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 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.