A 66-year-old previously well man presented with an 18-year history of upper thoracic spine pain. The pain was initially intermittent and mild, but in the 14 months prior to presentation, it had gradually increased in severity and persistence. The pain radiated to the left side of the neck, and when severe, spread around both sides of the chest. The patient reported two episodes of left arm weakness lasting a few hours with spontaneous resolution, but denied paresthesia, sensory loss, or sphincter disturbance. There was no history of spinal surgery, trauma, or spinal disorders. Clinical examination demonstrated an upper thoracic spine gentle kyphosis. There were no abnormal findings on neurological motor, sensory, and reflex examination. A suboptimal quality MRI of the thoracic spine performed at a different institution was interpreted as an intradural mid-thoracic lesion, with a described intradural extramedullary mass indenting the dorsal aspect of the spinal cord. These findings were initially thought to be a dorsal arachnoid cyst. Repeat MRI at our institution demonstrated findings consistent with the characteristic features of ISCH. T2-weighted images showed anterior kinking and mild flattening of the spinal cord at T5, with widening of the subarachnoid space posterior to the cord and pulsation artifact within the CSF space []. The patient was treated with conservative management, with clinical and radiological surveillance. The patient remained neurologically stable at 4 months after presentation.
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).