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Disc herniation, occult on preoperative imaging but visualized microsurgically, as the cause of idiopathic thoracic spinal cord herniation

  • Case Report - Spine
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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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Abbreviations

CSF:

Cerebrospinal fluid

ISCH:

Idiopathic spinal cord herniation

MRI:

Magnetic resonance imaging

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Contribution of authors

Christian T. Ulrich: conception and design, acquisition of data, analysis and interpretation of data, drafting the article, critically revising the article, administrative/technical/material support, and study supervision

Christian Fung: acquisition of data, analysis and interpretation of data, and critically revising the article

Eike Piechowiak: acquisition of data, analysis and interpretation of data, and critically revising the article

Jan Gralla: acquisition of data, analysis and interpretation of data, and critically revising the article

Andreas Raabe: acquisition of data, analysis and interpretation of data, and critically revising the article

Jürgen Beck: conception and design, acquisition of data, analysis and interpretation of data, critically revising the article, and study supervision

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Authors and Affiliations

  1. Department of Neurosurgery, Bern University Hospital, Inselspital, 3010, Bern, Switzerland

    Christian T. Ulrich, Christian Fung, Andreas Raabe & Jürgen Beck

  2. Institute of Neuroradiology, Bern University Hospital, Inselspital, Bern, Switzerland

    Eike Piechowiak & Jan Gralla

Authors
  1. Christian T. Ulrich
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  2. Christian Fung
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  3. Eike Piechowiak
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  4. Jan Gralla
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  5. Andreas Raabe
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  6. Jürgen Beck
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Corresponding author

Correspondence to Jürgen Beck.

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The patient has consented to submission of this case report to the journal.

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Comments

The experience at our department is that the majority of thoracic ISCH have an anatomical correlation to a locally degenerated disk. The perception is that the etiology of these dura defects, together with medullary adhesions and posterior arachnoid cyst-like membranes which all show a similar appearance on sagittal MRI of a typically ventrally displaced and deformed spinal cord, is primarily caused by local inflammatory processes in the acute phase of a disk degeneration. Only secondarily, an erosion of the dura is caused by spondylophytes and/or calcifications of the disk.

The authors’ opinion is that a locally bulging disk has eroded the dura. This bulging is quite discrete as it is not clearly visible on the MRI. It is of course difficult to estimate the degree of pressure on the dura from the enclosed image (Fig. 2).

I do not share the theory of mechanical erosion as main cause of the pathology in this case. An intraoperatively visualized dural opening or defect amounting to 14 mm cranio-caudally is described. A standard mid-thoracic dorsal disk height normally amounts to about 3–4 mm, and a bulging would cause another mm of disk exposed to the dura.

It is known (Takaguchi 2009 and others) that there is next to no vertical shift of the dura in the thoracic region. At the Th11–12 level, there is a sub mm shift compared to the mid-lumbar region with about 3 mm shift. An erosion alone from a small disk bulging or herniation 4–5 mm in height therefore does not explain a 14-mm defect. There etiology may be a congenital disorder or more probable, a local inflammatory reaction from the initial disk-degeneration phase. An erosion of the dura causing a defect by means of friction may play only an accessory role in this case. In either case, a local degeneration should be established as one of the main etiologies for ventral dural defects as the cause of spinal cord herniation and/or CSF leakage and associated signs and symptoms of intracranial hypotension.

Kyrre Pedersen

Stockholm, Sweden

The paper reports an interesting finding and a novel theory regarding the pathogenesis of spinal cord herniation; thoracic disk extrusion or spur, even small as depicted in this case, can cause dural erosion, defect, and subsequent cord herniation. The theory appears to be sound, albeit leaving some uncertainty as to if it is in fact the cause in the majority of cases with spinal cord herniation. The issue is to be solved in future with accumulation of experiences in our community. Despite the limitation, the paper indicates a rationale for surgical strategy of microsurgical dural repair and is very educative.

Phyo Kim

Tochoghi, Japan

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Ulrich, C.T., Fung, C., Piechowiak, E. et al. Disc herniation, occult on preoperative imaging but visualized microsurgically, as the cause of idiopathic thoracic spinal cord herniation. Acta Neurochir 160, 467–470 (2018). https://doi.org/10.1007/s00701-018-3466-3

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  • DOI: https://doi.org/10.1007/s00701-018-3466-3

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