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

Erwin M. J. Cornips, Emile A. M. Beuls, Biene W. Weber, Johannes S. H. Vles

Department of Child Neurology, Maastricht University Medical Center, Maastricht, The Netherlands.
Department of Forensic Medicine and Pathology, University Hospital Antwerp, Antwerp, Belgium.
Department of Neurosurgery, Maastricht University Medical Center, Maastricht, The Netherlands.

DOI: 10.4236/ijcm.2014.512094                

Abstract

Purpose: 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. The coexistence of both conditions has not been previously reported and may be a diagnostic and therapeutic challenge. Methods: 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. Results: 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. Conclusions: 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.

Keywords

Clinical Presentation, Disc Herniation, Tethered Cord, Therapy, Thoraco-Lumbar Junction, Tight Filum

Conflicts of Interest

The authors declare no conflicts of interest.

References

[1]	Tokuhashi, Y., Matsuzaki, H., Uematsu, Y. and Oda, H. (2001) Symptoms of Thoracolumbar Junction Disc Herniation. Spine, 26, 512-518. http://dx.doi.org/10.1097/00007632-200111150-00021
[2]	Cornips, E.M.J., Janssen, M.L.F. and Beuls, E.A.M. (2011) Thoracic Disc Herniation and Acute Myelopathy: Clinical Presentation, Neuroimaging Findings, Surgical Considerations and Outcome. Journal of Neurosurgery (Spine), 14, 520-528. http://dx.doi.org/10.3171/2010.12.SPINE10273
[3]	Kesler, H., Dias, M.S. and Kalapos, P. (2007) Termination of the Normal Conus Medullaris in Children: A Whole-Spine Magnetic Resonance Imaging Study. Neurosurgical Focus, 23, E7. http://dx.doi.org/10.3171/FOC-07/08/E7
[4]	Cornips, E.M.J., Vereijken, I.M., Beuls, E.A.M., Weber, J.W., Soudant, D.L., van Rhijn, L.W., Callewaert, P.R. and Vles, J.S.H. (2012) Clinical Characteristics and Surgical Outcome in 25 Cases of Childhood Tight Filum Syndrome. European Journal of Paediatric Neurology, 16, 103-117. http://dx.doi.org/10.1016/j.ejpn.2011.07.002
[5]	Abbott, K.H. and Retter, R.H. (1956) Protrusions of Thoracic Intervertebral Disks. Neurology, 6, 1-10. http://dx.doi.org/10.1212/WNL.6.1.1
[6]	Brennan, M., Perrin, J.C.S., Canady, A. and Wesolowski, D. (1987) Paraparesis in a Child with a Herniated Thoracic Disc. Archives of Physical Medicine and Rehabilitation, 68, 806-808.
[7]	Demetriades, A.K., Naik, S. and Gunasekera, L. (2010) Conus Medullaris Syndrome form a Transdural Disc Herniation at the Thoracolumbar Juntion. Acta Neurochirurgica, 152, 1081-1082. http://dx.doi.org/10.1007/s00701-009-0586-9
[8]	Giblin, E.A. and Hochheiser, G.M. (2008) Thoracic Disk Herniation Resulting in Acutely Progressing Paraplegia in a Pediatric Patient. Pediatric Emergency Care, 24, 550-553. http://dx.doi.org/10.1097/PEC.0b013e318180ff1d
[9]	Kleopa, K.A., Zamba-Papanicolaou, E. and Kyriakides, T. (2003) Compressive Lumbar Myelopathy Presenting as Segmental Motor Neuron Disease. Muscle Nerve, 28, 69-73. http://dx.doi.org/10.1002/mus.10405
[10]	Love, J.G. and Kiefer, E.J. (1950) Root Pain and Paraplegia Due to Protrusions of Thoracic Intervertebral Disks. Journal of Neurosurgery, 7, 62-69. http://dx.doi.org/10.3171/jns.1950.7.1.0062
[11]	Lyu, R.K., Chang, H.S., Tang, L.M. and Chen, S.T. (1999) Thoracic Disc Herniation Mimicking Acute Lumbar Disc Disease. Spine, 24, 416-418. http://dx.doi.org/10.1097/00007632-199902150-00025
[12]	Overvliet, G.M., Beuls, E.A.M., Ter Laak-Poort, M. and Cornips, E.M.J. (2009) Two Brothers with a Symptomatic Thoracic Disc Herniation at T11-T12: Clinical Report. Acta Neurochirurgica, 151, 393-396. http://dx.doi.org/10.1007/s00701-009-0244-2
[13]	Rajpal, S., Tubbs, R.S., George, T., Oakes, W.J., Fuchs, H.E., Gadley, M.N. and Iskandar, B. (2007) Tethered Cord Due to Spina Bifida Occulta Presenting in Adulthood: A Tricenter Review of 61 Patients. Journal of Neurosurgery: Spine, 6, 210-215. http://dx.doi.org/10.3171/spi.2007.6.3.210
[14]	Umur, A.S., Selcuki, M., Selcuki, D., Beduk, A. and Doganay, L. (2008) Adult Tethered Cord Syndrome Mimicking Lumbar Disc Disease. Child’s Nervous System, 24, 841-844. http://dx.doi.org/10.1007/s00381-007-0539-7
[15]	Anand, N. and Regan, J.J. (2002) Video-Assisted Thoracoscopic Surgery for Thoracic Disc Disease: Classification and Outcome Study of 100 Consecutive Cases with a 2-Year Minimum Follow-Up Period. Spine, 27, 871-879. http://dx.doi.org/10.1097/00007632-200204150-00018
[16]	Bajard, X., Renault, F., Benharrats, T., Mary, P., Madi, F. and Vialle, R. (2010) Intervertebral Disc Calcification with Neurological Symptoms in Children: Report of Conservative Treatment in Two Cases. Child’s Nervous System, 26, 973-978. http://dx.doi.org/10.1007/s00381-010-1117-y
[17]	Nicolau, A., Diard, F., Darrigade, J.M., Dorcier, F. and Vital, J.M. (1985) Posterior Hernia of a Calcified Disk in Children. Apropos of 2 Cases. Journal de Radiologie, 66, 683-688.
[18]	Wu, X.D., Chen, H.J., Yuan, W., Wang, X.W., Zhou, X.H., Li, H., Sheng, X.L. and Xu, S.M. (2010) Giant Calcified Thoracic Disc Herniation in a Child: A Case Report and Review of the Literature. Journal of Bone and Joint Surgery. American Volume, 92, 1992-1996. http://dx.doi.org/10.2106/JBJS.I.01652
[19]	Fabiano, A.J., Khan, M.F., Rozzelle, C.J. and Li, V. (2009) Preoperative Predictors for Improvement after Surgical Untethering in Occult Tight Filum Terminale Syndrome. Pediatric Neurosurgery, 45, 256-261. http://dx.doi.org/10.1159/000228983
[20]	Wood, K.B., Garvey, T.A., Gundry, C.R. and Heithoff, K.B. (1995) Magnetic Resonance Imaging of the Thoracic Spine. Evaluation of Asymptomatic Individuals. Journal of Bone and Joint Surgery. American Volume, 77, 1631-1638.
[21]	Kim, D.S., Lee, J.K., Jang, J.W., Ko, B.S., Lee, J.H. and Kim, S.H. (2010) Clinical Features and Treatments of Upper Lumbar Disc Herniations. Journal of Korean Neurosurgical Society, 48, 119-124. http://dx.doi.org/10.3340/jkns.2010.48.2.119
[22]	Sanderson, S.P., Houten, J., Errico, T., Forshaw, D., Bauman, J. and Cooper, P.R. (2004) The Unique Characteristics of “Upper” Lumbar Disc Herniations. Neurosurgery, 55, 385-389. http://dx.doi.org/10.1227/01.NEU.0000129548.14898.9B
[23]	Kapetanos, G.A., Hantzidis, P.T., Anagnostidis, K.S. and Kirkos, J.M. (2006) Thoracic Cord Compression Caused by Disk Herniation in Scheuermann’s Disease. European Spine Journal, 15, 553-558. http://dx.doi.org/10.1007/s00586-005-0053-0
[24]	Iwasaki, M., Akino, M., Hida, K., Yano, S., Aoyama, T., Saito, H. and Iwasaki, Y. (2011) Clinical and Radiographic Characteristics of Upper Lumbar Disc Herniation: Ten-Year Microsurgical Experience. Neurologia Medico-Chirurgica (Tokyo), 51, 423-426. http://dx.doi.org/10.2176/nmc.51.423
[25]	Yamada, S., Zinke, D.E. and Sanders, D. (1981) Pathophysiology of “Tethered Cord Syndrome”. Journal of Neurosurgery, 54, 494-503. http://dx.doi.org/10.3171/jns.1981.54.4.0494
[26]	Yamada, S., Iacono, R.P., Andrade, T., Mandybur, G. and Yamada, B.S. (1995) Pathophysiology of Tethered Cord Syndrome. Neurosurgery Clinics of North America, 6, 311-323.
[27]	Yamada, S., Won, D.J., Pezeshkpour, G., Yamada, B.S., Yamada, S.M., Siddiqi, J., Zouros, A. and Colohan, A.R. (2007) Pathophysiology of Tethered Cord Syndrome and Similar Complex Disorders. Neurosurgical Focus, 23, 1-10. http://dx.doi.org/10.3171/FOC-07/08/E6
[28]	McInerney, J. and Ball, P.A. (2000) The Pathophysiology of Thoracic Disc Disease. Neurosurgical Focus, 9, 1-8. http://dx.doi.org/10.3171/foc.2000.9.4.2
[29]	Reina, M.A., De Leon Casasola, O., Villanueva, M.C., Lopez, A., Maches, F. and De Andres, J.A. (2004) Ultrastructural Findings in Human Spinal Pia Mater in Relation to Subarachnoid Anesthesia. Anesthesia & Analgesia, 98, 1479-1485. http://dx.doi.org/10.1213/01.ANE.0000113240.09354.E9
[30]	Pang, D. and Wilberger Jr., J.E. (1982) Tethered Cord Syndrome in Adults. Journal of Neurosurgery, 57, 32-47. http://dx.doi.org/10.3171/jns.1982.57.1.0032
[31]	Regan, J.J., Mack, M.J. and Picetti III, G.D. (1995) A Technical Report on Video-Assisted Thoracoscopy in Thoracic Spinal Surgery. Preliminary Description. Spine, 20, 831-837. http://dx.doi.org/10.1097/00007632-199504000-00018
[32]	Rosenthal, D., Rosenthal, R. and de Simone, A. (1994) Removal of a Protruded Thoracic Disc Using Microsurgical Endoscopy: A New Technique. Spine, 19, 1087-1091. http://dx.doi.org/10.1097/00007632-199405000-00018