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Unilateral paramedian transpedicular approach for repair of anterior transdural spinal cord herniation: report of a case and literature review.

Kasliwal MK, O'toole JE, Deutsch H - Asian Spine J (2012)

Bottom Line: Idiopathic spinal cord herniation is a rare but potentially treatable cause of thoracic myelopathy.The rarity and variable clinical presentation often results in missed diagnosis and delay in treatment.Considering the anterior location of the dural defect, a posterolateral allows for a more ventral view without spinal cord manipulation.

View Article: PubMed Central - PubMed

Affiliation: Department of Neurosurgery, Rush University Medical Center, Chicago, IL, USA.

ABSTRACT
Idiopathic spinal cord herniation is a rare but potentially treatable cause of thoracic myelopathy. The rarity and variable clinical presentation often results in missed diagnosis and delay in treatment. Posterior midline approach with laminectomy has been the most common approach performed for spinal cord herniation in cases described in the literature. A posterior approach is limited by the danger of retracting the spinal cord and difficulty visualizing the dural defect. Considering the anterior location of the dural defect, a posterolateral allows for a more ventral view without spinal cord manipulation. We report a rare case of idiopathic spinal cord herniation which was managed by unilateral paramedian transpedicular approach with an excellent clinical outcome.

No MeSH data available.


Related in: MedlinePlus

Intraoperative photograph very clearly demonstrating the anterior dural defect with the reduced spinal cord.
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Figure 2: Intraoperative photograph very clearly demonstrating the anterior dural defect with the reduced spinal cord.

Mentions: A 48-year-old female presented with two year history of back pain and progressive difficultly walking. She gradually developed increasing numbness in both lower limbs over one year. She also developed increasing urinary retention. There was no history of trauma/fever or any other systemic disease. She was evaluated by an orthopedic spine surgeon and was referred to a physician following a negative lumbar magnetic resonance imaging (MRI). Neurological examination revealed presence of weakness in bilateral lower extremities (4-/5, Medical Research Council [MRC] grade) and asymmetrical sensory loss from T8 below consistent with a diagnosis of thoracic myelopathy (Nurick grade 4). Persistent symptoms with worsening gait imbalance led us to perform of thoracic spine MRI which surprisingly revealed presence of a focal anterior kink of the thoracic cord at the T7-T8 level (Fig. 1). The spinal cord at T7/8 level was narrow and deformed without any definite T2 signal abnormality with prominence of the dorsal subarachnoid space. The MRI imaging was suspicious of a diagnosis of anterior transdural spinal cord herniation (Fig. 1). Surgical management was planned and a unilateral right paramedian incision was used to perform a transpedicular exposure due to slight eccentric location of the spinal cord herniation to the right (Fig. 1). Intraoperative neuromonitoring was performed recording somatosensory evoked potentials (SSEPs) and motor evoked potentials (MEPs). T7/T8 pediculotomy was performed with partial costotransversectomy to provide the optimal anterolateral trajectory. A paramedian right dura incision was made, providing exquisite visualization of the anterior dural defect with the herniated spinal cord (Fig. 2). Using a Woodson dissector, the spinal cord was reduced back into the thoracic dura. The SSEP's were normal throughout the procedure. There was transient reduction in MEP amplitude during mobilization of the spinal cord to reduce the herniation. The MEP amplitude returned to baseline status an hour later. A Duragen (Integra Life Sciences Corp., Plainsboro, NJ, USA) patch was used as graft to seal the defect which was reinforced with Tisseel fibrin glue. (Baxter Healthcare Corp., Deerfield, IL, USA) No fusion or instrumentation was performed. Patient experienced improvement in sensory symptoms right after the surgery and had improvement in her pain, motor strength (4+/5, MRC grade) and gait at three months follow-up with improvement in her Nurick myelopathy grade to 2. Postoperative MRI revealed reduction of the spinal cord with no evidence of herniation (Fig. 3).


Unilateral paramedian transpedicular approach for repair of anterior transdural spinal cord herniation: report of a case and literature review.

Kasliwal MK, O'toole JE, Deutsch H - Asian Spine J (2012)

Intraoperative photograph very clearly demonstrating the anterior dural defect with the reduced spinal cord.
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC3302916&req=5

Figure 2: Intraoperative photograph very clearly demonstrating the anterior dural defect with the reduced spinal cord.
Mentions: A 48-year-old female presented with two year history of back pain and progressive difficultly walking. She gradually developed increasing numbness in both lower limbs over one year. She also developed increasing urinary retention. There was no history of trauma/fever or any other systemic disease. She was evaluated by an orthopedic spine surgeon and was referred to a physician following a negative lumbar magnetic resonance imaging (MRI). Neurological examination revealed presence of weakness in bilateral lower extremities (4-/5, Medical Research Council [MRC] grade) and asymmetrical sensory loss from T8 below consistent with a diagnosis of thoracic myelopathy (Nurick grade 4). Persistent symptoms with worsening gait imbalance led us to perform of thoracic spine MRI which surprisingly revealed presence of a focal anterior kink of the thoracic cord at the T7-T8 level (Fig. 1). The spinal cord at T7/8 level was narrow and deformed without any definite T2 signal abnormality with prominence of the dorsal subarachnoid space. The MRI imaging was suspicious of a diagnosis of anterior transdural spinal cord herniation (Fig. 1). Surgical management was planned and a unilateral right paramedian incision was used to perform a transpedicular exposure due to slight eccentric location of the spinal cord herniation to the right (Fig. 1). Intraoperative neuromonitoring was performed recording somatosensory evoked potentials (SSEPs) and motor evoked potentials (MEPs). T7/T8 pediculotomy was performed with partial costotransversectomy to provide the optimal anterolateral trajectory. A paramedian right dura incision was made, providing exquisite visualization of the anterior dural defect with the herniated spinal cord (Fig. 2). Using a Woodson dissector, the spinal cord was reduced back into the thoracic dura. The SSEP's were normal throughout the procedure. There was transient reduction in MEP amplitude during mobilization of the spinal cord to reduce the herniation. The MEP amplitude returned to baseline status an hour later. A Duragen (Integra Life Sciences Corp., Plainsboro, NJ, USA) patch was used as graft to seal the defect which was reinforced with Tisseel fibrin glue. (Baxter Healthcare Corp., Deerfield, IL, USA) No fusion or instrumentation was performed. Patient experienced improvement in sensory symptoms right after the surgery and had improvement in her pain, motor strength (4+/5, MRC grade) and gait at three months follow-up with improvement in her Nurick myelopathy grade to 2. Postoperative MRI revealed reduction of the spinal cord with no evidence of herniation (Fig. 3).

Bottom Line: Idiopathic spinal cord herniation is a rare but potentially treatable cause of thoracic myelopathy.The rarity and variable clinical presentation often results in missed diagnosis and delay in treatment.Considering the anterior location of the dural defect, a posterolateral allows for a more ventral view without spinal cord manipulation.

View Article: PubMed Central - PubMed

Affiliation: Department of Neurosurgery, Rush University Medical Center, Chicago, IL, USA.

ABSTRACT
Idiopathic spinal cord herniation is a rare but potentially treatable cause of thoracic myelopathy. The rarity and variable clinical presentation often results in missed diagnosis and delay in treatment. Posterior midline approach with laminectomy has been the most common approach performed for spinal cord herniation in cases described in the literature. A posterior approach is limited by the danger of retracting the spinal cord and difficulty visualizing the dural defect. Considering the anterior location of the dural defect, a posterolateral allows for a more ventral view without spinal cord manipulation. We report a rare case of idiopathic spinal cord herniation which was managed by unilateral paramedian transpedicular approach with an excellent clinical outcome.

No MeSH data available.


Related in: MedlinePlus