Intradural disc herniation at L4/5 level causing Cauda equina syndrome

Abstract

Rationale: Intradural disc herniation has been documented rarely and the pathogenesis remains unclear. The region most frequently affected by intradural lumbar disc herniations is L4–5 level, and the average age of intradural disc herniations is between 50 and 60 years. Although magnetic resonance imaging is a valuable tool in the diagnosis of this disease, it is still difficult to make a definite diagnosis preoperatively. Patient concerns: In this report, we described a 58-year-old male patient who presented with intermittent pain of low back and radiating pain of the both lower extremities for 2 years as well as decreased muscle strength of the both legs and dysfunction of urinary and defecation for 1 month. Diagnosis: Lumbar disc herniation was diagnosed during the first clinical examination in the local hospital. Magnetic resonance imaging revealed a mass disc filling almost the entire spinal canal at the L4/5 level and a stalk connecting the mass to the intervertebral disc was detected in the sagittal T2-weighted image. The massive lesion caused cauda equina compression, resulting in dysfunction of urinary and defecation. Interventions: Considering the mass's volume, bilateral hemilaminectomy, and transforaminal lumbar interbody infusion were performed. During the surgery, we found a perforation in the ventral dura and major part of herniated disc was located in the intradural space through it. The disc was carefully dissected from the surrounding nerve roots and the ventral dura and then totally removed. The defect on the ventral dura was sutured to prevent cerebrospinal fluid leakage. Outcomes: The patient presented complete recovery of the radiculopathy and cauda equina syndrome and significant improvement of muscle strength of both legs at 12 months follow-up. Lessons: The diagnosis of intradural disc herniations is very difficult and mainly based on intraoperative and histopathological results. Surgical intervention is only effective method to manage this disease and to relieve symptoms and prevent severe neurological deficits.

Intradural disc herniation at the L1-2 level

“…such as suturing or applying coagulation materials to the ventral dura) showed no postoperative CSF leakage. [ 1 - 6 , 8 , 9 , 11 - 13 , 17 , 18 , 20 , 20 - 29 ]…”

Multispecialty perspective on intradural disc herniation: diagnosis and management - A case report -

“…The first reported case of IDH was in 1942, and since other cases have been reported [ 1 - 4 , 6 , 8 , 9 ], yet it remains a very rare cause of lower extremity radiculopathy and CES [ 1 - 4 , 7 - 9 ]. Most IDH are found in the lumbar spine (95%) with the L4-5 level being the most commonly affected (55%) followed by the L3-4 level (16%) and then the L5-S1 level (10%) [ 2 , 6 ].…”

“…Most IDH are found in the lumbar spine (95%) with the L4-5 level being the most commonly affected (55%) followed by the L3-4 level (16%) and then the L5-S1 level (10%) [ 2 , 6 ]. IDH has a 4:1 male to female ratio with an average age of onset of 50-60 years [ 1 - 4 , 5 - 7 ].…”

“…The pathogenesis for IDH remains uncertain. Several factors are thought to be responsible for this atypical herniation, including narrowing of the spinal canal due to congenital or iatrogenic causes, adhesions between the annulus fibrosus, PLL, and dura, and dura fragility [ 1 - 4 ]. Adhesion formation is thought to be the most important factor [ 2 , 6 - 7 ].…”

Intradural Disc Herniation Concurrent with Ossification of the Posterior Longitudinal Ligament, Ossification of the Ligamentum Flavum, and Cauda Equina Schwannoma at the L1-L2 Level: A Case Report

“…IDH concurrent with other compressive lesions at the same spinal level has been identified to be rare 4,5) , and to the best of our knowledge, this is the first report of a case of IDH concurrent with an intradural tumoral lesion at the same spinal level. Currently, the pathogenesis of IDH remains unclear 6, 7) ; several reports have described that adhesions between the posterior longitudinal ligament and ventral dura mater may play an important role 2,[6][7][8] . Thus, OPLL may be associated with the development of IDH in this case.…”