A 67-year-old female presented with complains slowly progressing bilateral leg weakness with associated chronic low back pain. There was no bowel or bladder involvement. On examination, motor and sensory exams were normal. Lab work was unremarkable. Magnetic resonance imaging (MRI) was performed which demonstrated anterior displacement of the spinal cord with an associated kink at T6 level with cerebrospinal fluid (CSF) pulsation artifacts in the posterior subarachnoid space []. High-resolution thin slice T2-weighted imaging demonstrated subtle small focus of herniated cord through the dural defect []. The findings favored spinal cord herniation instead of a posterior arachnoid cyst. To confirm the findings, a CT myelogram was performed which showed anterior cord kink at T6 with complete opacification of CSF posterior to the kinked and anteriorly displaced spinal cord confirming spinal cord herniation and excluding arachnoid cyst [].
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.