Thoraco-Lumbar Junction Disc Herniation and Tight Filum: A Unique Combination?

The 
incidence of both symptomatic thoraco-lumbar junction disc herniation (TLJDH) 
and tight filum (TF) may be underestimated. Both conditions have a complex 
clinical presentation that may involve the distal spinal cord, conus 
medullaris, and/or cauda equina, including upper and/or lower motor neuron 
impairment, sensory impairment, urological and sexual dysfunction.  
coexistence of both conditions has not been previously reported and may be a 
diagnostic and therapeutic challenge.  We report three teenage girls, 
a 24-year-old woman, and two middle-aged women who were diagnosed with both 
conditions and treated at our institution.  Disc herniation level was 
T11-T12 in 2, T12-L1 in 3, and L1-L2 in one. All patients had a fatty filum (n = 
5) and/or a low-lying CM (at or above L1-L2 in 2, at or below L2-L3 in 4), and 
were treated with filum sectioning first. All patients noted marked 
improvement of preoperative complaints including back pain (n = 5), leg pain 
and fatigue (n = 4), urological complaints (n = 4), and toe gait (n = 1). One 
16-year-old girl successfully underwent a thoracoscopic microdiscectomy for 
persisting pain at the thoraco-lumbar junction two years after filum 
sectioning.  Thoraco-lumbar junction disc herniation and tight 
filum both act on the distal spinal cord close to the transition to the cauda 
equina. Both conditions may coincide and may even act synergistically, the disc 
herniation acting as a fulcrum, aggravating the deleterious effect of the 
tethering force (and vice versa). This might explain why both conditions 
combined may present at a younger age. We suggest filum sectioning as the 
primary treatment option in all patients, however, more cases and a longer follow-up are needed to better understand their unique combination and interaction. 
Nevertheless, when confronted with a symptomatic TLJDH especially in young 
patients we advise to rule out a coinciding TF by careful consideration of all 
clinical, radiological, and urological data.

Related papers:

title: Symptoms of Thoracolumbar Junction Disc Herniation
abstract: A retrospective clinical review of patients with thoracolumbar junction disc herniation.  To evaluate the clinical features of thoracolumbar junction disc herniation and to prepare a chart for the level diagnosis in the neurologic findings and symptoms.  Thoracolumbar junction disc herniations show a variety of signs and symptoms because of the complexity of the upper and lower neurons of the spinal cord, cauda equina, and nerve roots. Furthermore, much is still unknown about thoracolumbar junction disc herniations because of their rare frequency.  The clinical features of 26 patients who had undergone operations for single disc herniations at T10–T11 through L2–L3 were investigated. Affected levels were as follows: 2 patients with disc herniation at T10–T11 disc, 4 patients at T11–T12, 3 patients at T12–L1, 6 patients at L1–L2, and 11 patients at L2–L3. The level of disc space of interest was confirmed with whole-spine plain roentgenograms. The caudal end of the cord was judged by magnetic resonance imaging and computed tomographic myelogram.  Two patients with T10–T11 disc herniation showed moderate lower extremity weakness, increased patellar tendon reflex, and sensory disturbance of the entire lower extremities. Three of four patients with T11–T12 disc herniation experienced lower extremity weakness, and three patients had accentuated patellar tendon reflex. Sensory disturbance was observed in the anterolateral aspect of the thigh in one patient and on the entire leg in three patients. Bowel and bladder dysfunction was noted in three patients. In the T12–L1 disc herniation group (n = 3), muscle weakness and atrophy below the leg were advanced, and bowel and bladder dysfunction were also noted. Two of these three patients had bilateral drop foot, and one patient had unilateral drop foot; sensory disturbance was noted in the sole or foot and around the circumference of the anus, and the patellar tendon reflex and Achilles tendon reflex were absent. All six patients with L1–L2 disc herniation showed severe thigh pain and sensory disturbance at the anterior aspect or lateral aspect of the thigh. On the other hand, there were no clear signs of lower extremity weakness, muscle atrophy, deep tendon reflex, or bowel and bladder dysfunction in these patients. In the L2–L3 disc herniation group (n = 11), all patients had severe thigh pain and sensory disturbance of the anterior aspect or the lateral aspect ofthe thigh. Weakness in the quadriceps was noted in five patients and weakness in the tibialis anterior in two patients. Decreased or absence of patellar tendon reflex was observed in nine patients. Five patients had positive straight leg raising test results, and eight patients showed positive femoral nerve stretch test results.  Among thoracolumbar junction disc herniations, T10–T11 and T11–T12 disc herniations were considered upper neuron disorders, T12–L1 disc herniations were considered lower neuron disorders, L1–L2 disc herniations were considered mild disorders of the cauda equina and radiculopathy, and L2–L3 disc herniations were considered radiculopathy. These findings had relatively distinct differences among herniated disc levels.

title: Thoracic disc herniation and acute myelopathy: clinical presentation, neuroimaging findings, surgical considerations, and outcome.
abstract: Thoracic disc herniations (TDHs) may occasionally present with an acute myelopathy, defined as a variable degree of motor, sensory, and sphincter disturbances developing in less than 24 hours, and resulting in a Frankel Grade C or worse. Confronted with such a patient, the surgeon has to decide whether to perform an emergency operation and whether to use an anterior or posterior approach. The authors analyze their own experience and the pertinent literature, focusing on clinical presentation, imaging findings, surgical timing, technique, and outcome.



Among 250 patients who underwent surgery for symptomatic TDH, 209 had at least 1 year of follow-up at the time of writing, including 8 patients who presented with an acute myelopathy. They were surgically treated using standard thoracoscopic microdiscectomy, careful blood pressure monitoring, and intravenous methylprednisolone. The authors analyzed pre- and postoperative neuroimaging, and Frankel scores preoperatively, at discharge, and 1 year postoperatively.



Although 5 patients had multiple TDHs, the symptomatic TDH was invariably situated between T9-10 and T11-12. Seven TDHs were giant, 6 were calcified, 6 were accompanied by myelomalacia, and 4 were accompanied by segmental stenosis. Although sudden dorsalgia was the initial symptom in 6, a precipitating event was noted in only 1. All patients had severe neurological deficits by the time they underwent surgery. Frankel grades improved from B to D in 2 patients, from C to E in 4, and from C to D and B to E in 1 patient each. All patients regained continence and ambulation. Transient complications were CSF leak (in 2 patients), and intraoperative blood loss greater than 1000 ml, reversible ischemic neurological deficit, and subileus (in 1 patient each).



Approximately 4% of TDHs present with an acute myelopathy. They are often situated between T9-10 and T11-12, large or giant, and even calcified. They almost invariably cause important cord compression (sometimes aggravated by an associated segmental stenosis) and myelomalacia. Their clinical presentation may be misleading, and diagnosis may be delayed until other causes (especially vascular) have been excluded and the clinical picture has become more complete. Interestingly, whereas a precipitating event or trauma is rarely present, dorsalgia frequently precedes profound myelopathy and may help to make an early diagnosis. Remarkable recovery is possible even with profound neurological deficit, a delay of several days, in the elderly, and in the presence of myelomalacia, provided the spinal cord is adequately decompressed and intraoperative hypotension is strictly avoided. Although alternative approaches more familiar to most neurosurgeons may be used, the anterior transthoracic approach has the advantage of reaching the TDH in front of the compromised spinal cord, avoiding any manipulation. In experienced hands, thoracoscopic microdiscectomy combines the advantage and versatility of an anterior approach with minimal postoperative discomfort. The authors conclude that TDH-related acute myelopathy may have a favorable outcome when managed correctly, and they strongly recommend that every single patient should undergo surgical treatment.

title: Clinical characteristics and surgical outcome in 25 cases of childhood tight filum syndrome.
abstract: Tight filum syndrome (TFS) is caused by a thick (abnormal T1 MRI), shortened (low-lying conus), or non-elastic filum (strictly normal MRI). We carefully analyzed children treated for suspect TFS with or without radiological abnormalities.



Twenty-five children, operated between 2002 and 2009, were retrospectively identified. All children had been evaluated by a multidisciplinary team preoperatively. Symptoms, signs and diagnostic test results were categorized (neurologic, urologic, orthopedic, dermatologic) and compared pre- and one year postoperatively. Normal MR was defined as conus medullaris (CM) at or above mid-body L2 and filum diameter less than 2 mm. Occult TFS (OTFS) was defined as TFS with normal MR.



17 girls, 8 boys, age 2-18 years, including 11 syndromal children.



all children had problems in the neurologic category and at least one other category: urologic (n = 17), orthopedic (n = 21), and dermatologic (n = 11).  low-lying CM (n = 14) including 2 with thick filum, normal CM but fatty filum (n = 2), strictly normal (n = 9). Clinical outcome one year postoperatively: neurologic 20 improved, 5 stabilized; urologic 13 improved, 3 stabilized, 1 worsened; orthopedic (8 children presenting with scoliosis) 3 improved, 4 stabilized, 1 worsened. All children with OTFS (n = 9) improved in at least one and 8 improved in all affected categories.



Children with strong clinical suspicion for TFS (≥ 2 affected categories) with or without abnormal MR findings will likely benefit from surgery. In such cases we suggest a detailed full spine MR, a multidisciplinary diagnostic work-up, and eventual untethering through an interlaminar microsurgical approach.

title: Adult tethered cord syndrome mimicking lumbar disc disease
abstract: ObjectThis paper reports four tethered cord cases who initially applied with lumbar disk disease symptoms.Materials and methodsAll of them were investigated by magnetic resonance imaging (MRI) and somatosensory evoked potential (SSPE). In two patients, MRI revealed thick and fatty filum terminale, while in remaining two, the filum terminale appeared as normal in thickness. SSEP revealed pathological conduction values in all, and it was the main indicator for surgical sectioning in patients especially with normal MRI investigations. All patients had benefit from the surgical sectioning of the fila terminalia with either thick and fatty or normal appearance. particular patient with lumbar disc disease symptoms having normal MRI should also be investigated for tight filum terminale. If there is no pathological appearance in MRI investigation (both in regard to disc herniation and thick and fatty filum terminale), SSEP investigation should be done to check whether a conduction block or delay is present, indicating cord tethering.

title: Thoracic disc herniation mimicking acute lumbar disc disease.
abstract: Case report of a 49-year-old woman with a lower thoracic disc herniation mimicking acute lumbosacral radiculopathy.



To describe an unusual case of thoracic disc herniation mimicking acute lumbar disc disease.



Symptomatic thoracic disc herniation is rare and its clinical manifestations differ widely from those of cervical and lumbar disc herniations. Midline back pain and signs of spinal cord compression progressing over months or years are the predominant clinical features. Acute and subacute thoracic disc herniation occurs in less than 10% of patients, and isolated root pain is unusual.



A 49-year-old woman had acute low back pain radiation into the left buttock and the lateral aspect of the left leg and left foot. Magnetic resonance imaging study showed a bulging disc and posterior osteophytes at T11-T12.



Surgical removal of the herniated disc and osteophytes rapidly relieved her symptoms and neurologic deficits. A follow-up neurologic examination 3 years later showed normal motor and sensory functions, although low back soreness was noted occasionally.



A case of thoracic disc herniation mimicking an acute lumbosacral radiculopathy is presented. Compression of the lumbosacral spinal nerve roots at the lower thoracic level after exit from the lumbar enlargement may be the mechanism for this unusual presentation.

title: Compressive lumbar myelopathy presenting as segmental motor neuron disease
abstract: Four patients presented with slowly progressive, bilateral, asymmetric weakness and muscle atrophy in the lower extremities, accompanied by cramps and fasciculations. Sensory symptoms were insignificant. There was no bladder or bowel disturbance. Upper extremities and cranial nerves were normal. Weakness was found in lumbosacral myotomes, ranging from L2 to S1. The tendon reflexes varied, and extensor plantar responses were found in one case with proximal leg involvement. Nerve conduction studies were normal, but segmental chronic and often active denervation confined to the weak myotomes in the lower extremities was found in the electromyogram. Magnetic resonance imaging showed evidence of spondylotic lumbosacral myelopathy associated with disc herniation or osteophytic arthropathy at the T11/T12 spinal level in all patients, with increased signal within the adjacent cord. This unusual purely motor presentation may result from ischemic myelopathy secondary to compression of the anterior spinal artery. Muscle Nerve 28: 69–73, 2003

title: Video-Assisted Thoracoscopic Surgery for Thoracic Disc Disease: Classification and Outcome Study of 100 Consecutive Cases With a 2-Year Minimum Follow-up Period
abstract: Prospectively collected data from regular clinical follow-up evaluations were tabulated, analyzed, reviewed using a patient self-reported questionnaire.  To develop a classification system and present the long-term functional outcome of video-assisted thorascopic surgery for refractory thoracic disc disease.  Recent studies have found an 11.1% to 14.5% prevalence of thoracic disc herniations. Surgical approaches have included laminectomy, pediculectomy, costotransversectomy, lateral extracavitary, transverse arthropediculectomy, transthoracic-transpleural thoracotomy, and thoracoscopy. Recent reports have documented encouraging early results with video-assisted thorascopic surgery for thoracic disc herniations. Comparisons between thoracoscopy and open thoracotomy have demonstrated improvement in postoperative pain and morbidity with the use of endoscopic techniques.  This study included 100 consecutive patients (45 women and 55 men) with an average follow-up evaluation of 4 years (range, 2–6 years). The average age of the patients was 42 years (range, 22–76 years). The average duration of symptoms was 26 months (range, 6–96 months), and 18 patients had undergone prior spine surgery. Patients were graded as follows according to the presenting symptoms (Table 1): Grade 1 (pure axial; n = 28), Grade 2 (pure radicular; n = 5), Grade 3A (axial and thoracic radicular; n = 38), Grade 3B (axial with lower leg pain; n = 19), Grade 4 (myelopathic; n = 8), or Grade 5 (paralytic = 2). Table 1.  A total of 117 discs were excised in 100 patients. Of the 40 patients who underwent fusion, 27 had autologous rib struts and 13 had threaded fusion. The mean operative time was 173 minutes, blood loss 259 mL, average ICU stay less than 1 day, and average hospital stay 4 days. Minor complications occurred in 21 patients, all of which resolved with no untoward effect. No patient’s neurologic status worsened. Four patients underwent a secondary fusion, and a pseudarthrosis developed in one patient. Clinical success was defined objectively as an improvement in Oswestry score of 20% or more at 2 years and at final follow-up assessment, as compared with the preoperative Oswestry score. Overall, objective clinical success was observed at 2 years in 73% of the patients, and at final follow-up assessment in 70% of patients. The average percentage of improvement in Oswestry scores was most marked in Grade 4 patients (myelopathy; 60%), followed by Grade 3A patients (axial and thoracic radicular pain; 37%), Grade 3B patients (axial with leg pain; 28%), and Grade 1 patients (pure axial; 24%). The Oswestry disability score (Table 2) and back pain visual analog score (Table 3) also were significantly improved (P < 0.05) at 2 years and at final follow-up assessment in these patients. In the Grade 2 patients, those pure thoracic radicular pain, Oswestry scores initially improved significantly up to 1 year (P < 0.05). At 2 years, no significant improvement could be shown, and four of the five Grade 2 patients reported increased axial pain as their main symptom at the final follow-up assessment. Significant improvement also was seen in patients with no prior spine surgery and patients with preoperative Oswestry disability scores greater than 50. Of the 68 patients who responded to the final questionnaire, 12 rated the procedure as excellent, 37 as good, 11 as fair, and 8 as poor. Also, 57 (83.8%) of these 68 patients were satisfied and indicated they would recommend the surgery. Of the 36 patients at the final follow up assessment who had severe disability, 34 (94%) were satisfied, as compared with 23 of the 32 patients (72%) who had presented with milder disability. Table 2. Percentage Improvement in Oswestry Scores With Number of Patients Achieving “Clinical Success” at 2 Years and at Final Follow-Up (Grade 5 Patients Excluded) Table 3. Average Oswestry Disability Score* Significance at P < 0.05 (paired t test). The statistical significance was established between the patient’s preoperative score and the follow-up score.  The clinical classification system helps in differentiating different presentations of thoracic disc disease and their final outcome. Video-assisted thorascopic surgery appears to be a safe and efficacious method for the treatment of refractory symptomatic thoracic disc herniations. The current data suggest that the procedure has an acceptable long-term outcome, with an 84% overall subjective patient satisfaction rate, and with objective long-term clinical success achieved in 70% of patients.

title: Paraparesis in a child with a herniated thoracic disc.
abstract: Herniated thoracic disc after minor trauma, causing paraparesis in an 11-year-old boy, proved difficult to diagnose. Myelogram and computer tomography of the thoracic spine appeared normal, but magnetic resonance imaging demonstrated a small herniation at T4-T5. Disc material adherent to the dura was found at laminectomy. The child made progressive recovery preoperatively and postoperatively and was able to ambulate in parallel bars with a left knee-ankle-foot orthorsis at the time of discharge from the hospital.

title: Intervertebral disc calcification with neurological symptoms in children: report of conservative treatment in two cases
abstract: PurposeIntervertebral calcifications are rare in the paediatric population. Two cases of children with symptomatic intervertebral calcifications responsible for spinal cord compression and neurological compromise are presented.MethodsThe data of two children treated conservatively for a symptomatic intervertebral calcification responsible for spinal cord compression and neurological compromise were retrospectively reviewed.ResultsFrontal and lateral radiographs are usually sufficient to determine the presence and extent of the calcified cervical disc protrusion. Conservative treatment with antalgics and bracing was applied in both cases. The two patients were completely free of symptoms 4 weeks after initial treatment. Magnetic resonance imaging screening showed a complete vertebral canal clearance at final follow-up.ConclusionDespite the lack of significance due to the small number of patients, conservative treatment should be considered in children with moderate neurological symptoms due to calcified disc protrusion.

title: Giant calcified thoracic disc herniation in a child: a case report and review of the literature.
abstract: Calcified thoracic disc herniation in childhood is a rare disease, and it differs from calcified thoracic disc herniation in adults in several respects, including the natural history, clinical presentation, treatment, and prognosis1,2. Herniation of a calcified disc occasionally leads to acute nerve-root or spinal cord compression. Conservative treatment has been recommended for the majority of patients, even those with mild neurological deficits, since spontaneous resorption of the calcified lesion can be expected1,3-8. In other rare cases, giant herniation of the disc may cause intractable pain and a progressive neurological deficit, which has been an indication for surgical treatment1,5,6,8. We report the case of a child with giant herniation of an intervertebral disc calcification in the thoracic spine and present a literature review. The parents of the patient were informed that data concerning the case would be submitted for publication, and they consented.

A twelve-year-old girl presented with upper back pain for one month, preceded by a fever forty days earlier. The pain radiated to the front of the chest, was aggravated by spinal motion, particularly bending forward and deep breathing, and was relieved by analgesics.

She had tenderness at the spinous processes of T2 and T3 with paraspinal muscle spasm. Spinal motion was extremely painful. Neurological examination was unremarkable, except for a minimal sensory deficit of the left T2 and T3 dermatomes. During the febrile period, the serum calcium level was 2.74 mmol/L (normal, 2.29 to 2.73 mmol/L), the serum phosphorus level was 1.60 mmol/L (normal, 0.81 to 1.45 mmol/L), and the serum alkaline phosphatase level was 157 U/L (normal, 15 to 112 U/L). The erythrocyte sedimentation rate and leukocyte count were normal.

The lateral radiograph of the cervical spine indicated a …

title: Preoperative Predictors for Improvement after Surgical Untethering in Occult Tight Filum Terminale Syndrome
abstract: An occult tight filum terminale syndrome has been described wherein clinical symptoms result from tension on the spinal cord despite nondiagnostic spinal magnetic resonance imaging (MRI). Recent reports have suggested a role for surgical untethering in this patient population; however, controversy remains regarding the surgical treatment of this condition. Owing to the various clinical presentations, the relationship of presenting signs and symptoms to postoperative outcomes might be useful in surgical selection.  A retrospective review was conducted of 22 pediatric cases of surgical untethering for suspected occult tight filum terminale syndrome. All patients had nondiagnostic MRI findings, defined as a conus medullaris above the L3 vertebral body and a filum terminale diameter of less than 2 mm. Preoperative symptoms, signs and urodynamic test results were collected and compared with surgical outcomes determined by clinical notes and postoperative urodynamics reports. Abnormal findings on presentation were categorized as dermatologic, urologic, orthopedic and neurologic.  Patient age ranged from 7 months to 17 years, and 12 were female. Sixteen (73%) patients experienced subjective and/or objective improvement following surgical untethering. Fourteen patients had abnormal preoperative urodynamic testing, of which 12 underwent postoperative urodynamic testing. Five of these 12 (42%) demonstrated objective improvement postoperatively. Patients presenting with abnormal findings in at least 2 categories were more likely to improve following untethering (88%) than those with abnormalities in only 1 category (20%; p = 0.009).  Spinal cord untethering is a treatment option for occult tight filum terminale syndrome. Further evaluation of the relationship between preoperative findings and surgical outcomes may facilitate the selection of surgical candidates.

title: Two brothers with a symptomatic thoracic disc herniation at T11–T12: clinical report
abstract: BackgroundIn contrast to what is commonly believed, thoracic disc herniations are not rare lesions. Their etiopathogenesis is largely unknown, but may be linked to trauma, Scheuermann’s disease or a degenerative back.ObjectiveWe report two brothers with a symptomatic thoracic disc herniation at T11–T12 and address the possibility of a genetic factor as well as other factors in the etiopathogenesis of (symptomatic) thoracic disc herniations.Clinical featuresBoth brothers were in their early thirties and had a physically demanding job, however, only the first one was a smoker and was diagnosed with Scheuermann’s disease.ConclusionThe etiology of thoracic disc herniations is likely multifactorial. Their occurrence in siblings may reflect some genetic predisposition or may be merely coincidental, given the high prevalence of thoracic disc herniations in asymptomatic individuals. Further research, including genetic studies, is warranted.

title: Magnetic resonance imaging of the thoracic spine. Evaluation of asymptomatic individuals.
abstract: We reviewed magnetic resonance imaging studies of the thoracic spines of ninety asymptomatic individuals to determine the prevalence of abnormal anatomical findings. This group included sixty individuals who had no history of any thoracic or lumbar pain and thirty individuals who had a history of low-back pain only. In addition, we reviewed imaging studies of eighteen patients who had an operatively proved herniation of a thoracic disc and studies of thirty-one patients who had been seen with thoracic pain. Sagittal T1-weighted spin-echo and axial multiplanar gradient refocused images at each disc level were interpreted by us (two neuroradiologists and two orthopaedic spine surgeons); we had no clinical information about the patients. Sixty-six (73 percent) of the ninety asymptomatic individuals had positive anatomical findings at one level or more. These findings included herniation of a disc in thirty-three subjects (37 percent), bulging of a disc in forty-eight (53 percent), an annular tear in fifty-two (58 percent), deformation of the spinal cord in twenty-six (29 percent), and Scheuermann end-plate irregularities or kyphosis in thirty-four (38 percent). This study documents the high prevalence of anatomical irregularities, including herniation of a disc and deformation of the spinal cord, on the magnetic resonance images of the thoracic spine in asymptomatic individuals. We emphasize that these findings represent roentgenographic abnormalities only, and any clinical decisions concerning the treatment of pain in the thoracic spine usually require additional studies.

title: Thoracic Disk Herniation Resulting in Acutely Progressing Paraplegia in a Pediatric Patient
abstract: Thoracic intervertebral disk herniation is an uncommon entity. Acute presentation of this entity in the pediatric population is exceptionally rare. Given the infrequent prevalence, accurate diagnosis of acute symptomatic thoracic disk herniation can be difficult.  The purpose of this article is to describe the presentation of acute nontraumatic thoracic disk herniation in a pediatric patient and the diagnostic workup and surgical management of this rare entity.  This is a case report regarding a pediatric patient with nontraumatic acutely symptomatic thoracic disk herniation. The order of diagnostic studies and method of surgical decompression used are described. Progressive follow-up neurological improvement is detailed in the report.  A 16-year-old adolescent girl with acutely symptomatic paramedian disk herniation at T10 to T11 underwent left thoracotomy followed by microdiscectomy. Decompression of T10 to T11 was followed by fusion of T10 to T11 with rib strut graft.  Postoperatively, the patient recovered near-complete resolution of bilateral lower extremity paralysis and dysesthesias.  Thoracic intervertebral disk herniation is a rare phenomenon. It is a particularly uncommon entity in the pediatric population. As such, the diagnosis and management of thoracic disk herniation can be a considerable challenge. As illustrated in our case report, the clinician's focus should not exclusively rest on lumbar disk pathology as the etiology for such rapidly evolving neuromuscular deficits. Thoracic disk herniation must be included in the differential diagnosis, and appropriate diagnostic workup should be instituted in an expeditious manner. Plain radiographic studies may not delineate the causative factor of pathology, and emergent magnetic resonance imaging can aid in obtaining a timely diagnosis. Early intervention and decompression have been shown to significantly improve functional recovery.

title: Clinical and radiographic characteristics of upper lumbar disc herniation: ten-year microsurgical experience.
abstract: Upper and lower lumbar disc herniation apparently have different background, symptoms, and operative results. This retrospective study reviewed the clinical records of 403 patients (409 discs) who underwent lumbar microdiscectomy performed by different surgeons at our institute between 1999 and 2009. The 290 male (72.0%) and 113 female (28.0%) patients were aged from 19 to 77 years (mean 44 years). Demographics, symptoms, and static and dynamic radiographic and magnetic resonance images obtained at the L1-2, L2-3, L3-4, L4-5, and L5-S1 intervertebral levels were analyzed. Of the 409 herniations, 3 were at L1-2, 9 at L2-3, 21 at L3-4, 166 at L4-5, and 210 at L5-S1. The mean age at herniation at L1-2 and L2-3 levels was 55.7 years. Patients with herniation of discs at L3-4 or above were significantly older than patients who suffered herniation at L4-5 or below (p < 0.0001), and the incidence of urinary disturbance was significantly higher in patients with herniation at L1-2 and L2-3 levels (p = 0.0013). The incidence of degenerative scoliosis was significantly higher in patients with herniation at L1-2 and L2-3 than in those with herniated discs at L3-4 or below (p < 0.0001). Patients with upper lumbar disc herniation were older and manifested a higher incidence of urinary disturbance. A high incidence of degenerative scoliosis was noted in the course of prolonged degenerative processes.

title: Tethered cord due to spina bifida occulta presenting in adulthood: a tricenter review of 61 patients.
abstract: OBJECT
Children with spina bifida occulta require early surgery to prevent neurological deficits. The treatment of patients with a congenitally tethered cord who present in adulthood remains controversial.



The authors studied the medical records of 61 adult patients who underwent surgical untethering for spina bifida occulta at three institutions between 1994 and 2003. Patients who had undergone prior myelomeningocele repair or tethered cord release surgery were excluded. The most common intraoperative findings were lipomyelomeningocele (41%) and a tight terminal filum (36%). The follow-up duration ranged from 10.8 to 149.5 months. Of the 34 patients with back pain, status improved in 65%, worsened in 3%, remained unchanged in 18%, and improved and later recurred in 15%. Lower-extremity pain improved in 16 patients (53%), remained unchanged in 23%, improved and then recurred in 17%, and worsened in 7%. Lower-extremity weakness improved in 47%, remained unchanged in 47%, and improved and then recurred in 5%. Finally, of the 17 patients with lower-extremity sensory changes, status improved in 35%, remained unchanged in 35%, and the information on five patients was unavailable. Surgical complications included three wound infections, one cerebrospinal fluid leak, and two pseudomeningoceles requiring surgical revision. One patient developed acute respiratory distress syndrome and sepsis postoperatively and died several days later.



Adult-age presentation of a congenital tethered cord is unusual. Despite a slight increase in postoperative neurological injury in adults, surgery has relatively low risk and offers good potential for neurological improvement or stabilization. As they do in children, the authors recommend early surgery in adults with this disorder. The decision to undertake surgery, however, should be modulated by other factors such as a patient's general medical condition and risk posed by anesthesia.

title: Pathophysiology of tethered cord syndrome and similar complex disorders.
abstract: Tethered cord syndrome (TCS) is a stretch-induced functional disorder of the spinal cord due to the fact that its caudal portion is anchored by an inelastic structure. The functional lesion of TCS is generally situated in the lumbosacral cord, and many authors have shown that the syndrome is reversible via surgery to untether the cord. To clarify the expressions relevant to TCS, such as "cord tethering" and "tethered cord," the authors have formulated three categories. These categories include cases that show the anatomical appearance of spinal cord stretching. Among them, Category 1 is isolated to represent the "true TCS." The authors focus their discussion of the pathophysiology of TCS on Category 1 to explain the impaired oxidative metabolism and electrophysiological derangements within the tethered spinal cord, which is the primary intrinsic cause of the dysfunction. Furthermore, they extend the discussion to the extrinsic (outside the spinal cord) factors and other complex conditions that mimic TCS.

title: The pathophysiology of thoracic disc disease.
abstract: Nucleus pulposus herniations are far less common in the thoracic spine than at the cervical and lumbar regions. Traditionally, diagnosis of thoracic disc herniations has been challenging because the signs and symptoms are often subtle early in their course. As a result, delays in diagnoses are common. Because they are uncommon as well as difficult to diagnosis, the neurosurgical community has sparse data on which to base good clinical decision making for the treatment of these herniations. In this review the authors seek to place the phenomenon of thoracic disc disease into the context of its pathophysiology. After a careful evaluation of the available clinical, pathological, and basic science data, a case is made that the cause of nucleus pulposus herniations in the thoracic spine is similar to those occurring in the lumbar and cervical regions. The lower incidence of herniations is ascribed primarily to the reduced allowable flexion at the thoracic level compared with the lumbar and cervical levels. To a lesser extent, the contribution of the ribs to weight-bearing may also play a role. Further review of clinical data suggests that thoracic disc herniations, like herniated cervical and lumbar discs, may be asymptomatic and may respond to conservative therapy. Similarly, good surgery-related results have been reported for herniated thoracic discs, despite the more challenging nature of the surgical procedure. The authors conclude that treatment strategies for thoracic disc herniations may logically and appropriately follow those commonly used for the cervical and lumbar levels.

title: Ultrastructural Findings in Human Spinal Pia Mater in Relation to Subarachnoid Anesthesia
abstract: We examined ultrastructural details such as the cellular component and membrane thickness of human spinal pia mater with the aim of determining whether fenestrations are present. We hypothesized that pia mater is not a continuous membrane but, instead, that there are fenestrations across the pial cellular membrane. The lumbar dural sac from 7 fresh human cadavers was removed, and samples from lumbar spinal pia mater were studied by special staining techniques, immunohistochemistry, and transmission and scanning electron microscopy. A pial layer made by flat overlapping cells and subpial tissue was identified. We found fenestrations in samples from human spinal pia mater at the thoracic-lumbar junction, conus medullaris, and nerve root levels, but these fenestrations did not appear at the thoracic level. We speculate whether the presence of fenestrations in human spinal pia mater at the level of the lumbar spinal cord and at the nerve root levels has any influence on the transfer of local anesthetics across this membrane.

title: Tethered cord syndrome in adults.
abstract: Patients with tethered cord syndrome (TCS) rarely have symptomatic onset in adulthood. Twenty-three adult patients with TCS were studied with respect to the clinical, radiological, and pathological features of this syndrome. Specific circumstances involving either additional tugging of the already tight conus, narrowing of the spinal canal, or direct trauma to the back or buttocks precipitated symptomatic onset in 60% of patients. Diffuse and non-dermatomal leg pain, often referred to the anorectal region, was the most common presenting symptom. Progressive sensorimotor deficits in the lower extremities as well as bladder and bowel dysfunction were also common findings; but, unlike TCS in children, progressive foot and spinal deformities were not seen. As in TCS with onset in childhood, the most common tethering lesions were thickened filum, intradural lipoma, and fibrous adhesions. The degree of cord traction, rather than the type or distribution of the tethering lesions, probably determines the age of symptom onset: less severe traction remains asymptomatic in childhood but results in neurological dysfunction in later life due to repeated tugging of the conus during natural head and neck flexion, or when abnormal tension is aggravated by trauma or spondylotic canal stenosis. Metrizamide myelography revealed the diagnosis of tethered conus in most cases, but the addition of computerized tomographic imaging provided valuable structural details concerning the tethering lesion. The surgical outcome was gratifying in relation to pain and motor weakness but disappointing in the resolution of bowel and bladder dysfunction. Early diagnosis and adequate release of the tethered conus are the keys to successful management.

title: Removal of a Protruded Thoracic Disc Using Microsurgical Endoscopy: A New Technique
abstract: The first clinical implementation of a microsurgical endoscope technique for removal of thoracic disc herniation is described.  To decompress the spinal cord with a ventral approach, combining microsurgical and endoscopic techniques, while reducing the “approach-related trauma.”  A detailed description of the preoperative preparation as well as the surgical technique is given. Advantages and disadvantages of the microsurgical endoscopic technique are discussed and compared with other surgical procedures described in the literature.  A herniated disc at T6-T7 was removed and the spinal cord was decompressed. The patient recovered completely and was discharged at the seventh postoperative day. He returned to work 4 weeks later.  The microsurgical endoscopic technique allows spinal cord decompression with a substantial reduction in surgical trauma. It may shorten bed confinement and allow early return to active life. Application of this technique in other areas is being studied.