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 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.