First Case of Spontaneous Spinal Cord Herniation Resolution Reported
Commentary by Michael G. Fehlings, MD, PhD and Jefferson Walter Daniel, MD, PhD
“This is a very unusual case,” said senior author of the case report Michael G. Fehlings, MD, PhD. “I have never before seen spontaneous resolution of idiopathic spinal cord herniation,” Dr. Fehlings said.
The case patient was a 58-year-old man with a 15-month history of mild thoracic myelopathy. Magnetic resonance imaging (MRI) conducted 1 year prior to referral for neurosurgical evaluation suggested focal anterolateral spinal cord displacement at T6-T7 with kinking and associated T2 signal change in the spinal cord. Complete loss of cerebral spinal fluid was found at the site of the anterolateral spinal cord herniation through the dura mater.
After this initial scan, the patient underwent physical therapy, Dr. Fehlings explained. A follow-up scan taken 1 month before presentation for neurosurgical evaluation showed complete resolution of the spinal cord kinking. A 6-month follow-up MRI showed sustained resolution of spinal cord herniation.
“Patients with [spinal cord herniation and] milder symptoms should have a trial of nonoperative management and careful clinical and imaging follow-up in view of our care report of spontaneous resolution of this rare condition,” Dr. Fehlings concluded.
Jefferson Walter Daniel, MD, PhD
Guilherme Brasileiro De Aguiar, MD
Department of Surgery, Division of Neurosurgery
Santa Casa de São Paulo Medical School
São Paulo, Brazil
The authors report a remarkable case of a patient with spontaneous resolution of an idiopathic thoracic spinal herniation. This is the only published case of a patient who experienced resolution from this rare but increasingly recognized clinical entity. As stated in the manuscript, fewer than 200 cases of idiopathic thoracic spinal herniation have been reported in the literature to date. Therefore, the authors have filled a gap in literature on a previously unknown variability in the natural history of this condition.
The clinical implication of the case report is that there is variation of the prognostic parameter for idiopathic thoracic spinal cord herniation. For this reason, patients with nonprogressive mild neurological deficits can be considered for initial nonoperative treatment. On the other hand, microsurgical spinal cord herniation reduction and repair of the ventral dural defect must be considered for patients who harbor progressive neurological deficits.
Another merit in this case report is that a pilot treatment algorithm can now be contemplated since patients with spontaneous resolution of idiopathic thoracic herniation can be compared to those with progressive idiopathic thoracic spinal herniation.
As more clinical articles in this topic are published, further knowledge on the diagnosis, prognosis, and treatment of idiopathic spinal cord herniation will be acquired. In the future, perhaps guidelines may be feasible to develop.