IMAGE OF THE MOMENT
Transdural spinal cord herniation with extradural cerebrospinal fluid collection Liam S Carroll, James T H Teo Department of Neurology, Princess Royal University Hospital, King’s College Hospital NHS Trust, London, UK Correspondence to Dr James T H Teo, Department of Neurology, Princess Royal University Hospital, King’s College Hospital NHS Trust, London BR6 8ND, UK; [email protected] Accepted 25 May 2015
To cite: Carroll LS, Teo JTH. Pract Neurol Published Online First: [ please include Day Month Year] doi:10.1136/ practneurol-2015-001159
A 58-year-old female nurse with a background of asthma gave a 7-year history of slowly progressing ‘stiff knees’ and stumbles. A rheumatological diagnosis was suspected; however, bilateral lower-limb radiological investigations were normal. Her gait slowed to the extent that she had to take leave from work and required a walking stick. Subsequently, she developed gradual onset of altered sensation below the thorax with urinary incontinence and difficulty in passing stool. She therefore presented to the emergency department. On examination, she had reduced strength of right ankle dorsiflexion and plantarflexion and a sensory level with a loss of proprioception and touch sensation below T6. An MR scan of spine (figure 1A) showed a spinal cord
herniation at T5/T6 adjacent to a vertebral osteophyte, indicating a site and mechanism of a dural tear. We noted anterior cerebrospinal fluid (CSF) signal that was extradural and anterior to the thecal sac (figure 1B) extending from the cervical cord to the lumbar spine (figure 1A). A CT myelogram (figure 1C, D) confirmed an epidural collection of contrast, consistent with a CSF leak (figure 1C, yellow asterisk) and more clearly identified the vertebral osteophyte (figure 1D, blue arrow). Neurosurgical management involved a T4, T5 laminectomy with identification of a rightward rotated spinal cord. The surgeon identified the dural defect and noted a herniated spinal cord with a yellowish, gliotic appearance. The dural opening was expanded and adhesions
Figure 1 Imaging of transdural spinal cord herniation. MR scan of spine in sagittal (A) and transverse section (B) shows cord herniation at T5/T6 with anterior cerebrospinal fluid (CSF) signal extradurally. CT myelogram in identical planes (C and D) confirming an epidural CSF leak (C, yellow asterisk) and vertebral osteophyte (D, blue arrow). Carroll LS, et al. Pract Neurol 2015;0:1–2. doi:10.1136/practneurol-2015-001159
1
IMAGE OF THE MOMENT dissected with a dural substitute (Neuropatch) applied anteriorly to the cord. Intraoperative neurophysiological monitoring showed reduced motor-evoked potentials to the right lower limb with an intact D-wave. Postoperatively, she was well and following physiotherapy her right ankle dorsiflexion and plantarflexion strength had improved relative to baseline. However, at the time of discharge from hospital, her sensory level persisted. Transdural spinal cord herniation with extradural fluid collection is an uncommon cause of gradual onset weakness. However, multiple cases have been described in the literature.1 2 Some have followed trauma but most are apparently spontaneous, although in retrospect there may be associated osteophytes or disc protrusions.2 Thus, transdural spinal cord
2
herniation is an important diagnosis to consider in patients with gradual onset weakness of unclear cause. Contributors LSC prepared the manuscript which was then reviewed and edited by JTHT. Competing interests None declared. Patient consent Obtained. Provenance and peer review Not commissioned; internally peer reviewed.
REFERENCES 1 Castelnovo G, Hladky JP, Renard D. Spontaneous transdural spinal cord herniation. Neurology 2014;82:1290. 2 Brus-Ramer M, Dillon WP. Idiopathic thoracic spinal cord herniation: retrospective analysis supporting a mechanism of diskogenic dural injury and subsequent tamponade. AJNR Am J Neuroradiol 2012;33:52–6.
Carroll LS, et al. Pract Neurol 2015;0:1–2. doi:10.1136/practneurol-2015-001159
Transdural spinal cord herniation with extradural cerebrospinal fluid collection Liam S Carroll, James T H Teo Department of Neurology, Princess Royal University Hospital, King’s College Hospital NHS Trust, London, UK Correspondence to Dr James T H Teo, Department of Neurology, Princess Royal University Hospital, King’s College Hospital NHS Trust, London BR6 8ND, UK; [email protected] Accepted 25 May 2015
To cite: Carroll LS, Teo JTH. Pract Neurol Published Online First: [ please include Day Month Year] doi:10.1136/ practneurol-2015-001159
A 58-year-old female nurse with a background of asthma gave a 7-year history of slowly progressing ‘stiff knees’ and stumbles. A rheumatological diagnosis was suspected; however, bilateral lower-limb radiological investigations were normal. Her gait slowed to the extent that she had to take leave from work and required a walking stick. Subsequently, she developed gradual onset of altered sensation below the thorax with urinary incontinence and difficulty in passing stool. She therefore presented to the emergency department. On examination, she had reduced strength of right ankle dorsiflexion and plantarflexion and a sensory level with a loss of proprioception and touch sensation below T6. An MR scan of spine (figure 1A) showed a spinal cord
herniation at T5/T6 adjacent to a vertebral osteophyte, indicating a site and mechanism of a dural tear. We noted anterior cerebrospinal fluid (CSF) signal that was extradural and anterior to the thecal sac (figure 1B) extending from the cervical cord to the lumbar spine (figure 1A). A CT myelogram (figure 1C, D) confirmed an epidural collection of contrast, consistent with a CSF leak (figure 1C, yellow asterisk) and more clearly identified the vertebral osteophyte (figure 1D, blue arrow). Neurosurgical management involved a T4, T5 laminectomy with identification of a rightward rotated spinal cord. The surgeon identified the dural defect and noted a herniated spinal cord with a yellowish, gliotic appearance. The dural opening was expanded and adhesions
Figure 1 Imaging of transdural spinal cord herniation. MR scan of spine in sagittal (A) and transverse section (B) shows cord herniation at T5/T6 with anterior cerebrospinal fluid (CSF) signal extradurally. CT myelogram in identical planes (C and D) confirming an epidural CSF leak (C, yellow asterisk) and vertebral osteophyte (D, blue arrow). Carroll LS, et al. Pract Neurol 2015;0:1–2. doi:10.1136/practneurol-2015-001159
1
IMAGE OF THE MOMENT dissected with a dural substitute (Neuropatch) applied anteriorly to the cord. Intraoperative neurophysiological monitoring showed reduced motor-evoked potentials to the right lower limb with an intact D-wave. Postoperatively, she was well and following physiotherapy her right ankle dorsiflexion and plantarflexion strength had improved relative to baseline. However, at the time of discharge from hospital, her sensory level persisted. Transdural spinal cord herniation with extradural fluid collection is an uncommon cause of gradual onset weakness. However, multiple cases have been described in the literature.1 2 Some have followed trauma but most are apparently spontaneous, although in retrospect there may be associated osteophytes or disc protrusions.2 Thus, transdural spinal cord
2
herniation is an important diagnosis to consider in patients with gradual onset weakness of unclear cause. Contributors LSC prepared the manuscript which was then reviewed and edited by JTHT. Competing interests None declared. Patient consent Obtained. Provenance and peer review Not commissioned; internally peer reviewed.
REFERENCES 1 Castelnovo G, Hladky JP, Renard D. Spontaneous transdural spinal cord herniation. Neurology 2014;82:1290. 2 Brus-Ramer M, Dillon WP. Idiopathic thoracic spinal cord herniation: retrospective analysis supporting a mechanism of diskogenic dural injury and subsequent tamponade. AJNR Am J Neuroradiol 2012;33:52–6.
Carroll LS, et al. Pract Neurol 2015;0:1–2. doi:10.1136/practneurol-2015-001159
