Elsevier

The Spine Journal

Volume 11, Issue 8, August 2011, Pages e9-e14
The Spine Journal

Case Report
Idiopathic spinal cord herniation at two separate zones of the thoracic spine: the first reported case and literature review

https://doi.org/10.1016/j.spinee.2011.07.003Get rights and content

Abstract

Background context

Idiopathic spinal cord herniation (ISCH) is a rare cause of progressive myelopathy. Preoperative diagnosis can be made with magnetic resonance imaging (MRI). Many surgical techniques have been applied by various authors, and ISCH is usually reversible by surgical treatment.

Purpose

To present a case of ISCH in two separate zones at two thoracic levels. To our knowledge, this is the first such case to be published in English literature. We also discuss the clinical findings, surgical procedures, and surgical outcomes for other previously reported cases of ISCH in the literature.

Study design

Case report.

Methods

A 52-year-old woman with bilateral lower extremity weakness underwent thoracic MRI, which revealed transdural spinal cord herniation at two separate zones, namely, the T4–T5 and T5–T6 intervertebral disc levels.

Results

During surgery, the spinal cord was reduced, the two separate dural defects were connected, and the new single defect was restored then reinforced with a thin layer of fascial graft. The posterior dural defect was then closed with interrupted stitches. The patient’s neurologic status was characterized by no changing of the preoperative motor status. Follow-up MRI scans showed that the cord was replaced in the dural sac and showed cord hyperintensity in the herniation levels. The patient could move with a cane at the sixth month postoperatively.

Conclusions

Idiopathic spinal cord herniation is a rare clinical condition that should be considered in the differential diagnosis of paraplegia. Although progression of neurologic deficits can be very slow, reduction of the spinal cord and repair of the defect are crucial to stop or reverse the deterioration. The outcome for patients who initially have Brown-Séquard syndrome is significantly better than for patients who presented with spastic paralysis. To our knowledge, this case study represents the first reported instance in which two separate anterior dural defects caused two levels of anterior spinal cord herniation.

Introduction

Idiopathic spinal cord herniation (ISCH) can be defined as herniation of the spinal cord, usually at the thoracic level, through an anterior dural sleeve. The spinal cord becomes herniated and compromised as a result of adhesion, distortion, or vascular impairment. However, the exact cause of the dural defect is still not known [1]. Idiopathic spinal cord herniation typically presents initially as Brown-Séquard syndrome [2], [3], [4], [5], although some patients may evolve into a severe paraparesis [6].

Different surgical techniques have been recommended to treat this disease, including the use of primary sutures to close the dural defect [7], [8], [9], [10], the use of a dural graft to close the defect [5], [10], [11], [12], [13], [14], [15], [16], [17], and enlargement of the dural defect [3], [18], [19], [20], [21]. Surgical treatment of spinal cord herniation is usually followed by stabilization or improvement in the neurologic symptomatology, but unfavorable postoperative outcomes are also reported [22].

Here, we report a case of ISCH in two separate zones at two levels. To our knowledge, this is the first such case to be published in English literature. We also summarize the clinical findings, surgical procedures, and surgical outcomes for other previously reported cases of ISCH in the literature.

Section snippets

Case report

A 52-year-old female patient presented with a 3-year history of numbness and a burning sensation above her legs. After complaints of difficulty in walking, the patient sought treatment at a state hospital where she was diagnosed with ISCH. As surgery was not recommended, the patient was referred to a physical therapy clinic. Her first neurologic examination at the physical therapy clinic revealed paraparesis below the level of T5. During the examination, she experienced diminished tactile and

Discussion

Idiopathic spinal cord herniation is increasingly recognized as a cause of progressive thoracic myelopathy. Because it is easily treatable by surgical repair, it represents a reversible cause of spinal cord dysfunction. The condition was first reported by Wortzman et al. [23] in 1974 then subsequently in a small series of studies from different authors before the MRI era. Technological advancements and increased clinical attention has resulted in a marked increase in the number of published

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    Author disclosures: ALA: Nothing to disclose. MS: Nothing to disclose. BE: Nothing to disclose. HS: Nothing to disclose. SO: Nothing to disclose. AFO: Nothing to disclose.

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