A 51-year-old female presented with a 3-year history of thoracic back pain. Her medical history included diabetes, rheumatoid arthritis, and Sjögren's syndrome. The pain, when severe, was associated with nausea and vomiting. The patient reported longstanding reduced sensation bilaterally, in the L5 and S1 distribution, secondary to chronic lumbar spondylosis. There was no change in her lower limb neurological symptoms, specifically, no radicular pain or sphincter disturbance. There was no history of spinal trauma. Upon clinical examination, there was mild mid-thoracic tenderness. Lower limb neurological examination was complicated by leg stiffness related to the Sjögren's syndrome. There was global mild weakness Medical Research Council (MRC) grade 4/5 in bilateral lower limbs, and reflexes were normal. There was reduced sensation in the L5 and S1 distribution, which was a longstanding finding. MRI of the thoracic spine demonstrated features consistent with ISCH. T2-weighted images showed anterior deviation and flattening of the spinal cord at the T7 vertebral body level, with a small ventral dural defect and mild cord herniation []. The patient was treated conservatively, and at 4-year follow-up, her neurological condition remained stable.
A 52-year-old male fell 10 years before presentation from a scaffolding. Immediately after this fall, he noticed a diffuse sensibility loss in his right leg, which did not improve. Remarkably, he did not notice temperature changes or pain in that leg. Gradually, the strength in his left leg diminished. In recent years, this has clearly been progressive. In his lower left leg, he noticed paresthesias. He had a normal erectile function, but was unable to ejaculate.\nOn neurological examination, his left leg was slightly paretic. Vital and gnostic sensibility loss were present on the right side below T8. Within the L4 dermatoma on the left side, the vital sensibility was lost. The reflexes of both legs were pathologically increased with a Babinski’s sign on both sides. Radiological examination revealed a herniation of the SC at T4–T5 (Figure ).\nDuring surgery, the dura was opened after a midline approach with laminectomy T4 and T5. The dentate ligaments were transected on both sides, allowing some manipulation of the SC. On the ventral side, a defect of the dura was seen, along with many adhesions from the dura to the SC. These were sharply transected from both sides. Finally, the SC was freed from the dural defect and a mass originating from the ventral part of the SC was developed from the dural defect (Figure ). To prevent re-herniation, an artificial graft was gently placed in front of the SC covering the defect and was fixated laterally to the dural sleeve. Throughout the entire surgery, MEPs, SSEPs, and D-waves were monitored. During manipulation, the signals diminished twice. After waiting for several minutes, the signals returned to a normal level. Post-operatively, the patient did not notice any new complaints. The neurology is his right leg remained unaltered three months after surgery, whereas the symptoms in his left leg had improved.