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Medicine by Alexandros G.Sfakianakis,Anapafseos 5 Agios Nikolao

Medicine by Alexandros G.Sfakianakis

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Τρίτη, 3 Ιανουαρίου 2017

Intradural lumbar disc fragment with free migration


  • An intradural lumbar disc fragment with free migration: A case of a missed intradural disc herniation

  • Pages 17-21
  • Alaa Eldin Elsharkawy, Prodromos Avramidis, Bert Baume, Evariste Gafumbegete, Bettina Lange, Peter Douglas Klassen
  • Highlights

    Intradural lumbar disc herniation (ILDH) is a unique complication of relatively frequent spinal degenerative processes.
    The confirmation of ILDH diagnosis can often only be accomplished intraoperatively.
    A missed intradural disc fragment can be clinically dormant for years.
    Migration is a factor leading to subsequent need of surgical extraction.
    We propose potential mechanism of the missed diagnosis and pathological factors for migration of an intradural disc.





Highlights

Intradural lumbar disc herniation (ILDH) is a unique complication of relatively frequent spinal degenerative processes.
The confirmation of ILDH diagnosis can often only be accomplished intraoperatively.
A missed intradural disc fragment can be clinically dormant for years.
Migration is a factor leading to subsequent need of surgical extraction.
We propose potential mechanism of the missed diagnosis and pathological factors for migration of an intradural disc.

Abstract

Introduction

Intradural lumbar disc herniation (ILDH) is a very rare pathological entity. The pathomechanisms and the natural course remain unclear.

Case presentation

The authors present the case of a 58-year-old Germans male with repetitive microdiscectomies (MD) and intraoperative missed diagnosis of ILDH. The patient underwent standard MD due to lumbar disc herniation (LDH) at the level L4/5. Incidental durotomy (ID) was sealed with a ventromedial patch. Postoperative course was uneventful. 14 months later the patient presented with a L4 radiculopathy, having his second MD at the level L3/4. At this point the radiological images showed already a free floating intradural fragment at the level S1, clinically not significant. As in the previous surgery, the postoperative course was uneventful. After 18 months, he presented again complaining of low back pain and electric-like attacks of pain along the right L5 root for the prior five months. Contrast-MRI revealed that the known intradural disc-mass migrated from S1 to the level L4/5. A left L4 hemilaminectomy was performed. The durotomy identified a hard, white, shiny mass. The patient was pain-free until the last follow-up at 13 months.

Conclusions

Intraoperative manipulation of disc fragments in the presence of an ID potentially leads to iatrogenic ILDH.

Abbreviations

  • IDincidental durotomy
  • ILDHintradural lumbar disc herniation
  • LDHlumbar disc herniation
  • MDmicrodiscectomies
  • MRIMagnetic Resonance Imaging

Keywords

  • Intradural lumbar disc
  • Fragment with free migration

1. Introduction

Intradural lumbar disc herniation (ILDH) is a unique complication of relatively frequent spinal degenerative processes with incidence ranges between 0.19 and 1.1%. The pathogenesis of ILDH is not well known [1][2][3] and [4]. Naturally, a disc herniation may penetrate the posterior longitudinal ligament and the anterior wall of the dura and the fragment of disc migrate intrathecally [5]. Iatrogenic liberation of disc fragment intrathecally has been also reported after endoscopic lumbar discectomy [6]
Prompt operative treatment of ILDH is highly advocated.
The optimal operative treatment remains a challenge, since the confirmation of diagnosis can often only be accomplished intraoperatively and not anticipating this possibility can lead to missed intradural disc fragments. The present case is another example of a missed intradural disc herniation after a L4/5 microdissectomy. From our case, we learn that a missed intradural disc fragment can be clinically dormant for years and that migration is a factor leading to subsequent need of surgical extraction, and that a finding of an incidental durotomy during a first ever surgery should ALWAYS makes one wonder whether maybe an intradural disc is also present. With our case we propose potential mechanism of the missed diagnosis and pathological factors for migration of an intradural disc.

2. Case presentation

January 2012, a 58-year-old Germans male patient presented in our outpatient clinic complaining of low back pain radiating to the right leg along L5 root for the prior 12 months. Physical examination demonstrated an active right ipsilateral straight leg raising sign at approximately 30 degrees as with real cross straight leg raising sign; weakness of the right extensor halluces longus and toe extensors graded as a 4/5 and hypesthesia in the right L5 dermatome. Deep tendon reflexes were preserved and normal bilaterally at the knee and the ankle. The patient had no fasciculations, atrophy or upper motor neuron signs. The MRI of the lumbar spine showed a lumbar disc herniation at level L4/5. After failing conservative care, a right L4–5 discectomy was performed.
After interlaminar approach, intraoperative was the disc herniation much bigger compared with MRI scan with massive adhesions along the dura. Standard exploration of the nerve structures showed a great disc material ventromedial to the dural sac with completes ID and CSF leakage. Removal of the disc after separation of the dura from the intervertebral disc with gentle medialization of the dural sac was performed. Dural tear was closed with a patch (TachoSil) after surgery; the patient was pain-free for 12 months (Fig. 1).
Fig. 1
Fig. 1. 
Preoperative MRI showing a disc herniation at level 4/5 re, 3 & 4 MRI after seven months from surgery showing an intradural mass at the level S1, 5 & 6 2-years after the surgery showing the same position of the intradural disc herniation.
After 14 months, he presented in our outpatient complaining of low back pain and a right leg pain along the L4 root since 2 months. The MRI of the lumbar spine showed a lumbar disc herniation at level L3/4 and an intradural mass at the level S1 without any symptoms.
At this moment, the retrospective diagnosis of ILDH of the first surgery was made. Our explanation of the free intradural disc fragment was that the extradural part of the ILDH had been removed while the intradural part has been liberated during manipulation of the adhesions (Fig. 2).
Fig. 2
Fig. 2. 
Artwork showed our explanation to the intradural fragment. Painted by Mohamed Hosny, Egyptian artist.
The patient underwent standard right L3–4 discectomy. After surgery, the patient was pain-free for 18 months.
July 2015, more than three years from index surgery, he presented to our outpatient clinic complaining of low back pain and electric-like attacks of pain along the right L5 root for the prior five months. Physical examination demonstrated an active right ipsilateral straight leg raising sign at 60 degrees as with negative cross straight leg raising sign and residual hypesthesia in the right L5 dermatome from the index surgery. Contrast MRI of the lumbar spine showed a migration of the intradural disc fragment from S1 to the level L4/5. Therefore, surgical removal of the intradural mass was recommended. (Fig. 3). The pathology was approached from the left side to avoid adhesions on the right side. Left L4 hemilaminectomy and durotomy was performed. A hard, white, shiny mass on the right side of the dura was founded. The mass was free in the intradural space and was very hard to catch (Fig. 4). The postoperative period was uneventful. The Patient is still pain-free until the last follow-up in August 2016.
Fig. 3
Fig. 3. 
Intraoperative picture showing a white shiny intradural mass, 1.2 × 1.2 cm.
Fig. 4
Fig. 4. 
Pathological examination showed a disc tissue with central balloon-type cystic degenerative changes with a ring of healthy tissue about 5 μm.
Pathological examination showed a disc tissue with central balloon-type cystic degenerative changes with a ring of healthy tissue about 5 μm.

3. Discussion

Intradural disc herniation is defined as rupture of a lumbar intervertebral disc with tearing of the posterior longitudinal ligament, dura mater and arachnoid with a displacement of the nucleus pulposus into the dural sac. It is a rare presentation of a relatively common pathology. The most frequently intradural disc herniation occurs at level L4/5[7].
Diagnosis of ILDH is difficult. MRI is the most useful imaging modality in cases of ILDH. Characteristic findings are the loss of PLL continuity, “hawk-beak” sign which show a triangular lesion with a beak-like appearance compressing the dural sac on T2-weighted axial images, and the contrast-enhanced MRI may show ring enhancement of the herniated portion. Despite radiologic findings, most cases of are IDH intraoperatively discovered which is rarely suspected preoperatively [6] and [8].
The suspicions for IDH rise in the case of the absence of extradural disc material, the presence of the CSF, and the presence of a tense dural sac. In our case, the ILDH was difficult to diagnosis due to the presence of extradural disc material and normal tense dural sac.
We assume two scenarios to explain the presence of the free disc fragment in the intradural sac. First scenario: missing diagnosis of ILDH at the first surgery. The surgeon has not taken into account the intradural part of the herniated disc, removing the extradural part of herniation. During manipulation of the dura to explore the disc, he liberated the fragment in the dural sac.
Second scenarios: the adhesion and dural tear during the first surgery lead to a new intradural disc herniation not related to the first disc herniation with the loose fragment in the intradural sac.
Intrathecal migration of disc fragment after ruptured disc has been reported [6] and [8]. The migration of the disc fragment in our case initially caudally then cranially may be explained by the unusual central balloon-type cystic degenerative changes with a vacuum-like effect, which reduces the mass density of the fragment over time which makes the piece floating to the top.
Mut et al. divided intradural disc herniation into two types: A - herniation in the dural sac B - herniation in preganglionic nerve root [9]. The Özer et al. suggest the term “pseudointradural/intraarticular” in cases of only outer layer perforation and “true intradural/intraarticular disc herniation” if both layers are perforated with a cerebrospinal fluid leak [10].
In our case, the intradural disc herniation was type A, with CSF leak from ventral dura. We suggest adding a subtype with combined intradural und extradural components.
Our case is in agreements with published data regarding the site, clinical presentation, and surgical outcome. The published data showed that ID's occur mostly (92%) in the lumbar region, more than half of them at level L4–L5 (55%) [3] and [7]. Low-back pain and sciatica for more than a year are the most frequently clinical presentation [2] and [3]. Our patient showed improvement of symptoms after surgery which is in agreement with previously reported cases, which showed that that the prognosis of intradural disc herniation is entirely satisfactory [11].
The pathogenesis of IDH is not well known. It is presumed that adhesions between the dura, PLL, and the disc annulus are the crucial predisposing factors [2][12]. Adhesions may be congenital origin as suggested by Yildizhan et al. [13], due to the observed adhesions in the newborn/ abortion group which were similar in terms of levels of adhesions with the adult group [13], acquired due to previous spine surgery or trauma or spontaneously due to degenerative disc disease with or without association to an ossification of the PLL. The adhesions enable the disc material to erode through the dura into the subdural space[3] and [5]. In our case, massive adhesions have been noticed during the first surgery which is in agreement with published data.

4. Conclusions

Our case highlights the fact that ILDH diagnosis may be missed before, during and after surgery. The surgeons must have knowledge regarding this condition and pay attention to difficulty in dissecting the anterolateral element of the dural sac from the annulus fibrosus of the intervertebral disc. Liberation of the intradural part intrathecally LDH is a possible postoperative complication

Disclosure

The authors report no conflicts of interest.
The authors report no financial disclosure.
This manuscript has not been previously published and is not under consideration for publication elsewhere.

References

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Corresponding author at: Bonifatius Hospital, Wilhelmstr. 13, 49808 Lingen, Germany.


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Tinnitus

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3. Marcondes RA, Sanchez TG, Kii MA, Langguth et al. Repetitive transcranial magnetic stimulation improve tinnitus in normal hearing patients: a double-blind controlled, clinical and neuroimaging outcome study. Eur J Neurol. 2009. [Epub ahead of print] ) [Abstract]

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HIPPOCRATE'S OATH

"I swear by Apollo, the healer, Asclepius, Hygieia, and Panacea, and I take to witness all the gods, all the goddesses, to keep according to my ability and my judgment, the following Oath and agreement:

To consider dear to me, as my parents, him who taught me this art; to live in common with him and, if necessary, to share my goods with him; To look upon his children as my own brothers, to teach them this art.

I will prescribe regimens for the good of my patients according to my ability and my judgment and never do harm to anyone.

I will not give a lethal drug to anyone if I am asked, nor will I advise such a plan; and similarly I will not give a woman a pessaryto cause an abortion.

But I will preserve the purity of my life and my arts.

I will not cut for stone, even for patients in whom the disease is manifest; I will leave this operation to be performed by practitioners, specialists in this art.

In every house where I come I will enter only for the good of my patients, keeping myself far from all intentional ill-doing and all seduction and especially from the pleasures of love with women or with men, be they free or slaves.

All that may come to my knowledge in the exercise of my profession or in daily commerce with men, which ought not to be spread abroad, I will keep secret and will never reveal.

If I keep this oath faithfully, may I enjoy my life and practice my art, respected by all men and in all times; but if I swerve from it or violate it, may the reverse be my lot."

MAIMONIDE'S PRAYER

"Almighty God, Thou has created the human body with infinite wisdom. Ten thousand times ten thousand organs hast Thou combined in it that act unceasingly and harmoniously to preserve the whole in all its beauty the body which is the envelope of the immortal soul. They are ever acting in perfect order, agreement and accord. Yet, when the frailty of matter or the unbridling of passions deranges this order or interrupts this accord, then forces clash and the body crumbles into the primal dust from which it came. Thou sendest to man diseases as beneficent messengers to foretell approaching danger and to urge him to avert it.

"Thou has blest Thine earth, Thy rivers and Thy mountains with healing substances; they enable Thy creatures to alleviate their sufferings and to heal their illnesses. Thou hast endowed man with the wisdom to relieve the suffering of his brother, to recognize his disorders, to extract the healing substances, to discover their powers and to prepare and to apply them to suit every ill. In Thine Eternal Providence Thou hast chosen me to watch over the life and health of Thy creatures. I am now about to apply myself to the duties of my profession. Support me, Almighty God, in these great labors that they may benefit mankind, for without Thy help not even the least thing will succeed.

"Inspire me with love for my art and for Thy creatures. Do not allow thirst for profit, ambition for renown and admiration, to interfere with my profession, for these are the enemies of truth and of love for mankind and they can lead astray in the great task of attending to the welfare of Thy creatures. Preserve the strength of my body and of my soul that they ever be ready to cheerfully help and support rich and poor, good and bad, enemy as well as friend. In the sufferer let me see only the human being. Illumine my mind that it recognize what presents itself and that it may comprehend what is absent or hidden. Let it not fail to see what is visible, but do not permit it to arrogate to itself the power to see what cannot be seen, for delicate and indefinite are the bounds of the great art of caring for the lives and health of Thy creatures. Let me never be absent- minded. May no strange thoughts divert my attention at the bedside of the sick, or disturb my mind in its silent labors, for great and sacred are the thoughtful deliberations required to preserve the lives and health of Thy creatures.

"Grant that my patients have confidence in me and my art and follow my directions and my counsel. Remove from their midst all charlatans and the whole host of officious relatives and know-all nurses, cruel people who arrogantly frustrate the wisest purposes of our art and often lead Thy creatures to their death.

"Should those who are wiser than I wish to improve and instruct me, let my soul gratefully follow their guidance; for vast is the extent of our art. Should conceited fools, however, censure me, then let love for my profession steel me against them, so that I remain steadfast without regard for age, for reputation, or for honor, because surrender would bring to Thy creatures sickness and death.

"Imbue my soul with gentleness and calmness when older colleagues, proud of their age, wish to displace me or to scorn me or disdainfully to teach me. May even this be of advantage to me, for they know many things of which I am ignorant, but let not their arrogance give me pain. For they are old and old age is not master of the passions. I also hope to attain old age upon this earth, before Thee, Almighty God!

"Let me be contented in everything except in the great science of my profession. Never allow the thought to arise in me that I have attained to sufficient knowledge, but vouchsafe to me the strength, the leisure and the ambition ever to extend my knowledge. For art is great, but the mind of man is ever expanding.

"Almighty God! Thou hast chosen me in Thy mercy to watch over the life and death of Thy creatures. I now apply myself to my profession. Support me in this great task so that it may benefit mankind, for without Thy help not even the least thing will succeed."

Information for Health Professionals

Information for Patients

Modern challenged parts of the oath:

  1. To teach medicine to the sons of my teacher. In the past, medical schools gave preferential consideration to the children of physicians.
  2. To practice and prescribe to the best of my ability for the good of my patients, and to try to avoid harming them. This beneficial intention is the purpose of the physician. However, this item is still invoked in the modern discussions of euthanasia.
  3. I will not give a lethal drug to anyone if I am asked, nor will I advise such a plan. Physician organizations in most countries have strongly denounced physician participation in legal executions. However, in a small number of cases, most notably the U.S. states of Oregon,[10] Washington,[11]Montana,[12] and in the Kingdom of the Netherlands,[13] a doctor can prescribe euthanasia with the patient's consent.
  4. Similarly, I will not give a woman a pessary to cause an abortion. Since the legalization of abortion in many countries, the inclusion of the anti-abortion sentence of the Hippocratic oath has been a source of contention.
  5. To avoid violating the morals of my community. Many licensing agencies will revoke a physician's license for offending the morals of the community ("moral turpitude").
  6. I will not cut for stone, even for patients in whom the disease is manifest; I will leave this operation to be performed by practitioners, specialists in this art. The "stones" referred to are kidney stones or bladder stones, removal of which was judged too menial for physicians, and therefore was left for barbers (the forerunners of modern surgeons). Surgery was not recognized as a specialty at that time. This sentence is now interpreted as acknowledging that it is impossible for any single physician to maintain expertise in all areas. It also highlights the different historical origins of the surgeon and the physician.
  7. To keep the good of the patient as the highest priority. There may be other conflicting 'good purposes,' such as community welfare, conserving economic resources, supporting the criminal justice system, or simply making money for the physician or his employer that provide recurring challenges to physicians
http://www.worldallergy.org/educational_programs/world_allergy_forum/barcelona2008/rabe/

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