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.