Penetration of the intervertebral disk material into the intradural space in the lumbar region is a clinical and neurosurgical casuistic. According to literature data available, this pathology occurs in less than 0,3 per cent of the operated patients with lumbar disk herniation. The few clinical reports aim at forming a typical clinical syndrome. The authors presented two own clinical observations of operatively verified patients with total intradural disk protrusion in the lumbar region at the level of L4-L5 vertebrae. The unexpected operative finding required a revision of the intradural space. Good surgical results could be obtained in early decompression of the flattened nerve roots

Cholakov, D.

Kalevski, S.

Trendafilov, P.

English

Varna Medical University Press: Journals

Scripta Scientifica Medica, vol. 31 (1999), pp. 73-76 Copyright © Medical University, Varna TOTAL INTRADURAL DISK PROLAPSE IN T H E LUMBAR R E G I O N S. Kalevski, P. Trendafilov, D. Cholakov Department of Neurosurgery, Medical University of Varna, Varna Penetration of the intervertebral disk material into the intradural space in the lumbar region is a clinical and neurosurgical casuistic. According to literature data available, this pathology occurs in less than 0,3 per cent of the operated patients with lumbar disk herniation. The few clinical reports aim at forming a typical clinical syn-drome. The authors presented two own clinical observations of operatively verified patients with total intradural disk protrusion in the lumbar region at the level of L4-L5 vertebrae. The unexpected operative finding required a revision of the intradural space. Good surgical results could be obtained in early decompression of the flattened nerve roots. ... . Key-words: Intervertebral disk herniation, intradural space, symptoms, diagnosis, neurosurgery, case reports 5000 operated ones. Clinically, the patient presents mainly with an acute cauda equina compression and manifested neu-rological deficiency. Preoperative diagno-sis is difficult and almost impossible. That is why the diagnosis can be commonly clarified during operation. Being ac-quainted with the intervertebral disk pa-thology of this type, as well as with the peculiarities of the pathological morphol-ogy, diagnostics, and operative technique is of utmost practical importance. In the present communication, two clinical cases with intradural disk hernia-tion are reported. CASE ONE A 44-year old male patient (R.M.D., Record No 8003/5.VI. 1996) complained one week prior to hospital-Intradural disk herniations are a very rare complication of spinal degenera-tive changes (1,3,5,7). They have been first described by Dandy in 1942 (2) and since that time despite the great number of op-erations performed on the occasion of disk herniation in the whole world, there are only a few case reports in the literature available. According to Tronnier et al. (8), their incidence rate remains less than 0,3 per cent of all the cases with operated disk hernia. Peyser et al. (6) detect two cases out of a total of 753 operated ones while Prestar et al. (7) establish 3 cases among Address for correspondence: S. Kalevski, Dept. of Neurosurgery, Medical University, 55 Marin Drinov St, BG-9002 Varna, BULGARIA E-mail: neurosur@mail. vega.bg S. Kalevski, P. Trendafilov, D. Cholakov ization of lumbar pains and paraesthesia in the left leg without any reason for that. Very rapidly, both pains and paraesthesiae covered the right leg, too. He began to move independently rather difficultly. At the time of admission to the Department of Neurossurgery, Medical University of Varna, he already suffered from urinary retention as well. Clinical examination established a normal somatic status and lack of accom-panying diseases. A syndrome of lower torpid papaparesis with anaesthesia for pain in S1-S4 dermatomes, absent Achil-les and knee tendon reflexes could be di-agnosed. There was urinary and faecal retention, too. Urgently performed myel-ography with Omnipaque established a full "stop" of the contrast matter at L5 level. The paraclinical parameters were within normal ranges. The patient was operated as emergency case with a preliminary diag-nosis of a tumour of cauda equina. After laminectomy of L5, a strongly strenuous and dense dural sac was observed. After its opening, amids the roots a free disk se-quester of a volume of about 2 cm^ was detected. It was totally extirpated after careful ecarting the roots. A dura mater defect, about 1 cm long, in the left-lateral region was found out through which the disk hernia had penetrated. Both dura mater sheets were separated and the ori-fices of the external and internal layer did not mutually covered each other. By this way, between the sheets a 5 mm-long ca-nal was formed through which the disk hernia entered freely the subdural space. Wound was sutured layer by layer after careful hermetization of the sac. The post-operative period was smooth and char-acterized by complete restoration of the neurological functions and disappearance of the pelvic reservoir disturbances. CASE TWO A 54-year-old male patient (Y.N.P., Record No 4656/24.111.1998) complained two months prior to hospital-ization of acute lumbar pains irradiating towards both legs. Later on, urinary in-continence appeared, too. The clinical ex-amination revealed a normal somatic sta-tus and lack of accompanying diseases. Gait was paretic without any vertebral syn-drome. A hypaesthesia of radicular type involved the S-dermatomes bilaterally. There was also areflexia of the Achilles tendon and positive growth phenomena bilaterally along with urinary incontinence. Myelography with Omnipaque established a "stop" of the contrast matter at L4-L5 level. The paraclinical data were within normal ranges. No contraindications were present. The patient was operated as emergency case with a preliminary di-agnosis of median disk herniation. A par-tial laminectomy at L4 level was carried out. Dura mater was strenuous and dense at palpation. After the opening a disk materail was observed among the roots. After disk hernia extirpation, a defect of the anterior wall of the dural sac was de-tected. The postoperative period was comparatively smooth. A considerable reduction of the neurological deficiency as 74 Total intradural disk prolapse in . well as of the pelvic reservoir disorders was achieved. Three months after the op-erative intervention, the patient moved in-dependently and reported insignificant sub-ective complaints only. DUSCUSSION These two case reports illustrate the rare occurrence of disk material in the intradural space as well as the rapidly ad-vancing cauda equina syndrome with nanifested neurological deficiency typical f this kind of pathology. Most authors ,4,7,10) emphasize that the more dense dhesion of dura mater to the posterior longitudinal ligament in the caudal portion of the spinal column and mostly at L4 and L5 levels where the herniations of this type jjb most common (7,10) is an important athomorphological reason for this disor-er. At the aforementioned levels, the ven-al dura mater is thinner than the dorsal one because of the intensive flexion-ex-tension movements in this segment. Tronnier et al. (8) consider the preceding injuries of the spinal column and the mini-mal, latent fractures of the vertrebral bod-ies as a probable reason for dura mater lacerations. Along the mechanical factor, some authors outline the probable etiologi-cal role of the congenital defects or mal-formations, as well as of the intradural cysts facilitating the intervertebral disk pen-etration into the subdural space. The clinical picture is character-ized by a relatively rapid formation of cauda equina syndrome preceded by in-tensive lumbar pains irradiating towards both legs. The preoperative diagnosis of the intradural disk herniations is difficult. Both myelography and computer-assisted to-mography are of informative value (7,9) while in the recent years, NMR significantly contributes to specification of the diagno-sis of this rare pathological anomaly (5,7,10). Treatment is operative in any cases. Laminectomy provides a good ac-cess to the dural sac and is, therefore, rec-ommended by most authors (3,5,7). Af-ter opening the dura mater, the roots should be very carefully separated from the disk material as they are very often rather intimately attached to it. Induction of microhaemorrhages in the roots can delay or even compromise the restoration process. One has to look for the dural defect through which the disk material has penetrated and then the defect needs to be hermetized. Timely and perfect opera-tive intervention leads to rapid involution of the painful neurological syndromes and thus to definitive healing (6,9,10). CONCLUSION These two cases reported repre-sent a rare variant in lumbar disk pathol-ogy. The acquaintance of the pathological morphology and clinical characteristics of the disease could to a considerable extent shorten the diagnostic period and thus en-able an effective operative management. The timely removal of intradurally located disk hernia results in a rapid and definitive health status restoration. 75 S. Kalevski, P. Trendafilov, D. Cholakov R E F E R E N C E S 1. Б л а г о д а т с к и й , M . Д . , и др. Bonp. нейрохир., 1990, № 2, 36-3 7 . - 2 . D a n d y , W. Е. JAMA, 119, 1942, 474-477.- 3. F a n g et a l . Chang Gung Med. J., 17, 1990, No 3, 297-300.- 4. G a s k i l l , e t a l . Imaging Spine, 4, 1991,753-764.-5.Hodge, C . J . , et a 1. Spine,3,1978,346-350.-6.Peyser, E . , et a l . Surg. Neurol., 8, 1977, 95-98.-7. P r e s t a r , F . J . , et al. Minim. Invas. Neurosurg., 38, 1995, 125-128.- 8. T r o n n i e r et a l . Neurosurgery, 29, 1991, No 6, 916-919.-9. W i t t a k e r , С . K . , et a l . Spine, 19, 1994, No 13, 1505-1507.- 10. Y i d i z h a u t t et a l . Actaneurochir. (Wien), 110,1991,160-165. Тотален интрадурален дисков пролапс в лумбалната облает С. Калевски, П. Трендафилов, Д. Чолаков Катедра по неврохирургия, Медицински университет-Варна Резюме: Проникването на дисков материал в интрадуралното пространство в лумбалната облает е клинична и хирургична казуистика. Тази патология се среща според различни автори при по-малко от 0,3 % от оперираните пациента с лумбални дискови хернии. В литературата са описани единични случаи, като се правят опити да се оформи характерен клиничен синдром. Представени са две лични клинични наблюдения на оперативно верифицирани случаи с тотална интрадурална дискова протрузия в лумбална област на ниво Ь4-Ь5-прешлени. Неочакваната интраоперативна находка налага ревизиране на интрадуралното пространство. Добри хирургични резултати се постигат при ранна декомпресия на притиснатите коренчета. 76 

TOTAL INTRADURAL DISK PROLAPSE IN THE LUMBAR REGION

https://journals.mu-varna.bg/index.php/ssm/article/download/2935/2397

TOTAL INTRADURAL DISK PROLAPSE IN THE LUMBAR REGION

Abstract

Similar works

Full text

Available Versions

Varna Medical University Press: Journals