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Age: 53

Sex: Female

Indication: Back pain

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Spinal Cord Herniation


Findings

  • MRI
    • Focal ventral deviation of the spinal cord from the level of the inferior endplate of T4 through the mid T5 vertebral body with a C-shaped concavity along the dorsal margin of the cord at this level and likely dural defect with no CSF signal visualized along the ventral aspect of the deviated cord
    • Thin CSF signal ventral epidural collection immediately cranial and caudal to the cord contour abnormality extending throughout the thoracic spine
    • Mild multilevel degenerative disc disease with a small posterior disc bulge at T7-T8 and multilevel mild facet hypertrophy and ligamentum flavum thickening. No significant spinal canal or neural foraminal stenosis
    • No abnormal cord signal
    • No abnormal marrow signal
    • Normal alignment

 

  • CT myelogram
    • Status post multilevel midthoracic laminectomies
    • Persistent focal ventral deviation of the spinal cord from the level of the inferior endplate of T4 through the mid T5 vertebral body with a C-shaped concavity along the dorsal margin of the cord at this level and likely dural defect with no CSF signal visualized along the ventral aspect of the deviated cord

 


Diagnosis

  • Spinal cord herniation

Sample Report

MRI preliminary report:

Focal ventral displacement of the spinal cord at the level of T4-T5 with likely associated dural defect concerning for spinal cord herniation. The differential diagnosis also includes a dorsal arachnoid cyst, which is considered less likely given lack of a defined collection and CSF pulsation artifact along the dorsal aspect of the cord at this level, and arachnoid web, though the cord contour abnormality is not as typical for an arachnoid web. Recommend neurosurgical evaluation and consideration of CT myelogram for further assessment.

Thin CSF signal ventral epidural collection immediately cranial and caudal to the cord contour abnormality extending throughout the thoracic spine concerning for CSF leak associated with the dural defect. No significant associated mass effect on the cord.


Discussion

  • Unlike patients with dorsal arachnoid cysts and webs, patients with ventral cord herniation will not benefit from exploration/fenestration of the dorsal thecal sac
  • Given the potential overlapping imaging appearances of these entities, patients with cord herniation are at risk for surgical mismanagement
  • CT myelography can be a useful problem-solving tool in these cases because a dorsal arachnoid cyst should have delayed filling with contrast material compared to the remainder of the thecal sac
  • Given that cord herniation involves the spinal cord (which lives in the subarachnoid space) extending through the dura, cord herniation may be accompanied by a CSF leak, so patients with cord herniation can present with signs and symptoms of intracranial hypotension


Images

Focal ventral deviation of the thoracic spinal cord through a likely dural defect, concerning for cord herniation. Focal ventral deviation of the thoracic spinal cord through a likely dural defect, concerning for cord herniation. CT myelography confirms the MRI findings, raising primary concern for cord herniation rather than an arachnoid cyst or web.



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