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.
A 66-year-old female farm worker presented with 7 years of progressive back pain and impaired motor and sphincter function. On neurological examination, she exhibited a sensory level at T4 with a spastic paraparesis and bilateral (right greater than left) muscle atrophy.[] The MR revealed a ventral dural gap at the T4 level [Figure –]. She underwent a T4 laminectomy at which time the ventral dural gap was repaired (e.g. ventral dura mater defect repaired utilizing a 5-0 prolene suture to attach a muscle/fascia patch to the surrounding healthy dura mater) and the cord was reduced [] at surgery. The herniated cord appeared “violaceous/pale” in color and was hardened []. Postoperatively, the patient showed improvement in muscle strength in the lower limbs, allowing her to walk with assistance (with a cane or walker).