12/16/2023 0 Comments Spine bulging disk xraySince then many authors have demonstrated ring enhancement of intradural disc fragments, differentiating it from a variety of intradural tumors that present with progressive leg pain, back pain or neurological deficits and can often be differentiated on clinical symptoms. The rim enhancement was attributed to granulation tissue around the avascular disc fragment, which was confirmed on histopathology. Some IDH demonstrate peripheral disc enhancement on Gd-MRI. An abrupt loss of continuity of the posterior-longitudinal ligament on MRI is also suggestive of lumbar IDH, and thought to indicate the portion of the ligament that was transversed by the disc fragment. Preoperative diagnostic of IDH was rare, but MRI with gadolinium injection can be helpful when it reveals the ‘hawk-beak’ sign, which is composed of a beak-like mass that experiences ring enhancement at the intervertebral space. In the case of the less frequent intradural extraarachnoid disc herniation, the arachnoid is peeled from the dura by the disc herniation and the disc tissue enters this virtual space, but does not reach the rootlets and the CSF. IDH can be divided into intraarachnoid (as in our patient) and extraarachnoid. Those could have had a scarring effect while the cortisteroid injections could have fragilized the posterior longitudinal ligament and the dura. In our case, the patient had lumbar surgery 15 years earlier, and surgery was followed by many percutaneous procedures in this area (periradicular corticosteroid injections, facet joint denervation). IDH is more frequent if the patient had previous lumbar spine surgery. 4A and 4B).Īlthough an exact pathogenesis for lumbar IDH has not been yet determined, it is generally accepted that adhesions between the annulus fibrosus, posterior longitudinal ligament (PLL), and ventral aspect of the dura represent a predisposing factor. The neurosurgeon found the disc fragment in the spinal fluid to be “spongious, more friable and softer than the usual extradural herniation (Fig. The herniation was plain to see inside the dural sac, clearly causing a compression of most adjacent rootlets, but not really adherent to them (maybe due to the contact of cerebro-spinal fluid). Surgery was performed in prone, antilordotic position under general anesthesia, via hemilaminectomy L4 and L5 on the clinically dominant right side with adjacent hemiflavectomy 元/4 and L5/S1, making a sharp parasagittal dural opening possible from a normal aspect of the dural sac into a heavily, scar tissue related metaplastic part of it (as often seen in reoperations and accountable for a higher risk of dural leak). It has irregular borders, heterogeneous nodular structure and variable diameter. The IDH enters at the L4-L5 level (white arrow) and extends downwards in the CSF, to the L5-S1 level (black stars). 2A and 2B), irregular borders and no contrast enhancement.Īxial T2 slices of the lumbar spine, from the level of the L4-L5 disk to the sacrum. 1A), and some peripheric contrast enhancement can be seen after gadolinium injection, while the intradural part seems to be less compact, with a “crumbled” appearance (Fig. The upper part of the disc fragment, at the level when it enters the dura, is “compact”, as usually seen in extradural disc herniations (Fig. 2A and B), reaching the level of the upper sacrum, the disc fragment being surrounded by the rootlets ( Fig. 1A and 1B), The intradural “part” of the herniation is very large and extends downwards (Fig. It perforates the common longitudinal ligament and the anterior aspect of the dura, and enters the thecal sac (Fig. MRI performed in July 2014 shows a disc herniation originating from the L4-L5 disc. In June 2014, the patient complained of a very severe bilateral L5 sciatalgy with paresthesias but no motor dysfunction. Several intra-foraminal L4-L5 and L5-S1 corticosteroid injections were performed during the last 10 years, as well as percutaneous radiofrequency denervation at the L4-L5 and L5-S1 facet joints. Imaging at that time showed no new disc herniation and he was referred to the pain clinic. Three years later, he complained of pain recurrence in the right L5 territory. The patient is a 66 years old male patient who had prior spine surgery 15 years ago for a right L4-L5 disc herniation with initial good clinical results.
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