This is a case for Prof. Dr. Dillon.
It is in press by our neurosurgeons and us, for the use of Duragen.
Idiopathic herniation of the thoracic spinal cord: a case report and technique note.
Ulivieri S.1, Oliveri G.1, Petrini C.1, D’Elia F.2, Cuneo G.L.3, Cerase A.4
Units of 1Neurosurgery, and 4Neuroradiology, “Santa Maria alle Scotte” Hospital, Siena, Italy
2Unit of Radiology, and 3Section of Neuroradiology, Department of Neurology, “San Donato” Hospital, Arezzo, Italy
A 35-year-old man presented with insidiously progressive and disabling pain in the left leg. There was no history of trauma or surgery; neurological examination revealed features suggestive of thoracic level Brown-Séquard syndrome.
The patient underwent a thoracic laminectomy at T9–T10. The dura was opened under the microscope and an atrophic spinal cord displaced to the left was visible. The spinal cord was incarcerated through a 2.5 cm wide anterolateral dural defect and had an exophytic edematous appearance. In order to perform an anterior untethering, the dentate ligament was transected and the nerve roots were preserved. The spinal cord was gently mobilised out of the dural defect. Notably, there were no major adhaesions and thus there was no need to manipulate the cord. Then, it was decided to position hemostatic material (Spongostan®) and glue (Tissucol®) around the defect and finally a sheet of collagenous membrane (DuraGen®) anterior to the spinal cord. The wound was closed in layers without external cerebrospinal fluid drainage. No spinal cord monitoring was used. The initial post-operative neurological deficit was unchanged and there was no sign of cerebrospinal fluid leakage. The patient was discharged seven days after surgery to rehabilitation.
Best regards to all of you.
I think these csf extradural collections occur from prior disc or osteophyte penetration of ventral dura.
Dear Dr. Shirouzu- Many thanks for your comment. Could you please elaborate on the concept of increased CSF production in this condition? You call it the Holy Grail but many of us are not sure how it can play a role.
A nice surgery case.
From our experience (Tokyo Univ. and Kanto Medical Center), a herniation pit communicates a longitudinally extended pouch which is also filled with CSF. We named “(Ventrally) duplicated dura matter”, but some authors refers it simply as a extra-dural cyst or meningocele. (I doubt it) The holy grail of this disease is the existence of this surplus CSF of unknown etiology. Surgical intervention prevents further aggravation of neurological symptoms, but in general, present neurological deficit may not be improved. So in my opinion, we must detect this mysterious extradural CSF pouch, prior to clinical manifestation, or in the early stage.
Best regards,
Ichiro Shirouzu MD,
Dept. of Radiology, Kanto Medical Center NTT EC, Tokyo JAPAN.