- Department of Orthopaedics, Naha City Hospital, Naha City, Japan.
Hisashi Serikyaku, Department of Orthopaedics, Naha City Hospital, Naha City, Japan.
DOI:10.25259/SNI_561_2021Copyright: © 2021 Surgical Neurology International This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-Share Alike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.
How to cite this article: Hisashi Serikyaku, Shoichiro Higa, Tetsuya Yara. Intradural disc herniation at the L1-2 level. 12-Jul-2021;12:351
How to cite this URL: Hisashi Serikyaku, Shoichiro Higa, Tetsuya Yara. Intradural disc herniation at the L1-2 level. 12-Jul-2021;12:351. Available from: https://surgicalneurologyint.com/surgicalint-articles/10957/
Background: Intradural disc herniations (IDHs) are rare, are difficult to diagnose on preoperative MR/CT imaging, and typically, are most readily confirmed at the time of surgery. However, one of the greatest challenges posed by these lesions, is the repair of the ventral dural rent.
Case Description: A 55-year-old male with a 20-year history of lumbago presented with low back pain and right lower extremity sciatica of 3 months’ duration. The MR and CT studies showed a compressive lesion at the L1-2 level. There was no original suspicion that this was an IDH. At surgery, performed under the operating microscope, a subtotal L1-L2 laminectomy was performed (i.e. while lysing severe adhesions between the posterior longitudinal ligament and the ventral dura, a traumatic durotomy occurred. White, spongious, friable, soft tissue, and free-floating disc fragments extruded through the durotomy site. Notably, it was initially considered to be a tumor rather than a disc. Once all fragments had been delivered, unsuccessful attempts were made to repair the ventral dura. Further efforts were curtailed due to concern that they would result in damage to multiple ventral nerve rootlets. Despite the lack of primary dural repair, the secondary measures resulted in no postoperative recurrent cerebrospinal fluid leakage (CSF) and a smooth postoperative surgical course.
Conclusion: IDH at the L1-2 level is rare, and preoperative MR/CT studies may not always document their intradural location. Ideally, ventral dural tears attributed to these lesions should be directly repaired and/or managed with additional adjunctive CSF leak repair techniques (i.e. muscle patch grafts, microfibrillar collagen, and fibrin sealants).
Keywords: Intradural disc herniation, Lumbar spine, Laminectomy, Durotomy, Suturing of ventral dura, Cerebrospinal fluid leakage, L1-2 level
Intradural disc herniations (IDHs) are very rare (0.26% and 0.30%).[
A 55-year-old male presented with low back pain and right leg sciatica of 3 months’ duration. His preoperative neurological examination was normal.
X-rays, MR, and CT studies
The preoperative X-rays, MR, and CT did not show pathognomonic findings for an IDH. Plain X-rays showed no widening of interpedicular distance or significant vertebral scalloping. The MR revealed a compressive lesion ventral to the dural sac at the L1-2 level (i.e. T2-weighted sagittal and axial images), while the gadolinium-enhanced MR showed peripheral enhancement of the lesion [
A subtotal laminectomy of L1 and L2 was performed under a surgical microscope. Several attempts were made to retract the dural sac on the right side to expose the disc fragments. However, this was very difficult due to marked adhesions between the posterior longitudinal ligament (PLL) and the ventral dura. An inadvertent median durotomy occurred, resulting in the spontaneous extrusion of multiple white, spongious, friable, soft free-floating disc fragments. At first, this was thought to be a spinal tumor, but was later confirmed to constitute disc [
Attempt at ventral dural repair
Several attempts were made to suture the ventral dura, but were unsuccessful. Secondary measures including microfibrillar collagen and fibrin sealants were utilized for dural repair resulting in no apparent residual leak utilizing Valsalva maneuvers.
The pathological was consistent with degenerated cartilaginous tissue consistent with disc (i.e. myxoid degeneration/edematous tissue).
The postoperative course was uneventful, and there was no further CSF leakage. The MRI 3 months later showed confirmed no residual disc herniation, and the patient had fully recovered.
IDHs are rare, occurring from 0.26% to 0.30% of the time in the lumbar spine.[
Etiology of lumbar IDHs
Establishing the diagnosis of an IDH is often difficult. Discontinuity of the PLL and a “hawk-beak sign” on MRI may help diagnose IDH.[
Surgical documentation of IDH
The diagnosis of intradural herniation is often made at the time of surgery. Of the 122 cases, we identified in the literature, only eight were accurately diagnosed preoperatively.[
Surgery is the only way to remove an IDH, noting that some may regress spontaneously like other discs. Here, however, the ventral durotomy, whether deliberate or traumatic, should be closed where feasible to avoid postoperative CSF fistulas, pseudomeningoceles, meningitis, and postural headaches.[
Here, we reported an IDH at the L1-2 level that was removed through an L1-L2 laminotomy without being able to perform a primary ventral dural repair; only secondary measures were utilized (i.e. microfibrillar collagen and fibrin sealants). Although this did not result in postoperative recurrent CSF leakage, other may have this complication, thus confirming the need to perform a primary repair of the attendant durotomy whenever feasible.
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