Intradural Lumbar Disc Herniation Associated with Degenerative Spine Disease

Abstract

The first case of lumbar intradural disc herniation was reported as early as 1942; since then more than 150 cases have been reported, mostly in the lumbar spine. Gadolinium-enhanced magnetic resonance image (MRI) is considered the "gold standard" for diagnosing this entity, although it is rarely performed routinely in lumbar disc disease and diagnosis is often made intra-operatively and in retrospect in regard to the imaging.A 63-year-old Italian man presented to the emergency department complaining of lower back pain, difficulty in walking, and in urination, with bilateral leg pain. On examination, he showed uneven gait, pain in the right thigh and leg with intact sphincter function. A magnetic resonance image of the lumbar spine showed a large mediolateral herniated disc at L3-L4, also the patient had a stenosis at the thoracic level at T11-T12 and T12-L1. The plan was to do an MRI with Gado however the patient went into retention and so was operated before the MRI with Gado.Results: Intraoperatively the pathology was first identified as a big cyst like structure, that as thought to be a synovial cyst, and then once it was opened it turned out to be an intradural extension of a herniated disc. Decompression was also done at the thoracic level and finally instrumentation was done from T10 to S1. Conclusion:Intradural lumbar disc herniations are a rare entity, most of the time the diagnosis is not made pre operatively, however once it is diagnosed intra-operatively, careful removal of the herniated material should be done to avoid damaging the rootlets, sometimes u have double pathologies that need to be addressed like in this patient where he had both lumbar and thoracic stenoses.Keywords: Disc; Intradural; Lumbar stenosis; Thoracic stenosis; Decompression; Dual pathology Case ReportThe first case of lumbar intradural disc herniation was reported in 1942 [1] since then, more than 150 cases have been reported, mostly affecting the lumbar spine.It has been postulated that chronic spinal degenerative disease coupled with adhesions between the Posterior Longitudinal Ligament (PLL) and the Dura are the pathomechanisms responsible [2].We report a case of a 63 year old Italian man, who presented to us with difficulty walking and urinating, with a sequestered disc at the level of L3-L4 which was found to be intradural disc herniation intraoperatively, he also had a stenosis secondary to a disc herniation at T11-T12 and T12-L1 that needed to be addressed.A 63 year old man, previously known to have hypertension, the patients history dates back to a couple of years before his presentation when he had leg pain that was successfully treated with a discectomy at the L5-S1 level.He was doing well till a couple of months before presenting to us when he was having progressively increasing back pain and right thigh numbness and pain and a couple of days prior to presentation he started having difficulty with urination.On examination he had numbness along the L3 right distribution, and he had right L3 radiculopathy, with ...