Idiopathic spinal cord herniation: a treatable cause of the Brown-Sequard syndrome--case report

Symptomatic herniation of the spinal cord through the dura is an uncommon clinical problem. Since 1989, we have encountered three patients who each presented with an unexplained, longstanding Brown-Sequard syndrome and were found to have idiopathic herniation of the thoracic spinal cord. This report describes the clinical, radiographic, and surgical findings in these three patients and reviews the five previously reported patients with this syndrome. Idiopathic herniation of the spinal cord is a treatable cause of the Brown-Sequard syndrome that may be more common than is currently recognized and should be known to all surgeons managing spinal disorders.

Spinal epidural haematoma: report of 11 cases and review of the literature

Spinal epidural haematomas (SEH) are rare; most are caused by trauma, anticoagulant therapy, vascular anomalies, hypertension, blood dyscrasias, epidural anaesthesia or, rarely, spinal surgery. We report 11 cases and review the literature (16 cases). The clinical picture is that of acute spinal cord compression. MRI characteristics are quite specific. On sagittal sections, the SEH appears as a biconvex mass, dorsal to the thecal sac, clearly outlined and with tapering superior and inferior margins. The dura mater is seen as curvilinear low signal separating the haematoma from the cord. Within 24 h of onset, the haematoma is isointense with the cord on T1-weighted images and heterogeneous on T2-weighted images. Later, it gives high signal on both T1- and T2-weighted images. Differential diagnosis must include subdural haematoma, epidural neoplasm and abscess. Complete neurological recovery rapidly follows laminectomy and removal of the clot. In three of our cases, the haematoma resolved spontaneously. MRI is the best examination for diagnostic and follow-up.

Idiopathic spinal cord herniation: report of eight cases and review of the literature

STUDY DESIGN

A case series of eight patients with idiopathic spinal cord herniation and a review of the literature.

OBJECTIVE

To report on this rare entity, provide insight on its natural history, and propose an optimal management strategy.

SUMMARY OF BACKGROUND DATA

Idiopathic spinal cord herniation is a rare disease with 50 cases reported before the current study.

METHODS

Eight cases (follow-up 1 month to 8 years) are reported using available information from patient charts, interviews, and assessments. All imaging studies are reviewed. The review of the literature was performed using PUBMED.

RESULTS

Four patients, followed without surgical intervention, have not progressed. Of the three patients who underwent surgical repair by one of the authors, two improved and one was unchanged. A fourth patient, who was initially treated by another surgeon who failed to identify the dural defect and herniation, had a poor outcome.

CONCLUSION

The pathophysiology of the dural defect is still uncertain. The typical presentation is Brown-Séquard syndrome. Microsurgical repair in cases with progression of neurologic deficits is usually successful in achieving recovery of function or arrest of progression.

Idiopathic dural herniation of the thoracic spinal cord

Symptomatic anterior or anterolateral dural herniation of the spinal cord is rare, and not uncommonly misdiagnosed, both clinically and radiologically. We present four patients with a radiological diagnosis of herniation of the thoracic spinal cord, and review the current literature. All affected patients have been adults, typically presenting with long-standing, unexplained sensory symptoms and eventually developing a Brown-Séquard syndrome, with or without motor changes. Herniation occurs in the upper or midthoracic region, between the T2 and T8 levels.

Spontaneous spinal cord herniation: case report and review of the literature

OBJECTIVE AND IMPORTANCE

Spontaneous herniation of the spinal cord substance through a previously uninjured and/or untouched dura is a very exceptional occurrence. Spontaneous spinal cord herniation, which was first reported 25 years ago, is a cause of myelopathy that is treatable but difficult to diagnose.

CLINICAL PRESENTATION

A 49-year-old female patient who presented with a 3-year history of a burning sensation and hyperesthesia in her right leg and a 3-month history of left leg stiffness was diagnosed as exhibiting signs of Brown-Séquard syndrome. Magnetic resonance imaging of the thoracic spinal canal demonstrated S-shaped anterior kinking and transdural herniation of the spinal cord at the T3-T4 levels.

INTERVENTION

The patient underwent surgery via a three-level laminectomy. The herniated part of the spinal cord was microsurgically reduced, and the dural defect was repaired with Gore-Tex membrane (WL Gore & Associates, Flagstaff, AZ). The outcome of surgery was excellent.

CONCLUSION

Review of the world literature revealed 29 reported cases, with 27 of these cases being published since 1990. The clinical features, radiological diagnosis, and treatment options for this unique entity are summarized, with a synopsis of numerous misconceptions that appeared in the literature. With more familiarity with and increased awareness of this entity, more cases will be diagnosed.

Progressive spontaneous herniation of the thoracic spinal cord: case report

OBJECTIVE AND IMPORTANCE

We report one case of spontaneous thoracic spinal cord herniation. To our knowledge, this is the first case involving radiological documentation of the development of herniation. Clinical features and surgical techniques are also presented.

CLINICAL PRESENTATION

We describe the case of a 51-year-old female patient who experienced progressive Brown-Sequard syndrome for 2 years. Three magnetic resonance imaging examinations were performed; they revealed the progressive development of anterolateral spinal cord herniation at the level of T6 during those 2 years.

INTERVENTION

After laminectomy at T6, the herniated myelon was microsurgically removed and the neurological symptoms improved.

CONCLUSION

We present the possible causes, the proposed pathophysiological mechanisms, and the clinical and radiological development of this rare entity, with a review of the literature published to date. We propose that a preexisting weakness of the ventral dural fibers, combined with abnormal adhesion of the spinal cord to the anterior dural sleeve, leads to progressive herniation throughout life. Microsurgical treatment may halt the exacerbation of the neurological symptoms.

Idiopathic spinal cord herniation: report of three cases and review of the literature

STUDY DESIGN

Three case reports and a literature review are presented.

OBJECTIVE

To describe characteristic clinical and radiographic findings of idiopathic spinal cord herniation.

SUMMARY OF BACKGROUND DATA

Idiopathic spinal cord herniation is a rare disease, with only 26 cases reported before the current study.

METHODS

Three cases of idiopathic spinal cord herniation are reported, and previous reports on this subject are reviewed.

RESULTS

The responsible regions were in the thoracic spine from T2 to T7. Symptoms were mainly unilateral muscle atrophy in the lower extremity and sensory disturbance below the thoracic level. These symptoms had been progressing gradually. Magnetic resonance imaging demonstrated a unique feature: The spinal cord shifted anteriorly in a few segments. Computed tomographic myelogram showed another distinctive picture: There was no subarachnoid space anterior to the spinal cord.

CONCLUSIONS

Because idiopathic spinal cord herniation is out of the concept of "compression myelopathy," this condition may be a pitfall in the diagnosis. Idiopathic spinal cord herniation should be recognized as one of the treatable causes for thoracic myelopathy.

Brown-Sequard syndrome after management of vertebral hemangioma with intralesional alcohol. A case report

STUDY DESIGN

This report describes Brown-Sequard syndrome after intralesional injection of absolute alcohol into vertebral hemangioma.

OBJECTIVE

To discuss whether the described technique is safe in the management of vertebral hemangiomas.

SUMMARY OF BACKGROUND DATA

The management of vertebral hemangiomas remains controversial. There have been reports of successful management using intralesional absolute alcohol.

METHODS

The clinical and radiologic features of the reported complication are detailed.

RESULTS

Intralesional injection of absolute alcohol caused Brown-Sequard syndrome.

CONCLUSION

This case shows that intralesional alcohol injection cannot be considered a safe technique for management of vertebral hemangiomas with spinal cord compression.

Ventral transdural herniation of the thoracic spinal cord: surgical treatment in four cases and review of literature

BACKGROUND

A specific cause of progressive Brown-Sequard syndrome has been identified: a ventral herniation of the thoracic spinal cord through the dural sleeve on one side.

METHOD

Four female patients who were affected by a progressive Brown Sequard syndrome related to a transdural spinal cord herniation have been investigated and were submitted to surgery and postoperative evaluation.

FINDINGS

The MRI scan showed atrophy and forward displacement of the spinal cord on one side and adhesion of the spinal cord to the dura mater. CT myelography demonstrated the disappearance of the premedullar rim at the level of the herniation and the shadow of the extradural herniation. Surgical treatment consisted in the excision of the arachnoid cyst when there was one, section of the dentate ligament, release of the adhesions, detachment of the spinal cord from the hernial orifice, and lastly suture of the dural tear or placement by a patch. Follow-up examination showed motor improvement with persistent sensory deficit in two cases and stabilisation in two cases.

INTERPRETATION

The cause of the dural tear, either traumatic or congenital could not be confirmed in the four cases. Symptoms probably occur when herniation fills the orifice and strangulation happens which explains the late appearance and progressive evolution of this myelopathy. Mobilisation of the herniated spinal cord back into the intradural space can be achieved by surgery and may stop the evolution of the symptoms and signs.

Brown-Sèquard syndrome produced by cervical disc herniation: report of two cases and review of the literature

BACKGROUND CONTEXT

Brown-Sèquard syndrome is most commonly seen with spinal trauma and extramedullary spinal neoplasm. A herniated cervical disc has rarely been considered to be a cause of Brown-Sèquard syndrome.

PURPOSE

To report and discuss two cases of Brown-Sèquard syndrome produced by herniated cervical disc.

STUDY DESIGN/SETTING

Case studies in Japan.

PATIENT SAMPLE

The first patient was a 64-year-old man who presented with right leg weakness and diminished sensation to pain and temperature in the left side below the T4 dermatome. The second patient was a 39-year-old man who presented with right-sided weakness and diminished sensation to pain and temperature in the left side below the T6 dermatome.

OUTCOME MEASURES

American Spinal Cord Injury Association (ASIA) impairment scale (only our cases).

METHODS

These patients were diagnosed to have Brown-Sèquard syndrome produced by herniated cervical disc. Anterior cervical discectomy with fusion was performed for these patients.

RESULTS

These cases revealed contralateral deficit in sensation of pain and temperature of more than a few levels below the cord compression, and showed paracentral protruded disc in magnetic resonance images and cervical spinal stenosis in cervical spine X-rays. Postoperatively, motor and sensory function of these patients returned to normal.

CONCLUSIONS

Characteristic finding in discogenic Brown-Sèquard syndrome are contralateral deficit in sensation of pain and temperature of more below than a few levels below the cord compression and paracentral protruded disc with cervical spinal stenosis. Outcomes are favorable in rapid diagnosis by magnetic resonance images and performance of anterior approach.

Intramedullary spinal cord metastasis of lung adenocarcinoma presenting as brown-sequard syndrome

BACKGROUND

It is extremely rare for cancer to present first as an intramedullary spinal cord metastasis. Furthermore, because it is unlikely for spinal cord neoplasm to present acutely, an acute presentation may signify metastatic disease and should be considered in the initial differential diagnosis.

METHODS

The authors present a case of a 59-year-old man presenting with Brown-Sequard syndrome and in whom metastatic lung adenocarcinoma to the spinal cord was subsequently discovered. Review of the literature reveals this case to be one of only a very few where intramedullary tumor was the first manifestation of metastatic disease.

RESULTS

The mainstay of treatment for intramedullary spinal metastases remains steroids, radiation, and chemotherapy, though no well-designed study compares these modalities by long-term survival and functional results. This patient underwent local radiation and systemic chemotherapy following surgical resection.

CONCLUSIONS

This patient had no preoperative signs suggesting disease in other organs, making the diagnosis of lung adenocarcinoma metastatic to the intramedullary cord surprising, especially given the extremely rare incidence of spinal intramedullary metastatic disease. However, the patient had an acute presentation, uncommon for primary neoplasm, which may be an indication of metastatic disease.

Spinal intramedullary cavernoma: clinical presentation and surgical outcome

OBJECT

Improved neuroimaging techniques have led to an increase in the reported cases of intramedullary cavernomas. The purpose of this study was to define the spectrum of presenting signs and symptoms in patients with spinal intramedullary cavernomas and to analyze the role of surgery as a treatment for these lesions.

METHODS

The authors reviewed the charts of 16 patients who underwent surgery for spinal intramedullary cavernomas. All patients underwent preoperative magnetic resonance imaging studies. Cavernomas represented 14 (5.0%) of 280 intramedullary lesions found in adults and two (1.1%) of 181 intramedullary lesions found in pediatric cases. A posterior laminectomy and surgical resection of the malformation were performed in all 16 patients.

CONCLUSIONS

Magnetic resonance imaging is virtually diagnostic for spinal cavernoma lesions. Patients with spinal intramedullary cavernomas presented with either an acute onset of neurological compromise or a slowly progressive neurological decline. Acute neurological decline occurs secondary to hemorrhage within the spinal cord. Chronic progressive myelopathy occurs due to microhemorrhages and the resulting gliotic reaction to hemorrhagic products. There is no evidence that cavernomas increase in size. The rate of rebleeding is unknown, but spinal cavernomas appear to be clinically more aggressive than cranial cavernomas, probably because the spinal cord is less tolerant of mass lesions. Complete surgical removal of the cavernoma was possible in 15 of 16 of the authors' cases.

Cervical disc herniation producing Brown-Sequard syndrome: case report

BACKGROUND

Brown-Sequard syndrome is an incomplete spinal cord lesion characterized by a clinical picture reflecting hemisection of the spinal cord in the cervical or thoracic region. Brown-Sequard syndrome may be the result of penetrating injury to the spine, but many other etiologies have been described. In particular, cervical disc herniation has been rarely reported as a cause of this syndrome, and including the first article of Stookey in 1928, 9 only 22 cases have been reported.

METHODS

The case of a man with a large left paramedian C5-C6 disc herniation, with ipsilateral spinal cord compression, is reported. An area of left-sided spinal cord hyperintensity was also present on MRI, an expression of left hemicord damage. Microdiscectomy and anterior cervical fusion with carbon fiber cage containing a core of granulated coralline hydroxylapatite was performed. A complete motor deficit recovery and a marked sensitive deficit improvement was obtained.

CONCLUSION

A critical review of the pertinent literature is proposed, and the neuroradiologic, therapeutic, and prognostic implications are discussed. Brown-Sequard syndrome produced by a cervical disc herniation is presumably often underdiagnosed, and early surgical intervention is always recommended.

Brown-Sequard syndrome produced by cervical disc herniation: case report and literature review

BACKGROUND

The Brown-Sequard Syndrome is most commonly described in conjunction with a traumatic injury to the spinal cord. the condition involves ipsilateral loss of motor function, proprioception, and vibratory sensation, combined with contralateral loss of pain and temperature sensation.

CASE REPORT

A 56 year-old female developed left thigh discomfort and numbness. Over the next five months, this spread to involve her left leg and chest to the axilla. Physical examination revealed myelopathy. Also present were motor, proprioceptive, and vibratory deficits in the right leg. A left sensory level to T2 was present. An MRI scan showed a large right cervical herniated disc with unilateral spinal cord compression. Following anterior cervical discectomy and fusion, the patient's symptoms have steadily improved.

CONCLUSIONS

The Brown-Sequard Syndrome can be caused by a herniated cervical disc. MRI scans should be employed early in the diagnostic evaluation of such patients, particularly in the absence of penetrating trauma or other obvious causes of the syndrome.

Myelopathy following influenza vaccination in inflammatory CNS disorder treated with chronic immunosuppression

We report a patient who developed a transverse myelitis with Brown-Séquard syndrome following a prophylactic influenza vaccination, despite being chronically immunosuppressed for a steroid-responsive optic neuropathy. Although influenza vaccination is recommended in patients receiving chronic immunosuppression, its use may on occasion be associated with neurological complications previously reported in immunocompetent individuals.

Idiopathic spinal cord herniation causing progressive Brown-Séquard syndrome

We report a 59-year-old woman with a 2.5 year history of progressive loss of temperature sensation and dysesthesia in the right and weakness in the contralateral lower limb. Magnetic resonance imaging (MRI) and computed tomography myelography of the spinal cord demonstrated transdural herniation and deformation of the spinal cord in the upper thoracic spine. The herniated part of the spinal cord was untethered and replaced, and the anterior dural defect was closed. At a clinical follow-up 3 months later, the motor and sensory functions were almost restored. MRI at this time showed disentanglement of spinal cord adherence.

Transdural spinal cord herniation: pre- and postoperative MRI findings

Idiopathic transdural spinal cord herniation (ICSH), a rare condition which may cause progressive myelopathy, can be diagnosed preoperatively by MRI. Surgical treatment usually results in the resolution of symptoms and, thus, familiarity with the imaging findings in this condition impacts patient management. We present the case of a 36-year-old woman in whom the initial MRI findings were thought to be consistent with only an arachnoid cyst compressing the spinal cord. After surgery, her symptoms remained unchanged, and a repeat MRI study was interpreted as being compatible with a transdural spinal cord herniation. Repeated surgery with reduction of the herniation resulted in significant clinical improvement.

Traumatic transdural spinal cord herniation and the nuclear trail sign: case report

A woman with a history of spine injury in her remote past developed Brown-Sequard syndrome due to a thoracic transdural spinal cord herniation. A clue about the underlying mechanism was offered by the unexpected imaging feature of a nuclear trail sign just below the herniated cord. As suggested by Watters et al., who reported a similar case, this finding is consistent with the hypothesis that intrathecal rupture of disk material could have resulted in an acquired tear of the ventral dural, through which the cord herniated.

A case of Brown-Sequard syndrome with associated Horner's syndrome after blunt injury to the cervical spine

A 26 year old motorcyclist was received by the trauma team in our accident and emergency department after a head on collision with a motor vehicle. He had been correctly immobilised and his primary survey was essentially normal. He was alert and orientated with a Glasgow Coma score of 15 and had no symptoms or signs of spinal injury. His cervical spine radiography was also normal. Neurological examination however, revealed anisocoria, his left pupil being smaller than his right, and a Brown-Sequard syndrome, with a sensory level at C6. Immobilisation was maintained and he was transferred to the regional neurosurgical centre where magnetic resonance imaging revealed a contusion of the left half of the spinal cord adjacent to the 6th cervical vertebrae. Computed tomography revealed no bony injury but spinal column instability was demonstrated after flexion-extension spinal views and he underwent surgery to fuse his spine at the C5-C6 level. This report highlights the necessity to observe strict ATLS guidelines. This must include a thorough examination of the central and peripheral nervous system where spinal injury is suspected, even in the absence of radiographic abnormality and neck pain. This article also presents the unusual phenomena of Brown-Sequard syndrome and unilateral Horner's syndrome after blunt traumatic injury to the cervical spine.

Multiple sclerosis presenting with a Brown-Séquard syndrome

The Brown-Séquard syndrome as spinal hemiplegia with contralateral sensory deficits has been related to a variety of underlying diseases. We describe the case of a 35-year-old right-handed white female presenting with a Brown-Séquard syndrome as the first and sole symptom of multiple sclerosis, underscoring the importance of multiple sclerosis as a rare condition for the Brown-Séquard syndrome.

Intradural cervical disc herniation and Brown-Séquard's syndrome. Report of three cases and review of the literature

Although cervical disc herniation commonly requires surgical intervention, the intradural sequestration of a herniated cervical disc fragment is rare. In searching the world literature on this topic, the authors found six case reports. They report three new cases of intradural cervical disc herniation in which the patients presented with Brown-Séquard's syndrome and they review the literature. Although Brown-Séquard's syndrome is a rare clinical finding in extradural disc herniation, six of the nine patients with intradural cervical disc herniation (our cases and those from the literature) presented with symptoms of this syndrome. The remaining patients presented with para- or quadriparesis. This suggests that intradural disc herniation should be considered preoperatively in patients in whom there is magnetic resonance imaging or myelographic evidence of cervical disc herniation and Brown-Séquard's syndrome. In patients who underwent anterior cervical discectomy for the treatment of intradural cervical disc herniations, better outcomes were demonstrated than in those in whom posterior procedures were performed.

Brown-Séquard-plus syndrome due to stab injury: a case report

STUDY DESIGN

Case report.

OBJECTIVE

To describe the mechanism of injury in this case and its clinical features. Magnetic resonance (MR) images of hemorrhage in spinal cord injury due to stab wound are discussed.

METHODS

We describe the case of a 21-year-old woman who was stabbed in the right side of her neck and developed left-sided Brown-Séquard syndrome plus loss of bilateral proprioceptive sensation. Neither plain radiographs nor computed tomography of the cervical spine demonstrated any foreign bodies or fractures of the cervical spine. T2-weighted cervical MR images confirm spinal cord hemiresection at C5-C6.

RESULTS

MR imaging was performed serially at 4 days, 4 weeks, and 8 weeks after trauma. The signal pattern of the spinal cord at the site of injury varied iso, iso, and low on T1-weighted consecutive images. Meanwhile, high signal intensity on T2-weighted images was consistent during the 8 weeks after incidence of trauma. A T2-weighted sagittal image showed a tiny spot of low intensity in the high signal band at the site of penetration, demonstrating hemosiderin formation in the spinal cord. The patient was treated conservatively and, recovered from Frankel grade C to grade D.

CONCLUSION

Spinal cord injuries (SCI) following stab wounds are rare. MR imaging is definitely useful for recording and monitoring the pathology of SCI.

Thoracic neurenteric cyst in a middle aged adult presenting with Brown-Sequard syndrome

STUDY DESIGN

To report an unusual presentation of a thoracic neurenteric cyst.

OBJECTIVES

To increase knowledge about the pathogenesis and treatment of intraspinal neurenteric cyst.

SUMMARY OF BACKGROUND DATA

Intraspinal neurenteric cysts (enterogenous cysts) are very rare congenital cysts of endodermal origin. The diagnosis usually is established during the first or second decade of life. Those cysts are frequently associated with vertebral or spinal cord anomalies and dual malformation with mediastinal or abdominal cysts.

METHODS

A 50-year-old man presented with 1 year of left midthoracic intercostal pain after chest compression injury. Several months before admission, he felt left lower extremity weakness with right-side numbness. Plain radiography of thoracic spine was normal while MRI showed a cystic mass at T7, T8 level ventral to the spinal cord with cord compression. The spinal cord was displaced to the posterior more to the right side, mimicking hemisection of the left side of the spinal cord.

RESULTS

Thoracic laminectomy was performed and the intraspinal cyst was removed. The pathology report indicated neuroenteric cyst. The postoperative course was uneventful and the signs of myelopathy improved immediately. The patient appeared well after 2 years of follow-up.

CONCLUSIONS

Intraspinal neuroenteric cyst without plain vertebral anomaly may occur after trauma in middle aged adult life with Brown-Sequard syndrome. Successful treatment requires early recognition of those cysts and their associated abnormalities.