ventral cord herniation

Long-term
course of anterior spinal cord herniation presenting with an upper motor neuron syndrome: case report illustrating diagnostic and therapeutic implications. Longitudinal course of anterior spinal cord herniation. a Magnifications of the Th2/Th3 segment obtained in T2-weighted sagittal imaging at different visits. Arrowheads highlight evolving anterior spinal cord herniation and a postoperative myelopathy signal. The red arrow highlights the early subtle sign of ventral spinal cord misplacement and posterior indentation. b Corresponding axial images of Th2/3. c MEP including transcranial (lines 1–2) and lumbar stimulation (lines 3–4) to the right (R) and to the left (L) tibialis anterior muscle. Central motor conductance was pathological after 8 years follow-up (arrow; amplitude R 1.27 mV, L 2.88 mV). After 11 years, spasticity had progressed to the left leg, along with affection of the left leg central motor conductance (arrow; R 1.0 mV, L 2.47 mV). Six months after neurosurgery, there were no significant changes in MEP (R 0.68 mV, L 3.02 mV). Five years after neurosurgery, cortical MEP were absent to the right leg (arrow; R –, L 2.59 mV), despite unchanged MRI. d SEP-recordings during follow-up visits, obtained from stimulation of the right (R) and left (L) tibial nerve. At 8 years follow-up, SEP P40-latency was prolonged bilaterally (R 51.8 ms, L 52.0 ms). At presentation with Brown-Séquard syndrome involving right-sided hypesthesia, SEP from the right was absent (arrow; R –, L 50.8 ms). Six months after neurosurgery, SEP from the right gradually improved (arrow; R 51.2 ms, L 51.2 ms). Five years after neurosurgery, SEP from the right leg was absent again (arrow; R –, L 53.6 ms), despite unchanged MRI. Scale: C, 20 ms/ Div. and 2000 μV/ Div.; D, 20 ms/ Div. and 1.0 μV/ Div. f/u follow-up, n/a not available
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Long-term
course of anterior spinal cord herniation presenting with an upper motor neuron syndrome: case report illustrating diagnostic and therapeutic implications. Schematic depiction of progressive anterior spinal cord herniation. a Schematic drawing of the central position of the thoracic spinal cord within the dura. The ventral dural defect may have been caused by congenital, traumatic and/ or degenerative changes. b The 8 years follow-up MRI showed ventral displacement of the spinal cord (red) as an early sign of aSCH without sensory symptoms. c When sensory symptoms evolved and surgery was performed, a substantial part of the anterior hemicord was herniated through the dural defect. 1 Vestibulospinal tract, 2 Olivospinal tract, 3 Rubrospinal tract, 4 Lateral corticospinal tract, 5 Tectospinal tract, 6 Anterior corticospinal tract, 7 Anterior reticulospinal tract, 8 Anterior spinothalamic tract, 9 Anterior spinocerebellar tract, 10 Lateral spinothalamic tract, 11 Posterior spinocerebellar tract, 12 Fasciulus gracilis
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Radiopaedia • CC-by-nc-sa 3.0 • de

Ventral cord herniation, also known by a variety of other terms such as spontaneous thoracic cord herniation or idiopathic spinal cord herniation, is a rare cause of focal myelopathy due to herniation of the thoracic cord through a dural defect.

Post-surgical cord herniation can occur at any level, usually dorsally in the cervical region following laminectomy . The remainder of this article deals with spontaneous ventral thoracic herniation.

Epidemiology

In the majority of cases, no possible antecedent cause is identified and the dural defect is thought to be congenital or idiopathic in nature. In a number of patients, a history of previous trauma or surgery in the thoracic region may be present .

Clinical presentation

Clinical presentation is variable, generally with features of myelopathy. However, progressive Brown-Sequard syndrome is classical, due to herniation of only one side of the cord .

Pathology

The underlying cause of ventral cord herniation is thought to be a dural defect allowing the subarachnoid space to communicate with the extradural space, which can be congenital or acquired . The thoracic cord, naturally closely applied to the ventral dura due to the normal thoracic kyphosis then 'plugs' the hole and gradually herniates through the defect. It is this normal anatomical relationship between the ventral theca and anterior thoracic cord which accounts for this entity only being encountered in the anterior aspect of the mid to upper thoracic spine. The distortion of the cord parenchyma, formation of adhesions, and possible vascular compromise, in turn, leads to myelopathy and neurological dysfunction .

Radiographic features

The key finding is focal distortion of the cord with a focal defect in the dura and localized cord signal change.  Although both CT and conventional myelography are able to visualize the distortion, MRI is the modality of choice to assess cord signal change and to evaluate for the differential diagnoses of spinal arachnoid cyst and dorsal thoracic arachnoid web.

MRI

Ventral cord herniation is only encountered between T2 and T8 where the normal thoracic kyphosis leads to the thoracic cord being in close proximity to the ventral theca .

The key feature is focal distortion and rotation of the cord with no CSF seen between it and the ventral theca. In most instances, the cord is seen to bulge beyond the confines of the theca and is associated with T2 signal abnormality at that level .

Small extradural CSF intensity collection may also be seen, thought to represent the bulging CSF-filled arachnoid layer .

CT

A linear hyperattenuation corresponding to a focal calcification of the nucleus pulposus at the level of the herniation with its leakage has been described and named the nuclear trail sign .

Treatment and prognosis

Surgery with division of adhesions and closure of the dural defect, which may require a dural graft/duroplasty, is curative. In most cases symptoms improve, however depending on the degree of pre-operative myelopathy complete recovery may not occur . Prominent T2 signal change within the cord may be a poor prognostic factor for full recovery .

Differential diagnosis

The key differential diagnoses include:

  • spinal arachnoid cyst
    • ​smooth indentation of the cord rather than a very focal distortion
    • altered CSF flow may be visible (on T2 or CSF flow studies)
    • myelography usually demonstrates cyst to fill slower than surrounding CSF
    • intact dura, possibly with CSF seen between the cord and the anterior theca
  • dorsal thoracic arachnoid web
    • scalpel sign due to focal compression from behind
    • intact dura, possibly with CSF seen between the cord and the anterior theca

Depending on the amount of signal abnormality within the cord, other causes of intramedullary cysts/abnormal signal should also be considered and contrast is important to exclude an intramedullary mass (e.g. ependymoma).

Siehe auch:
Assoziationen und Differentialdiagnosen zu Herniation Rückenmark:
Myelopathie
 
Wikipedia • CC BY-SA 4.0
Brown-Séquard-Syndrom
 
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