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 48-year-old female presented 3 years after being thrown against a wall with a sequela of traumatic brain injury (TBI) with cerebral palsy, worsening myelopathy, and gait ataxia. She initially utilized a walker for ambulation, but progressed to wheelchair bound by the time of presentation [].\nShe underwent MRI studies of the brain and spine, plus EMG and NCV of the lower extremities. The thoracic MRI showed a ventral thecal sac irregularity with accompanying distortion of the ventral cord, consistent with “tethering;” cervical and lumbar studies were unremarkable []. The CT myelogram was suggestive of ventral dural tear and spinal cord herniation at the T7-8 levels and a diffuse ventral subdural fluid collection extending from T1 to T10 [].\nWe performed a T7-T8 laminectomy and unilateral facetectomy with removal of the right T7 pedicle and transverse process, exposing the T7-8 nerve roots []. After using ultrasounds to confirm the level, the right T7 nerve root was ligated. Using microsurgical technique, the dural defect was approached from the right side intra- and extradurally. Once the dural defect was identified, it was repaired with onlay and inlay DuraGen (Integra LifeSciences, Princeton, NJ, USA) and, after weighing the risk and benefits, we reinforced with DuraSeal (Integra LifeSciences, Princeton, NJ, USA) to minimize risk of postoperative CSF leak.\nPostoperatively, the patient went to rehab and within 2 months, she was ambulating with assistance using a walker. Her strength continued to improve at her 4-month and 1-year neurosurgical follow-up visits []. She is now ambulating independently with a walker. On repeat, MRI at 4 months postoperatively demonstrates postsurgical changes with a well-circumscribed right paraspinal fluid collection with minimal mass effect on the spinal cord []. There was no clinical or radiographic evidence of recurrent herniation, and the patient did not experience clinical signs or symptoms of CSF leak.