Intradural lumbar disc herniation-Is it predictable preoperatively? A report of two cases

BACKGROUND CONTEXT: Intradural disc herniations are thought to be rare events, and there have been relatively few literature reports of intradural disc herniations available with regard to magnetic resonance imaging findings. PURPOSE: The authors describe two patients with intradural lumbar disc herniations, one with and one without preoperative diagnosis, who had different postoperative outcomes. STUDY DESIGN: Case study METHODS: The first patient underwent an extended L3 subtotal laminectomy followed by bilateral medial facetectomy and foraminotomy at L3-L4. A durotomy uncovered large disc fragments comprised of friable disc materials and end plates, after no clear disc herniation was found in the epidural space. The second patient underwent anterior lumbar interbody fusion after a preoperative diagnosis of intradural disc herniation. RESULTS: The first patient experienced a marked reduction of pain and progressive recovery of sensory disturbance, but neurologic examination showed right foot drop postoperatively. Two years after surgery, she can not walk without a cane because the neurologic deficit of the right ankle has shown no improvement. Two days after surgery, the second patient was allowed to ambulate with a lumbar orthosis. Neurologic examination showed no motor deficit. Twenty-one months after surgery, the patient reports minimal back pain when sitting on a chair for prolonged periods of time. CONCLUSION: Our cases highlight the importance of preoperative diagnosis in the treatment of intradural lumbar disc herniations. The potential presence of an intradural disc herniation must always be considered preoperatively on a patient whose magnetic resonance imaging study demonstrates the "hawk-beak sign" on axial imaging as well as abrupt loss of continuity of the posterior longitudinal ligament (PLL). This association results in an adequate surgical approach, thereby reducing the chance of postoperative neurologic deficit. Finally, anterior lumbar interbody fusion can be a reasonable alternative in the treatment of intradural lumbar disc herniations. (C) 2007 Elsevier Inc. All rights reserved.