Intradural disc herniation at the L1-2 level

Abstract

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).

Herniating Intradural Disc at Lumbar L4-L5 Level: A Case Report

“…After successfully removing the intradural disc, the surgeons in our case opted for primary repair of the dural defect, which was the preferred approach in previously documented studies as well [13]. Almost all the previously reported cases were also diagnosed intra-operatively as a case of ILDH with no evidence on pre-operative imaging, supporting the scenario of our case [10,14]. This point warrants the need for more advanced and specific imaging modalities for better pre-operative planning of such cases.…”

Intradural lumbar disc herniation of L2–L3: A case report and literature review

“…Some hemostatic materials should be placed on the ventral dural sac to prevent the occurrence of CSF leakage (37). A study by Serikyaku et al (38) demonstrated that no postoperative CSF leakage was found in all patients of ventral durotomy without repair. The treatment of ventral dural defect remains controversial.…”

Intradural disc herniation of L2/3: A case report and literature review

“…Serikyaku et al. reported 16 cases of ventral durotomy without repair, none of which showed postoperative CSF leakage [15] . Additionally, chronic inflammation leads to dural fragility.…”