An 82-year-old man presented with a 10-day history of progressive bilateral lower limb weakness and generalized numbness in his thorax and lower limbs. He reported a 3-week history of worsening gait ataxia, on a background history of 5 years of mild gait disturbance. On admission, the patient denied having problems with defecation, but had acute difficulty with micturition which resulted in catheter insertion. There was no history of spinal surgery, trauma, or spinal disorders. His medical history included ischemic heart disease, stroke, prostate cancer, and Paget's disease. Clinical examination was significant for a T4 sensory level, with reduced sensation to pin prick and light touch. Motor assessment revealed reduced power in bilateral lower limbs, with the following MRC grades: 1+/5 proximal and 3/5 distal. MRI was diagnostic for ISCH. T2-weighted images demonstrated ventral displacement of the thoracic spinal cord with moderate flattening, focal atrophy, and anterior herniation through the dura at T3-5 []. The CSF flow pattern dorsal to the cord at that level was preserved, but ventral to the cord, the CSF flow pattern was absent. Following a full discussion of the options with the patient, the decision was made for non-operative management. At 3 months after presentation, the patient remained neurologically stable.
A 33-year-old woman visited our hospital for slowly developing left leg weakness for 3 month without history of trauma. She also had progressive right side paresthesia which had developed six years ago. At that time, she had orthostatic headache and examinations to find cerebrospinal fluid (CSF) leakage were performed to rule out spontaneous intracranial hypotension (SIH) at another university hospital. However, there were no specific findings and orthostatic headache improved spontaneously. She has been suffering from nocturia and residual urine sense for five months with no sign of defecation disorder. Neurological examination revealed some indications of Brown-Sequard syndrome, such as decreased pain and temperature sensation (70/100) in the region below right T4 dermatome and muscular weakness (Grade IV) and a poor tactile and vibration sense (70/100) in the region below left T4 dermatome. Deep tendon reflex (DTR) was increased in both lower limbs. The blood test showed no specific finding. Initial MRI showed left antero-lateral displacement of the thoracic spinal cord in T3-4 with expanded subarachnoid space, but there was no abnormal signal change within the spinal cord (). With the diagnosis of ISCH, we performed T3 total laminectomy and found that spinal cord was herniated through the dural defect on the left antero-medial side of T3 level (). After reduction of herniated spinal cord into intra-dural space, we patched dural defect with Tacho-comb® both intradurally and extradurally (). Postoperatively, the patient's symptoms gradually alleviated. Decreased pain and temperature sensation improved by 90% and left side weakness was restored to full muscular strength after 10 days. Dysuria due to the neurogenic bladder was slowly cured and was fully recovered approximately 6 months later.