Volume 2, Issue 4 ( 2017)                   IrJNS 2017, 2(4): 18-21 | Back to browse issues page


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Thiam A B, Thioub M, Agbo-Panzo M G E, Sy C E H N, Faye M, Badiane S B. Intradural Lumbar Disc Herniation: Report of Two Cases and Review of the Literature. IrJNS. 2017; 2 (4) :18-21
URL: http://irjns.org/article-1-79-en.html
1- Neurosurgery Department, National Teaching Hospital of Fann, BP 5035, Dakar, Senegal
2- Neurosurgery Department, National Teaching Hospital of Fann, BP 5035, Dakar, Senegal , panzojeff@yahoo.fr
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Intradural Lumbar Disc Herniation: Report of Two Cases and Review of the Literature

Alioune B. Thiam 1, Mbaye Thioub 1, Martial G. E. Agbo-Panzo 1*, Cheikh E. H. N. Sy 1, Mohameth Faye 1, Seydou B. Badiane 1

1 Neurosurgery Department, National Teaching Hospital of Fann, BP 5035, Dakar, Senegal

*Corresponding Author Address: BP 5035 Dakar, TelFax: +221774685008. Email: panzojeff@yahoo.fr

Article Type: Case Series          Received: December 11, 2016, Last Revised: January 26, 2017, Accepted: February 3, 2017, Published: March 31, 2017 

Abstract
Background and Importance: Intradural lumbar disc herniation is a rare and uncommon presentation of lumbar disc herniation. It signifies a challenge for diagnostic and therapeutic scheme, and is associated with a greater incidence of cauda equina syndrome at presentation.
Case Presentation: We describe two cases of intradural disc herniation who underwent surgery in Senegal review literature, and discuss difficulties in the preoperative diagnosis, surgical technique and functional outcome of our patients.
Conclusion: We conclude that diagnosis of this affection in developing countries is done during surgery, and the functional outcome of patients can be excellent.
Keywords: Intradural Disc Herniation; Cauda Equina Syndrom; Discectomy; Durotomy
 
Please cite this paper as: Thiam AB, Thioub M, Agbo-Panzo MGE, Sy CEHN, Faye M, Badiane SB. Intradural Lumbar Disc Herniation: Report of Two Cases and Review of the Literature. IrJNS. 2017;2(4):18-21

Background & Importance
The intradural disc herniation (IDH) is defined as a nucleus pulposus fragment of the intervertebral disc intruding through the dural sheath [1]. The first case of this pathology was described in 1942 by Dandy [2]. It is a relatively rare complication of the disc herniation, with a rate of about 0.27% to 0.33% of all cases. About 151 cases of IDH have been reported since 1942 with 92% being at the lumbar level, 5% at the dorsal level, and 3% at the cervical level [3]. The preoperative diagnosis remains difficult in spite of great improvement of neuroradiological evaluations with the help of CT scan (CTs) and Magnetic Resonance Imaging (MRI) [4] with final diagnosis usually made during surgery in most cases. In this paper, we report two cases of lumbar IDH who have been operated in Dakar, that were diagnosed intra-operatively. We discuss probable etiology and pathogenesis, diagnostic aspects, and functional outcome of our two patients and review the patient literature, accordingly.

Case Presentation
Both patients included in this study showed their informed consent for publishing their CT-scans, MRIs, intra-operative images, and history.

Case 1
A 25-year-old fisherman presented with a history of low back pain for two years. The beginning of the illness was marked by bilateral S1 hyperalgesia resistant to the common pain killers. Two months before his admission to our center, the pain was complicated by sense of weakness and tingling in bilateral S1 distribution with walking distance limited to 100 meters due to claudication. On admission, the patient was not able to walk but could stand up. The neurological examination showed a lumbar kyphosis, and a finger-to-toe distance of 30 cm. There was paravertebral muscles spasm from L2 to S1 level, and the tapping of the spinous apophysis of vertebra was painful; Lasègue’s sign was positive at 30° bilaterally with a motor force of 2/5 in S1 distribution. The patient had bowel and urinary retention and saddle's hypoesthesia. The lumbar axial CTs and sagittal reconstruction showed a voluminous L4-L5 disc herniation occupying about 70% of the vertebral canal and the patient was selected for surgery. After a complete L4 and partial L5 laminectomy, we noticed a reddish, thinned, very tense and indurated dura mater which was impossible to be mobilized in the vertebral canal. After a midline posterior durotomy, intradural exploration was performed under surgical microscope. A voluminous intradural disc herniation was noticed covered by fibrosis which had compressed rootlets posteriorly and medially. The disc material was removed and the dura mater tightly closed. Just after surgery, we noticed a clinic improvement with disappearance of sciatalgia, sphincter disturbances, and motor strength improvement to 4/5 in bilateral S1 distributions. However, pre-operative saddle’s hypoesthesia did not change. The patient was discharged on day 9 after surgery, and started a motor and urology rehabilitation. One month after surgery, the patient returned with recurrence of the same signs and symptoms but exacerbated with a urinary incontinence. The lumbar spine MRI with contrast enhancement suggested a remnant of L4-L5 disc herniation anterior to the dural sac occupying more than 50% of the vertebral canal with peripheral enhancement (Figure 1). In second surgery, disc herniation was found and removed lateral to the dural sheath with complete decompression of the vertebral canal. The patient was discharged on day 6 of the second surgery. Bilateral sciatalgia motor, and sensory deficits completely recovered. The patient was able to walk without aid by a month. Although the urinary incontinence disappeared after four months, the saddle hypoesthesia has persisted 6 months after surgery.

 
Type of Study: Case report | Subject: Gamma Knife Radiosurgery

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