CASE 16562 Published on 08.11.2019

Idiopathic ventral herniation of the spinal cord

Section

Neuroradiology

Case Type

Clinical Cases

Authors

Leon Sergot, Mohamed Hussien, Julian Chakraverty

University Hospitals Bristol NHS Trust, Marlborough Street, Bristol, United Kingdom, BS1 3NU
Corresponding Author:
Leon Sergot
leon.sergot@doctors.org.uk

Patient

38 years, male

Categories
Area of Interest Musculoskeletal spine, Neuroradiology spine ; Imaging Technique MR
Clinical History

A 38-year-old male patient presented with persistent thoracic back pain, including nocturnal pain, radiating anteriorly and into his right flank. No focal neurological abnormality on examination.

Imaging Findings

Standard MRI whole spine sequences were performed including axial and sagittal T2-sequences, as well as sagittal T1-and STIR-sequences.
On the sagittal sequences, there is focal deviation of the spinal cord anteriorly (Figs. 1 and 2) with obliteration of the normal CSF space between the spinal cord and ventral theca, best demonstrated on axial imaging (Fig. 3). This is often accompanied by focal high-signal within the cord. Free flow of CSF through the defect results in turbulent flow dorsal to the cord (Fig. 3) which helps differentiate this from an intradural extramedullary pathology, such as an arachnoid cyst pushing the cord anteriorly [1].

Discussion

Idiopathic ventral herniation of the spinal cord is a rare condition characterised by protrusion of the spinal cord through a focal defect in the dura. The postulated cause of the dural defect is variable. Theories include an underlying congenital aetiology, micro or clinically occult trauma and herniation of an intervertebral disc thinning or eroding the ventral dura [1,2].

It most commonly involves the thoracic cord between the levels of T4 and T7, thought to be a result of a combination of normal mechanic flexion-extension stresses and the physiological ventral curve and ventral position of the spinal cord due to the normal thoracic kyphosis [1,3].

Clinical presentation is variable, ranging from pain to progressive myelopathy. One of the most common presentations is a progressive Brown-Sequard syndrome as a result of focal herniation of half of the cord [1,3]. This case of a male in his 4th decade presented with thoracic pain radiating anteriorly and into his right flank with significant pain at night.

The imaging characteristics are classical. Best appreciated on MRI, there is focal deviation of the spinal cord anteriorly (Figs. 1 and 2) with obliteration of the normal CSF space between the spinal cord and ventral theca (Fig. 3). This is often accompanied by focal high-signal within the cord. Free flow of CSF through the defect results in turbulent flow dorsal to the cord (Fig. 3) which helps differentiate this from an intradural extramedullary pathology such as an arachnoid cyst pushing the cord anteriorly [1].

The management of the condition often necessitates surgical reduction and repair of the dural defect. In the absence of progressive symptoms, conservative management with watchful monitoring may be more appropriate [1].

Written patient consent for this case was waived by the Editorial Board. Patient data may have been modified to ensure patient anonymity.

Differential Diagnosis List
Idiopathic ventral herniation of the spinal cord
Intradural extramedullary arachnoid cyst deviating the cord anteriorly
Spinal cord herniation following significant trauma
Iatrogenic spinal cord herniation
Final Diagnosis
Idiopathic ventral herniation of the spinal cord
Case information
URL: https://www.eurorad.org/case/16562
ISSN: 1563-4086

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