J Korean Soc Spine Surg.  2019 Sep;26(3):105-110. 10.4184/jkss.2019.26.3.105.

Delayed-Onset Leg Weakness Caused by Posterior Migration of a Herniated Disc to the Thecal Sac Mimicking Epidural Hematoma in a Flexion-Distraction Injury of the Lumbar Spine: A Case Report

• Jeon CH
• Chung NS
• Lee HD
• Chung HW

• KMID: 2459760
• DOI: http://doi.org/10.4184/jkss.2019.26.3.105

Abstract

STUDY DESIGN: Case report.
OBJECTIVES
To document the first known case of posterior migration of a herniated disc in a lumbar flexion-distraction injury. SUMMARY OF LITERATURE REVIEW: Lumbar disc herniation is sometimes confused with epidural hematoma, especially when the disc migrates posterior to the thecal sac. There has been no report of posterior migration of a herniated disc after a lumbar flexion-distraction injury.
MATERIALS AND METHODS
A 47-year-old woman with no pertinent medical history was diagnosed with a flexion-distraction injury of the L2-L3 vertebrae after a motor vehicle accident. The patient had no neurological deficit initially. Magnetic resonance imaging (MRI) showed a space-occupying lesion with T2 hyperintensity and T1 isointensity on the dorsal side of the thecal sac at L2-L3. After posterior lumbar fixation and fusion, progressive leg weakness occurred 1 week postoperatively.
RESULTS
A second operation revealed no evidence of epidural hematoma, but a sequestrated disc. Decompression and sequestrectomy were performed, and the patient's neurological status had recovered fully at 4 months postoperatively.
CONCLUSIONS
This case highlights the potential for posterior migration of a herniated disc with flexion-distraction injuries of the thoracolumbar spine. Discontinuity of the posterior annulus fibrosus on MRI may aid the distinction of posterior migration of a herniated disc from epidural hematoma. Because posterior migration of a herniated disc is associated with progressive neurological deficits, surgeons must consider decompression surgery when such herniation is suspected, even in the absence of neurological symptoms.

Keyword

Posterior migration; Herniated nucleus pulposus; Flexion-distraction injury; Motor weakness; Epidural hematoma

MeSH Terms

Decompression
Female
Hematoma*
Humans
Intervertebral Disc Displacement*
Leg*
Magnetic Resonance Imaging
Middle Aged
Motor Vehicles
Spine*
Surgeons

Figure

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  Fig. 1. Anteroposterior (A) and lateral (B) radiographs of the lumbar spine at the initial assessment show a compression fracture of L3 (arrow) and increased distance between the L2 and L3 spinous processes (bidi-rectional arrow).

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  Fig. 2. T2-weighted sagittal (A) and axial (B) magnetic resonance images of the lumbar spine at the initial assessment show a hyperintense lesion (white arrow). T1-weighted sagittal (C) and axial (D) images show an isointense lesion (gray arrow).

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  Fig. 3. Anteroposterior (A) and lateral (B) radiographs of the lumbar spine after the first operation show single-level fusion with instrumentation and the correction of spinal alignment.

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  Fig. 4. T2-weighted sagittal (A) and axial (B) magnetic resonance images of the lumbar spine after the first operation show increased compression of the cauda equina (white arrow).

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  Fig. 5. Sequestrated disc fragment.

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  Fig. 6. T2-weighted sagittal magnetic resonance image shows discontinuity of the posterior annulus (arrow).

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