Case report:
A 37-year-old male patient visited the outpatient clinic with insidious
onset of upper back pain and altered sensations of pain and temperature
over the right half of the body below the nipple 2 months before the
examination. The patient did not have motor weakness of lower limbs,
abnormal/ involuntary movements, or loss of control over the bowel and
bladder. There was no history of injury to the back, fever, weight loss,
or any other constitutional symptoms. There was no history of Diabetes
Mellitus, hypertension, or other co-morbidities. There was no specific
tenderness or visible deformity of the spine. The complete neurological
examination is described in table 1.
The radiologic examination was done in the form of X-rays of the
thoracic spine in anteroposterior and lateral views. There were no
significant findings on the x-ray of the thoracic spine. Magnetic
Resonance Imaging (MRI) of the thoracic spine showed an anterolateral
defect(left) in the dura at the level of the T2-T3 vertebra (Fig 1A&B).
Computed Tomography(CT) scan of the thoracic spine also showed a defect
of the spinal cord at the T2-T3 vertebral level(2A-C). A differential
diagnosis of spontaneous spinal cord herniation and arachnoid cysts was
considered. Surgical intervention was planned as the patient had
neurological deficits.
A posterior approach was chosen to repair the spinal cord defect. After
laminectomy, the dural defect was assessed and the diagnosis of
spontaneous spinal cord herniation was confirmed (Fig 3A). The cord with
roots was reduced into the dura. The defect was covered by a dural graft
(Lyodura) and the wound was closed with a drain insitu (Fig 3B). The
patient’s sensory deficits improved on the first postoperative day. The
output from the drain was 100 ml on the first postoperative day and 50
ml on the second postoperative day. The drain was removed in the evening
of second postoperative day. In the early morning of the third
post-operative day, the patient complained of pain over the operated
site and inability to move bilateral lower limbs. On examination, there
was a marked swelling over the operated site and paraplegia. The motor
weakness was also associated with sensory loss below the nipples
bilaterally. However, bowel and bladder control was not lost. The
patient was immediately taken into the operating room as there was
swelling and tenderness over the wound and a hematoma compressing the
spinal cord was suspected. The stitches were removed and the wound was
explored. There was a hematoma at the operated site which was removed
(Fig 4). The bleeders were identified and cauterised. Repair of the
defect was re-examined and was found to be satisfactory. Layer-wise
closure was done. The check MRI showed good closure of the defect and
compression over spinal cord(Fig 5A & 5B). The motor weakness recovered
but the sensory paraesthesia persisted till the ninth postoperative day.
The patient was discharged on the ninth postoperative day with residual
sensory deficits and was kept under regular follow-up. The deficits were
completely recovered at one-month follow-up. The recovery was maintained
till the last follow-up at 10 years.