Neurology India, Vol. 59, No. 3, May-June, 2011, pp. 447-450
Cervical intradural disc herniation and cerebrospinal fluid leak
Ritesh Kansal, Amit Mahore, Sanjay Kukreja
Department of Neurosurgery, L.T.M.G. Hospital, Sion, Mumbai, India
Correspondence Address:Ritesh Kansal Department of Neurosurgery, L.T.M.M.C and L.T.M.G.H, Sion, Mumbai India firstname.lastname@example.org
Date of Submission: 07-Jan-2011
Code Number: ni11128
AbstractCervical intradural disc herniation (IDH) is a rare condition and only 25 cases of cervical have been reported. We report a 45-year-old male who presented with sudden onset right lower limb weakness after lifting heavy weight. Magnetic resonance imaging of the cervical spine showed C5/6 disc prolapse with intradural extension. The patient underwent C5/6 discectomy through anterior cervical approach. Postoperatively, the patient improved in stiffness but developed cerebrospinal fluid leak and the leak resolved with multiple lumbar punctures.
Keywords: Brown-Sequard syndrome, cerebrospinal fluid leak, cervical intradural disc herniation
Intradural herniation of disc fragments is an unusual manifestation of prolapsed intervertebral disc and results from perforation of posterior longitudinal ligament and dura mater. , Most of the reported cases have been at lumbar spine  and cervical site is rare.  Most common clinical presenting features of intradural disc herniation (IDH) are Brown-Sequard syndrome and/or Horner's syndrome and the presence of these features should suggest the diagnostic possibility of IDH.  We report a case of cervical IDH with cerebrospinal fluid (CSF) leak.
A 45-year-old male presented with sudden onset weakness of right lower limb after heavy weight lifting in gymnasium. Neurological examination revealed decreased pinprick sensation below T3 dermatome on the left side and proprioceptive and vibratory sensations impairment and motor weakness in the right lower limb. Reflexes were brisk in right lower limb and right plantar response was extensor. Findings were suggestive of Brown-Sequard syndrome. Magnetic resonance imaging scan of cervical spine revealed prolapsed C5/6 disc with widened subarachnoid space at that level raising the suspicion of intradural extension and cord compression [Figure - 1] and [Figure - 2]. The patient underwent removal of the disc with anterior cervical approach. The disc material was found herniating through the posterior longitudinal ligament and dura mater. The disc was removed gently. The spinal cord was visible through the defect. The defect was repaired with fat graft and fibrin glue. He did not undergo fusion or instrumentation. Postoperatively the patient had improvement in his weakness, but developed CSF leak from the wound on the third postoperative day. Multiple lumbar punctures (8 hourly) were done over 3 days and he was also started on intravenous antibiotics with which the leak resolved.
Disc herniation in cervical spine most frequently occurs at C6/7 level followed by C5/6 level and the predilection for these sites is due to the force exerted at these levels as it acts as a fulcrum for the mobile head and spine. Disc herniation posteriorly is prevented by the posterior longitudinal ligament. IDH occurs when there is perforation of posterior longitudinal ligament and dura mater. Dandy suggested that acute pressure of the protruded extradural disc may erode and penetrate the anterior wall of the dura mater.  This hypothesis was also supported by Lyons and Wise.  IDH is more frequently reported at the sites where there is increased spinal movement. The prolapsed disc may result in chronic irritation and tear of dura mater secondary to vertebral movement.
The physiological and pathological features of IDH have not been fully defined. The possible mechanisms of IDH include the following: (1) adhesions between the annulus fibrosus, posterior longitudinal ligament, and dura mater; (2) congenital narrowing of the spinal canal with less epidural space; and (3) congenital and iatrogenic thinness of the dura mater. , The important factor among these is adhesions. These adhesions also serve as a barrier to lateral migration of the fragment, forcing it directly dorsally through the annulus-posterior longitudinal ligament-dural layer. Previous trauma is suggested to be associated with intradural herniation of intervertebral disc. Trauma has been hypothesized to cause adhesions between the ligaments and dura mater causing rupture of disc through the dura as a secondary event. 
The common site of IDH is lumbar spine and rarely at cervical or thoracic spine. Over 100 cases of IDH have been reported,  however, only in 25 cases, including the present patient, the site of IDH is cervical spine ,,,,,,,,,,,,,,,,,,,,, [Table - 1]. The common clinical presenting features of IDH are Brown-Sequard syndrome, ,,,,,,, transverse myelopathy, ,,,,,,, and rarely adiculopathy.  The onset of symptoms is typically sudden, although there may be a period of local and radicular pain. Our patient presented with features of Brown-Sequard syndrome.
Our patient underwent discectomy through anterior cervical approach and postoperatively had improvement in his symptoms but developed CSF leak from the operative wound on the third postoperative day. CSF leak following cervical discectomy is an uncommon complication. In our patient the preexisting dural defect has probably predisposed to the leak. Precaution against CSF leak is essential in these patients. The defect was covered at the time of surgery with fat graft and fibrin glue in our patient. In spite of this, the patient manifested with CSF leak. This was managed with prophylactic antibiotics and serial lumbar puncture and CSF drainage for 3 days. CSF leak resolved with this management. The management of this problem has not been discussed much in the literature. Suturing of the defect through anterior approach has been described.  Prophylactic lumbar drainage should be considered in such cases for 3-5 days. This is essential to avoid the risk of meningitis secondary to the CSF leak.
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