A patient with thoracic intradural disc herniation

Intradural disc herniation is a rare disease that occurs most commonly in the lumbar region, while fewer than 5% occur in the thoracic and cervical regions. We report a patient with thoracic intradural disc herniation at T12-L1 who presented with radiculopathy and motor weakness. The preoperative MRI did not demonstrate an intradural lesion, and it was identified intraoperatively by inspection and palpation of the thecal sac. The disc was removed, and the patient experienced good neurological recovery and remains pain free 1 year after surgery.     

Intradural herniation of intervertebral disc at the level of Lumbar 1-Lumbar 2

Intradural disc herniation is a serious and rare complication of intervertebral disc rupture. The preoperative diagnosis of intradural disc herniation is still difficult despite new neuroradiologic investigation possibilities including computerized tomography and magnetic resonance imaging and it is usually diagnosed by during surgery. Here we present an intradural disc herniation case at the level of L1-L2 with accompanying significant myelopathic neurologic deficits. A 50-year-old female patient was admitted to the hospital with pain and weakness in both legs. Her neurological examination revealed paraparesis. Magnetic resonance imaging showed an extruded disc hernia of central localization at the L1-L2 level. She underwent total laminectomy at the level of L1-L2 and her intradural disc fragment was extirpated by microsurgical methods.     

Cervical intradural disc herniation and cerebrospinal fluid leak

Cervical intradural disc herniation (IDH) is a rare condition and only 25 cases of cervical have been reported. We report a 45-year-old male who presented with sudden onset right lower limb weakness after lifting heavy weight. Magnetic resonance imaging of the cervical spine showed C5/6 disc prolapse with intradural extension. The patient underwent C5/6 discectomy through anterior cervical approach. Postoperatively, the patient improved in stiffness but developed cerebrospinal fluid leak and the leak resolved with multiple lumbar punctures.     

Spontaneous cervical intradural disc herniation

Cervical intradural disc herniation (IDH) is a rare condition with very few case reports in the literature. We report a 64-year-old man who presented with sudden onset neck pain and rapidly progressing weakness in the left upper and lower limb. There was no history of trauma. MRI of the cervical spine showed a C6–C7 disc prolapse, for which he underwent a C6–C7 discectomy and fusion with bone graft through an anterior cervical approach. To our knowledge, all patients with a cervical IDH reported in the literature have a traumatic etiology. To the best of our knowledge, we report the first patient with a spontaneous cervical IDH.     

Solitary thoracic intradural extramedullary ependymoma

Intradural extramedullary ependymomas of the cervical or thoracic spine are extremely rare. We present a 62-year-old woman with progressive thoracic back pain over 9 months. Magnetic resonance imaging rerevealed a thoracic intradural extamedullary tumour which was surgically removed in total. Histologic examination identified the tumour as ependymoma, WHO Grade II. Our radiological and surgical findings are consistent with the hypothesis that these turnouts develop from heterotopic glial tissue pinched off from the neural tube during its closure.     

Cervical intradural ventral arachnoid cyst resected via anterior corpectomy with reconstruction: a case report

Intradural arachnoid cysts are rare lesions that frequently arise posterior to the spinal cord in the thoracic spine region. Those located at the cervical spine level, anterior to the spinal cord are even rarer. The usual treatment of symptomatic intradural spinal cysts involves surgical removal through a posterior approach using a laminectomy or laminotomy. However, ventrally located intradural cysts are frequently not amenable to complete resection without undue manipulation of the cord and aggressive removal through a posterior approach may result in spinal cord injury. The authors present a 29-year-old male harbouring an intradural ventral cervical arachnoid cyst which was successfully resected via an anterior approach with corpectomy and reconstruction. CONCLUSION: For purely ventral cervical intradural arachnoid cysts, which compress the spinal cord dorsally, an anterior approach can allow access to the lesion without any need for intraoperative manipulation of the spinal cord. For such cases, the anterior approach prevents the consequent risk of neurological injury due to posterior approaches.     

MR imaging in the diagnosis of intradural extramedullary tuberculoma. Report of a case and review of the literature

Intradural extramedullary tuberculoma without any bony involvement is exceptional. Nineteen cases were found in the literature. We report the case of 5-year-old boy who presented acute paraplegia 8 months after a tuberculous meningitis under antituberculous treatment. Dorsal gadolinium enhanced MRI revealed an intradural extramedullary bunch-shaped enhancing mass at T5-T6 level. The tuberculous nature was confirmed by histology after surgical removal of the lesion followed by a good recovery. To our knowledge, this is the first intradural extramedullary tuberculoma detected by MRI. We underline the role of MRI in the diagnosis of this particular localisation of tuberculosis.     

Intraradicular extruded disc herniation as a rare cause of failed back surgery - case report and review of the literature

We report an unusual case of intradural intraradicular lumbar disc herniation, in which an extruded fragment of disc was found within the sheath of the left S1 nerve root. Previous surgery of our patient in another medical centre was not beneficial. The diagnosis of intraradicular extruded disc herniation was made at the time of surgery during exploration of the L5-S1 disc space. Although magnetic resonance imaging is a useful diagnostic tool in all patients with lumbar disc herniation, preoperative correct diagnosis is usually difficult, as occurred in our patient. A careful observation of the root during surgery is indicated to detect such an anatomical abnormality, especially in cases with recurrent disc herniation.     

Intradural Migration of a Sequestrated Lumbar Disc Fragment Masquerading as a Spinal Intradural Tumor

Intervertebral intradural lumbar disc herniation (ILDH) is a quite rare pathology, and isolated intradural lumbar disc herniation is even more rare. Magnetic resonance imaging (MRI) may not be able to reveal ILDHs, especially if MRI findings show an intact lumbar disc annulus and posterior longitudinal ligament. Here, we present an exceedingly rare case of an isolated IDLH that we initially misidentified as a spinal intradural tumor, in a 54-year-old man hospitalized with a 2-month history of back pain and right sciatica. Neurologic examination revealed a positive straight leg raise test on the right side, but he presented no other sensory, motor, or sphincter disturbances. A gadolinium-enhanced MRI revealed what we believed to be an intradural extramedullary tumor compressing the cauda equina leftward in the thecal sac, at the L2 vertebral level. The patient underwent total L2 laminectomy, and we extirpated the intradural mass under microscopic guidance. Histologic examination of the mass revealed a degenerated nucleus pulposus.     

Leptomeningeal metastasis of an intradural malignant peripheral nerve sheath tumor

Malignant peripheral nerve sheath tumors (MPNST) are defined as any malignant tumor arising from or differentiating towards the peripheral nerve sheath. Intradural MPNST metastases are very rare. We report, to our knowledge, the first case of leptomeningeal metastasis of a MPNST to the spine and intracranial space. A 56-year-old woman with primary intradural MPNST of the S1 nerve root developed leptomeningeal metastases as well as brain metastases 19 months after diagnosis. The patient had a history of non-Hodgkins lymphoma for which she had received irradiation to the spine 15 years prior to this presentation. She had no stigmata of neurofibromatosis type 1. Patients with MPNST may also develop leptomeningeal metastases as demonstrated in this patient with intradural post-radiation MPNST.     

A long-segment string of bead- like schwannoma of cauda equina: a case report

Spinal schwannomas are one of the most common intradural extramedullary spinal tumors. However, a string of bead-like intradural extramedullary schwannoma is highly uncommon. In the paper we present a case of a long-segment string of bead-like intradural extramedullary schwannoma of cauda equina from L2 to S2.The patient had been suffering progressive low back pain and sciatica with progressive neurological deficits for three years. She was misdiagnosed as lumbar disc herniation at her first time of hospitalization after a simple lumbar computed tomography (CT) scanning and a discectomy. We found her tumor by magnetic resonance imaging (MRI) and totally removed it. We therefore emphasize differentiating this almost completely curable tumor from other lumbar diseases such as lumbar disc herniation. It is suggested that a reasonable and careful strategy of surgery for these tumors is important.     

Extradural and intradural characteristics of the cervical nerve root anomalies

The anomalous anatomical arrangement of the cervical spinal nerve roots within the spinal canal can complicate the surgical treatment of several pathologies. This work aimed to reveal intraspinal anatomical anomalies of the extradural and also intradural cervical spinal nerve roots courses. The anatomical study was realised in 43 cadavers with a mean age of 53.7 (32 men and 11 women). After opening the spinal canal and also the dural sac the intradural and extradural anomalies of the cervical spinal nerve roots (bilaterally) were explored and documented. We found completely 49 cases (56.98%) of intraspinal cervical nerve root anomalies. Extradural anomalies were found in 11 cases (12.79%) including atypical spacing, two roots exiting through one neuroforamen, extradural communications, aberrant root. Intradural anomalies observed in 28 cases (32.56%) comprised: communications between the dorsal roots and ventral roots separately or together and the multiple communications. Other anomalies (10 cases, 11.63%) included various types of atypical spacing of the roots and their asymmetry. All the results are differentiated according to the plexus type (pre-, postfixed, normotyped). This study describes intraspinal (extradural and intradural) anatomical anomalies of the cervical spinal nerve root courses. Knowledge of these variabilities should help to prevent the failure of several medical procedures.     

Idiopathic intradural dorsal thoracic arachnoid cysts: A case series and review of the literature

BackgroundSpinal intradural arachnoid cysts (SIAC) are cerebrospinal fluid (CSF) filled sacs formed by arachnoid membranes and may be either idiopathic or acquired. Idiopathic cysts represent a separate entity and their aetiology remains uncertain. By far the most difficult differential diagnosis is distinguishing between idiopathic anterior spinal cord herniation (IASCH) and dorsal thoracic intradural arachnoid cysts (TIAC), due to their similarity in radiological appearance. Cine-mode (SSFP) is emerging as a novel technique in the diagnosis and operative planning of SIAC.MethodRetrospective analysis of patients with idiopathic TIACs that were surgically managed at Royal North Shore Hospital and North Shore Private Hospital between November 2000 and November 2015.ResultsTen patients were included in this study. Age ranged from 20 to 77 years with a mean age of 60 years and a female preponderance. The most common clinical features were progressive gait ataxia and lower limb myelopathy. Radicular pain tends to improve following surgery, however gait ataxia may not.DiscussionWhile there are circumstances in which the distinction between dorsal thoracic intradural arachnoid cysts and idiopathic anterior spinal cord herniation are radiologically obvious, in cases where the appearances are less clear, cine-mode SSFP MRI imaging can provide an invaluable tool to differentiate these pathologies and lead the clinician towards the correct diagnosis and management. The mainstay of surgical management for dorsal TIACs is laminectomy and cyst excision or fenestration. Surgery for gait ataxia should be aimed towards preventing deterioration, while maintaining the potential for symptomatic improvement, whereas surgery for radicular pain should be curative.     

Intradural Lumbar Disc Herniations Associated with Epidural Adhesion : Report of Two Cases

Intradural lumbar disc herniation (ILDH) is rare. In this report, authors present 2 cases of ILDHs associated with severe adhesion between the dural sac and posterior longitudinal ligament. In a 40-year-old man, ILDH occurred in association with epidural adhesion due to ossification of the posterior longitudinal ligament (OPLL). In other 31-year-old man, ILDH occurred in presence of epidural adhesion due to previous spine surgery.     

Spinal subdural epidermoids - a separate entity: report of 3 cases

Intradural extramedullary epidermoid cysts are rare tumors especially those not associated with spinal dysraphism. We report 3 cases of spinal intradural extramedullary epidermoid cysts. In all the cases, the lesion was situated at dorsal level. The clinical features, MRI characteristics and surgical treatment of such rare intradural extramedullary benign tumors are discussed and relevant literature is reviewed.     

显微手术治疗脊椎椎管硬膜内肿瘤

目的探讨显微手术方法治疗脊椎椎管内肿瘤的疗效。方法对43例颈、胸椎椎管内肿瘤病人在显微镜下进行肿瘤切除手术。结果本组39例手术全切,4例髓内肿瘤部分切除。随访38例,随访时间8个月～6年,34例术后恢复良好,4例神经功能恢复不明显,生活需他人帮助。结论早期诊断、早期手术切除,是治疗椎管内肿瘤,恢复脊髓功能的最有效方法。     

Concurrent syringomyelia and intradural extramedullary tuberculoma as late complications of tuberculous meningitis

Tuberculous meningitis (TBM) is a common presentation of extrapulmonary tuberculosis. TBM is associated with many complications. However, concurrent syringomyelia and intradural extramedullary tuberculoma occurring in a patient treated for TBM is rare. Only one such case has been reported earlier. A 27-year-old woman presented with paraparesis of 2 months duration. She had been treated for TBM 8 months earlier. She was found to have an extensive syringomyelia from C2 to the conus medullaris and an intradural extramedullary tuberculoma at the lower thoracic levels. At surgery, a thick, granulomatous lesion was found in the intradural extramedullary plane. Following excision of the granulomatous lesion, a syringostomy was done. The patient was treated with antituberculous drugs and steroids. Six months after treatment, there was no significant change in her neurological status. Concurrent syringomyelia and intradural extramedullary tuberculoma should be entertained in the differential diagnosis when a patient presents with myelopathy following TBM. The pathogenesis of syringomyelia in this condition is discussed.     

Spinal Intradural Extramedullary Cavernoma Presenting with Intracranial Superficial Hemosiderosis

A case of intradural extramedullary cavernous angioma is presented with headache, dizziness, and bilateral sensorineural hearing loss caused by an intracranial superficial hemosiderosis. It was incidentally found in a patient with a 3-month history of sustained headache, dizziness and a 3-year history of hearing difficulty. The neurological examination was unremarkable in the lower extremity. MR images showed an intracranial superficial hemosiderosis mostly in the cerebellar region. Myelography and MR images of the thoracolumbar spine revealed an intradural extramedullary mass, which was pathologically proven to be a cavernous angioma. T12 total laminoplastic laminotomy and total tumor removal were performed without any neurologic deficits. The patient''s symptoms, including headache and dizziness, have been absent for three years. Intradural extramedullary cavernous angioma can present with an intracranial superficial hemosiderosis as a result of chronic subarachnoid hemorrhage.     

Primary intradural pontocerebellar chordoma metastasizing in the subarachnoid spinal canal

Chordomas that are entirely extraosseous and intradural are rare. Additionally subarachnoid spinal implantation from such a cranial, intradural chordoma has never been reported before. The authors present a case of a widespread primary intradural chordoma in the basal cisterns of a 48-year-old woman which shows seeding of neoplastic cells to the spinal leptomeninges. It is concluded that also in cases of intradural and intracranial chordomas a tumor staging should include the search for spinal subarachnoid metastases.