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Thread: Spontaneous or induced herniation of the spinal cord as a cause of Brown-Sequard syndrome

  1. #1

    Spontaneous or induced herniation of the spinal cord as a cause of Brown-Sequard syndrome

    • Adams RF and Anslow P (2001). The natural history of transdural herniation of the spinal cord: case report. Neuroradiology. 43 (5): 383-7. Summary: We report a patient with a Brown-Sequard syndrome who developed ventral transdural spinal cord herniation, showing the imaging findings changing over time from two thoracic disc protrusions with a normal spinal cord to a cord trapped within a bony defect in a thoracic vertebra. Neuroradiology Department, Radcliffe Infirmary, Oxford, UK.
    • Aizawa T, Sato T, Tanaka Y, Kotajima S, Sekiya M and Kokubun S (2001). Idiopathic herniation of the thoracic spinal cord: report of three cases. Spine. 26 (20): E488-91. Summary: STUDY DESIGN: Cases are reported and the literature is reviewed. OBJECTIVE: To present three cases involving idiopathic herniation of the thoracic cord. SUMMARY OF BACKGROUND DATA: Idiopathic spinal cord herniation is a very rare condition. Only 20 cases have been reported. The radiographic and intraoperative findings concerning this herniation remain insufficient, and its pathophysiology is less understood. METHODS: Idiopathic herniation of the thoracic spine was managed operatively in the three cases. The clinical, radiologic, and intraoperative features in these cases are described, and the pathophysiology of this disorder is discussed from a review of the literature. RESULTS: Two of the three patients had a defect in the inner layer of the duplicated ventral dura mater through which the spinal cord was herniated. The third patient had a ventral epidural cyst into which the spinal cord had protruded. Operative reduction of the spinal cord improved motor power in all three patients, although sensory disturbance remained unchanged. CONCLUSIONS: There should be several types of idiopathic spinal cord herniation. This is the first report of this herniation that focuses the abnormalities of the ventral dura mater, together with image and intraoperative findings. Department of Orthopaedic Surgery, Tohoku University School of Medicine, Japan.
    • Antich PA, Sanjuan AC, Girvent FM and Simo JD (1999). High cervical disc herniation and Brown-Sequard syndrome. A case report and review of the literature. J Bone Joint Surg Br. 81 (3): 462-3. Summary: We describe a rare herniation of the disc at the C2/C3 level in a 73-year-old woman. It caused hemicompression of the spinal cord and led to the Brown-Sequard syndrome. The condition was diagnosed clinically and by MRI six months after onset. Discectomy and fusion gave complete neurological resolution. Spine Surgery Department, Hospital de Sabadell, Barcelona, Spain.
    • Berbel A, Porta-Etessam J, Martinez-Salio A, Perez-Martinez DA, Saiz-Diaz RA, Rivas JJ and Ruiz J (2001). [Idiopathic spinal cord herniation. Presentation of a new case and review of the literature]. Rev Neurol. 32 (1): 54-7. Summary: INTRODUCTION: Idiopathic herniation of the spinal cord is a rarely diagnosed condition. It is important since this cause of paraparesis is potentially curable if diagnosis is made early. Our aim is to report a new case, review the relevant literature, describe the radiological findings and consider the etiopathogenic findings. CLINICAL CASE: We report the case of a 56 year old man with increasing difficulty in walking attributed to stenosis of the lumbar spinal canal, which did not improve after laminectomy. On examination he had sensory and motor deficits compatible with the Brown-Sequard syndrome. Dorsal MR showed ventral displacement of the thoracic spinal cord with disappearance of the anterior subarachnoid space together with a posterior arachnoid cyst at the same site. A further operation was done at the same place and the cyst removed. However, it was impossible to free the spinal cord since there was severe spinal arachnoiditis. The patient made little improvement. CONCLUSIONS: Herniation of the spinal cord is a rarely diagnosed condition. After careful study of the literature it seems that all patients present in a similar manner. Clinically there is a disorder of gait compatible with the Brown-Sequard syndrome. On MR there is sudden ventral displacement of the thoracic spinal cord, associated in some cases with an arachnoid cyst. When surgery is effective there is great improvement, so this diagnosis should be remembered in all cases of progressive paraparesis. Servicio de Neurologia, Hospital 12 de Octubre, Madrid, Espana.
    • Cellerini M, Bayon S, Scazzeri F, Mangiafico S, Amantini A, Guizzardi GC and Giordano GP (2002). Idiopatic spinal cord herniation: a treatable cause of Brown-Sequard syndrome. Acta Neurochir (Wien). 144 (4): 321-5. Summary: We report two cases of thoracic idiopathic spinal cord herniation (ISCH) focusing on the peculiar diagnostic and therapeutic issues posed by this rare disorder. In particular MR evaluation of CSF dynamic with a 2D PC cine-MR technique and demonstration of progressive cord herniation on consecutive MR examinations allowed insight on the differential diagnosis and pathophysiological mechanisms of ISCH. Neuroradiology Unit, Careggi Hospital, Florence, Italy.
    • Ewald C and Hassler WE (2001). [Spontaneous herniation of the thoracic spinal cord as the etiology of progressive Brown-Sequard syndrome. A description of 3 cases]. Nervenarzt. 72 (6): 441-4. Summary: Spontaneous herniation of the spinal cord through a ventral dural defect is a rare neurological entity. We report on 3 patients treated in our clinic within 6 months. In 2 cases, the lesions were located at the BWK6 level and, in one case, at BWK2. The clinical presentation of all patients was f progressive Brown-Sequard's Syndrome. Diagnosis was confirmed by magnetic resonance imaging. In all cases, operation was performed. The myelon was replaced in the dural sleeve and the defect covered with a patch of lyophilized dura. After 1 year, symptoms were stable in 2 patients. In one case there was a slight deterioration because of an inexplicable swelling of the spinal cord which could not be controlled with a second operation. Pathophysiological, clinical, and radiological aspects are presented and discussed. Neurochirurgische Klinik, Klinikum Duisburg, Zu den Rehwiesen 7-9, 47055 Duisburg.
    • Ewald C, Kuhne D and Hassler WE (2000). Progressive spontaneous herniation of the thoracic spinal cord: case report. Neurosurgery. 46 (2): 493-5; discussion 495-6. Summary: OBJECTIVE AND IMPORTANCE: We report one case of spontaneous thoracic spinal cord herniation. To our knowledge, this is the first case involving radiological documentation of the development of herniation. Clinical features and surgical techniques are also presented. CLINICAL PRESENTATION: We describe the case of a 51-year-old female patient who experienced progressive Brown-Sequard syndrome for 2 years. Three magnetic resonance imaging examinations were performed; they revealed the progressive development of anterolateral spinal cord herniation at the level of T6 during those 2 years. INTERVENTION: After laminectomy at T6, the herniated myelon was microsurgically removed and the neurological symptoms improved. CONCLUSION: We present the possible causes, the proposed pathophysiological mechanisms, and the clinical and radiological development of this rare entity, with a review of the literature published to date. We propose that a preexisting weakness of the ventral dural fibers, combined with abnormal adhesion of the spinal cord to the anterior dural sleeve, leads to progressive herniation throughout life. Microsurgical treatment may halt the exacerbation of the neurological symptoms. Neurochirurgische Klinik, Klinikum Duisburg, Germany.
    • Kenez J, Barsi P, Varallyay G, Bobest M and Veres R (2002). [In Process Citation]. Ideggyogy Sz. 55 (5-6): 168-72. Summary: Transdural herniation of the spinal cord is thought to be previously extremely rare and very often misdiagnosed. Possible reasons may be iatrogenic and traumatic or in about one third of cases it may be unknown, where the probable origin might be a congenital dural defect. The pathology may show characteristic and misleading MR patterns of the thoracic spine, emphasising the importance of these patterns. This anomaly can lead to progressive Brown-Sequard syndrome. Surgical intervention, consisting the repair of the dural defect may result in improvement or even complete regression of the neurologic deficits. Semmelweis Egyetem, Egeszsegtudomanyi Kar, Neuroradiologiai Tanszek, 1021 Budapest, Huvosvolgyi ut 116.
    • Massicotte EM, Montanera W, Ross Fleming JF, Tucker WS, Willinsky R, TerBrugge K and Fehlings MG (2002). Idiopathic spinal cord herniation: report of eight cases and review of the literature. Spine. 27 (9): E233-41. Summary: STUDY DESIGN: A case series of eight patients with idiopathic spinal cord herniation and a review of the literature. OBJECTIVE: To report on this rare entity, provide insight on its natural history, and propose an optimal management strategy. SUMMARY OF BACKGROUND DATA: Idiopathic spinal cord herniation is a rare disease with 50 cases reported before the current study. METHODS: Eight cases (follow-up 1 month to 8 years) are reported using available information from patient charts, interviews, and assessments. All imaging studies are reviewed. The review of the literature was performed using PUBMED. RESULTS: Four patients, followed without surgical intervention, have not progressed. Of the three patients who underwent surgical repair by one of the authors, two improved and one was unchanged. A fourth patient, who was initially treated by another surgeon who failed to identify the dural defect and herniation, had a poor outcome. CONCLUSION: The pathophysiology of the dural defect is still uncertain. The typical presentation is Brown-Sequard syndrome. Microsurgical repair in cases with progression of neurologic deficits is usually successful in achieving recovery of function or arrest of progression. Division of Neurosurgery and; Neuro-radiology, University of Toronto, Toronto, Ontario, Canada.
    • Miyaguchi M, Nakamura H, Shakudo M, Inoue Y and Yamano Y (2001). Idiopathic spinal cord herniation associated with intervertebral disc extrusion: a case report and review of the literature. Spine. 26 (9): 1090-4. Summary: 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-Sequard 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. Orthopaedic Surgery, Osaka City University Medical School, Japan.
    • Morokoff AP, Tress BM and Kaye AH (2001). Idiopathic spinal cord herniation. J Clin Neurosci. 8 (2): 180-3. Summary: Spinal cord herniation is a rare condition that has become increasingly recognised in the last few years. The authors report a case of idiopathic spinal cord herniation in a 33 year old woman who presented with progressive Brown-Sequard syndrome. The diagnosis was made on MR imaging. After repairing the herniation the patient made a gradual improvement. Potential causes are discussed, including the possible role of dural tethering. In conclusion, idiopathic spinal cord herniation is a potentially treat able condition that should be more readily diagnosed with increased awareness and newer imaging techniques such as high resolution MRI. Department of Neurosurgery, Royal Melbourne Hospital, University of Melbourne, Parkville, VIC 3050, Australia.
    • Tekkok IH (2000). Spontaneous spinal cord herniation: case report and review of the literature. Neurosurgery. 46 (2): 485-91; discussion 491-2. Summary: OBJECTIVE AND IMPORTANCE: Spontaneous herniation of the spinal cord substance through a previously uninjured and/or untouched dura is a very exceptional occurrence. Spontaneous spinal cord herniation, which was first reported 25 years ago, is a cause of myelopathy that is treatable but difficult to diagnose. CLINICAL PRESENTATION: A 49-year-old female patient who presented with a 3-year history of a burning sensation and hyperesthesia in her right leg and a 3-month history of left leg stiffness was diagnosed as exhibiting signs of Brown-Sequard syndrome. Magnetic resonance imaging of the thoracic spinal canal demonstrated S-shaped anterior kinking and transdural herniation of the spinal cord at the T3-T4 levels. INTERVENTION: The patient underwent surgery via a three-level laminectomy. The herniated part of the spinal cord was microsurgically reduced, and the dural defect was repaired with Gore-Tex membrane (WL Gore & Associates, Flagstaff, AZ). The outcome of surgery was excellent. CONCLUSION: Review of the world literature revealed 29 reported cases, with 27 of these cases being published since 1990. The clinical features, radiological diagnosis, and treatment options for this unique entity are summarized, with a synopsis of numerous misconceptions that appeared in the literature. With more familiarity with and increased awareness of this entity, more cases will be diagnosed. Department of Neurosurgery, Bayindir Medical Center, Ankara, Turkey.
    • Ugarriza LF, Cabezudo JM, Porras LF and Rodriguez-Sanchez JA (2001). Cord compression secondary to cervical disc herniation associated with calcification of the ligamentum flavum: case report. Neurosurgery. 48 (3): 673-6. Summary: OBJECTIVE AND IMPORTANCE: Calcification of the ligamentum flavum is a rare disease that occurs almost exclusively in elderly Japanese people. We report the case of a young Caucasian woman who presented with a C5-C6 disc herniation associated with a cervical calcified ligamentum flavum. CLINICAL PRESENTATION: The patient presented with a cord compression syndrome of 76 hours' evolution. At exploration, a Brown-Sequard syndrome at the C6 level was found. Magnetic resonance imaging and computed tomography led to a correct diagnosis and planning for decompression. INTERVENTION: We operated on the patient through a combined anterior and posterior approach. After the patient underwent anterior discectomy with intersomatic arthrodesis, we performed posterior decompression. During the operation, we observed that the dura mater could not be separated from the ligamentum, so an en bloc excision of both structures was performed. Microscopic examination indicated that the excised ligamentum had calcification, and total integration of the dura mater into the structure of the ligamentum was demonstrated. To our knowledge, this circumstance has never been described before. A posterior C3-C7 arthrodesis was performed to prevent postoperative kyphosis. Recovery was successful, with total recovery from neurological deficits 4 months later. CONCLUSION: Calcification of the ligamentum flavum is a progressive disease that starts early in life and becomes symptomatic later in life when spinal stenosis occurs. Magnetic resonance imaging and computed tomography provide adequate diagnosis and allow proper surgical planning for decompression. The presence of hyperintense areas within the spinal cord parenchyma, in the absence of a traumatic antecedent, does not preclude a complete recovery. Servicio de Neurocirurgia, Hospital Universitario Infanta Cristina, Carretera de Portugal s/n, Badajoz, Spain.
    • Wada E, Yonenobu K and Kang J (2000). Idiopathic spinal cord herniation: report of three cases and review of the literature. Spine. 25 (15): 1984-8. Summary: STUDY DESIGN: Three case reports and a literature review are presented. OBJECTIVE: To describe characteristic clinical and radiographic findings of idiopathic spinal cord herniation. SUMMARY OF BACKGROUND DATA: Idiopathic spinal cord herniation is a rare disease, with only 26 cases reported before the current study. METHODS: Three cases of idiopathic spinal cord herniation are reported, and previous reports on this subject are reviewed. RESULTS: The responsible regions were in the thoracic spine from T2 to T7. Symptoms were mainly unilateral muscle atrophy in the lower extremity and sensory disturbance below the thoracic level. These symptoms had been progressing gradually. Magnetic resonance imaging demonstrated a unique feature: The spinal cord shifted anteriorly in a few segments. Computed tomographic myelogram showed another distinctive picture: There was no subarachnoid space anterior to the spinal cord. CONCLUSIONS: Because idiopathic spinal cord herniation is out of the concept of "compression myelopathy," this condition may be a pitfall in the diagnosis. Idiopathic spinal cord herniation should be recognized as one of the treatable causes for thoracic myelopathy. Department of Orthopaedic Surgery, Osaka University Medical School, Suita, Japan.

  2. #2
    200+ cases now in literature. I have this diagnosis and underwent repair/reconstruct nine months ago. I am curious about the thoracic vertebrae defect correlation to this problem. I have read in the literature that an vertebral endplate anomaly is commonly seen on the MRI at the level of the dural hole. While, I am told that there is no way to determine the cause of the dural defect, I think it would be valuable to identify if this is a potential congenital problem or from trauma.

    I would also really like to connect with other people that have undergone this repair.

  3. #3
    Hey! I'm 37 years old, male, with SCI T1 since 1998, on Sep 2014 I had a three-level laminectomy to repair T8 - T10 herniated disc.

    after a couple of months my back start to crack when sitting on chair or bed when I stretch with my arms, it crack on the way up and on the way down.

    is that normal?

  4. #4
    Disc herniation is not the same as spinal cord herniation (the topic of this thread).


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