Upper Lumbar Intradural Disc Herniation: A Rare Case Report and Etiologic Analysis

Abstract

Background: Intradural disc herniation (IDH) is a rare type of disc degeneration that infrequently affects the upper lumbar spine. Pre-and intraoperative diagnosis and surgical management of IDH are challenging. The present case study provides insight into these aspects of upper lumbar IDH and discusses possible mechanisms. Case Description: A 63-year-old female with a history of chronic lower back and leg pain presented with an acute lumbar sprain that had occurred 1 month prior. The pain progressed and spread to the front of the left thigh, which affected her ability to lift her leg when ascending/descending stairs. Sagittal gadolinium-enhanced magnetic resonance imaging (MRI) revealed a disc protruding into the ventral dural sac showing a hawk-beak sign, and the posterior edge of the disc annulus and local posterior longitudinal ligament was broken. Total L2 laminectomy was performed, and the dorsal side of the dural sac was exposed and incised to enable exploration of the ventral side of the dura. We found two free fragments protruding into the inner wall of the dura through the left ventral dura mater defect. After carefully and completely removing the mass, we repaired the defect and performed internal fixation. Postoperative pathologic analysis confirmed that the mass was nucleus pulposus tissue from the degenerated disc. The patient's pain significantly improved after surgery, and she was able to walk normally at the 1-month follow-up. Conclusion:Upper lumbar IDH is an extremely rare type of disc degeneration. An enhanced MRI scan can provide diagnostic evidence, but the final diagnosis requires surgical exploration of the path of herniation and pathologic examination of the mass lesion.

Intradural disc herniation: case report

“…The pathophysiological aspect that causes intradural disc herniation is not clearly elucidated in the literature (4, 9, 10). However, it is understood that there is a preexisting abnormality, predisposing a lesion formation (10,11,12). During the anamnesis and physical examination, it is noticed that the patients present chronic low back pain, acute radicular pain and progressive neurological deficit as symptoms (13).…”

Difficulties in Diagnosis and Operation Associated With Lumbar Intradural Disc Herniation: A Case Report

“…12 Local adhesions are stimulated and eroded by the release of inflammatory substances by a ruptured disc. 13 The adhered local dural sac thins due to this erosion and the mechanical pressure exerted by herniated disc fragments, and eventually ruptures as a result, permitting loose disc pieces to reach the subdural region where they push against and activate the cauda equina nerve. 13 Acute and more severe neurological symptoms may now appear in people with chronic intermittent pain.…”

“…13 The adhered local dural sac thins due to this erosion and the mechanical pressure exerted by herniated disc fragments, and eventually ruptures as a result, permitting loose disc pieces to reach the subdural region where they push against and activate the cauda equina nerve. 13 Acute and more severe neurological symptoms may now appear in people with chronic intermittent pain. 12 Preoperative diagnosis of IDH requires thorough review of the patient's medical history, physical exam, and imaging.…”

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

“…Prolapse of intervertebral disc (PID) has a trend of increasing frequency among the late middle-aged to older population. However, intradural lumbar disc herniation (ILDH) is a rare phenomenon, especially in the young and middle-aged population [1]. It affects lower lumbar intervertebral discs (L4/L5 or L5/S1) more than upper lumbar (L1/L2/L3) discs [1].…”

“…However, intradural lumbar disc herniation (ILDH) is a rare phenomenon, especially in the young and middle-aged population [1]. It affects lower lumbar intervertebral discs (L4/L5 or L5/S1) more than upper lumbar (L1/L2/L3) discs [1]. Diagnosing ILDH pre-operatively is found to be challenging because of being misinterpreted frequently as intradural metastatic deposits, tumors, or cysts [2].…”