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Neuroradiologie Scan 2015; 05(01): 61-79
DOI: 10.1055/s-0034-1391272
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© Georg Thieme Verlag KG Stuttgart · New York

Die idiopathische Rückenmarkshernie und ihre Differenzialdiagnosen[1]

Differentiation of idiopathic spinal cord herniation from CSF-isointense intraspinal extramedullary lesions displacing the cord
Marc D. Haber
,
Dustin D. Nguyen
,
Shan Li
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Publication History

Publication Date:
02 January 2015 (online)

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Zusammenfassung

Ursache einer fokalen Verlagerung des Rückenmarks kann eine idiopathische Rückenmarksherniation (Idiopathic Spinal Cord Herniation) sein, bei der das Rückenmark durch einen Duradefekt in den Epiduralraum gedrängt wird. Dies führt zu einer Verlagerung und Einklemmung des Rückenmarks. Die idiopathische Rückenmarksherniation ist eine seltene Krankheit und wird in vielen Fällen zunächst fehldiagnostiziert – mit entsprechender Verzögerung des Behandlungsbeginns. Das Krankheitsbild der idiopathischen Rückenmarksherniation ist leicht mit liquorisointensen intraspinalen, extramedullären Raumforderungen zu verwechseln, wie z. B. Epidermoidzysten oder Teratomen, intraduralen Arachnoidalzysten, epiduralen Hämatomen oder Abszessen, zystischen Tumoren der Nervenscheiden, Synovial- oder Tarlov-Zysten, Meningozelen und Pseudomeningozelen. Bei den ersten Untersuchungen mittels CT und nativer MRT zeigt sich eine fokale Verlagerung des Rückenmarks mit gleichzeitiger Erweiterung des Liquorraums, doch reicht der Befund häufig nicht aus, um die Ursache zu erkennen. Die hochauflösende Dünnschicht-MRT ermöglicht die genaue Lokalisierung des Duradefekts und des durch diesen Defekt in den Epiduralraum drängenden Rückenmarks. Sind in den Aufnahmen Artefakte erkennbar, die eine unbehinderte Liquorpulsation innerhalb des erweiterten Liquorraums anzeigen, schließt dies eine raumfordernde Läsion aus. Umgekehrt kann ein Füllungsdefekt in einer konventionellen oder einer CT-Myelografie zur Bestätigung einer liquorisointensen Raumforderung beitragen. Der Ausschluss einer extramedullären Zyste mit Randverstärkung wird durch intravenöse Verabreichung eines Kontrastmittels erleichtert. Das klinische Bild ist gewöhnlich unspezifisch, aber der akute Charakter der Symptome, das Auftreten von Fieber und die Kenntnis eines stattgehabten Traumas können die Befundung der bildgebenden Darstellungen leiten und bei der Eingrenzung der Differenzialdiagnose helfen. Ein multimodales Vorgehen bei der Bildgebung ist entscheidend für die Differenzierung einer idiopathischen Rückenmarksherniation von liquorisointensen intraspinalen, extramedullären Raumforderungen.

Abstract

Focal spinal cord displacement can be caused by idiopathic spinal cord herniation (ISCH), in which the cord protrudes through a dural defect into the epidural space, causing cord displacement and tethering. ISCH is uncommon and often is misdiagnosed initially, which results in delayed management. ISCH can be mimicked by space-occupying cerebrospinal fluid (CSF)-isointense intraspinal extramedullary lesions, such as epidermoid cysts or teratomas, intradural arachnoid cysts, epidural hematomas or abscesses, cystic nerve sheath tumors, synovial or Tarlov cysts, meningoceles, and pseudomeningoceles. Initial computed tomography (CT) and unenhanced magnetic resonance (MR) imaging studies may depict focal cord displacement and a widened CSF space but often are not sufficient to identify the underlying cause. High-resolution thin-section MR imaging can delineate the exact location of the dural defect and the protrusion of the herniated cord through this defect into the epidural space. At imaging, unimpeded CSF pulsation artifacts seen within a widened CSF space exclude a space-occupying lesion. A filling defect seen at conventional or CT myelography can help confirm a CSF-isointense space-occupying lesion; intravenous contrast agent administration can help exclude a rim-enhancing cystic extramedullary lesion. The clinical presentation usually is nonspecific, but symptom acuity, fever, and trauma can guide the imaging evaluation and help narrow the differential diagnosis. A multimodality imaging approach is essential to differentiate ISCH from space-occupying CSF-isointense intraspinal extramedullary lesions.

1 ©2014 The Radiological Society of North America. All rights reserved. Originally puplished in English in RadioGraphics 2014; 34: 313 – 329. Online published in 10.1148 /rg.342125136. Translated and reprinted with permission of RSNA. RSNA is not responsible for any inaccuracy or error arising from the translation from English to German.


 

  • Literatur

  • 1 Wortzman G, Tasker RR, Rewcastle NB et al. Spontaneous incarcerated herniation of the spinal cord into a vertebral body: a unique cause of paraplegia – case report. J Neurosurg 1974; 41: 631-635
    CrossrefSearch in Google Scholar
  • 2 Lee ST, Lui TN, Jeng CM. Spinal cord herniation after stabbing injury. Br J Neurosurg 1997; 11: 84-86
    CrossrefSearch in Google Scholar
  • 3 Tekkök IH. Spinal cord herniation: Which one is really traumatic?. AJNR Am J Neuroradiol 2000; 21: 609-612
    Search in Google Scholar
  • 4 Groen RJ, Middel B, Meilof JF et al. Operative treatment of anterior thoracic spinal cord herniation: three new cases and an individual patient data meta-analysis of 126 case reports. Neurosurgery 2009; 64: ons145-ons159 , discussion ons 159 – ons160
    Search in Google Scholar
  • 5 Imagama S, Matsuyama Y, Sakai Y et al. Image classification of idiopathic spinal cord herniation based on symptom severity and surgical outcome: a multicenter study. J Neurosurg Spine 2009; 11: 310-319
    CrossrefPubMedSearch in Google Scholar
  • 6 Batzdorf U, Holly LT. Idiopathic thoracic spinal cord herniation: report of 10 patients and description of surgical approach. J Spinal Disord Tech 2012; 25: 157-162
    CrossrefSearch in Google Scholar
  • 7 Zairi F, Thines L, Bourgeois P et al. Spinal cord herniation: a misdiagnosed and treatable cause of thoracic myelopathy. Acta Neurochir (Wien) 2010; 152: 1991-1996
    CrossrefSearch in Google Scholar
  • 8 Novak K, Widhalm G, de Camargo AB et al. The value of intraoperative motor evoked potential monitoring during surgical intervention for thoracic idiopathic spinal cord herniation. J Neurosurg Spine 2012; 16: 114-126
    CrossrefSearch in Google Scholar
  • 9 Singh P, Vyas S, Gogoi D et al. Idiopathic spinal cord herniation. Ann Indian Acad Neurol 2011; 14: 136-137
    CrossrefSearch in Google Scholar
  • 10 Nakamura M, Fujiyoshi K, Tsuji O et al. Long-term surgical outcomes of idiopathic spinal cord herniation. J Orthop Sci 2011; 16: 347-351
    CrossrefSearch in Google Scholar
  • 11 Sasani M, Ozer AF, Vural M et al. Idiopathic spinal cord herniation: case report and review of the literature. J Spinal Cord Med 2009; 32: 86-94
    Search in Google Scholar
  • 12 Prada F, Saladino A, Giombini S et al. Spinal cord herniation: management and outcome in a series of 12 consecutive patients and review of the literature. Acta Neurochir (Wien) 2012; 154: 723-730
    CrossrefSearch in Google Scholar
  • 13 Kwong Y, Jakanani G, Rao N et al. MRI findings in herniation of the spinal cord. J Radiol Case Rep 2010; 4: 1-5
    Search in Google Scholar
  • 14 Aydin AL, Sasani M, Erhan B et al. Idiopathic spinal cord herniation at two separate zones of the thoracic spine: the first reported case and literature review. Spine J 2011; 11: e9-e14
    PubMedSearch in Google Scholar
  • 15 Groen RJ, Middel B. Idiopathic cord herniation [letter]. J Neurosurg Spine 2010; 12: 714-716 , author response 716 – 718
    CrossrefSearch in Google Scholar
  • 16 Brugières P, Malapert D, Adle-Biassette H et al. Idiopathic spinal cord herniation: value of MR phase-contrast imaging. AJNR Am J Neuroradiol 1999; 20: 935-939
    Search in Google Scholar
  • 17 Dix JE, Griffitt W, Yates C et al. Spontaneous thoracic spinal cord herniation through an anterior dural defect. AJNR Am J Neuroradiol 1998; 19: 1345-1348
    Search in Google Scholar
  • 18 Lai SW, Chan WP, Chen CY et al. MRI of epidermoid cyst of the conus medullaris. Spinal Cord 2005; 43: 320-323
    CrossrefSearch in Google Scholar
  • 19 Roux A, Mercier C, Larbrisseau A et al. Intramedullary epidermoid cysts of the spinal cord: case report. J Neurosurg 1992; 76: 528-533
    Search in Google Scholar
  • 20 Munshi A, Talapatra K, Ramadwar M et al. Spinal epidermoid cyst with sudden onset of paraplegia. J Cancer Res Ther 2009; 5: 290-292
    CrossrefSearch in Google Scholar
  • 21 Er U, Yigitkanli K, Kazanci A et al. Primary lumbar epidermoid tumor mimicking schwannoma. J Clin Neurosci 2006; 13: 130-133
    CrossrefSearch in Google Scholar
  • 22 Kodama H, Maeda M, Hirokawa Y et al. MRI findings of malignant transformation of epidermoid cyst: case report. J Neurooncol 2007; 82: 171-174
    CrossrefSearch in Google Scholar
  • 23 Scarrow AM, Levy EI, Gerszten PC et al. Epidermoid cyst of the thoracic spine: case history. Clin Neurol Neurosurg 2001; 103: 220-222
    CrossrefSearch in Google Scholar
  • 24 Chang PF, Wang PJ, Tu YK. Intradural extramedullary epidermoid cyst of the spinal canal: report of one case. Zhonghua Min Guo Xiao Er Ke Yi Xue Hui Za Zhi 1996; 37: 222-224
    Search in Google Scholar
  • 25 Yen CP, Kung SS, Kwan AL et al. Epidermoid cysts associated with thoracic meningocele. Acta Neurochir (Wien) 2008; 150: 305-308 , discussion 308 – 309
    CrossrefSearch in Google Scholar
  • 26 Smirniotopoulos JG, Chiechi MV. Teratomas, dermoids, and epidermoids of the head and neck. RadioGraphics 1995; 15: 1437-1455
    CrossrefSearch in Google Scholar
  • 27 Amato VG, Assietti R, Arienta C. Intramedullary epidermoid cyst: preoperative diagnosis and surgical management after MRI introduction – case report and updating of the literature. J Neurosurg Sci 2002; 46: 122-126
    Search in Google Scholar
  • 28 Osborn AG, Preece MT. Intracranial cysts: radiologic-pathologic correlation and imaging approach. Radiology 2006; 239: 650-664
    CrossrefSearch in Google Scholar
  • 29 Gupta S, Gupta RK, Gujral RB et al. Signal intensity patterns in intraspinal dermoids and epidermoids on MR imaging. Clin Radiol 1993; 48: 405-413
    CrossrefSearch in Google Scholar
  • 30 Teksam M, Casey SO, Michel E et al. Intraspinal epidermoid cyst: diffusion-weighted MRI. Neuroradiology 2001; 43: 572-574
    CrossrefPubMedSearch in Google Scholar
  • 31 Matsui H, Kanamori M, Yudoh K et al. Cystic spinal cord tumors: magnetic resonance imaging correlated to histopathological findings. Neurosurg Rev 1998; 21: 147-151
    CrossrefSearch in Google Scholar
  • 32 Visciani A, Savoiardo M, Balestrini MR et al. Iatrogenic intraspinal epidermoid tumor: myelo-CT and MRI diagnosis. Neuroradiology 1989; 31: 273-275
    CrossrefSearch in Google Scholar
  • 33 Khosla A, Wippold 2nd FJ. CT myelography and MR imaging of extramedullary cysts of the spinal canal in adult and pediatric patients. AJR Am J Roentgenol 2002; 178: 201-207
    CrossrefSearch in Google Scholar
  • 34 Song KW, Shin SI, Lee JY et al. Surgical results of intradural extramedullary tumors. Clin Orthop Surg 2009; 1: 74-80
    CrossrefPubMedSearch in Google Scholar
  • 35 Nabors MW, Pait TG, Byrd EB et al. Updated assessment and current classification of spinal meningeal cysts. J Neurosurg 1988; 68: 366-377
    CrossrefPubMedSearch in Google Scholar
  • 36 Kriss TC, Kriss VM. Symptomatic spinal intradural arachnoid cyst development after lumbar myelography: case report and review of the literature. Spine 1997; 22: 568-572
    Search in Google Scholar
  • 37 Kumar A, Sakia R, Singh K et al. Spinal arachnoid cyst. J Clin Neurosci 2011; 18: 1189-1192
    CrossrefSearch in Google Scholar
  • 38 Bond AE, Zada G, Bowen I et al. Spinal arachnoid cysts in the pediatric population: report of 31 cases and a review of the literature. J Neurosurg Pediatr 2012; 9: 432-441
    Search in Google Scholar
  • 39 Hughes G, Ugokwe K, Benzel EC. A review of spinal arachnoid cysts. Cleve Clin J Med 2008; 75: 311-315
    Search in Google Scholar
  • 40 Silbergleit R, Brunberg JA, Patel SC et al. Imaging of spinal intradural arachnoid cysts: MRI, myelography and CT. Neuroradiology 1998; 40: 664-668
    CrossrefPubMedSearch in Google Scholar
  • 41 Raja IA, Hankinson J. Congenital spinal arachnoid cysts: report of two cases and review of the literature. J Neurol Neurosurg Psychiatry 1970; 33: 105-110
    CrossrefSearch in Google Scholar
  • 42 Kendall BE, Valentine AR, Keis B. Spinal arachnoid cysts: clinical and radiological correlation with prognosis. Neuroradiology 1982; 22: 225-234
    CrossrefPubMedSearch in Google Scholar
  • 43 Kim IS, Hong JT, Son BC et al. Noncommuni­cating spinal extradural meningeal cyst in thoraco­lumbar spine. J Korean Neurosurg Soc 2010; 48: 534-537
    CrossrefSearch in Google Scholar
  • 44 Awaji M, Okamoto K, Nishiyama K. Magnetic resonance cisternography for preoperative evaluation of arachnoid cysts. Neuroradiology 2007; 49: 721-726
    CrossrefSearch in Google Scholar
  • 45 Dietemann JL, Filippi de la Palavesa MM, Kastler B et al. Thoracic intradural arachnoid cyst: possible pitfalls with myelo-CT and MR. Neuroradiology 1991; 33: 90-91
    CrossrefSearch in Google Scholar
  • 46 Pradilla G, Nagahama Y, Spivak AM et al. Spinal epidural abscess: current diagnosis and management. Curr Infect Dis Rep 2010; 12: 484-491
    CrossrefSearch in Google Scholar
  • 47 Kricun R, Shoemaker EI, Chovanes GI et al. Epidural abscess of the cervical spine: MR findings in five cases. AJR Am J Roentgenol 1992; 158: 1145-1149
    CrossrefSearch in Google Scholar
  • 48 Davis DP, Salazar A, Chan TC et al. Prospective evaluation of a clinical decision guideline to diagnose spinal epidural abscess in patients who present to the emergency department with spine pain. J Neurosurg Spine 2011; 14: 765-770
    CrossrefSearch in Google Scholar
  • 49 Zimmerer SM, Conen A, Müller AA et al. Spinal epidural abscess: aetiology, predisponent factors and clinical outcomes in a 4-year prospective study. Eur Spine J 2011; 20: 2228-2234
    CrossrefSearch in Google Scholar
  • 50 Huang PY, Chen SF, Chang WN et al. Spinal epidural abscess in adults caused by Staphylococcus aureus: clinical characteristics and prognostic factors. Clin Neurol Neurosurg 2012; 114: 572-576
    CrossrefSearch in Google Scholar
  • 51 Numaguchi Y, Rigamonti D, Rothman MI et al. Spinal epidural abscess: evaluation with gadolinium-enhanced MR imaging. RadioGraphics 1993; 13: 545-559 , discussion 559 – 560
    CrossrefPubMedSearch in Google Scholar
  • 52 Eastwood JD, Vollmer RT, Provenzale JM. Diffusion-weighted imaging in a patient with vertebral and epidural abscesses. AJNR Am J Neuroradiol 2002; 23: 496-498
    Search in Google Scholar
  • 53 Borges G, Bonilha L, Proa Jr M et al. Imaging features and treatment of an intradural lumbar cystic schwannoma. Arq Neuropsiquiatr 2005; 63: 681-684
    CrossrefSearch in Google Scholar
  • 54 Parmar HA, Ibrahim M, Castillo M et al. Pictorial essay: diverse imaging features of spinal schwannomas. J Comput Assist Tomogr 2007; 31: 329-334
    CrossrefSearch in Google Scholar
  • 55 Hsieh CT, Tsai WC, Liu MY. Intradural lumbar cystic schwannoma. Neurosciences (Riyadh) 2011; 16: 366-368
    Search in Google Scholar
  • 56 Vikram M, Pande A, Vasudevan MC et al. Cervical solitary long segment cystic schwannoma. Br J Neuro­surg 2010; 24: 208-210
    Search in Google Scholar
  • 57 Friedman DP, Tartaglino LM, Flanders AE. Intradural schwannomas of the spine: MR findings with emphasis on contrast-enhancement characteristics. AJR Am J Roentgenol 1992; 158: 1347-1350
    CrossrefSearch in Google Scholar
  • 58 Santhosh K, Kesavadas C, Thomas B et al. Fluid-fluid levels in cystic lumbosacral schwannomas: a report of three cases. Singapore Med J 2009; 50: e16-e21
    Search in Google Scholar
  • 59 Karataş A, Iş M, Yildirim U et al. Thoracic intradural cystic schwannoma: a case report. Turk Neurosurg 2007; 17: 193-196
    Search in Google Scholar
  • 60 Ross JS. Magnetic resonance imaging of the postoperative spine. Semin Musculoskelet Radiol 2000; 4: 281-291
    Thieme ConnectSearch in Google Scholar
  • 61 Koen JL, McLendon RE, George TM. Intradural spinal teratoma: evidence for a dysembryogenic origin – report of four cases. J Neurosurg 1998; 89: 844-851
    CrossrefSearch in Google Scholar
  • 62 Georgy BA, Snow RD, Hesselink JR. MR imaging of spinal nerve roots: techniques, enhancement patterns, and imaging findings. AJR Am J Roentgenol 1996; 166: 173-179
    CrossrefPubMedSearch in Google Scholar
  • 63 Sklar E, Quencer RM, Green BA et al. Acquired spinal subarachnoid cysts: evaluation with MR, CT myelography, and intraoperative sonography. AJR Am J Roentgenol 1989; 153: 1057-1064
    CrossrefSearch in Google Scholar
  • 64 Boukobza M, Guichard JP, Boissonet M et al. Spinal epidural haematoma: report of 11 cases and review of the literature. Neuroradiology 1994; 36: 456-459
    CrossrefPubMedSearch in Google Scholar
  • 65 Braun P, Kazmi K, Nogués-Meléndez P et al. MRI findings in spinal subdural and epidural hematomas. Eur J Radiol 2007; 64: 119-125
    CrossrefSearch in Google Scholar