Superficial siderosis due to dural defect with thoracic spinal cord herniation

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.

Download Full-text

Imaging Findings in Dorsal Thoracic Arachnoid Web and the Differential Diagnosis of “Scalpel Sign”

Neurographics ◽

10.3174/ng.1900037 ◽

2020 ◽

Vol 10 (2) ◽

pp. 96-102

Author(s):

P.M. Brasil ◽

L.P. Pereira ◽

D.G.F. Távora ◽

A.C.F. Camara ◽

C.L. Macedo Filho ◽

...

Keyword(s):

Spinal Cord ◽

Mr Imaging ◽

Correct Diagnosis ◽

Dural Defect ◽

Imaging Findings ◽

Thoracic Spinal Cord ◽

Ventral Cord ◽

Thoracic Spinal ◽

Spinal Cord Herniation ◽

Idiopathic Spinal Cord Herniation

A dorsal thoracic arachnoid web represents an intradural extramedullary transverse band of arachnoid tissue that causes mass effect and dorsal cord indentation, and can or cannot be associated with spinal cord altered signal. On sagittal MR imaging, this focal dorsal indentation of the thoracic spinal cord resembles a scalpel with its blade pointing posteriorly (called a “scalpel sign”). Although very suggestive of dorsal thoracic arachnoid web, this sign is not specific and should be differentiated from other ventral cord displacement causes (eg, idiopathic spinal cord herniation and spinal arachnoid cyst). In idiopathic spinal cord herniation, cord tissue protrudes through a ventral dural defect, and the focal deformity can be seen along the ventral aspect of the cord on spinal axial MR imaging and with a characteristic “C sign” on sagittal MR imaging; in spinal arachnoid cysts, the marginated walls and the presence of smooth, wide scalloping of the cord surface can be identified. Recognition of these imaging findings, especially the scalpel sign, can help radiologists and clinicians make a correct diagnosis of ventral cord displacement causes and allow subsequent prompt treatment for the patient.

Download Full-text

Differentiation of idiopathic spinal cord herniation from dorsal arachnoid webs on MRI and CT myelography

Journal of Neurosurgery Spine ◽

10.3171/2016.11.spine16696 ◽

2017 ◽

Vol 26 (6) ◽

pp. 754-759 ◽

Cited By ~ 13

Author(s):

Randall Schultz ◽

Andrew Steven ◽

Aaron Wessell ◽

Nancy Fischbein ◽

Charles A. Sansur ◽

...

Keyword(s):

Spinal Cord ◽

Subarachnoid Space ◽

Herniated Disc ◽

Dural Defect ◽

Thoracic Spinal Cord ◽

Ct Myelography ◽

Presenting Symptoms ◽

Signal Abnormality ◽

Thoracic Spinal ◽

Spinal Cord Herniation

OBJECTIVEDorsal arachnoid webs (DAWs) and spinal cord herniation (SCH) are uncommon abnormalities affecting the thoracic spinal cord that can result in syringomyelia and significant neurological morbidity if left untreated. Differentiating these 2 entities on the basis of clinical presentation and radiological findings remains challenging but is of vital importance in planning a surgical approach. The authors examined the differences between DAWs and idiopathic SCH on MRI and CT myelography to improve diagnostic confidence prior to surgery.METHODSReview of the picture archiving and communication system (PACS) database between 2005 and 2015 identified 6 patients with DAW and 5 with SCH. Clinical data including demographic information, presenting symptoms and neurological signs, and surgical reports were collected from the electronic medical records. Ten of the 11 patients underwent MRI. CT myelography was performed in 3 patients with DAW and in 1 patient with SCH. Imaging studies were analyzed by 2 board-certified neuroradiologists for the following features: 1) location of the deformity; 2) presence or absence of cord signal abnormality or syringomyelia; 3) visible arachnoid web; 4) presence of a dural defect; 5) nature of dorsal cord indentation (abrupt “scalpel sign” vs “C”-shaped); 6) focal ventral cord kink; 7) presence of the nuclear trail sign (endplate irregularity, sclerosis, and/or disc-space calcification that could suggest a migratory path of a herniated disc); and 8) visualization of a complete plane of CSF ventral to the deformity.RESULTSThe scalpel sign was positive in all patients with DAW. The dorsal indentation was C-shaped in 5 of 6 patients with SCH. The ventral subarachnoid space was preserved in all patients with DAW and interrupted in cases of SCH. In no patient was a web or a dural defect identified.CONCLUSIONSDAW and SCH can be reliably distinguished on imaging by scrutinizing the nature of the dorsal indentation and the integrity of the ventral subarachnoid space at the level of the cord deformity.

Download Full-text

Repair of Thoracic Spinal Cord Herniation: 2-Dimensional Operative Video

Operative Neurosurgery ◽

10.1093/ons/opy409 ◽

2019 ◽

Vol 17 (4) ◽

pp. E161-E161

Author(s):

Siri Sahib S Khalsa ◽

Yamaan S Saadeh ◽

Brandon W Smith ◽

Jacob R Joseph ◽

Mark E Oppenlander

Keyword(s):

Spinal Cord ◽

Lower Extremities ◽

Urinary Symptoms ◽

Dural Defect ◽

Thoracic Myelopathy ◽

Thoracic Spinal Cord ◽

Thoracic Spinal ◽

Spinal Cord Herniation ◽

Patient Consent ◽

Progressive Weakness

Abstract Spinal cord herniation is an uncommon surgically treatable cause of thoracic myelopathy and progressive paraplegia. The thoracic spinal cord focally protrudes through a defect in the dura, resulting in progressive weakness, numbness, and spasticity affecting the lower extremities, in addition to possible urinary symptoms. In this video, we present the case of a 69-yr-old female who presented with 3 yr of progressive thoracic myelopathy due to a thoracic spinal cord herniation at T4-T5. We demonstrate the surgical steps to lyse arachnoid webs, mobilize the spinal cord, reduce the spinal cord herniation, and repair the dural defect. Appropriate patient consent was obtained.

Download Full-text

Transdural herniation of the thoracic spinal cord: untethering via a posterolateral transpedicular approach

Journal of Neurosurgery Spine ◽

10.3171/spi.2004.1.2.0223 ◽

2004 ◽

Vol 1 (2) ◽

pp. 223-227 ◽

Cited By ~ 20

Author(s):

Ryder Gwinn ◽

Fraser Henderson

Keyword(s):

Spinal Cord ◽

Posterior Approach ◽

Thoracic Spinal Cord ◽

Dural Repair ◽

Content Type ◽

Transpedicular Approach ◽

Thoracic Spinal ◽

Novel Approach ◽

Spinal Cord Herniation ◽

Thoracic Cord

✓ Anterior spinal cord herniation is a well-documented condition in which the thoracic cord becomes tethered within a defect in the anterior dura mater. Typical procedures have involved a posterior approach with direct manipulation of the thoracic cord to expose and blindly release its point of tethering. The authors report three cases in which a novel approach for the treatment of anterior thoracic cord herniation was performed, cord manipulation and traction are minimized, and direct dural repair of the defect is performed.

Download Full-text

Focal Anterior Displacement of the Thoracic Spinal Cord without Evidence of Spinal Cord Herniation or an Intradural Mass

Korean Journal of Radiology ◽

10.3348/kjr.2014.15.6.733 ◽

2014 ◽

Vol 15 (6) ◽

pp. 733 ◽

Cited By ~ 1

Author(s):

Jong Yoon Lee ◽

Joon Woo Lee ◽

Guen Young Lee ◽

Heung Sik Kang

Keyword(s):

Spinal Cord ◽

Thoracic Spinal Cord ◽

Anterior Displacement ◽

Thoracic Spinal ◽

Spinal Cord Herniation

Download Full-text

Thoracic Spinal Cord Herniation presenting with Brown-Sequard Syndrome

Japanese Journal of Neurosurgery ◽

10.7887/jcns.10.389 ◽

2001 ◽

Vol 10 (6) ◽

pp. 389-393

Author(s):

Motohiro Kajiwara ◽

Junya Hanakita ◽

Hideyuki Suwa ◽

Kazuhiko Shiokawa ◽

Masaaki Saiki ◽

...

Keyword(s):

Spinal Cord ◽

Thoracic Spinal Cord ◽

Thoracic Spinal ◽

Spinal Cord Herniation ◽

Brown Sequard Syndrome

Download Full-text

Upper thoracic spinal cord herniation after traumatic nerve root avulsion

Neurosurgical FOCUS ◽

10.3171/foc.2004.16.5.20 ◽

2004 ◽

Vol 16 (5) ◽

pp. 306-309

Author(s):

Victor R. DaSilva ◽

Mubarak Al-Gahtany ◽

Rajiv Midha ◽

Dipanka Sarma ◽

Perry Cooper

Keyword(s):

Spinal Cord ◽

Nerve Root ◽

Signs And Symptoms ◽

Root Avulsion ◽

Thoracic Spinal Cord ◽

First Case ◽

Thoracic Spinal ◽

Spinal Cord Herniation ◽

Nerve Root Avulsion ◽

Upper Thoracic

✓ Transdural herniation of the spinal cord, a rare but well-documented entity, has been reported sporadically for more than 25 years as a possible cause for various neurological signs and symptoms ranging from isolated sensory or motor findings to myelopathy and Brown–Séquard syndrome. The authors report, to the best of their knowledge, the first case of upper thoracic spinal cord herniation occurring after traumatic nerve root avulsion.

Download Full-text