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LETTER TO EDITOR
Year : 2012  |  Volume : 60  |  Issue : 2  |  Page : 257-259

Intradural thoracic disc presenting with radiculopathy


Department of Neurosurgery, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Pondicherry - 605006, India

Date of Submission29-Feb-2012
Date of Decision04-Mar-2012
Date of Acceptance29-Mar-2012
Date of Web Publication19-May-2012

Correspondence Address:
Venkatesh S Madhugiri
Department of Neurosurgery, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Pondicherry - 605006
India
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DOI: 10.4103/0028-3886.96435

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How to cite this article:
Madhugiri VS, Gundamaneni SK, Yadav AK, Sasidharan GM, Roopesh Kumar V R, Shankar Ganesh C V. Intradural thoracic disc presenting with radiculopathy. Neurol India 2012;60:257-9

How to cite this URL:
Madhugiri VS, Gundamaneni SK, Yadav AK, Sasidharan GM, Roopesh Kumar V R, Shankar Ganesh C V. Intradural thoracic disc presenting with radiculopathy. Neurol India [serial online] 2012 [cited 2014 Sep 20];60:257-9. Available from: http://www.neurologyindia.com/text.asp?2012/60/2/257/96435


Sir,

Intradural herniation of an intervertebral disc is a rare phenomenon and occurs most commonly in the lumbar spine. Thoracic intradural herniations are rare.

A 65-year-old lady presented with mid backache and numbness over the left groin of 1 month duration. On examination, she had sensory loss over the left T12 and L1 dermatomes and no motor signs. Deep tendon reflexes were normally elicited and plantars were mute. Magnetic resonance imaging (MRI) of the spine revealed a ventrally placed intradural lesion opposite the T12 vertebral body, hypointense on T1-weighted and isointense on T2-weighted images [Figure 1]a. Contrast sequences showed peripheral enhancement and extension of the lesion into the left neural exit foramen [Figure 1]b. Disc height at all adjacent levels was preserved. An incidental L1 vertebral body hemangioma was also noted. The extension into the neural foramen and the fact that the patient had presented with pure radiculopathy led to schwannoma being considered as the first diagnosis. The patient underwent T11-L1 laminectomy; no lesion was found in the extradural space. On opening the dura, the conus was seen humped over the lesion and displaced to the right. The lesion was covered by a layer of arachnoid, and was white, fibrous, and avascular. It was not adherent to ventral dura and could easily be lifted off. No defect was noted in the ventral dura. In the immediate postoperative period, the patient developed weakness of the left lower limb (grade 2/5). She improved gradually with physiotherapy and 4 months later is ambulant with left lower limb power of grade 4 + /5. On histopathology, the lesion was a degenerated disc fragment. No granulation tissue was seen surrounding the disc fragment [Figure 1]c. Post-op MRI revealed complete excision of the lesion with an intact dural tube [Figure 1]d.
Figure 1: (a) T2 sagittal section showing the disc fragment at D12 level. (b) Axial Gd contrast-enhanced image showing the dense peripheral contrast enhancement and extension of the contrast enhancement into the left neural foramen. (c) The lesion comprised a matrix with chondrocytes and spicules of calcification suggestive of a degenerated disc fragment. No granulation tissue was seen. (H and E, ×40). (d) Post-op MRI, T2 sagittal image showing excision of the lesion

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Since Dandy first described intradural disc herniation in 1942, more than a 100 cases have been reported. Of all intradural disc herniations, 5% are found in the thoracic, 3% in the cervical, and 92% in the lumbar region. [1],[2] The pathogenesis of intradural migration of an intervertebral disc fragment is not fully understood and a number of theories have been postulated. Dandy hypothesized that the sudden increase in pressure created by a herniated disc would lead to erosion and penetration of underlying dura by the disc fragment. Yildizhan et al.[3] studied the relationship between the ventral spinal dura and the posterior longitudinal ligament (PLL). They found that the ventral dura was firmly attached to the PLL. It was found in some cases that the connection between the dura, PLL, and the annulus fibrosis of the disc was so firm that it could not be divided by blunt dissection. Thus, when these structures were firmly adherent, a herniated disc could penetrate through them as if they were one structure. Most patients with intradural thoracic disc present with paraparesis. [4],[5],[6] This patient presented with pure radiculopathy despite significant compression of the conus.

The commonest thoracic intradural lesions are schwannomas and meningiomas. These lesions usually enhance on contrast MRI. Schwannomas may extend into the neural foramen and meningiomas may demonstrate a dural tail of enhancement. Errors in differentiating lesions on MRI can occur because various patterns of contrast enhancement occur with intradural disc fragments. In acute intradural discs where granulation tissue has not yet developed, the lesion will not enhance on MRI. [5],[6] As granulation tissue surrounds the disc, peripheral enhancement may be noted as in the present instance. When granulation tissue has infiltrated the disc fragment, the lesion tends to enhance homogeneously. [7] In this patient, it was not possible to determine the level of origin of the prolapsed disc since there was no ventral dural defect at surgery and MRI showed that the disc height was maintained at all adjacent intervertebral levels.


  Acknowledgments Top


The authors would like to acknowledge Prof. Surender Kumar Verma and Dr. Sajini Elizabeth Jacob, of the Department of Pathology at JIPMER for kindly providing us with the photomicrograph, and Dr. Elangovan and Dr. Ramesh of the Department of Radiodiagnosis, JIPMER, for the post-op MRI images.

 
  References Top

1.Epstein NE, Syrquin MS, Epstein JA, Decker RE. IDH in the cervical, thoracic and lumbar spine: report of 3 cases and review of the literature. J Spinal Disord 1990;3:396-403.  Back to cited text no. 1
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2.Negovetic L, Cerina V, Sajko T, Glavic Z. Intradural disc herniation at the T1-T2 level. Croat Med J 2001;42:193-5.  Back to cited text no. 2
    
3.Yildizhan A, Paþaoðlu A, Okten T, Ekinci N, Aycan K, Aral O. Intradural disc herniations pathogenesis, clinical picture, diagnosis and treatment. Acta Neurochir (Wien) 1991;110:160-5.  Back to cited text no. 3
    
4.D'Andrea G, Trillo G, Roperto R, Celli P, Orlando ER, Ferrante L. Intradural lumbar disc herniations: the role of MRI in preoperative diagnosis and review of the literature. Neurosurg Rev 2004;27:75-80.  Back to cited text no. 4
    
5.Holtas S, Nordstrom CH, Larsson EM, Pettersson H. MR imaging of IDH. J Comput Assist Tomogr 1987;11:353-6.  Back to cited text no. 5
    
6.Isla A, Roda JM, Bencosme J, Alvarez MP, Blazquez MG. Intradural herniated dorsal disc: Case report and review of literature. Neurosurg 1988;22:737-9.  Back to cited text no. 6
    
7.Aydin MV, Ozel S, Sen O, Erdogan B, Yildirim T. Intradural disc mimicking: A spinal tumor lesion. Spinal Cord 2004;42:52-4.  Back to cited text no. 7
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