Resident Physician NYU New York, New York, United States
Case Diagnosis: Thoracic Spinal Cord Herniation
Case Description: Idiopathic spinal cord herniation is a rare condition that usually affects the thoracic spinal cord. It is characterized by ventral displacement of the spinal cord through a dural defect, resulting in neurological impairment secondary to adhesion and vascular compromise.
This is a 75 year old female presenting with 8 months of left lower extremity pain rated a 5/10, numbness in bilateral lower extremities and progressive gait instability.
Patient had mild mid-thoracic tenderness and diminished sensation in bilateral lower extremities. Patient’s strength in bilateral lower limbs was a 4/5 and reflexes were normal.
MRI of the thoracic spine demonstrated that the right ventral aspect of the cord was tethered and herniated through dura above T6-7 with central disc protrusion suggestive of a cord herniation.
Discussions: ISCH patients may demonstrate an unusual presentation of myelopathy with progressive lower extremity weakness, asymmetric pain or temperature sensory loss and even possible incontinence. Several theories on the pathogenesis have been proposed, including congenital dural deficiency, history of trauma, pressure erosion of the dura, and duplication of the ventral dura. Thoracic spine involvement may be due to the normal kyphosis of the thoracic spine, the anterior position of the thoracic spinal cord, the impact of flexion and extension, and the physiological ventral movement of the spinal cord.
The patient underwent a T6-7 laminectomy and repair of ventral cord herniation with improvement in her gait and in her pain rated a 2/10 down from the initial 5/10.
Conclusions: The natural history of ISCH remains unknown, with most cases treated with surgical management at diagnosis. Thoracic spinal cord herniation is often treated either conservatively with clinical and radiological surveillance or surgically with reduction of spinal cord herniation. ISCH is a rare source of pain that is important to monitor and further investigate to improve its management.
