Diagnosis and treatment of spinal cord herniation: a combined experience

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Object

Idiopathic spinal cord herniation (ISCH) is an uncommon clinical entity typically presenting with lower-extremity myelopathy. Despite the existence of 85 ISCH cases in the literature, misdiagnosis and delayed diagnosis remain a major concern.

Methods

The authors conducted a retrospective review of patients who underwent surgery for ISCH at their institutions between 1993 and 2004. Seven patients were treated for ISCH, five in New York and two in Buenos Aires. The patients’ ages ranged from 32 to 72 years. There were three men and four women. The interval between the onset of symptoms and surgery ranged from 12 to 84 months (mean 42.1 months).

Preoperatively, spinal cord function in four patients was categorized as American Spinal Injury Association (ASIA) Grade D, and that in the other three patients was ASIA Grade C. In all patients a diagnosis of posterior intradural arachnoid cyst had been rendered at other institutions, and three had undergone surgery for the treatment of this entity. In all cases, the herniation was reduced and the defect repaired with a dural patch. The follow-up period ranged from 10 to 147 months (mean 49.2 months). Clinical recovery following surgery varied; however, there was no functional deterioration compared with baseline status. Syringomyelia, accompanied by neurological deterioration, developed postoperatively in two patients at 2 and 10 years, respectively.

Conclusions

Patients presenting with a diagnosis of posterior intradural arachnoid cyst should be evaluated carefully for the presence of an anterior spinal cord herniation. Based on the authors’ literature review and their own experience, they recommend offering surgery to patients even when neurological compromise is advanced.

Abbreviations used in this paper:ASIA = American Spinal Injury Association; CSF = cerebrospinal fluid; ISCH = idiopathic spinal cord herniation; MEP = motor evoked potential; MR = magnetic resonance; SSEP = somatosensory evoked potential; VB = vertebral body.

Article Information

Address reprint requests to: Noel I. Perin, M.D., F.R.C.S.(Ed), St. Luke’s–Roosevelt Hospital Center, Department of Neurosurgery, 1000 10th Avenue, Suite 5G-80, New York, New York 10019. email: nperin@chpnet.org.

© AANS, except where prohibited by US copyright law.

Headings

Figures

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    Artist’s rendition of ISCH, an anterior dural defect with the spinal cord herniating into the epidural space.

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    Intraoperative photographs of two spinal cord herniations. A: Case 2. The dura is opened posteriorly; the spinal cord is noted to be plastered to the anterior dura with an indentation noted in the cord (asterisk), corresponding to the location of the herniation anteriorly. B: Case 3. The spinal cord is rotated to the contralateral side using the divided dentate ligament as a handle. The dentate ligaments are clipped to the dural edge (asterisk). Note the cord herniation and the anterior dural defect (arrow).

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    Case 5. A: Preoperative sagittal computed tomography (CT) myelogram reconstruction showing T6–7 disc herniation and a T5–6 ISCH. B: Preoperative axial CT myelogram showing the spinal cord plastered anteriorly. C: Stage I. Postoperative sagittal T2-weighted MR image revealing changes in the T6–7 VB following a thoracoscopic discectomy. D: Stage II. Postoperative sagittal CT myelogram obtained after reduction of the ISCH. E: Long-term follow-up T2-weighted MR image demonstrating development of thoracic syringomyelia.

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    Case 7. Structural differences between ISCH and dorsal intradural arachnoid cyst. A: Sagittal T2-weighted MR image showing an anterior T4–5 cord herniation. Note the flow void posterior to the herniation. B: Sagittal T2-weighted MR image revealing a posterior intradural arachnoid cyst. The gross similarity to image A emphasizes the difficulties of making a correct diagnosis. Reprinted with permission from Lippincott Williams & Wilkins. C: Axial T2-weighted MR image showing the same anterior spinal cord herniation shown in A. Note the nerve roots traversing the posterior subarachnoid space (arrows). Thin-cut images facilitate the visualization of this hallmark sign, helping to differentiate the two diagnostic entities. D: Axial T2-weighted MR image showing a posterior intradural arachnoid cyst. No nerve roots can be seen because the cyst wall has forced them to move anterolaterally. Reprinted with permission from Lippincott Williams & Wilkins. E: Artist’s rendering depicting the findings shown in C, with part of the spinal cord herniating anteriorly (arrow). F: Artist’s rendering emphasizing the findings in D. Note how the cyst wall forces the nerve roots anterolaterally.

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