Posterior longitudinal ligament and its implications in intradural cervical disc herniation: Case report and review of the literature

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1 SNI: Spine OPEN ACCESS For entire Editoril Bord visit : Editor: Nncy E. Epstein, MD Winthrop Hospitl, Mineol, NY, USA Cse Report Posterior longitudinl ligment nd its implictions in intrdurl disc hernition: Cse report nd review of the literture Christin Brogn 1,2, José Pedro Lvrdor 1, Sin Ptel 1, Frncesco Vergni 1, Snjeev Bssi 1, Gordn Grhovc 1, Rnjeev Bhngoo 1, Keyoumrs Ashkn 1 1 Neurosurgicl Deprtment, King s College Hospitl Foundtion Trust, 2 Institute of Psychitry, Psychology nd Neuroscience, King s College London, London, United Kingdom E mil: *Christin Brogn Christin.rogn@nhs.net; Jose Pedro Lvrdor josepedro.lvrdor@nhs.net; Sin Ptel sptel21@nhs.net; Frncesco Vergni frncesco.vergni@nhs.net; Snjeev Bssi snj.ssi@nhs.net; Gordn Grhovc gordn.grhovc@nhs.net; Rnjeev Bhngoo rnj.hngoo@nhs.net; Keyoumrs Ashkn k.shkn@nhs.net *Corresponding uthor Received: 12 Ferury 18 Accepted: 23 April 18 Pulished: 18 June 18 Astrct Bckground: Intrdurl disc hernitions (IDH) re rre, prticulrly in the spine, where they ccount for less thn 5% of ll discs. Adhesions etween the ossified/clcified posterior longitudinl ligment (OPLL), dur, nd ossified/clcified disc hernitions increse the complexity of resecting these lesions. Cse Description: A 42 yer old mle presented with rpidly progressive myelopthy over 2 month period. This ws ttriuted to n ossified/clcified intrdurl disc hernition in conjunction with OPLL. The nterior (ACDF) resulted in durl defect ut there ws no cererospinl fluid (CSF) fistul s the rchnoid memrne remined intct. Hd there een CSF lek, it would hve wrrnted oth wound peritonel (WP) nd lumo peritonel shunts (LP). The surgeons should hve nticipted tht CSF lek would likely occur prior to performing the ACDF, nd should hve prophylcticlly prepred nd drped the domen for potentil WP, followed y LP shunt. Three months postopertively, the ptient s proprioceptive deficit improved, nd he lmost completely recovered motor function. Conclusion: Performing n ACDF for resection of n intrdurl clcified/ossified disc with OPLL often results in oth durl defect nd CSF fistul. As the rchnoid memrne rrely remins intct, the spine surgeon should e prepred to immeditely perform oth WP shunt, nd susequently, n LP. In this cse, following n ACDF, resection of n intrdurl ossified disc with OPLL resulted in n isolted durl defect without CSF fistul nd did not require no durl repir or shunting procedures. Access this rticle online Wesite: DOI: /sni.sni_29_18 Quick Response Code: Key Words: CSF lek, intrdurl disc hernition, posterior longitudinl ligment This is n open ccess journl, nd rticles re distriuted under the terms of the Cretive Commons Attriution-NonCommercil-ShreAlike 4.0 License, which llows others to remix, twek, nd uild upon the work non-commercilly, s long s pproprite credit is given nd the new cretions re licensed under the identicl terms. For reprints contct: reprints@medknow.com How to cite this rticle: Brogn C, Lvrdor JP, Ptel S, Vergni F, Bssi S, Grhovc G, et l. Posterior longitudinl ligment nd its implictions in intrdurl disc hernition: Cse report nd review of the literture. Surg Neurol Int 2018;9: Surgicl Neurology Interntionl Pulished y Wolters Kluwer - Medknow

2 INTRODUCTION Intrdurl hernitions (IDH) re rre nd most commonly present in the lumr (92%), followed y the thorcic (5%) nd spine (3%). [5] Since Mreg first descried IDH in 1959, [4] 30 such cses hve een reported in the literture [Tle 1]. [1,3 9] When clcified/ossified IDH typiclly occur in conjunction with OPLL, they result in oth durotomies nd CSF fistuls. [6,8] Anticiption of such CSF leks should prophylcticlly include preprtion to perform wound peritonel (WP) nd susequent lumo peritonel (LP) shunts. [2] Here, ptient with n ossified/clcified IDH with OPLL underwent n ACDF with durotomy ut without n ccompnying cererospinl fluid (CSF) fistul tht did not wrrnt ny shunting procedures. Figure 1: Axil T2-weighted () nd Sgitl T2-weighted () imges reveling centrl C4-C5 disc extrusion with effcement of the nterior surchnoid spce nd compression / indenttion of the spinl cord (hwk ek sign or Y sign, suggestive of intrdurl disc hernition rrow) CASE REPORT Clinicl findings A 42 yer old mle presented with 2 month history of myelopthy tht hd rpidly progressed over the pst 2 weeks. He exhiited left hemipresis (2/5 motor) ut norml function on the right side, which ws ccompnied y hypoesthesi in oth lower extremities. Interestingly, reflexes remined intct ilterlly, nd he retined norml sphincter function. Rdiogrphic evlution The spine mgnetic resonnce imging (MRI) showed lrge ossified/clcified centrl disc hernition t the C4/5 level with OPLL contriuting to mrked ventrl cord compression [Figure 1]. As no preopertive computed tomogrphy (CT) ws performed, no single lyer or doule lyer signs could clerly signl the presence of OPLL. When n ACDF ws performed, they encountered lrge clcified disc frgment with OPLL tht ws removed en loc. Although there ws ter in the dur, the rchnoid remined intct; there ws no ccompnying cererospinl fluid (CSF) fistul [Figure 2]. Therefore, no shunting procedures were wrrnted. Postopertively, the ptient s left hemipresis ws prtilly resolved, however, the sensory deficit remined. Notly, the postopertive MRI scn reveled dequte spinl cord decompression, ut punctte intrmedullry C4 C5 cord contusion [Figure 3]. There were no postopertive complictions, nd 3 months lter, the ptient s motor deficit fully resolved; however, he exhiited residul proprioceptive deficits. DISCUSSION The pthogenesis of IDH include congenitl nrrowing of the spinl cnl, chronic compression of highly moile Figure 2: () En loc removl of the clcified disc frgment, protruding through the posterior longitudinl ligment nd through the dur. () Centrl defect in the dur is oserved, with rchnoid exposed. No CSF lek. Cord seen nicely pulsting through the rchnoid Figure 3: Axil T2-weighted () nd Sgitl T2-weighted () imges reveling sttus post-nterior (sterix) with repermeiliztion of the nterior surchnoid spce nd decompression of the spinl cord (punctte left prmedin spinl cord lesion is seen - rrow) segment of the spinl cnl, nd dhesions etween the clcified/ossified ligments, OPLL, nd dur. [6,8] Here, the ptient hd clcified/ossified IDH with OPLL nd chronic cord compression. IDH with OPLL cn e intr rchnoidl (e.g. due to dhesions/clcifiction etween the PLL nd the dur) or extr rchnoidl. Therefore, high CSF lek rtes re reported for nterior OPLL surgery (e.g %). [5] In this review [Tle 1], [1,3 9] we report 6 CSF leks for

3 Tle 1: Historicl review of the pulished IDH cses [1,3 9] Author/yer Level Sex Age Precipitnt PLL Durtion of Mreg (1959) Durig et l. (1982) Rod et l. (1982) De Brros et l. (1984) Onset of Symptoms Surgicl pproch CSF lek Trum of the spine Adhesions 8 yers Acute Prplegi nd progression to Brown Séqurd C6 C7 M 43 Cervicl pin nd right upper lim wekness C4 M young Motor vehicle ccident Lminectomy 3 months Acute Lhermitte sign nd djcent discectomies Follow up Mild residul hemipresis Jomin et l. (1985) Eisenerg et l. (1986) Lechowski et l. (1986) C5 C6 Trum Incomplete recovery Verny et l. (1986) Prnell (1988) C5 C6 M 47 Sport ctivity Intct PLL 2 months Acute Cervicl pin nd right sided hemipresis Schneider et l. (1988) Destee et l. (1989) Lee et l. (1989) (Clowrd technique) (duroplsty with surgicell) C5 C6 nd C6/ C7 M 31 Spinl mnipultion OPLL 10 dys Sucute Spstic tetrpresis nd reflexic ldder (previous torticollis for right sided cervico rchil neurlgi) Two level nterior Hemipresis resolved nd neck pin improved 3 weeks fter surgery, the ptient ws le to stnd in the upright position C6 C7 M 53 Lod lifting Left hemipresis 6 months lter the ptient hd norml muscle strength on the left side Epstein et l. (1990) Sprick et l. (1991) Yildizhn et l. (1991) Ozer et l. C5 C6 F 36 Motor Cervicl pin (1994) vehicle nd right sided ccident hemipresis nd Mihr et l. (1998) Cervicl pin improved t 10 months of hypoestehesi follow up Contd...

4 Tle 1: Contd... Author/yer Level Sex Age Precipitnt PLL Durtion of Borm et l. (2000) Iwmur et l. (2001) Neroni et l. (2007) Woischneck et l. (2009) Hsieh et l. (2010) Onset of Symptoms C5 C6 M 40 Brown Séqurd C6 C7 M 45 Adhesion Brown Séqurd C6 C7 F 52 Acute Right hemipresis with right hnd txi (dignosed with Klippel Feil ) Surgicl pproch (C5 T1 with fiulr strut grft) ACDF nd plting C7 T1 F Trum C8 Dorsolterl cervico rchilgi pproch nd hypoestesi, lower lim txi C3 C4 Spinl mnipultion OPLL Acute Brown Séqurd Syndrome Knsl et l C5/6 M 45 After hevy lifting N/A Immedite Brown Séqurd Wrde et l. C6/7 M 64 Spontneous 2 weeks 24 hours Cervicl pin (2013) nd left sided hemipresis Westwick C4/5 F 52 Spontneous OPLL 4 weeks 72 hours Cervicl pin, et l. (2014) C5/6 tetrpresis nd sensory deficits Wng (2014) C5/6 M 52 Spontneous OPLL 6 months Acute Brown Sequrd Syndrome Yng et l. (2016) Budrcco et l. (2017) Present report, 2018 C4 C5 nd C5 C6 M 32 Spinl Adhesions 24 hours Acute Tetrpresis nd mnipultion voiding difficulty C4 C5 F 45 Acute Brown Séqurd nd Clude Bernrd Horner C4/5 M 42 Spontneous No 2 months 1 week Brown Sequrd with nterior plting CSF lek Follow up Complete resolution of No Complete motor recovery with residul minor sensory disturnce No Postopertive remission of Complete recovery 6 months fter surgery Brown Sequrd improved nd the ptient chieved 5/5 muscle power t 3 month follow up ACD Post op Improved wekness ACD Residul presis Two level ACDF nd plting corpectomy No No Full recovery Improved wekness, mild presthesi Nerly full muscle power t 12 months Complete recovery t 6 months postopertive ACDF No Mild improvement, ongoing presthesi ACDF; 50% were due to OPLL. In this cse, the potentil for CSF lek should hve een nticipted, nd prophylcticlly, the ptient should hve een prepred nd drped for possile immedite intropertive WP shunt followed y LP shunt. [2] Nevertheless, fortuntely the C4 C5 clcified/ossified disc/opll excision resulted in durotomy without CSF fistul nd no such shunts were required.

5 CONCLUSION Here, ptient with clcified/ossified IDH/OPLL sustined durotomy without CSF fistul during n ACDF. No shunting procedures (WP nd LP shunts) were required s the rchnoid remined intct. In the future, the spinl surgeon should otin preopertive CT to supplement MRI s this would est identify the clssicl single or doule lyer signs indicting OPLL durl penetrnce. This would hve wrned the surgeon of potentil nterior durl/rchnoidl fistul, nd would hve enled them to prophylcticlly prepre nd drpe for nd nticipte CSF fistul requiring oth n immedite WP, followed y n LP shunt. Declrtion of ptient consent The uthors certify tht they hve otined ll pproprite ptient consent forms. In the form the ptient(s) hs/hve given his/her/their consent for his/her/ their imges nd other clinicl informtion to e reported in the journl. The ptients understnd tht their nmes nd initils will not e pulished nd due efforts will e mde to concel their identity, ut nonymity cnnot e gurnteed. Finncil support nd sponsorship Nil. Conflicts of interest There re no conflicts of interest. REFERENCES 1. Budrcco I, Grhovc G, Russo VM. Spontneous intrdurl disc hernition presenting with Brown Séqurd nd Horner s : Lesson lerned from very unique cse. Eur Spine J 2017;26(Suppl 1): Epstein NE. Wound peritonel shunts: Prt of the complex mngement of nterior durl lcertions in ptients with ossifiction of the posterior longitudinl ligment. Surg Neurol 2009;72:630 4;discussion Hrrison J, Goldstein CL, Shmji MF. Acute spontneous disc hernition cusing rpidly progressive myelopthy in ptient with comorid ossified posterior longitudinl ligment: Cse report nd literture review. Surg Neurol Int 2014;5: Mreg T. Erni del disco e espuls nel scco durle. Arch Putti Chir Orgni Mov 1959;12: Pn J, Li Lijun, Qin L, Teng H, Shen B, Tn J, et l. Intrdurl disc hernition. Spine 2011;36: Wng X, Chen D, Yun W, Zhng Y, Xio J, Zho J. surgery in selective ptients with mssive ossifiction of posterior longitudinl ligment of spine: Technicl note. Eur Spine J 2012;121: Wng Z, Sunn T. Intrdurl lumr disc hernition ssocited with degenertive spine disese. Int J Neurorehil 2015;2: Wrde AG, Misr BK. Spontneous intrdurl disc hernition. J Clin Neurosci 2014;21: Yng HS, Oh YM, Eun JP. Cervicl intrdurl disc hernition cusing progressive qudripresis fter spinl mnipultion therpy: A cse report nd literture review. Medicine (Bltimore) 2016;95:e2797.