Case report of a cervical myelomalacia caused by a thoracolumbar intradural disc herniation leading to intracranial hypo
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LETTER TO THE EDITORS
Case report of a cervical myelomalacia caused by a thoracolumbar intradural disc herniation leading to intracranial hypotension M. Ueberschaer1 · M. Patzig2 · K. Mueller3 · J. Schwarting1 · R. Trabold1 · J.‑C. Tonn1 Received: 3 September 2020 / Revised: 24 September 2020 / Accepted: 25 September 2020 © The Author(s) 2020
Abstract A 50-year-old patient was admitted with symptoms of intracranial hypotension. MRI revealed a cervical myelomalacia caused by engorged epidural veins leading to a stenosis of the spinal canal. This condition is rarely described in patients with hydrocephalus and ventricular shunts suffering from chronic overdrainage. However, the reason in this patient was a CSF leak caused by an intradural disc herniation at T12/L1. After surgery, symptoms resolved and the cervical myelomalacia and the swollen epidural veins disappeared on postoperative MRI.In patients with engorged cervical epidural veins without a ventricular shunt, a CSF leak has to be considered. Keywords Case report · Intradural disc herniation · Intracranial hypotension · Myelomalacia · CSF leak
Introduction Intradural disc herniation (IDH) is a rare entity accounting for 0.26–0.3% of all disc herniations [1, 4, 7]. They typically occur at the lower lumbar spine (92%) and are usually associated with neurological deteriorations and/or local pain [3, 6, 7, 8, 12]. Here, we present the case of a 50-year-old patient who was admitted merely with orthostatic headache due to a CSF leak caused by an IDH at the level of T12/L1 with radiological signs of a cervical myelomalacia caused by an engorged epidural venous plexus.
Results Patient Information and clinical findings A 50-year-old female patient was admitted with a 7-week history of postural headache deteriorating in upright position * M. Ueberschaer [email protected]‑muenchen.de 1
Department of Neurosurgery, University Hospital, LMU Munich, Marchioninistr. 15, 81377 Munich, Germany
2
Institute of Neuroradiology, University Hospital, LMU Munich, Munich, Germany
3
Department of Neurology, University Hospital, LMU Munich, Munich, Germany
accompanied by nausea and vomiting. At neurological examination, she presented without any pathological findings, especially no symptoms of lumbar nerve root compression. The medical history of the athletic patient revealed no relevant previous disease or trauma.
Diagnostic assessment Cranial magnetic resonance imaging (MRI) disclosed bilateral subdural hygromas typical for intracranial hypotension (Fig. 1). MRI of the cervical spine showed massively engorged epidural veins leading to a severe stenosis of the spinal canal with concurrent signs of myelomalacia at C3 (Fig. 2a, b). MRI of the lumbar spine presented a prominent disc spur at the level of T12/L1. Additional CT-myelography revealed a CSF leakage at the right ventral circumference of the dural sac correlating with the herniated disc (Fig. 3).
Clinical course Initial treatment with caffeine did not lead to an improvement of the symptoms. A lumba
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