Presentation
The patient presented to the emergency department complaining of four months of progressive numbness with paraparesis in the lower limbs which progressed to gait disturbance. There was no history of any preceding trauma or surgery on the spine.
Patient Data
MR images of the spine show a left anterolateral displacement and anterior kink of the thoracic spinal cord at the T2-T3 level, with focal herniation through a ventral dural defect into the left anterior epidural space and disappearance of the cord from the bony canal at the level of herniation. The subarachnoid space widens with CSF pulsation artifacts dorsal to the dural fault, which indicates unimpeded CSF flow posterior to the cord.
Impression: The findings are consistent with ventral cord herniation at the T2-T3 level.
Computed tomography (CT) myelography demonstrates the left anterolateral herniation of a small portion of the spinal cord through a dural defect that confirms the idiopathic spinal cord herniation diagnosis. The dorsal subarachnoid space is widened without any apparent filling defect.
Impression: The features are typical of ventral cord herniation.
The patient went on to have spinal surgery to correct the dural defect.
The surgery consisted of a laminectomy of T2-T3, a reduction of the ventral cord herniation with cord release, and duroplasty.
Intraoperative photographs show confirmed cord herniation through the dural defect.
This patient's symptoms and functionality for daily activities improved after surgery; however, the patient did not completely recover to their original baseline.
The five-year post-surgical follow-up MRI demonstrated the absence of the anterior cord kink, which was present in the preoperative images, indicative of complete resolution of the ventral cord herniation. The focal area of T2 high signal intensity in the cord may be due to edema, gliosis, or postoperative changes.
Impression: Surgical resolution of the ventral cord herniation.
Case Discussion
Ventral cord herniation is an uncommon yet potentially curable form of thoracic myelopathy characterized by progressive neurological deficits, accompanied by distinctive imaging findings 1-3. Early diagnosis facilitated by MRI can play a pivotal role in identifying the condition and enabling timely intervention, which, in turn, can potentially reduce neurological deficits 1-3. The presented case demonstrates typical radiological appearances of a ventral cord herniation subsequently confirmed through surgical exploration.
Case courtesy
Ana Cristina Veiga Silva, neurosurgeon, MD - Department of Emergency
Diego Sousa, former radiology resident - Department of Radiology
Geraldo Sá MD, neurosurgeon - Department of Neurosurgery
Silvio Litvin MD, radiologist (retired) - Department of Radiology
Antonio Rodrigues de Aguiar Neto MD, radiologist - Department of Radiology
Hospital da Restauração – Recife, PE – Brazil
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