Intradural Disk Herniation at the Conus Medullaris: A Case Report With Emphasis on Patient Positioning and Neuromonitoring

Overview

Journal JBJS Case Connect

Publisher Wolters Kluwer

Date 2025 Jan 22

PMID 39841040

Authors

Michael J Kelly

Marco D Burkhard

Franziska C S Altorfer

Ronald G Emerson

Andrew A Sama

Affiliations

Soon will be listed here.

Abstract

Case: A 73-year old man who underwent previous L2-S1 decompression presenting with new right radicular leg pain. Imaging suggests a large central disk herniation at L1-2 with possible intrathecal extension requiring surgical decompression. When positioned prone on a Jackson frame, neuromonitoring motor signals became diminished, and thus, the case was aborted. On returning to the operating room 2 days later, careful positioning in a more neutral/flexed position facilitated normal neuromonitoring signals, allowing for an uneventful intradural approach and discectomy.

Conclusion: With conus-level intrathecal disk herniation, consider using prepositional neuromonitoring and avoid hyperextension with positioning to ensure neurological safety.

References

Deyo R, Mirza S . CLINICAL PRACTICE. Herniated Lumbar Intervertebral Disk. N Engl J Med. 2016; 374(18):1763-72. DOI: 10.1056/NEJMcp1512658. View

Javeed F, Khan J, Rehman L . Herniating Intradural Disc at Lumbar L4-L5 Level: A Case Report. Cureus. 2023; 15(2):e35067. PMC: 10024570. DOI: 10.7759/cureus.35067. View

DePasse J, Palumbo M, Haque M, Eberson C, Daniels A . Complications associated with prone positioning in elective spinal surgery. World J Orthop. 2015; 6(3):351-9. PMC: 4390897. DOI: 10.5312/wjo.v6.i3.351. View

Sasaji T, Horaguchi K, Yamada N, Iwai K . The specific sagittal magnetic resonance imaging of intradural extra-arachnoid lumbar disc herniation. Case Rep Med. 2012; 2012:383451. PMC: 3295378. DOI: 10.1155/2012/383451. View

Suess O, Mularski S, Czabanka M, Cabraja M, Hammersen S, Kombos T . The value of intraoperative neurophysiological monitoring for microsurgical removal of conus medullaris lipomas: a 12-year retrospective cohort study. Patient Saf Surg. 2014; 8:35. PMC: 4253119. DOI: 10.1186/s13037-014-0035-4. View

Chen Ming Low J, Rowland D, Kareem H . L1/2 Intradural Disc Herniation with Compression of the Proximal Cauda Equina Nerves: A Surgical Challenge. World Neurosurg. 2020; 142:147-151. DOI: 10.1016/j.wneu.2020.06.163. View

Austerman R, Sulhan S, Steele W, Sadrameli S, Holman P, Barber S . The utility of intraoperative neuromonitoring on simple posterior lumbar fusions-analysis of the National Inpatient Sample. J Spine Surg. 2021; 7(2):132-140. PMC: 8261562. DOI: 10.21037/jss-20-679. View

Serikyaku H, Higa S, Yara T . Intradural disc herniation at the L1-2 level. Surg Neurol Int. 2021; 12:351. PMC: 8326135. DOI: 10.25259/SNI_561_2021. View

Safi S, Allyan A, Ali A, Raza A . Diagnosis and management of thoracic intradural extra-arachnoidal disc herniation. Surg Neurol Int. 2022; 13:73. PMC: 8888305. DOI: 10.25259/SNI_16_2022. View

10.

Ihejirika R, Tong Y, Patel K, Protopsaltis T . Intradural lumbar disc herniation: illustrative case. J Neurosurg Case Lessons. 2022; 2(18):CASE21336. PMC: 9435552. DOI: 10.3171/CASE21336. View

11.

Pholprajug P, Wiratapesuporn T, Satayasoontorn K, Atiprayoon S, Kotheeranurak V . Intradural disc herniation of L2/3: A case report and literature review. N Am Spine Soc J. 2022; 11:100138. PMC: 9256825. DOI: 10.1016/j.xnsj.2022.100138. View

12.

Pojskic M, Bisson E, Oertel J, Takami T, Zygourakis C, Costa F . Lumbar disc herniation: Epidemiology, clinical and radiologic diagnosis WFNS spine committee recommendations. World Neurosurg X. 2024; 22:100279. PMC: 10911853. DOI: 10.1016/j.wnsx.2024.100279. View

13.

Bhattarai U, Gurung P, Shrestha J, Dhakal S, Acharya S, Pant B . A case of intradural lumbar disc herniation. Clin Case Rep. 2023; 11(6):e7514. PMC: 10264920. DOI: 10.1002/ccr3.7514. View

14.

Choi J, Lee W, Sung K . Intradural lumbar disc herniation--is it predictable preoperatively? A report of two cases. Spine J. 2007; 7(1):111-7. DOI: 10.1016/j.spinee.2006.02.025. View

15.

Cheng C, Che-Chao Chang M, Lin H, Chuang H, Lin R, Foo N . Intradural lumbar disc herniation: A case report and literature review. Heliyon. 2022; 8(12):e12257. PMC: 9791832. DOI: 10.1016/j.heliyon.2022.e12257. View

16.

Kramer S, Ford L, Walsh J . Neuromonitoring Changes in Spinal Deformity Surgery. Orthop Clin North Am. 2023; 55(1):89-99. DOI: 10.1016/j.ocl.2023.07.002. View

17.

Nanpo K, Toribatake Y, Yonezawa N, Kato S, Shinmura K, Demura S . Cervical intradural disc herniation in a patient with cervical ossification of the posterior longitudinal ligament: A case report and review of the literature. J Orthop Sci. 2022; 29(1):434-438. DOI: 10.1016/j.jos.2022.08.006. View

18.

Sanchez Roldan M, Moncho D, Rahnama K, Santa-Cruz D, Lainez E, Baiget D . Intraoperative Neurophysiological Monitoring in Syringomyelia Surgery: A Multimodal Approach. J Clin Med. 2023; 12(16). PMC: 10455553. DOI: 10.3390/jcm12165200. View

19.

Nam K, Lee I, Song Y, Han I, Kim D . Imaging characteristics of intradural disc herniation: A comparison with large disc extrusion. Eur J Radiol. 2021; 137:109569. DOI: 10.1016/j.ejrad.2021.109569. View

20.

Song J, Oh J . Traumatic intradural disc herniation following a cervical facet dislocation: a case report. J Spine Surg. 2022; 8(1):76-83. PMC: 8990393. DOI: 10.21037/jss-21-106. View