Thoracic disk herniation with hematoma--case report

A 54-year-old man presented with an extremely rare case of intervertebral disk herniation with hematoma in the thoracic spine, manifesting as acute progressive numbness and muscle weakness in the bilateral lower extremities. He had been treated with anticoagulants. Magnetic resonance imaging of the thoracic spine showed intervertebral disk herniation and severe compression of the spinal cord at T9-10, appearing as hyperintense on T(1)- and hypointense on T(2)-weighted imaging suggestive of concomitant hematoma. His symptoms completely resolved after resection of the brownish herniated disk material. Old hemorrhage was also aspirated from the intervertebral disk space. Hemosiderin deposition was found in the cartilaginous tissue of the resected disk. Intervertebral disk herniation with hematoma is extremely rare, but may occur in patients with bleeding diathesis.     

Spontaneous thoracic spinal cord herniation--case report.

A 54-year-old female presented with spontaneous thoracic spinal cord herniation manifesting as chronic progressive motor weakness in both legs. Spastic paraparesis (4/5) and pathological reflexes such as ankle clonus were noted. She also had mild bladder dysfunction but no bowel dysfunction. She had no sensory disturbance, including tactile and pinprick sense. Magnetic resonance (MR) imaging revealed that the atrophic spinal cord was displaced into the ventral extradural space at the T4-5 intervertebral level with markedly dilated dorsal subarachnoid space. Computed tomography obtained after myelography showed no evidence of intradural spinal arachnoid cyst. She underwent surgical repair of the spinal cord herniation via laminectomy, and spinal cord herniation through the ventral dural defect was confirmed. Postoperative MR imaging revealed improvement of the spinal cord herniation, but her symptoms were not improved. Spontaneous spinal cord herniation is a rare cause of chronic myelopathy, occurring in the upper and mid-thoracic levels, and the spinal cord is usually herniated into the ventral extradural space. Early differential diagnosis from intradural spinal arachnoid cysts is important for a satisfactory outcome.     

Spinal cord compression due to tumoral idiopatic calcinosis

STUDY DESIGN: A case of thoracic spinal cord compression due to tumoral calcinosis (TC) is reported. SETTING: Galiza, Spain. CASE REPORT: A 59-year-old man was admitted to our hospital with a 2-month history of gradual leg weakness and sensory deficit. The neurological examination revealed paraparesis with T12 sensory level. Magnetic resonance imaging (MRI) showed an extradural right posterolateral mass at T11-T12 level, resulting in a marked spinal cord compression. He underwent T11-T12 laminectomy and mass excision. Histological examination finally led to the diagnosis of TC. CONCLUSION: TC is an uncommon cause of mass lesions of the spine. Since there is no typical spine TC MRI appearance, the final diagnosis is done by histological studies. TC should be considered in differential diagnosis of spinal cord compression and constitutes a treatable cause of paraparesis.     

Thoracic disc herniation leads to anterior spinal artery syndrome demonstrated by diffusion-weighted magnetic resonance imaging (DWI): a case report and literature review

BackgroundThoracic disc herniation rarely causes acute ischemic events involving the spinal cord. Few reports have suggested this as a mechanism leading to anterior spinal artery syndrome, and none with illustration through diffusion-weighted magnetic resonance imaging (DWI).PurposeThe purpose of this study was to report a case of anterior spinal artery syndrome secondary to thoracic disc herniation and demonstrate the first use of DWI to aid in diagnosis of this rare myelopathy.Study designCase report.MethodsA 36-year-old woman developed sudden onset of back pain followed by evolving paraparesis and sensory loss consistent with anterior spinal artery distribution ischemia. T2-weighted magnetic resonance imaging (MRI) demonstrated an acute herniated nucleus pulposus at the T7–T8 disc, which produced a focal indentation of the adjacent anterior spinal cord without cord displacement or canal stenosis. T2-weighted hyperintensities were seen at T4–T7 levels with corresponding brightness on DWI and reduction of the apparent diffusion coefficient, consistent with cord ischemia.ResultsRemarkably, within just a few days and following conservative treatment, including heparin and steroids, this patient's neurologic status began to show improvement. Within 3 weeks, she was ambulating with assisted devices, and at the 10-month follow-up, the patient had nearly complete neurological improvement. A follow-up MRI at 10 months showed normal T2-weighted imaging except for a 1×2-mm area of anterior-left lateral cord myelomalacia at T4–T5.ConclusionsAcute thoracic disc herniation with cord contact but without canal stenosis is able to disrupt blood flow to the cord leading to anterior spinal artery distribution ischemia. This case represents the first demonstrated use of DWI in diagnosing this rare cause of anterior spinal artery ischemia.     

Thoracic disc herniation mimicking acute lumbar disc disease

STUDY DESIGN: Case report of a 49-year-old woman with a lower thoracic disc herniation mimicking acute lumbosacral radiculopathy. OBJECTIVE: To describe an unusual case of thoracic disc herniation mimicking acute lumbar disc disease. SUMMARY OF BACKGROUND DATA: Symptomatic thoracic disc herniation is rare and its clinical manifestations differ widely from those of cervical and lumbar disc herniations. Midline back pain and signs of spinal cord compression progressing over months or years are the predominant clinical features. Acute and subacute thoracic disc herniation occurs in less than 10% of patients, and isolated root pain is unusual. METHODS: A 49-year-old woman had acute low back pain radiation into the left buttock and the lateral aspect of the left leg and left foot. Magnetic resonance imaging study showed a bulging disc and posterior osteophytes at T11-T12. RESULTS: Surgical removal of the herniated disc and osteophytes rapidly relieved her symptoms and neurologic deficits. A follow-up neurologic examination 3 years later showed normal motor and sensory functions, although low back soreness was noted occasionally. CONCLUSION: A case of thoracic disc herniation mimicking an acute lumbosacral radiculopathy is presented. Compression of the lumbosacral spinal nerve roots at the lower thoracic level after exit from the lumbar enlargement may be the mechanism for this unusual presentation.     

Emergency thoracic diskectomy for the acute onset of paraplegia: report of two cases

BACKGROUND: Thoracic disk herniation is a rare event, and acute presentation of this lesion is even less common. METHODS: Case reports. FINDINGS: Both patients presented with rapidly progressing lower extremity weakness and sphincter dysfunction. Radiographic work-up revealed large herniated thoracic disks with spinal cord compression. Emergency thoracic diskectomy was performed. RESULTS: Both patients had partial reversal of neurologic and sphincter abnormalities after emergency surgery. CONCLUSIONS: Thoracic disk herniation, although rare, should be considered when patients present with acute thoracic myelopathy. Early surgical intervention may reverse some neurologic injuries.     

Thoracic disk disease: diagnosis and treatment

Symptomatic degenerative disk disease is much less common in the thoracic spine than in the cervical and lumbar regions. Accurate diagnosis relies on a strong clinical suspicion that is confirmed with appropriate diagnostic imaging. Presenting symptoms vary tremendously, from atypical pain patterns to myelopathy. The use of computed tomography in combination with myelography and magnetic resonance imaging have greatly increased the ability to accurately visualize thoracic spine disorders. The superior resolution of available imaging modalities has made the incidental detection of asymptomatic thoracic disk abnormalities more frequent. Most patients with symptomatic thoracic disk disease will respond favorably to nonoperative management. Surgery is indicated for the rare patient with an acute thoracic disk herniation with progressive neurologic deficit (i.e., signs or symptoms of thoracic spinal cord myelopathy). Once surgical intervention has been chosen, careful preoperative planning is necessary. The level, anatomic location, and morphology of the herniation must be precisely determined to select the optimal approach. Posterior laminectomy has largely been abandoned for the treatment of symptomatic thoracic disk protrusions. Surgeons still may choose among anterior, lateral, and posterior approaches when surgically addressing the thoracic intervertebral disk.     

Spinal cord compression due to multivel thoracic disc herniation: surgical decompression using a "combined" approach. A case report and review of the literature

A case presenting with signs of spinal cord compression due to double contiguous thoracic disc herniation (TDH) is reported. A 66-year-old woman presented with a 4-month history of intermittent episodes of weakness and numbness in the lower extremities, and urinary dysfunction. Six weeks prior to admission complete paraplegia developed. The diagnosis was established by MRI. Treatment consisted of complete excision of the herniated discs (T8-T9 and T9-T10) and decompression of the spinal cord with a right transpedicular approach combined with standard posterior approach. The postoperative course was uneventful, and the improvement was dramatic. We also include a review of other 39 case reports from the literature. This article highlights the importance of consideration of TDH when one deals with a case with an anterior mass causing spinal cord compression.     

Single-level Calcified Cervical Disk Herniation in a 13-year-old Girl

This article describes a case of a 13-year-old girl with single-level calcified cervical disk herniation. The patient was treated conservatively for a symptomatic intervertebral calcification that caused neurological compression, and the data were reviewed retrospectively. Previous reports have shown that the natural history of the disease is self-limiting with a benign course and an excellent prognosis. However, on rare occasions when the calcified nucleus pulposus herniates into the spinal canal and compresses the spinal cord or its roots, neurological abnormalities can occur, such as radiculopathy and myelopathy. This also raises the question of whether operative therapy will eventually be necessary.In the current case, conservative treatment was applied. Plain radiographs are usually sufficient to determine the presence and extent of a calcified cervical disk, and computed tomography or magnetic resonance imaging can detect an associated disk herniation. Conservative treatment with antalgics, muscle relaxants, neurotrophic drugs, and a cervical collar were applied. The patient was completely free of symptoms 3 weeks after the initial treatment. Magnetic resonance imaging indicated complete vertebral canal clearance at final follow-up.Cervical intervertebral disk calcification and herniation is a rare disorder in children with an obscure etiology but a good prognosis. Conservative therapy produces satisfactory results, even if clinical symptoms due to nerve root or spinal cord compression are present. Surgical treatments are only suitable in rare cases with severe progressive radicular pain or neurological deficit.     

Idiopathic spinal cord herniation associated with intervertebral disc extrusion: a case report and review of the literature

STUDY DESIGN: A case of idiopathic spinal cord herniation is reported, and the literature is reviewed. OBJECTIVE: To report a case of thoracic spinal cord herniation with a ventral dural defect, probably caused by thoracic disc extrusion. SUMMARY OF BACKGROUND DATA: Recently, reports of spinal cord herniation have been increasing. This increase can be attributed to the development of magnetic resonance imaging and increased awareness of this entity. However, the cause of the ventral dural defect remains unknown. METHODS: A 54-year-old woman had experienced Brown-Séquard syndrome for 2 years. Magnetic resonance imaging demonstrated an S-shaped anterior kinking of the spinal cord, with dilation of the dorsal subarachnoid space. RESULTS: After incision of the dural sac and gentle retraction of the spinal cord, a dural defect was recognized into which the spinal cord had herniated. An extruded disc was visualized through the defect at T3-T4. The ventral dural defect and the dorsal incision of the dural sac were repaired with a fascial graft from the thigh. CONCLUSIONS: Intraoperative findings suggest that the thoracic disc herniation in the current case was the probable cause of the ventral dural defect. Surgical reconstruction using double fascial graft under careful spinal cord monitoring resulted in a satisfactory neurologic recovery.     

Vertebral hemangioma extending into the spinal canal: case report

A 73-year-old woman was admitted to our hospital presenting slowly progressive hypoesthesia below the 5th thoracic dermatome and spastic paraparesis. Computed tomography (CT) and magnetic resonance imaging (MRI) revealed a mass lesion in the T3 vertebral body extending into the spinal canal. The spinal cord was compressed to the left side and right T3 and T4 nerve roots were encased in the mass lesion. One week after admission, T2-T4 laminectomy was performed to relieve the spinal cord compression. A highly vascularized tumor was observed in the epidural space at T3 and T4 levels. The tumor in the spinal canal was removed. The histopathological diagnosis was cavernous hemangioma. The patient's symptoms improved after the surgery. Asymptomatic vertebral hemangiomas are common, but its extraosseus extension causing neurologic symptoms (compressive vertebral hemangioma) is rare. The clinical symptoms, the radiological features, and the strategies for the treatment of compressive vertebral hemangiomas were discussed.     

Emergency Thoracic Diskectomy For The Acute Onset Of Paraplegia: Report Of Two Cases

Abstract

Background: Thoraeie disk herniation is a rare event, and acute presentation of this lesion is even less common.

Methods: Case reports.

Findings: Both patients presented with rapidly progressing lower extremity weakness and sphincter dysfunction. Radiographie work-up revealed large herniated thoracic disks with spinal cord compression. Emergency thoracic diskectomy was performed.

Results: Both patients had partial reversal of neurologic and sphincter abnormalities after emergency surgery.

Conclusions: Thoraeie disk herniation, although rare, should be considered when patients present with acute thoracic myelopathy. Early surgical intervention may reverse some neurologic injuries.     

A case of idiopathic spinal cord herniation with duplicated dura mater

The patient was a 48-year-old man in whom a slow progression in walking difficulty occurred over a year. Magnetic resonance imaging (MRI) and computed tomography myelography (CTM) revealed duplicated dura mater from T1 to T12 and spinal cord herniation in the inner layer of the dura at the T4-T5 level. Idiopathic spinal cord herniation with duplicated dura mater was diagnosed, and surgery was performed. Intraoperative findings were of an elliptical defect of about 1 cm in the inner layer of the dura at the T4-T5 level, into which the spinal cord was herniated. A 1.5-cm cephalocaudal incision was created in the inner layer of the dura, and the incarcerated spinal cord was released, resulting in resolution of gait disturbance and an excellent postoperative clinical course. We reviewed the reports of 11 cases of idiopathic spinal cord herniation with duplicated dura mater and summarized the clinical and imaging characteristics as follows: 1) A hernial orifice was found at the T4-T6 level, 2) cross-sectional MRI or CTM showed a "snowman-like" deformation of the spinal cord, and 3) symptoms were often improved by widening the hernia orifice.     

Idiopathic spinal cord herniation associated with calcified thoracic disc extrusion--case report

A 48-year-old man presented with idiopathic spinal cord herniation associated with calcified thoracic disc extrusion at the T7-8 intervertebral level, manifesting as Brown-Sequard syndrome at the thoracic level persisting for 20 years. Preoperative magnetic resonance imaging and computed tomography myelography revealed ventral displacement of the spinal cord and extrusion of a calcified disc at the T7-8 intervertebral level. At surgery, the spinal cord herniation at this level was released from the dura mater and carefully returned to the dural sac. An extruded calcified thoracic disc was found just below the dural defect at the same level. The development of idiopathic spinal cord herniation is associated closely with a defect in the ventral dura mater of unknown etiology. In our case, the etiology of the ventral dural defect was probably associated with the calcified thoracic disc extrusion.     

经胸腔侧前方入路治疗胸椎间盘突出症

本文报告经胸腔侧前方入路切除椎间盘治疗胸椎间盘突出症９例。均为中央型和旁中央型，经过脊髓造影、ＣＴＭ或ＭＲＩ检查确诊。随访１～４年，平均２年１０个月。根据Ｏｔａｎｉ分级方法标准，结果为优３例，良５例，一般１例，优良率达８９％，获得较满意效果。采用ＣＴＭ或ＭＲＩ诊断胸椎间盘突出有较高价值。该手术方法直接、充分地显露硬膜囊和神经结构，切除突出的椎间盘和刮除骨赘，减压较安全有效，同时对脊柱的稳定性和脊髓的血供影响较小。作者认为经胸腔侧前方入路进行椎间盘切除减压是治疗胸椎间盘突出症的一种安全有效的方法。     

Thoracic cord compression in Scheuermann's disease

A 29-year-old man with spastic paraparesis of insidious onset was discovered to have thoracic cord compression by a combination of kyphosis and thoracic disc herniation. Radiologic evaluation showed evidence of Scheuermann's disease, of which thoracic kyphosis is one manifestation. Neurologic signs are uncommon in Scheuermann's disease and few cases have been successfully managed with resolution of neurologic deficit. This patient made a virtually complete recovery after thoracic cord decompressions by costrotransversectomy and transthoracic approaches.     

Dumbbell hydatid cyst of the spine: case report and review of the literature

STUDY DESIGN: A case report of a hydatid cyst in the retropleural space at T7-T8 with an extension into the spinal canal through an intervertebral foramen complicated by paraparesis due to thoracic cord compression. OBJECTIVE: To confirm that hydatid cyst should be considered in the differential diagnosis for any mass discovered in the human body. SUMMARY OF BACKGROUND DATA: Appearance of a dumbbell-shaped mass in the thoracic spine is highly suggestive of neurofibroma. Hydatid cyst, although very rare, may have the same appearance. The spine is involved in 50% of hydatid disease of the bone. A hydatid cyst of the bone and muscle is always primary. Neurologic recovery is possible because it is a slow-growing lesion. METHOD: Clinical symptoms, differential diagnosis, and treatment are reviewed. The patient was treated successfully by total surgical excision of the lesion through a posterior retropleural approach. No medical treatment was prescribed. RESULTS: Surgical excision is effective in the treatment of hydatid disease of the spine, particularly if there is no extensive bony destruction and it is possible to achieve neurologic recovery after decompression of the thoracic spine. CONCLUSION: Extra spinal hydatidosis may lead to spinal cord compression by extension through the intervertebral foramen. The possibility of cure is high when there is no bony involvement.     

Idiopathic spinal cord herniation which extended remarkably up- and downward from dural defect: case report

A case of idiopathic spinal cord herniation which extended remarkably up- and downward from a dural defect is described. A 53-year-old woman presented with numbness and pain of the right lower limb. Magnetic resonance (MR) imaging revealed ventral displacement of the spinal cord and dilation of the dorsal subarachnoid space at T4-5. CT Myelography showed ventral deviation of the spinal cord at the T4/5 level. A laminectomy of T3-T5 was performed, and the herniated spinal cord was untethered and wrapped by Goretex membrane. Postoperative MR image revealed normal location of the spinal cord. Among many cases of spinal cord herniations, this one is considered to be a rare case of idiopathic spinal cord herniation which showed marked protrusion up- and downward from a dural defect.     

Idiopathic Spinal Cord Herniation: Case Report and Literature Review

Summary  We report one case of spontaneous thoracic spinal cord herniation presenting with a progressive spastic paraparesis for 4 years in a 55 years old man. From preoperative MRI, showing a ventrally displaced atrophic spinal cord at T2–T3 level, a dorsal intradural arachnoid cyst was suspected. At operation, after a 3 level laminectomy, no arachnoid cyst was found and spinal cord herniation into a meningeal diverticulum was confirmed. The herniated myelon was replaced intradurally and the lumen of the diverticulum was filled with Teflon? settled with fibrin glue to prevent recurrence. Postoperatively some neurological recovery was achieved.  The literature was reviewed, regarding clinical and epidemiological features, proposed pathophysiological mechanisms, treatment options and outcome. Only 32 surgically proved cases of thoracic spinal cord herniation with no past history of spine trauma, injury or surgery were found.     

Upper thoracic disc herniation followed by acutely progressing paraplegia

STUDY DESIGN: Case report. OBJECTIVE: To report a rare thoracic intervertebral disc herniation followed by acutely progressing paraplegia. SETTING: Spinal Injuries Center, Fukuoka, Japan. METHOD: A 37-year-old man presented with sudden severe backache and acutely progressing motor impairments of both lower extremities after antecedent backache lasting about 5 days. Neurological examination showed analgesia and hypoesthesia below the T4 dermatome level, dysesthesia to pinprick below right inguinal level, and severe motor impairments of the lower extremities (Frankel classification C). Magnetic resonance (MR) imaging demonstrated spinal cord compression due to a postero-laterally existing epidural mass at the T2-T3 level. After laminectomy at the T2-T3 level, the sequestrated disc material was detected and excised as one piece through the right side of the dura. The excised herniated mass had a ring-like form and was thought to originate from the annulus fibrosis. RESULT: After the emergency surgery, he had complete relief from the backache and control of both lower extremities recovered gradually. At 4 weeks after the emergent operation, motor power of both lower extremities recovered almost completely. He was able to walk without any assistance. MR imaging study after surgery did not reveal the sequestrated mass, except for a mild disc bulging at the T2-T3 level. CONCLUSION: Accurate diagnosis of acute symptomatic thoracic disc herniation is occasionally difficult. However, timely and successful surgery could result in complete symptom relief and satisfactory results.