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.
Highlights
The thoraco-lumbar junction (TLJ) in its anatomical definition comprises the T12 and L1 vertebrae, considering the biomechanical weakness of T11 having free edged ribs, as well as individual variations in the location of the caudal end of the spinal cord, Tokuhashi [1] proposed the TLJ in its clinical definition comprises four vertebrae from T11 to L2
Incidence and Clinical Presentation of thoraco-lumbar junction disc herniation (TLJDH) In the adult population, the incidence of symptomatic thoracic disc herniations (TDHs) has been estimated at 1/1.000.000 [10] [12] [15] but may be higher considering a prevalence of 37% on magnetic resonance (MR) imaging in asymptomatic individuals [20]
tight filum (TF) and TLJDH may coincide, as we have demonstrated, the combination may be missed as clinicians may be familiar with merely one condition, or may not be looking for another diagnosis once an initial diagnosis has been made
Summary
The thoraco-lumbar junction (TLJ) in its anatomical definition comprises the T12 and L1 vertebrae, considering the biomechanical weakness of T11 having free edged ribs, as well as individual variations in the location of the caudal end of the spinal cord, Tokuhashi [1] proposed the TLJ in its clinical definition comprises four vertebrae from T11 to L2. We believed most findings except maybe for tenderness at the TLJ could be explained by a tethered cord and decided to cut the filum Three months postoperatively, she reported no more urinary urge or incontinence, no more fatigue in her legs, and markedly less pain at the TLJ no longer interfering with daily activities. A few weeks after filum sectioning, she reported markedly reduced pain, less urinary urge, and more complete bladder emptying She resumed her full-time secretarial job despite intermittent pain at the TLJ irradiating over the upper. Case 6 (Figure 6) A 58-year-old woman presented with an eight year history of progressive low back pain and leg pain with acute exacerbations She could walk less than 100 meters, was unable to lie down with her legs fully stretched, and reported incomplete bladder emptying. She was able to walk a kilometer in a more upright posture, which further improved with physiotherapy the following months
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