paraparesis groups, respectively. The monoparesis group had a significantly higher recovery rate than did the Brown-Sequard (p = 0.045) and paraparesis groups (p < 0.01). CONCLUSIONS Longer disease duration was correlated with the progression of neurologic deficit. Older age, and worse preoperative neurologic status hindered postoperative functional recovery. These results highlight the need to consider surgical timing before neurologic symptoms deteriorate.
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Affiliation(s)
- Yuichiro Hirose
- Department of Orthopaedic Surgery, Hino Municipal Hospital, 4-3-1 Tamadaira, Hino-shi, Tokyo, 191-0062, Japan
| | - Narihito Nagoshi
- Department of Orthopaedic Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan.
| | - Osahiko Tsuji
- Department of Orthopaedic Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan
| | - Hitoshi Kono
- Department of Orthopaedic Surgery, Keiyu Orthopedic Hospital, 2267-1 Akodacho, Tatebayashi-shi, Gunma, 374-0013, Japan
| | - Tsuyoshi Iida
- Department of Orthopaedic Surgery, Kitasato Institute Hospital, Department of Orthopaedic Surgery, 5-9-1 Shirokane, Minato-ku, Tokyo, 108-8642, Japan
| | - Satoshi Suzuki
- Department of Orthopaedic Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan
| | - Yohei Takahashi
- Department of Orthopaedic Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan
| | - Satoshi Nori
- Department of Orthopaedic Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan
| | - Mitsuru Yagi
- Department of Orthopaedic Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan
| | - Morio Matsumoto
- Department of Orthopaedic Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan
| | - Masaya Nakamura
- Department of Orthopaedic Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan
| | - Kota Watanabe
- Department of Orthopaedic Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan
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Sarigul B, Ogrenci A, Dalbayrak S. Surgical management of idiopathic thoracal ventral spinal cord herniation: a case report. EGYPTIAN JOURNAL OF NEUROSURGERY 2023. [DOI: 10.1186/s41984-023-00187-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/21/2023] Open
Abstract
Abstract
Introduction
Idiopathic spinal cord herniation is a rare entity that is characterized by the displacement of the spinal cord through a defect in the dural layer and presents with symptoms of myelopathy. Surgical management usually results in good outcomes.
Case presentation
A 58-year-old female patient presented with weakness of both legs since four months. Her neurological examination showed paraplegia in the lower extremities, and ventral herniation was detected in the T9 vertebral level. The patient underwent surgery. Left T9 hemilaminectomy was followed by the reduction in the herniated spinal cord into its physiological location and the covering the anteriorly located dural defect via circumferentially covering the dural surface of the corresponding vertebral level. Postoperatively, the patient’s neurological status improved gradually and radiological scans showed a total reduction in the herniation.
Conclusion
Despite the rarity of the pathology, spinal cord herniation should be included in the differential diagnosis of the patients presenting with myelopathy or Brown–Séquard syndrome.
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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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Mehta SH, Shah KA, Werner CD, White TG, Lo SFL. Ventral Spinal Cord Herniation Causing Spinal Intradural Hematoma and Subarachnoid Hemorrhage: A Case Report. Cureus 2022; 14:e28349. [PMID: 36168337 PMCID: PMC9506680 DOI: 10.7759/cureus.28349] [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: 08/24/2022] [Indexed: 11/23/2022] Open
Abstract
Ventral spinal cord herniation is a rare pathology, caused by a dural defect, that leads to progressive myelopathy. The true prevalence of ventral spinal cord herniation is unknown largely because of underdiagnosis due to its nonspecific symptoms. Though there are theories that attempt to describe how these dural defects are formed, the true causes of these defects are unknown. In this case report, we present a case of a 29-year-old female who had an idiopathic ventral spinal cord herniation causing an intradural hematoma and subarachnoid hemorrhage. This is the first reported case of spinal cord herniation causing hemorrhage.
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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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Gader G, Badri M, Rkhami M, Zammel I. Transdural spinal cord herniation: A rare cause of neurologic impairment: Report of two cases and review of the literature. Int J Surg Case Rep 2022; 93:106951. [PMID: 35313186 PMCID: PMC8935513 DOI: 10.1016/j.ijscr.2022.106951] [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: 01/11/2022] [Revised: 03/12/2022] [Accepted: 03/13/2022] [Indexed: 11/28/2022] Open
Abstract
Introduction Herniation of the thoracic spinal cord is a rare pathology related to the genesis of a breach in the anterior dura. Adding to the previously published cases, we report our department's experience with 2 cases of young adults who presented with transdural spinal cord herniation following spinal trauma. Presentation of the cases We report the cases of 2 men aged 27 and 57, with history of spinal trauma, who presented diverse clinical complaints (motor impairment, genito-sphincteric disorders, etc.). Spinal cord MRI showed an anterior displacement of the spinal cord. Both patients were operated. Peroperative findings and radiological features were concordant with transdural spinal cord herniation. Discussion Spinal cord herniation is a rare condition which is usually related to a misdiagnosed spinal trauma. Pathogenesis is still being debated. This condition may lead to a myelopathy potentially responsible for severe neurologic impairment, mainly presenting as a Brown-Sequard syndrome. Diagnosis is based on clinical and radiologic features on MRI. Surgical treatment is proposed when neurological signs are found. Long-term clinical and radiological monitoring is necessary for paucisymptomatic, non-operated patients. Conclusions Based on the described cases, we tried to review the main clinical, radiological and therapeutic features related to this condition. Herniation of the thoracic spinal cord is due to a breach in the anterior dura of an uncertain pathogenesis Transdural spinal cord herniation is a little known cause for myelopathy potentially responsible for severe neurologic impairment Main clinical features are related to a Brown-Sequard syndrome In symptomatic cases, surgical treatment may stabilize or even improve neurologic impairment
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Affiliation(s)
- Ghassen Gader
- Faculty of medicine of Tunis, University Tunis-El Manar, Department of Neurosurgery, Trauma and Burns Center, Ben Arous, Tunisia.
| | - Mohamed Badri
- Faculty of medicine of Tunis, University Tunis-El Manar, Department of Neurosurgery, Trauma and Burns Center, Ben Arous, Tunisia
| | - Mouna Rkhami
- Faculty of medicine of Tunis, University Tunis-El Manar, Department of Neurosurgery, Trauma and Burns Center, Ben Arous, Tunisia
| | - Ihsèn Zammel
- Faculty of medicine of Tunis, University Tunis-El Manar, Department of Neurosurgery, Trauma and Burns Center, Ben Arous, Tunisia
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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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Idiopathic dorsal spinal cord herniation perforating the lamina: a case report and review of the literature. Acta Neurochir (Wien) 2021; 163:2313-2318. [PMID: 33745029 DOI: 10.1007/s00701-021-04804-4] [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: 09/21/2020] [Accepted: 03/10/2021] [Indexed: 10/21/2022]
Abstract
Spinal cord herniation (SCH) is a rare condition associated with tethering of the spinal cord at the ventral dural defect. Idiopathic dorsal spinal cord herniation (IDSCH) is an extremely rare clinical entity. Here, we report the first case of IDSCH perforating the lamina in a patient with a history of ossification of the ligamentum flavum and diffuse idiopathic skeletal hyperostosis. Untethering of the spinal cord was performed by removing the surrounded ossified dura. Although urological symptoms and impaired proprioception remained, progressive neurological deterioration was prevented. Because this disease condition is extremely rare, it should be differentiated from ventral SCH.
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Menon D, Nair SS, Thomas B, Krishna Kumar K, Nair M. Clinico-radiological correlation and surgical outcome of idiopathic spinal cord herniation: A single centre retrospective case series. J Spinal Cord Med 2021; 44:437-441. [PMID: 30870118 PMCID: PMC8081328 DOI: 10.1080/10790268.2019.1579986] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
Abstract
Context: Idiopathic spinal cord herniation (ISCH) remains an obscure, under recognised but potentially treatable entity among the etiologies of compressive myelopathy.Findings: Here, we present a retrospective case series of eight patients of ISCH with their clinical features, imaging findings and long-term follow up data along with a relevant review of the literature. Mean age at presentation was 36 years with the duration of symptoms ranging from two months to more than thirty years. Contrary to existing data, only two patients in our series had the classical presentation of Brown-Sequard syndrome (n = 2). The clinical spectrum of the presentation was broad with pure spastic quadriparesis (n = 3), girdle sensation (n = 1) and radiculopathy (n = 1), the latter presentation has been unreported for ISCH. The typical radiological picture was seen in all patients. All except one patient was managed conservatively. In the one patient who underwent bilateral dentate ligament excision, there was mild functional improvement on long-term follow-up despite a definite worsening of the radiological picture. Five of the patients had a long-term follow-up with no clinically or functionally significant worsening.Clinical relevance: The current study highlights the wide clinical spectrum and relatively stable natural course of ISCH and reports on hitherto undescribed presentation as radiculopathy.
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Affiliation(s)
- Deepak Menon
- Department of Neurology, SCTIMST, Trivandrum, India,Correspondence to: Deepak Menon, Department of Neurology, SCTIMST, Trivandrum, KL695011, India.
| | | | - Bejoy Thomas
- Department of Imaging Sciences and Interventional Radiology, SCTIMST, Trivandrum, India
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Runza G, Maffei E, Cademartiri F. Idiopathic herniation of the thoracic spinal cord. ACTA BIO-MEDICA : ATENEI PARMENSIS 2021; 92:e2021143. [PMID: 33944828 PMCID: PMC8142771 DOI: 10.23750/abm.v92is1.9947] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Accepted: 06/03/2020] [Indexed: 11/23/2022]
Abstract
Since 1974, when Wortzman et al were the first to describe a case of idiopathic spinal cord herniation (ISCH), the number of reported cases has increased owing to magnetic resonance imaging (MRI) now is routinely available for patients with myelopathy and spinal surgeons are becoming more familiar with this clinical entity. This extremely rare herniation occurs exclusively in the thoracic spine, causing slowly progressive myelopathy. Diagnosis is based on ventral displacement of the spinal cord in the thoracic spine. MRI is the technique of choice to exclude a posterior arachnoid cyst, the most common mistaken diagnosis, and to recognize a spinal cord herniation when an anterior dural defect is present. A case of ISCH is reported and a Literature review of this clinical entity often mis-diagnosed has been obtained.
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Affiliation(s)
| | - Erica Maffei
- Department of Radiology, Area Vasta 1, ASUR Marche.
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15
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Idiopathic ventral thoracic spinal cord herniation – A case report and literature review. INTERDISCIPLINARY NEUROSURGERY 2021. [DOI: 10.1016/j.inat.2020.101000] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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Vanden Bulcke D, Baussart B, Auliac S, Boulin A, Gaillard S. A unique case of pure lateral spinal cord herniation. Neurochirurgie 2021; 67:624-627. [PMID: 33450267 DOI: 10.1016/j.neuchi.2020.12.006] [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: 09/12/2020] [Revised: 12/05/2020] [Accepted: 12/22/2020] [Indexed: 11/29/2022]
Abstract
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.
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Affiliation(s)
- D Vanden Bulcke
- Department of neurosurgery, Foch hospital, 40, rue Worth, 92150 Suresnes, France; Department of neurosurgery, cliniques universitaires Saint-Luc, avenue Hippocrate 10, 1200 Brussels, Belgium.
| | - B Baussart
- Department of neurosurgery, Foch hospital, 40, rue Worth, 92150 Suresnes, France.
| | - S Auliac
- Department of neuroradiology, Foch hospital, 40, rue Worth, 92150 Suresnes, France.
| | - A Boulin
- Department of neuroradiology, Foch hospital, 40, rue Worth, 92150 Suresnes, France.
| | - S Gaillard
- Department of neurosurgery, Foch hospital, 40, rue Worth, 92150 Suresnes, France.
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Hostettler IC, Butenschoen VM, Meyer B, Krieg SM, Wostrack M. Single-centre study comparing surgically and conservatively treated patients with spinal cord herniation and review of the literature. BRAIN AND SPINE 2021; 1:100305. [PMID: 36247388 PMCID: PMC9560695 DOI: 10.1016/j.bas.2021.100305] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/31/2021] [Revised: 10/09/2021] [Accepted: 10/17/2021] [Indexed: 11/21/2022]
Abstract
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. Evaluation of 17 patients with myelon herniation, 9 undergoing surgical treatment, 8 choosing conservative treatment. In the surgically treated group, 44.4% improved after surgery compared to none in the conservative group. 11.1% deteriorated in the surgically treated compared to 37.5% in the conservatively treated group. Surgically treated patients have a higher improvement rate. Lower preoperative JOA score is associated with less improvement advocating early surgery in symptomatic patients.
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Affiliation(s)
- Isabel C. Hostettler
- Department of Neurosurgery, Klinikum rechts der Isar, School of Medicine, Technical University Munich, Munich, Germany
- Department of Neurosurgery, Cantonal Hospital St. Gallen, Switzerland
- Corresponding author. Klinikum rechts der Isar, Department of Neurosurgery, Technical University Munich, Ismaninger Str. 22, 81675, Munich, Germany.
| | - Vicki M. Butenschoen
- Department of Neurosurgery, Klinikum rechts der Isar, School of Medicine, Technical University Munich, Munich, Germany
| | - Bernhard Meyer
- Department of Neurosurgery, Klinikum rechts der Isar, School of Medicine, Technical University Munich, Munich, Germany
| | - Sandro M. Krieg
- Department of Neurosurgery, Klinikum rechts der Isar, School of Medicine, Technical University Munich, Munich, Germany
| | - Maria Wostrack
- Department of Neurosurgery, Klinikum rechts der Isar, School of Medicine, Technical University Munich, Munich, Germany
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Herring EZ, Shin JH, Nagel SJ, Krishnaney AA. Novel Strategy of Ventral Dural Repair for Idiopathic Thoracic Spinal Cord Herniation: Report of Outcomes and Review of Techniques. Oper Neurosurg (Hagerstown) 2020; 17:21-31. [PMID: 30517700 DOI: 10.1093/ons/opy244] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2017] [Accepted: 07/28/2018] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Idiopathic ventral thoracic spinal cord herniation is a rare condition that usually presents with progressive myelopathy or Brown-Séquard syndrome. More than 100 cases have been reported with significant variance in surgical treatment strategies and likewise, significant variance in patient outcomes. Although laminectomy has often been used, to date, there is no consensus regarding the optimal surgical approach or strategy for ventral dural repair. OBJECTIVE To report and illustrate a novel approach to repair the ventral dural defect with more than 2 yr of clinical follow-up. The specific approach and graft used are both detailed. METHODS A retrospective chart review of all known cases of idiopathic spinal cord herniation at the Cleveland Clinic over the last 15 yr was performed. Postoperative outcome scores (including the Japanese Orthopedic Association score, European Myelopathy score, and Nurick) were calculated preoperatively and postoperatively. RESULTS A total of 5 patients were identified. Four of five patients improved clinically after surgery and 1 patient remained unchanged at last follow-up (average 23.2 mo, range 12-60 mo). There were no complications. All patients had postoperative magnetic resonance imaging demonstrating realignment of the spinal cord and no recurrence of tethering. CONCLUSION A unilateral dorsolateral, transpedicular approach combined with laminectomy provides excellent exposure for ventral or ventrolateral dural defects associated with idiopathic spinal cord herniation and minimizes spinal cord manipulation. A collagen matrix graft used as an onlay between the spinal cord and ventral dural defect is a safe and effective option for ventral dural repair.
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Affiliation(s)
- Eric Z Herring
- Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - John H Shin
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Sean J Nagel
- Department of Neurosurgery, Cleveland Clinic, Cleveland, Ohio
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Regensburger M, Schlachetzki JCM, Klekamp J, Doerfler A, Winkler J. Long-term course of anterior spinal cord herniation presenting with an upper motor neuron syndrome: case report illustrating diagnostic and therapeutic implications. BMC Neurol 2020; 20:321. [PMID: 32861240 PMCID: PMC7455782 DOI: 10.1186/s12883-020-01891-1] [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: 05/07/2020] [Accepted: 08/16/2020] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Anterior spinal cord herniation (aSCH) is a rare cause of myelopathy which may present as pure motor syndrome and mimic other degenerative diseases of the spinal cord. In slowly progressive cases, diagnosis may be impeded by equivocal imaging results and mistaken for evolving upper motor neuron disease. As early imaging studies are lacking, we aimed to provide a detailed description of imaging and neurophysiology findings in a patient with aSCH, focusing on the early symptomatic stages. CASE PRESENTATION We here present the case of a 51-year old male patient with an episode of pain in the right trunk and a normal spinal MRI. After a symptom-free interval of 8 years, spasticity and paresis evolved in the right leg. There was subtle ventral displacement and posterior indentation of the thoracic spinal cord on MRI which, in retrospect, was missed as an early sign of aSCH. After another 3 years, symptoms spread to the left leg and a sensory deficit of the trunk became evident. Follow-up MRI now clearly showed an aSCH. Neurosurgical intervention consisted of remobilization of the herniated spinal cord and patch closure of the dura defect. Over the following years, motor and sensory symptoms partially improved. CONCLUSIONS The history of this patient with aSCH illustrates the importance of careful longitudinal clinical follow-up with repeated imaging studies in progressive upper motor neuron syndromes. Specific attention should be paid to a history of truncal pain and to MRI findings of a ventrally displaced spinal cord. Neurosurgical intervention may halt the progression of herniation.
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Affiliation(s)
- Martin Regensburger
- Department of Molecular Neurology, University Hospital Erlangen, Schwabachanlage 6, 91054, Erlangen, Germany. .,Center for Rare Diseases Erlangen (ZSEER), University Hospital Erlangen, Erlangen, Germany. .,Department of Stem Cell Biology, University Hospital Erlangen, Erlangen, Germany.
| | - Johannes C M Schlachetzki
- Department of Molecular Neurology, University Hospital Erlangen, Schwabachanlage 6, 91054, Erlangen, Germany
| | - Jörg Klekamp
- Department of Neurosurgery, Christliches Krankenhaus, Quakenbrück, Germany
| | - Arnd Doerfler
- Department of Neuroradiology, University Hospital Erlangen, Erlangen, Germany
| | - Jürgen Winkler
- Department of Molecular Neurology, University Hospital Erlangen, Schwabachanlage 6, 91054, Erlangen, Germany
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Randhawa PS, Roark C, Case D, Seinfeld J. Idiopathic Spinal Cord Herniation Associated With a Thoracic Disc Herniation: Case Report, Surgical Video, and Literature Review. Clin Spine Surg 2020; 33:222-229. [PMID: 32101990 PMCID: PMC7337104 DOI: 10.1097/bsd.0000000000000896] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2018] [Accepted: 04/19/2019] [Indexed: 11/26/2022]
Abstract
PURPOSE The aim of this publication is to present a case of idiopathic spinal cord herniation (ISCH) associated with a transdural disk herniation, demonstrate an operative technique used to treat this condition and provide an updated review the literature. BACKGROUND CONTEXT ISCH is an infrequent condition that can cause progressive myelopathy leading to severe neurological dysfunction. This condition is characterized by ventral displacement of the spinal cord across a defect in the dura, either congenital or acquired, resulting in vascular compromise and adhesion that subsequently causes injury to the spinal cord. We present the management of such a patient, in addition to a review of the literature regarding management of ISCH. METHODS This patient underwent surgery using the dural graft sling technique for repair of the dural defect and restoration of normal spinal cord position within the thecal sac. A review of the literature revealed a total of 171 patients supplemented by our 1 patient, which were then analyzed. RESULTS The majority of patients, treated with a variety of surgical techniques, experienced improvements in symptomatology. Our patient experienced significant improvement in symptomatology. CONCLUSIONS Although ISCH is a rare clinical condition that causes myelopathy, patients managed with surgery generally, though not universally, have a favorable neurological outcome. The associated surgical technique video demonstrates the dural sling technique for the treatment of this rare disorder.
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Affiliation(s)
- Pal S Randhawa
- CU Department of Neurosurgery, University of Colorado, Aurora, CO
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21
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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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Sharma P, Soin P, Elbanan M, Kochar PS. Understanding Idiopathic Spinal Cord Herniation - A Comprehensive Review of Imaging and Literature. J Clin Imaging Sci 2019; 9:22. [PMID: 31448173 PMCID: PMC6702865 DOI: 10.25259/jcis-25-2019] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2019] [Accepted: 03/19/2019] [Indexed: 11/29/2022] Open
Abstract
Idiopathic spinal cord herniation (ISCH) is displacement of spinal cord through a dural or arachnoidal defect. Most patients present with back pain or myelopathy, paresthesia, and sensory or motor weakness. Imaging findings include anterior displacement of the cord with possible kink, no filling defect on CT myelography, and no restricted diffusion/mass lesion on magnetic resonance imaging. Abrupt kink in the spinal cord or widened cerebrospinal fluid (CSF) space can be caused by a variety of reasons. The differential considerations include arachnoid web, intradural extramedullary epidermoid or arachnoid cyst, abscess or cystic schwannoma. We discuss the features, imaging, differentials, and treatment of ISCH as a rare cause of such kink in the cord. While reading such cases, a radiologist should include the location, segments involved, cord signal abnormality, visible defect, scalpel sign or C–sign, ventral cord kink, nuclear trail sign, the ventral CSF space preservation, or obliteration and the type.
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Affiliation(s)
- Pranav Sharma
- Department of Radiology, Yale New Haven Health Bridgeport Hospital, Bridgeport, Connecticut, USA
| | - Priti Soin
- Department of Pathology and Laboratory Medicine, Weill Cornell College of Medicine, New York, USA
| | - Mohamed Elbanan
- Department of Radiology, Yale New Haven Health Bridgeport Hospital, Bridgeport, Connecticut, USA
| | - Puneet Singh Kochar
- Department of Radiology, Yale New Haven Health Bridgeport Hospital, Bridgeport, Connecticut, USA
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Gomez-Amarillo D, Garcia-Baena C, Volcinschi-Moros D, Hakim F. Thoracic idiopathic spinal cord herniation in a young patient: a diagnostic and therapeutic challenge. BMJ Case Rep 2019; 12:12/5/e227847. [PMID: 31118170 DOI: 10.1136/bcr-2018-227847] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Idiopathic Spinal Cord Herniation (ISCH) is considered to be a rare cause of Thoracic Myelopathy. It is secondary to the gliding of the Spinal Cord through an anterior dural defect, without a completely defined cause. We present a case of ISCH which, even though was in its usual location, developed in a woman at a younger age than expected. The patient was 20 years old when diagnosed with Brown-Séquard Syndrome. MRI showed herniation at T4-T5 level, which was corrected using a posterior approach to expose the dural defect, reduce the herniation and place a heterologous graft. Postoperatively, neurological function improved, and adequate reduction was seen on imaging. Given the reports of recurrence and deterioration that have been seen after 18 months, follow-up was prolonged for a total of 2 years. We consider postoperative MRI performance important to establish the degree of reduction and alignment of the Spinal Cord.
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Affiliation(s)
- D Gomez-Amarillo
- Department of Surgery, Neurosurgery Section, Hospital Universitario Fundacion Santa Fe de Bogota, Bogota, Colombia
| | - C Garcia-Baena
- Department of Surgery, Neurosurgery Section, Hospital Universitario Fundacion Santa Fe de Bogota, Bogota, Colombia
| | - D Volcinschi-Moros
- Department of Surgery, Neurosurgery Section, Hospital Universitario Fundacion Santa Fe de Bogota, Bogota, Colombia
| | - F Hakim
- Department of Surgery, Neurosurgery Section, Hospital Universitario Fundacion Santa Fe de Bogota, Bogota, Colombia
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Factors Affecting the Severity of Neurological Disorders in Thoracic Idiopathic Spinal Cord Herniation. Spine (Phila Pa 1976) 2018; 43:1552-1558. [PMID: 30383724 DOI: 10.1097/brs.0000000000002574] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective multicenter case-controlled study. OBJECTIVE The objective of this study was to quantitatively examine imaging findings of idiopathic spinal cord herniation (ISCH) and determine the relationship between the image findings and the severity of pre- and postoperative neurological symptoms. SUMMARY OF BACKGROUND DATA Many radiographic types of ISCH have been identified with regard to the location of the hernial opening or amount of herniated spinal cord. However, few previous studies have investigated the relationship between radiographic findings and the severity of neurological symptoms. METHODS Of 30,469 patients who underwent spinal surgery at 7 hospitals, 18 patients who underwent surgery for ISCH were identified. Their preoperative neurological severity, disease duration, magnetic resonance imaging findings, computed tomography myelography findings, surgical findings, and postoperative improvements were retrospectively examined. The spinal cord kink angle and minimum cord occupancy rate within the dural tube were measured. In addition, herniation was classified according to the location of the hiatus as either central (type C) or lateral (type L) type. RESULTS A negative correlation was found between the spinal cord kink angle and the minimum cord occupancy rate. Patient age was significantly higher in the severe paralysis group than in the mild paralysis group. In addition, the number of patients with type C herniation and the kink angle were significantly higher in the severe paralysis group. The number of patients with type L herniation was higher in the significant recovery group than in the mild recovery group; however, the difference was not significant. CONCLUSION Patients with a large spinal cord kink angle had a smaller spinal cord occupancy rate within the dural tube, and this resulted in severe preoperative conditions. Type C ISCH cases had a severe preoperative neurological deficit and poor postoperative neurological recovery, and the spinal cord in such cases might be damaged irreversibly. LEVEL OF EVIDENCE 4.
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Operative Management of Idiopathic Spinal Cord Herniation: Case Series and Novel Technique for Repair of Recurrent Herniation. Oper Neurosurg (Hagerstown) 2018; 16:415-423. [DOI: 10.1093/ons/opy129] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2017] [Accepted: 04/24/2018] [Indexed: 11/14/2022] Open
Abstract
Abstract
BACKGROUND
Idiopathic spinal cord herniation (ISCH) is a rare pathology of the spine defined by herniation of the spinal cord through a dural defect.
OBJECTIVE
To highlight the operative management of ISCH and the surgical nuances of ISCH repairs conducted at our institution.
METHODS
This retrospective review examines consecutive patients with ISCH who were treated surgically between January 1, 2010, and July 31, 2017, at Barrow Neurological Institute, Phoenix, Arizona.
RESULTS
Four patients with ISCH presented with thoracic myelopathy and lower extremity weakness during the study period. Treatment consisted of reduction of the herniated spinal cord and filling of the dural defect with a collagen-based dural regeneration matrix. In 3 patients the dural edges were covered with a collagen-matrix intradural sling, and in 1 patient they were repaired primarily with interrupted sutures. Three of the 4 patients experienced improvement in myelopathic symptoms; the fourth patient suffered neurological decline in the immediate postoperative period.
CONCLUSION
ISCH is a complex pathological condition likely to result in progressive myelopathy. Surgery offers patients the possibility of stabilizing the progression of the spinal cord dysfunction and perhaps restoring neurological function. However, extreme care must be taken during surgery to minimize manipulation of the fragile herniated cord.
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Pathophysiology and Grading of the Ventral Displacement of Dorsal Spinal Cord Spectrum. Asian Spine J 2018; 12:224-231. [PMID: 29713402 PMCID: PMC5913012 DOI: 10.4184/asj.2018.12.2.224] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2017] [Revised: 06/10/2017] [Accepted: 06/12/2017] [Indexed: 02/06/2023] Open
Abstract
Study Design A retrospective study of the ventral displacement of dorsal spinal cord (VDDSC) spectrum pathophysiology and grading. Purpose This study aimed at examining the pathophysiology of VDDSC between D3 and D7, using magnetic resonance imaging (MRI) correlation and severity grading. Overview of Literature The pathologies that lead to VDDSC were previously discussed in various articles. We attempted to group these pathological conditions under a single spectrum, and grade them according to their severity. Methods We reviewed the MRI images of the dorsal spines of 1,350 patients over a period of 4 years (February 2013–February 2017); all MRI images were analyzed by two experienced radiologists. Results Of the 1,350 patients, 28 exhibited VDDSC between D3 and D7. Additional findings included ventral transdural herniation of the spinal cord (n=10), anterior spinal cord adhesion (n=7), arachnoid web (n=6), and arachnoid cyst (n=5). Conclusions We grouped the pathologies that lead to VDDSC at the thoracic level into a single spectrum of varying severity and graded VDDSC, from mild to severe.
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Idiopathic thoracic spinal cord herniation. J Clin Neurosci 2018; 51:1-5. [DOI: 10.1016/j.jocn.2017.10.090] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2017] [Accepted: 10/23/2017] [Indexed: 11/23/2022]
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Bartels RHMA, Kusters B, Brunner H, Hosman AJF, van Alfen N, Grotenhuis JA. Pathogenesis of Idiopathic Ventral Herniation of Spinal Cord: Neuropathologic Analysis. World Neurosurg 2018. [PMID: 29530682 DOI: 10.1016/j.wneu.2018.02.187] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Idiopathic ventral herniation of the spinal cord is rarely seen as a cause of gradually increasing neurologic deficit. Its cause has never been clarified. It could be the result of a developmental disorder at 30- to 60-day gestational age. Neuropathologic analysis of herniated spinal cord tissue could probably support this hypothesis. CASE DESCRIPTION In a patient suffering from idiopathic ventral herniation of the spinal cord, a biopsy was performed in order to reduce the space-occupying effect. The biopsy was taken while intraoperative neuromonitoring was used. The patient recovered uneventfully without any additional deficit. Tissue analysis included histopathologic, immunohistochemical, and molecular examination (methylation profiling). The tissue did not appear as a normally functioning spinal cord; instead, a non-neoplastic glio-(neuronal) proliferation was found. CONCLUSION These findings support a developmental disorder as a cause for idiopathic ventral spinal cord herniation.
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Affiliation(s)
- Ronald H M A Bartels
- Department of Neurosurgery, Radboud University Medical Center, Nijmegen, The Netherlands.
| | - Benno Kusters
- Department of Pathological Anatomy, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Han Brunner
- Department of Human Genetics, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Allard J F Hosman
- Department of Orthopedic Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Nens van Alfen
- Department of Neurology and Clinical Neurophysiology, Donders Center for Neuroscience, Radboud University Medical Center, Nijmegen, The Netherlands
| | - J André Grotenhuis
- Department of Neurosurgery, Radboud University Medical Center, Nijmegen, The Netherlands
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Ulrich CT, Fung C, Piechowiak E, Gralla J, Raabe A, Beck J. Disc herniation, occult on preoperative imaging but visualized microsurgically, as the cause of idiopathic thoracic spinal cord herniation. Acta Neurochir (Wien) 2018; 160:467-470. [PMID: 29350292 DOI: 10.1007/s00701-018-3466-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2017] [Accepted: 01/08/2018] [Indexed: 10/18/2022]
Abstract
Idiopathic spinal cord herniation (ISCH) through an anterior dural defect is rare and the cause is uncertain. Recently, through interpreting imaging studies, disc herniation was proposed to be a major cause for ISCH. We describe the case of a 50-year-old woman with progressive myelopathy who was diagnosed with a thoracic spinal cord herniation. Microsurgical exploration revealed an anterior vertical dural defect and a small concomitant disc herniation, occult on the preoperative imaging, which caused the dural defect and led to ISCH. This intraoperative finding corroborates the emerging notion that disc herniation is the underlying cause of ISCH.
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Lui J, Sayal P, Choi D. Spinal Cord Suspension Using Dentate Ligament Hitch Stitches: A Novel Technique for the Repair of Ventral Spinal Cord Herniation. Oper Neurosurg (Hagerstown) 2018; 14:252-258. [PMID: 29462448 DOI: 10.1093/ons/opx108] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2016] [Accepted: 05/04/2017] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Idiopathic spinal cord herniation is usually repaired by releasing the spinal cord and inserting a dural patch to close the herniated segment of dura. However, reherniation is a potential limitation of this standard technique. OBJECTIVE To describe early results of a novel technique that utilizes the dentate ligament to hitch the spinal cord and prevent reherniation. METHODS Two patients underwent dural hernia repair and the dentate hitch technique was performed. RESULTS Restored lower limb power and mobility, and satisfactory reduction of spinal cord herniation on magnetic resonance imaging in 2 patients at 6- and 24-mo follow-ups, respectively. CONCLUSION The dentate hitch technique can achieve repair of spinal cord herniation, with satisfactory postoperative results and minimizes the risk of reherniation.
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Affiliation(s)
- Jonathan Lui
- University College London, London, United Kingdom
| | - Parag Sayal
- Department of Neurosurgery, The National Hospital for Neurology and Neurosurgery, London, United Kingdom
| | - David Choi
- Department of Neurosurgery, The National Hospital for Neurology and Neurosurgery, London, United Kingdom
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Turel MK, Wewel JT, Kerolus MG, O'Toole JE. Idiopathic thoracic transdural intravertebral spinal cord herniation. JOURNAL OF CRANIOVERTEBRAL JUNCTION AND SPINE 2017; 8:288-290. [PMID: 29021685 PMCID: PMC5634120 DOI: 10.4103/jcvjs.jcvjs_12_17] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
Idiopathic spinal cord herniation is a rare and often missed cause of thoracic myelopathy. The clinical presentation and radiological appearance is inconsistent and commonly confused with a dorsal arachnoid cyst and often is a misdiagnosed entity. While ventral spinal cord herniation through a dural defect has been previously described, intravertebral herniation is a distinct entity and extremely rare. We present the case of a 70-year old man with idiopathic thoracic transdural intravertebral spinal cord herniation and discuss the clinico-radiological presentation, pathophysiology and operative management along with a review the literature of this unusual entity.
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Affiliation(s)
- Mazda K Turel
- Department of Neurosurgery, Rush University Medical Center, Chicago, IL, USA
| | - Joshua T Wewel
- Department of Neurosurgery, Rush University Medical Center, Chicago, IL, USA
| | - Mena G Kerolus
- Department of Neurosurgery, Rush University Medical Center, Chicago, IL, USA
| | - John E O'Toole
- Department of Neurosurgery, Rush University Medical Center, Chicago, IL, USA
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Transdural Spinal Cord Herniation: Tips and Tricks. World Neurosurg 2017; 109:242-246. [PMID: 29017979 DOI: 10.1016/j.wneu.2017.09.195] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2017] [Revised: 09/27/2017] [Accepted: 09/28/2017] [Indexed: 11/20/2022]
Abstract
Recognition of transdural spinal cord herniation has increased over the past decade. This condition remains little known, particularly outside the specialized fields of spinal surgery and neuroradiology, leading to a significant delay in clinical diagnosis and treatment. It should be considered among the differential diagnoses in patients with gradual-onset lower-limb weakness of presumed spinal origin. Reaching a diagnosis using magnetic resonance imaging is essential to refer patients for surgery before their myelopathy worsens. We describe our surgical experience to untether the spinal cord by wrapping a dura graft around the spinal cord. Three case reports and a review of the literature are discussed.
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Bartels RHMA, Brunner H, Hosman A, van Alfen N, Grotenhuis JA. The Pathogenesis of Ventral Idiopathic Herniation of the Spinal Cord: A Hypothesis Based on the Review of the Literature. Front Neurol 2017; 8:476. [PMID: 28955299 PMCID: PMC5601982 DOI: 10.3389/fneur.2017.00476] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2016] [Accepted: 08/28/2017] [Indexed: 12/29/2022] Open
Abstract
Idiopathic ventral herniation of the spinal cord (SC) is not often encountered in daily practice. Its clinical prevalence, however, will increase through increasing awareness and more frequent use of MRI. A clear explanation of its pathophysiology has never been formulated. It was hypothesized that the findings during surgery might indicate the real causative mechanism. An extensive literature search was performed, using Embase, PubMed, and Google Scholar. Titles and abstracts were screened by two investigators, using strict inclusion and exclusion criteria. Reference lists of the full paper versions of each included article were checked. The following data were registered for the articles included: age, gender, level of herniation, relation to intervertebral disk, duration of symptoms, findings from surgery, and outcomes. Nine cases treated at our department were added. A total of 117 articles reporting on 259 patients were included. Including our cases, 268 patients were reviewed. Females outnumbered males (160/100). The mean age was 51.3 ± 12.0 years. In 236 patients, the duration of symptoms was reported: 55.5 ± 55.6 months. In 178 patients, the intraoperative findings for the herniated part of the SC were not mentioned. In 59 patients, a tumor-like extrusion was seen, without any alteration to the SC. Deformation of the SC itself was never observed. Biopsies of these structures were without clinical consequence. Based on the intraoperative findings reported in literature and the cases presented, acquired causes, such as trauma and erosion of the dura due to a herniated disk, were not plausible. We hypothesize that a non-functioning appendix to the SC can only develop during an early embryologic phase, in which several layers separate. We propose renaming this entity as congenital transdural appendix of the SC.
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Affiliation(s)
- Ronald H M A Bartels
- Department of Neurosurgery, Radboud University Medical Center, Nijmegen, Netherlands
| | - Han Brunner
- Department of Human Genetics, Radboud University Medical Center, Nijmegen, Netherlands
| | - Allard Hosman
- Department of Orthopedic Surgery, Radboud University Medical Center, Nijmegen, Netherlands
| | - Nens van Alfen
- Department of Neurology and Clinical Neurophysiology, Donders Center for Neuroscience, Radboud University Medical Center, Nijmegen, Netherlands
| | - J André Grotenhuis
- Department of Neurosurgery, Radboud University Medical Center, Nijmegen, Netherlands
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Clinical and Radiographical Differences Between Thoracic Idiopathic Spinal Cord Herniation and Spinal Arachnoid Cyst. Spine (Phila Pa 1976) 2017; 42:E963-E968. [PMID: 27926670 DOI: 10.1097/brs.0000000000002013] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN A retrospective, multicenter, case-controlled study. OBJECTIVE The aim of this study was to investigate the clinical and radiographical differences between thoracic idiopathic spinal cord herniation (ISCH) and spinal arachnoid cyst (SAC). SUMMARY OF BACKGROUND DATA ISCH and SAC are relatively rare diseases. Preoperative misdiagnose was frequently reported in both; however, these clinical and radiographical differences remain unclear. METHODS Of 30,469 patients who underwent spinal surgery, 18 (0.059%) and 22 (0.072%) patients were diagnosed as ISCH or SAC at nine hospitals, respectively, and their clinical and radiographical data were retrospectively evaluated. The spinal cord kink angle was measured on magnetic resonance or computed tomography myelography sagittal images; the kink angle was the exterior angle formed between the two tangents to the dorsal-side inflection points at the maximally affected level. RESULTS There were no significant differences in age, gender, and duration of symptoms. Preoperative motor deficit was significantly higher (94.4%) and severer (manual muscle testing: 3.1 ± 1.1) in ISCH. Brown-Séquard syndrome was observed in 38.9% of ISCH, while no patients in SAC. In addition, leg sensory disorder and bladder rectal disorder were significantly more common in ISCH, while back pain was significantly frequent in SAC. With respect to radiographical findings, the length of disease (5.1 ± 2.7 levels) and altered cerebrospinal flow (CSF) (81.8%) in the lesion was significantly longer and more common in SAC. On the contrary, the kink angle was significantly greater in ISCH (54.0 ± 23.1°) than in SAC (14.1 ± 12.0°) (P < 0.001). The cut-off value of the kink angle to distinguish ISCH and SAC was 32.8°. CONCLUSION Patients with ISCH commonly had severe preoperative neurological deficit, Brown-Séquard syndrome, and higher kink angle, while patients with SAC had back pain, longer length of disease, and altered CSF in the lesion. LEVEL OF EVIDENCE 4.
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Shimizu S, Kobayashi Y, Oka H, Kumabe T. Idiopathic spinal cord herniation: consideration of its pathogenesis based on the histopathology of the dura mater. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2017; 28:298-305. [PMID: 28593382 DOI: 10.1007/s00586-017-5147-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/05/2016] [Revised: 02/01/2017] [Accepted: 05/07/2017] [Indexed: 12/19/2022]
Abstract
INTRODUCTION We present a patient with idiopathic spinal cord herniation (ISCH) whose dura mater was histopathologically examined to elucidate its pathogenesis. CASE REPORT A 33-year-old previously healthy man presented with progressive walking difficulty, spasticity of the right lower leg, and hyperesthesia below the right chest. Neuroimaging revealed right ventral displacement of the spinal cord at T5-6. The diagnosis was ISCH and he underwent release of the herniation from the ventral dural opening. Dural biopsy at the edge of the ventral opening and in the dorsal durotomy was performed. Postoperatively, his gait was improved. Histopathological examination of the ventral dural specimen showed non-specific degeneration, i.e., loose arrangements of collagen fibers, edematous changes, minor inflammatory cell infiltration, and angiogenesis. The specimen from the dorsal durotomy was normal. CONCLUSION It is unclear whether the observed degeneration besides the ventral opening was the primary cause of ISCH or reflected secondary changes resulting from cumulative damage due to pulsation of the herniated spinal cord. However, the degeneration limited to the ventral opening suggests that ISCH was a local event in an individual with a normal dural theca.
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Affiliation(s)
- Satoru Shimizu
- Department of Neurosurgery, Yokohama Brain and Spine Center, l-2-1 Takigashira, Isogo-ku, Yokohama, Kanagawa, 235-0012, Japan.
| | - Yosuke Kobayashi
- Department of Spinal Surgery, Yokohama Brain and Spine Center, Yokohama, Kanagawa, Japan
| | - Hidehiro Oka
- Department of Neurosurgery, Kitasato University Medical Center, Kitamoto, Saitama, Japan.,Department of Neurosurgery, Kitasato University School of Medicine, Sagamihara, Kanagawa, Japan
| | - Toshihiro Kumabe
- Department of Neurosurgery, Kitasato University School of Medicine, Sagamihara, Kanagawa, Japan
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Guppy KH, Silverthorn JW. Spinal Cord Herniation After Cervical Corpectomy with Cerebrospinal Fluid Leak: Case Report and Review of the Literature. World Neurosurg 2017; 100:711.e7-711.e12. [DOI: 10.1016/j.wneu.2017.01.078] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2016] [Revised: 01/17/2017] [Accepted: 01/19/2017] [Indexed: 11/26/2022]
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Klekamp J. A New Classification for Pathologies of Spinal Meninges, Part 1: Dural Cysts, Dissections, and Ectasias. Neurosurgery 2017; 81:29-44. [DOI: 10.1093/neuros/nyx049] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2016] [Accepted: 01/30/2017] [Indexed: 12/19/2022] Open
Abstract
Abstract
BACKGROUND: The clinical significance of pathologies of the spinal dura is often unclear and their management controversial.
OBJECTIVE: To classify spinal dural pathologies analogous to vascular aneurysms, present their symptoms and surgical results.
METHODS: Among 1519 patients with spinal space-occupying lesions, 66 patients demonstrated dural pathologies. Neuroradiological and surgical features were reviewed and clinical data analyzed.
RESULTS: Saccular dural diverticula (type I, n = 28) caused by defects of both dural layers, dissections between dural layers (type II, n = 29) due to defects of the inner layer, and dural ectasias (type III, n = 9) related to structural changes of the dura were distinguished. For all types, symptoms consisted of local pain followed by signs of radiculopathy or myelopathy, while one patient with dural ectasia presented a low-pressure syndrome and 10 patients with dural dissections additional spinal cord herniation. Type I and type II pathologies required occlusion of their dural defects via extradural (type I) or intradural (type II) approaches. For type III pathologies of the dural sac no surgery was recommended. Favorable results were obtained in all 14 patients with type I and 13 of 15 patients with type II pathologies undergoing surgery.
CONCLUSION: The majority of dural pathologies involving root sleeves remain asymptomatic, while those of the dural sac commonly lead to pain and neurological symptoms. Type I and type II pathologies were treated with good long-term results occluding their dural defects, while ectasias of the dural sac (type III) were managed conservatively.
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Affiliation(s)
- Jörg Klekamp
- Department of Neurosurgery, Christliches Krankenhaus Quakenbrück, Quakenbr-ück, Germany
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Delgado-López PD, Gil-Polo C, Martín-Velasco V, Martín-Alonso J, Galacho-Harriero AM, Araus-Galdós E. Spinal cord herniation repair with microstaples: case report. J Neurosurg Spine 2017; 26:384-387. [DOI: 10.3171/2016.8.spine16318] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Idiopathic spinal cord herniation (ISCH) is a relatively rare and frequently misdiagnosed condition. It preferentially affects women and causes progressive thoracic myelopathy that presents as a Brown-Séquard syndrome or as spastic paraparesis. Although its etiology and pathogenesis are controversial, ISCH is characterized by the presence of an anterior dural defect that allows the incarceration of a segment of the cord. Typically, a C-shaped ventral displacement and kinking of the cord are visible on sagittal MRI. Surgery aimed at stopping or reversing myelopathic symptoms is usually recommended for symptomatic patients. Surgical options include reduction of the hernia and direct suturing, or enlargement of the dural defect, with or without patching. Suturing under the cord in a very tight space can be troublesome and may lead to neurological deterioration. The authors present the case of a symptomatic ISCH in which nonpenetrating titanium microstaples were used to close the dural defect after cord reduction. The patient experienced a good outcome, and the follow-up MRI study showed adequate cord repositioning and stability of the suture. The use of microstaples, which allows for an easier and faster dural closure than conventional suturing, is a novel technical adjunct that has not been previously reported for this condition. In addition, microstaples produce minimal metallic artifact that does not hinder the quality of follow-up MR images.
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Sadek AR, Nader-Sepahi A. Idiopathic thoracic intravertebral spinal cord herniation. Br J Neurosurg 2016; 32:297-298. [DOI: 10.1080/02688697.2016.1265091] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Ahmed-Ramadan Sadek
- Department of Neurosurgery, Wessex Neurological Centre, University Hospital Southampton, Southampton, UK
- Division of Clinical Neurosciences, School of Medicine, University of Southampton, Southampton, UK
| | - Ali Nader-Sepahi
- Department of Neurosurgery, Wessex Neurological Centre, University Hospital Southampton, Southampton, UK
- Division of Clinical Neurosciences, School of Medicine, University of Southampton, Southampton, UK
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Jeong KH, Lee HW, Kwon YM. Spontaneous Anterior Thoracic Spinal Cord Herniation through Dura Defect: A Case Report. KOREAN JOURNAL OF SPINE 2016; 13:77-9. [PMID: 27437019 PMCID: PMC4949173 DOI: 10.14245/kjs.2016.13.2.77] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/20/2015] [Revised: 02/23/2016] [Accepted: 02/24/2016] [Indexed: 11/19/2022]
Abstract
Thoracic spinal cord herniation is a rare disease cause of progressive myelopathy. Magnetic resonance image is a useful tool to diagnose preoperatively. Operation is a treatment of option. Sixty-six-year-old female visited Dong-A University Medical Center for progressive gait disturbance with falling tendency to right side. She had radiating pain and tingling sense on both leg. Sense of touch and temperature was decreased below T6 level. Both hip and knee motor power were grade IV. Magnetic resonance imaging scan showed anterior displacement of the spinal cord at T4-T5 vertebral level. Under the diagnosis of thoracic spinal cord herniation with dura defect, operation was performed for the patient with intraoperative neuromonitoring. Laminectomy at T4 and T5 level was done, and intradural exploration of the spinal cord revealed dura defect about 25mm×8mm in size. Spinal cord was released under microscope and dura defect was repaired with Lyoplant. The patient's symptom improved after the surgical procedure, but touch and temperature sense under T6 level had unchanged.
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Affiliation(s)
- Kyung-Ho Jeong
- Department of Neurosurgery, Dong-A University College of Medicine, Busan, Korea
| | - Hyun-Woo Lee
- Department of Neurosurgery, Dong-A University College of Medicine, Busan, Korea
| | - Young-Min Kwon
- Department of Neurosurgery, Dong-A University College of Medicine, Busan, Korea
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Rajapakse D, Mapara L, Maniharan S. Idiopathic spinal cord herniation of the cervical cord: unusual cause of proximal muscle weakness in upper limbs. BMJ Case Rep 2016; 2016:bcr-2016-215022. [PMID: 27190115 DOI: 10.1136/bcr-2016-215022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Idiopathic spinal cord herniation (ISCH) is a recognised rare cause of progressive and potentially curable myelopathy. Around 170 cases have been described in the literature, all to be found between the T2 and T8 vertebrae. We report a case of ISCH in the cervical region. A 23-year-old man with no history of trauma presented with a 6-year history of bilateral mild resting hand tremor and left scapular pain radiating to the left arm for a duration of 8 months. Nerve conduction studies showed some denervation changes of the upper limbs and bulbar regions. MRI of the spine showed anterior midline herniation of the spinal cord at the level of C7 vertebra with an associated collection of cerebrospinal fluid in the extradural space in the cervical region. Owing to the non-progressive nature of symptoms, currently the patient is managed conservatively.
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Affiliation(s)
| | - Leah Mapara
- Queen's Hospital, Burton upon Trent, Staffordshire, UK
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Aiyer SN, Shetty AP, Kanna R, Maheswaran A, Rajasekaran S. Spinal cord herniation following cervical meningioma excision: a rare clinical entity and review of literature. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2016; 25 Suppl 1:216-9. [PMID: 26846229 DOI: 10.1007/s00586-016-4412-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/31/2015] [Revised: 01/11/2016] [Accepted: 01/15/2016] [Indexed: 10/22/2022]
Abstract
BACKGROUND Spinal cord herniation following surgery is an extremely uncommon clinical condition with very few reports in published literature. This condition usually occurs as a spontaneous idiopathic phenomenon often in the thoracic spine or following a scenario of post traumatic spinal cord/nerve root injury. Rarely has it been reported following spinal cord tumor surgery. PURPOSE To document a case of cervical spinal cord herniation as a late onset complication following spinal cord tumor surgery with an atypical presentation of monoparesis. DESIGN Case report. METHODS We describe the clinical presentation, operative procedure, post operative outcome and review of literature of this rare clinical condition. RESULTS A 57-year-old man presented with right upper limb monoparesis due to a spinal cord herniation 6 years after a cervical intradural meningioma excision. The patients underwent surgery to reduce the herniation and duroplasty with subsequent complete resolution of symptoms. CONCLUSIONS Spinal cord herniation must be considered as differential diagnosis in scenarios of spinal cord tumor excision presenting with late onset neurological deficit. These cases may present as paraparesis, Brown-sequard syndrome and rarely as in our case as monoparesis.
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Affiliation(s)
- Siddharth N Aiyer
- Department of Spine Surgery, Ganga Hospital, 313, Mettupalayam Road, Coimbatore, India
| | - Ajoy Prasad Shetty
- Department of Spine Surgery, Ganga Hospital, 313, Mettupalayam Road, Coimbatore, India
| | - Rishi Kanna
- Department of Spine Surgery, Ganga Hospital, 313, Mettupalayam Road, Coimbatore, India
| | - Anupama Maheswaran
- Department of Spine Surgery, Ganga Hospital, 313, Mettupalayam Road, Coimbatore, India
| | - S Rajasekaran
- Department of Spine Surgery, Ganga Hospital, 313, Mettupalayam Road, Coimbatore, India.
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[Spinal cord displacement with progressive paraplegia]. Radiologe 2015; 56:170-5. [PMID: 26561026 DOI: 10.1007/s00117-015-0033-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Ju MW, Choi SW, Youm JY, Kwon HJ. Idiopathic Spinal Cord Herniation Presented as Brown-Sequard Syndrome : A Case Report and Surgical Outcome. J Korean Neurosurg Soc 2015; 58:294-7. [PMID: 26539277 PMCID: PMC4630365 DOI: 10.3340/jkns.2015.58.3.294] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2015] [Revised: 07/18/2015] [Accepted: 08/04/2015] [Indexed: 12/27/2022] Open
Abstract
Spinal cord herniation is a rare condition that has become increasingly recognised in the last few years. The authors report a case of idiopathic spinal cord herniation in a 33 year old woman performed with progressive Brown-Sequard syndrome. The diagnosis was made on MR imaging. After repairing the herniation, the patient made a gradual improvement. Potential causes are discussed, including a possible role of dural defect. In conclusion, idiopathic spinal cord herniation is a potentially treatable condition that should be more readily diagnosed that increasing awareness and improved imaging techniques.
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Affiliation(s)
- Min-Wook Ju
- Department of Neurosurgery, Chungnam National University Hospital, Daejeon, Korea
| | - Seung-Won Choi
- Department of Neurosurgery, Chungnam National University Hospital, Daejeon, Korea
| | - Jin-Young Youm
- Department of Neurosurgery, Chungnam National University Hospital, Daejeon, Korea
| | - Hyon-Jo Kwon
- Department of Neurosurgery, Chungnam National University Hospital, Daejeon, Korea
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Carter BJ, Griffith BD, Schultz LR, Abdulhak MM, Newman DS, Jain R. Idiopathic spinal cord herniation: an imaging diagnosis with a significant delay. Spine J 2015; 15:1943-8. [PMID: 25857588 DOI: 10.1016/j.spinee.2015.04.013] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2014] [Revised: 03/02/2015] [Accepted: 04/02/2015] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Idiopathic spinal cord herniation (ISCH) is an underrecognized entity that is often underappreciated by the neurosurgery and neuroradiologic communities. This leads to delayed diagnosis, multiple imaging studies, other diagnostic tests, inappropriate surgeries, and repeat office visits. PURPOSE To evaluate common associations between ISCH and patient demographics/clinical presentation and to analyze the potential for delayed diagnosis. PATIENT SAMPLE Patient sample included those diagnosed with ISCH on imaging at our institution from June 20, 2005 to December 3, 2012. OUTCOME MEASURES These were based on the patient improvement/stability/decline based on the patients' most recent clinic/office visit when compared with initial presentation. METHODS A retrospective search of radiology reports was performed using Illuminate software from June 20, 2005 to December 3, 2012, using the search term "idiopathic spinal cord herniation." Clinical data were reviewed including patient's age, sex, presenting clinical symptoms, number and type of imaging studies performed as part of the workup, other diagnostic tests, pain procedures, surgeries, and time between original presentation and diagnosis of ISCH on imaging. RESULTS A total of 55 patients had the search term "idiopathic spinal cord herniation" included in their radiology report, of which 37 patients were found to meet the imaging and clinical diagnosis of ISCH. The median time from presentation to imaging diagnosis was 20 months in patients younger than 60 years and 5 months in those 60 years or older (p=.02). Of the 37 patients evaluated, 27 (73%) had no change in symptoms, 5 patients (14%) experienced worsening of symptoms, and 5 (14%) experienced symptom improvement from original presentation to most recent office visit. Among all patients evaluated, three underwent repair of the ventral dural defect in ISCH, resulting in clinical improvement. There was a median of nine outpatient office visits, three magnetic resonance images (MRIs), and one electromyography (EMG) per patient presenting with ISCH. The most frequent complaints were neck/upper back pain in 70%, upper/lower extremity numbness/paresthesias/weakness in 49%, hyperreflexia in 22%, and burning chest pain in 22%. CONCLUSIONS Prolonged time to diagnosis and subsequent treatment of ISCH protracts patient symptoms and is associated with redundant diagnostic tests and patient visits. Earlier use of MRI in younger patients (younger than 60 years) may be warranted in those with a clinical presentation suggestive of Brown-Sequard symptomatology. Increasing recognition of ISCH in imaging and surgical communities would lead to improved patient care.
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Affiliation(s)
- Britton J Carter
- Department of Radiology, Henry Ford Health System, Detroit, MI, USA.
| | - Brent D Griffith
- Department of Radiology, Henry Ford Health System, Detroit, MI, USA
| | - Lonni R Schultz
- Department of Public Health Sciences, Henry Ford Health System, Detroit, MI, USA
| | | | - Daniel S Newman
- Department of Neurology, Henry Ford Health System, Detroit, MI, USA
| | - Rajan Jain
- Division of Neuroradiology, Department of Radiology, NYU Langone Medical Center, 221 Lexington Ave, New York, NY 10016, USA
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Martinez-del-Campo E, Moon K, Kalb S, Soriano-Baron H, Theodore N. Surgical Management of a Patient With Thoracic Spinal Cord Herniation. Neurosurgery 2015; 77:E492-8; discussion E498-9. [DOI: 10.1227/neu.0000000000000860] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
BACKGROUND AND IMPORTANCE:
Thoracic spinal cord herniation (TSCH) is rare and likely underdiagnosed. It is characterized by ventral herniation of the spinal cord through a dural defect, effacement of the anterior subarachnoid space, and increased posterior subarachnoid space. We present here a case of TSCH diagnosed and surgically treated at Barrow Neurological Institute, along with supplemental intraoperative video.
CLINICAL PRESENTATION:
A 61-year-old man with a history of progressive myelopathy causing left lower-extremity weakness with associated numbness, impaired gait, foot drop, incontinence, and sexual impotence was referred without any previous treatment. Computed tomographic myelography and magnetic resonance imaging of the thoracic spine showed ventral spinal cord herniation at T3-T4. Neurological monitoring was recorded preoperatively and intraoperatively. The patient underwent left-sided posterolateral exploration via T3-T4 laminectomies and costotransversectomy for intradural cord release/detethering of the spinal cord with additional superior and inferior extension and repair of the dural defect. Arthrodesis was not considered necessary. After cord release, motor evoked potentials showed immediate improvement from baseline. Dural duplication was considered the cause of TSCH in this case. Total reduction of herniation was evident in postoperative images. The postoperative course was uneventful, and at the last follow-up, the patient had regained ambulation and sphincter control.
CONCLUSION:
Anterior displacement of the thoracic spinal cord should elicit consideration of herniation to prevent misdiagnosis and inadequate surgery. Surgical cord release and enlargement of the dural defect are safe and associated with good clinical outcomes.
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Affiliation(s)
- Eduardo Martinez-del-Campo
- Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Karam Moon
- Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Samuel Kalb
- Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Hector Soriano-Baron
- Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Nicholas Theodore
- Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
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Samuel N, Goldstein CL, Santaguida C, Fehlings MG. Spontaneous resolution of idiopathic thoracic spinal cord herniation: case report. J Neurosurg Spine 2015; 23:306-8. [PMID: 26023901 DOI: 10.3171/2014.12.spine14950] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Spinal cord herniation is a relatively rare but increasingly recognized clinical entity, with fewer than 200 cases reported in the literature to date. The etiology of this condition remains unknown, and surgery is used as the primary treatment to correct the herniation and consequent spinal cord compromise. Some patients without clinical progression have been treated with nonoperative measures, including careful follow-up and symptomatic physical therapy. To date, however, there has been no published report on the resolution of spinal cord herniation without surgical intervention. The patient in the featured case is a 58-year-old man who presented with mild thoracic myelopathy and imaging findings consistent with idiopathic spinal cord herniation. Surprisingly, updated MRI studies, obtained to better delineate the pathology, showed spontaneous resolution of the herniation. Subsequent MRI 6 months later revealed continued resolution of the previous spinal cord herniation. This is the first report of spontaneous resolution of a spinal cord herniation in the literature. At present, the treatment of this disorder is individualized, with microsurgical correction used in patients with progressive neurological impairment. The featured case highlights the potential variability in the natural history of this condition and supports considering an initial trial of nonoperative management for patients with mild, nonprogressive neurological deficits.
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Affiliation(s)
| | | | - Carlo Santaguida
- Division of Neurosurgery, Spinal Program, University of Toronto;,Krembil Neuroscience Centre, University Health Network, Toronto, ON, Canada
| | - Michael G Fehlings
- Division of Neurosurgery, Spinal Program, University of Toronto;,Department of Genetics and Development, Toronto Western Hospital; and.,Krembil Neuroscience Centre, University Health Network, Toronto, ON, Canada
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Abd Elwahab SM, O'Sullivan MJ. Spinal cord herniation after resection of cervical spinal neurofibroma with a unique presentation. Spine J 2015; 15:e1-3. [PMID: 25500263 DOI: 10.1016/j.spinee.2014.12.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2013] [Revised: 10/03/2014] [Accepted: 12/02/2014] [Indexed: 02/09/2023]
Abstract
BACKGROUND CONTEXT Spinal cord herniation (SCH) is a very rare condition. It was first reported in the lumbar spine in 1974. Thereafter, cases were reported in the thoracic and cervical spine occurring either spontaneously or after vertebral fracture, nerve root avulsion, and trauma surgery. PURPOSE There is only one recorded case of SCH after tumor surgery. In this article, we reported the second case. STUDY DESIGN We described the original surgical procedure, the clinical presentation, the operative repair, and the postoperative course. METHODS No funding was required for this case report. RESULTS The patient was a 56-years-old man, who presented with SCH 5 years after subtotal excision of a cervical neurofibroma. He presented with right upper monoparesis. CONCLUSIONS To our knowledge, this presentation has not been reported previously in literature.
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Affiliation(s)
- Sami M Abd Elwahab
- Department of Neurosurgery, Cork University Hospital, Bishopstown Road, Wilton, Cork, Ireland.
| | - Michael J O'Sullivan
- Department of Neurosurgery, Cork University Hospital, Bishopstown Road, Wilton, Cork, Ireland
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Gao H, Li X, Wang C. Ankylosing spondylitis with idiopathic spinal cord herniation. Spine J 2015; 15:552-3. [PMID: 25463978 DOI: 10.1016/j.spinee.2014.10.024] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2014] [Accepted: 10/30/2014] [Indexed: 02/03/2023]
Affiliation(s)
- Hongxiang Gao
- Department of Orthopaedics, Zaozhuang Municipal Hospital, 41 Longtou Road, Zaozhuang, Shandong, China
| | - Xueju Li
- Department of Orthopaedics, Zaozhuang Municipal Hospital, 41 Longtou Road, Zaozhuang, Shandong, China
| | - Cunping Wang
- Department of Orthopaedics, Zaozhuang Municipal Hospital, 41 Longtou Road, Zaozhuang, Shandong, China
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Yamamoto N, Katoh S, Higashino K, Sairyo K. Idiopathic spinal cord herniation with duplicated dura mater and dorsal subarachnoid septum. Report of a case and review of the literature. Int J Spine Surg 2015; 8:14444-1029. [PMID: 25694934 PMCID: PMC4325502 DOI: 10.14444/1029] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background Idiopathic spinal cord herniation (ISCH) is a rare condition and its pathogenesis remains unclear. The purpose of this case report is to present an ISCH case with dorsal subarachnoid septum suggesting the pathogenesis of ISCH being adhesions from preexisting inflammation. Methods Single case report. Results A 60-year-old woman presented with Brown-Séquard syndrome below the level of T6. Magnetic resonance imaging revealed the thoracic spinal cord was displaced ventrally, and the dorsal subarachnoid space was enlarged and had a septum between the spinal cord and dura mater. Intraoperatively, the dorsal dura mater was seen to be adherent and the subarachnoid septum was identified after durotomy. The inner layer defect of the duplicated dura mater was found in the ventral dura mater, through which the spinal cord had herniated. After releasing the septum, the adhesions around the dura mater, and the hiatus, the spinal cord was reduced. Conclusions The present case indicates that adhesions around the dura mater can be the pathogenesis of ISCH.
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Affiliation(s)
- Norio Yamamoto
- Department of Orthopedics, Institute of Health Biosciences, The University of Tokushima Graduate School, Tokushima, Japan
| | - Shinsuke Katoh
- Department of Rehabilitation, Tokushima University Hospital, Tokushima, Japan
| | - Kousaku Higashino
- Department of Orthopedics, Institute of Health Biosciences, The University of Tokushima Graduate School, Tokushima, Japan
| | - Koichi Sairyo
- Department of Orthopedics, Institute of Health Biosciences, The University of Tokushima Graduate School, Tokushima, Japan
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