Epidural Migration Research Articles

Posterior epidural migration of huge free lumbar disc herniation with space occupying of vertebral canal:a case report and literature review

Posterior epidural migration of huge free lumbar disc herniation with space occupying of vertebral canal:a case report and literature review

Dorsal epidural migration of lumbar disc herniation at L3-L4 level treated by minimally invasive microtubular decompression and fixation: A case report

Abstract Lumbar disc herniation with dorsal epidural migration is a rare clinical condition that can present with severe neurological deficit and cauda equina syndrome. Diagnosis poses a challenge as it mimics other dorsal epidural pathologies like tumors, cysts, and abscesses. Timely diagnosis and early surgical intervention with wide decompression can improve the neurological outcome. Minimally invasive technique has the advantage of minimal muscle damage, early rehabilitation, and equal clinical outcomes to those of standard laminectomy. In this report, we describe a case of a 63-year-old male with lumbar disc herniation at L3-L4 level with foraminal extension and dorsal epidural migration with neurological deficit managed by minimally invasive microtubular decompression and spinal stabilization.

Üç Farklı Kateter Sabitleme Tekniğinde Epidural Kateter Migrasyonunun Karşılaştırılması: Prospektif Randomize Bir Çalışma

Objective: We hypothesized that subcutaneous tunnelling will be more efficacious in preventing epidural catheter migration in the postoperative period. To compare three different fixation techniques for migration of epidural catheter in the postoperative period. Methods: Patients undergoing elective surgery with planned postoperative analgesia with lumbar epidural were included. They were divided into 3 groups based on catheter fixation – Group I: transparent adhesive dressing tape, Group II: fixator device (Locklt Plus® ) and Group III: catheter subcutaneously tunnelled vertically. The catheter mark was noted during insertion and on removal at the end of second day. The primary outcome measure was epidural catheter migration; the secondary outcome measures were complications and patient satisfaction scores. Results: Of the 170 patients recruited, 150 patients were included. The Likelihood Ratio (LR) of migration of group I in comparison to group II was 13.28 (p<0.001) while with group III was 7.06 (p=0.007). There was no significant difference between groups II and III (LR 1.12, p=0.29). The satisfaction scores were comparable among Groups II and III. There was no difference in complications among groups. Conclusion: Epidural migration is significantly reduced by both tunnelling and Lockit plus® methods in comparison to a transparent adhesive dressing in patients on continuous lumbar epidural analgesia in the first two postoperative days. The subcutaneous tunnelling method is as safe in terms of migration as the LockIt plus® method of fixation. Keywords: Catheter adverse effects, epidural analgesia, epidural catheter, postoperative pain

Posteriorly migrated epidural lumbar disc extrusion with contralateral neurodeficit: An unusual presentation

Abstract The posterior epidural migration of lumbar disc herniation is a rare condition, and the overall reported incidence is 0.4%–1.04%. Most of these cases present with cauda equina syndrome or polyradiculopathy on ipsilateral side. We report a case of posterior epidural migration of lumbar disc causing contralateral neurodeficit. A 66-year-old gentleman presented with axial pain radiating to the left anterolateral thigh since 15 days after heavy weight lifting. Neurological examination revealed hypoesthesia over left L3 dermatome and left knee extensor weakness (Medical Research Council grade 3/5). Magnetic resonance imaging with contrast showed L2–L3 right-side extruded disc fragment migrated posteriorly in epidural space. Contralateral monoradiculopathy was an unusual presentation. Interlaminar decompression and discectomy were able to achieve complete neurological recovery at three months. To the best of our knowledge, this is the second case with contralateral neurodeficit due to posteriorly migrated lumbar disc herniation.

Ultrasound-guided erector spinae plane block in horses: a cadaver study

ObjectivesTo describe dye distribution and spinal nerve involvement after a simulated erector spinae plane (ESP) block performed on fresh equine cadavers. Study designExperimental cadaver study. AnimalsA group of 11 adult equine cadavers. MethodsThe spinal region surrounding the sixteenth thoracic vertebra (Th16) of one cadaver was removed and underwent magnetic resonance imaging. In 10 adult equine cadavers [body weight, 549 ± 58 kg (mean ± standard deviation)], 0.2 mL kg–1 of a 50:1 2% lidocaine/dye solution was injected bilaterally (n = 20 injections) into the fascial plane between the transverse process of Th16 and the erector spinae muscles. An in-plane ultrasound-guided technique with a convex transducer was used to guide injection. Dissection was performed immediately following injection. The craniocaudal and lateral extent of dye distribution was measured (cm) and the number of vertebral bodies involved were counted (n = 20). Abdominal and thoracic cavities as well as the epidural space were also examined for presence of dye (yes/no) (n = 20). Further dissection was performed to evaluate if staining of the dorsal and ventral rami of the spinal nerves and sympathetic chain occurred (n = 14). ResultsThe thoracolumbar fascia was stained in 17/20 (85%) injections and three injections terminated intramuscularly. Multisegmental staining of the dorsal rami was observed in the 14 injections in which staining was evaluated. Ventral rami staining was observed in 3/14 injections where staining was evaluated. Epidural migration was observed in 4/20 (20%) injections. No evidence of dye was found in the thoracic and abdominal cavities or on the sympathetic chain. Conclusions and clinical relevanceThe ESP block may prove beneficial to desensitize structures innervated by the dorsal rami of the thoracic spinal nerves. Further investigation is necessary to evaluate complications caused by epidural contamination.

Two cases of posterior epidural migration of herniated lumbar disc fragment which were difficult in a diagnosis

Two cases of posterior epidural migration of herniated lumbar disc fragment which were difficult in a diagnosis

Cauda Equina Syndrome after Sequestered Disc Herniation Migrating to the Dorsal Epidural Space: Case Report and Review of the Literature

Background: Posteriorly migrated epidural disc fragments (PMEDF) presenting with cauda equina syndrome are relatively common. These cases are sometimes inaccurately identified on MRI as; epidural tumors, abscesses, hematomas and or facet cysts. Proper description and identification are key to be able to provide effective and safe management. Currently we are presenting the case of a patient with cauda equina syndrome secondary to a posterior mass compression intraoperatively identified as a PMEDF. Case Description: 45-years-old male presenting with insidious low back pain that progressed to urinary retention and bilateral foot drop. An MRI of the lumbar spine showed a posteriorly located epidural lesion. That appeared to be dependent on a left facet cyst. The patient was treated with a decompressive laminectomy and multiple disc fragments were identified under the ligamentum flavum and over the posterior epidural space. Conclusion: Posterior epidural migration of a lumbar disc fragments (PEMLDF) are not a common presentation of intervertebral disc herniations and their differential diagnosis and treatment might require a different surgical approach; fusion vs decompression. PEMLDFs should be suspected on those patients presenting with sudden cauda equina syndrome and posteriorly located epidural lesions on MRI.

Posterior Epidural Migration of a Lumber Disc Fragment Causing Cauda Equina: a Case Report and Literature Review

Cauda equina syndrome manifests as bilateral leg pain and sensory disturbances in the perianal region. In this article, authors describe patient with posterior epidural disc migration of a lumber disc fragment causing cauda equina syndrome and provide review of the literature.

Posterior epidural migration of herniated lumbar disc fragment: a literature review.

Herniated disc fragments' migration to posterior epidural locations is a very rare pathological condition, and the mechanism is not well understood. Posterior epidural migration may lead to serious neurologic problems; however, its diagnosis and treatment are challenging. We searched PubMed and Google Scholar, using various keyword combinations, and found 111 cases of posterior epidural disc migration in the lumbar region reported between 1973 and 2018. There were 89 (80.2%) men and 22 (19.8%) women. The mean age at surgery was 54.05years (range, 26-83years); the mean duration of complaints was 26.3days. The locations were at the L3-L4 level in 41 cases (36.9%), the L4-L5 level in 37 (33.3%), the L2-L3 level in 21 (18.9%), the L5-S1 level in 8 (7.2%), and the L1-L2 in 4 (3.6%). The disc fragment appeared as hypointense and isointense in 60.3% and 33.8%, respectively, of cases in T1-weighted magnetic resonance imaging (MRI) and as hyperintense in 68.5% of cases on T2-weighted MRI. The initial symptoms were cauda equina syndrome, radiculopathy, and low back pain in 58 (52.2%), 52 (46.8%), and 12 (10.8%) patients, respectively. In addition, 107 patients (96.4%) underwent surgical treatment and 4 (3.6%) underwent conservative treatments, with total recovery, and subtotal recovery in 73 (65.8%), and 38 (34.2%), respectively. We found significant differences between patients at different ages with regard to the level of disc herniation (η = 0.405, p = .001): patients with a higher level of disc herniation were, on average, older. There was no significant difference in outcome between male and female patients, χ2(1) = 0.591, p = .469, or between patients with upper and lower lumbar spine, χ2(1) = 0.027, p > .999. Careful history documentation, clinical examinations, and contrast material-enhanced MRI with laboratory tests could help reveal herniated disc fragment and rule out several other pathological processes. In most cases, surgical treatment produced favorable outcomes.

Posterior epidural disc fragment masquerading as spinal tumor: Review of the literature

Posterior epidural lumbar disc fragment is infrequent because of anatomical barriers, and it is difficult to diagnose posterior epidural lumbar disc fragment because of its rare incidence and the ambiguity of radiologic evaluations. And it is difficult to differentiate it from other diseases such as spinal tumors. Differential diagnosis of posterior epidural lumbar disc fragment is clinically important because its diagnosis can affect treatment and prognosis. To investigate the incidence, anatomical concern, etiology, symptom, diagnostic tool, management and prognosis of posterior epidural lumbar disc fragment, we reviewed articles including case report. We performed a search of all clinical studies of posterior epidural lumbar disc fragment published to date. The following keywords were searched: Posterior epidural lumbar disc fragment, disc migration, posterior epidural disc, extradural migration, dorsal epidural migration, sequestrated disc, and disc fragment. We identified 40 patients of posterior epidural lumbar disc fragment from 28 studies. The most common presentation of posterior epidural lumbar disc fragment was sudden onset radiculopathy (70.0%), followed by cauda equina syndrome (27.5%). The most frequently used diagnostic modality was magnetic resonance imaging (MRI), conducted in 36 cases (90.0%), and followed by computed tomography in 14 cases (35.0%). After the imaging studies, the preoperative diagnoses were 45.0% masses, 20.0% lesions, and 12.5% tumors. Characteristic MRI findings in posterior epidural lumbar disc fragment are helpful for diagnosis; it typically displays low signals on T1-weighted images and high signals on T2-weighted images with respect to the parent disc. In addition, most of the disc fragments show peripheral rim enhancement on MRI with gadolinium administration. Electrodiagnostic testing is useful for verifying nerve damage. Surgical treatment was performed in all cases, and neurologic complications were observed in 12.5%. As posterior epidural lumbar disc fragment could be masqueraded as spinal tumor, if rim enhancement is observed in MRI scans with sudden symptoms of radiculopathy or cauda equina syndrome, it should be taken into consideration. Early diagnosis can lead to early surgery, which can reduce complications.

Posterior Epidural Migration of a Lumbar Intervertebral Disc Fragment Resembling a Spinal Tumor: A Case Report.

Posterior epidural migration of a lumbar intervertebral disc fragment (PEMLIF) is uncommon because of anatomical barriers. It is difficult to diagnose PEMLIF definitively because of its relatively rare incidence and the ambiguity of radiological findings resembling spinal tumors. This case report describes a 76-year-old man with sudden-onset weakness and pain in both legs. Electromyography revealed bilateral lumbosacral polyradiculopathy with a mass-like lesion in L2-3 dorsal epidural space on lumbosacral magnetic resonance imaging (MRI). The lesion showed peripheral rim enhancement on T1-weighted MRI with gadolinium administration. The patient underwent decompressive L2-3 central laminectomy, to remove the mass-like lesion. The excised lesion was confirmed as an intervertebral disc. The possibility of PEMLIF should be considered when rim enhancement is observed in the epidural space on MRI scans and electrodiagnostic features of polyradiculopathy with sudden symptoms of cauda equina syndrome.

Posterior epidural migration of a lumbar disk: an entity not to ignore.

Discal hernia with posterior epidural migration is exceptional. Its diagnosis is difficult and often takes the form of an intraspinal tumor lesion. It has a various clinical manifestations. The association of this entity to a cauda equina syndrome found as isolated cases which were reported in the literature. MRI with injection is the best diagnostic tool. We must always consider this diagnosis in front of a posterior epidural mass with a peripheral enhancement on the contrast-enhanced images. Emergency surgery is needed to prevent serious neurological deficits. We report the case of a 29-year old patient who presented an acute lumbo-sciatica associated with a deficit of both lower limbs and urinary incontinence after lifting a heavy load. Clinical examination revealed a motor deficit of the triceps surae and in the relievers of the foot rated 1 in bilateral sides, hypoesthesia at the anterolateral part of the two legs and the feet, weak or abolished tendon reflexes, anesthesia in the saddle, hypotonic anal sphincter and bladder distension. MRI of the lumbar spine showed a right lumbar discal hernia (L3-L4) excluded with right posterior epidural migration compressing the dural sheath. Surgical treatment was undertaken in emergency: a decompression and herniectomy were performed. A partial sensor-motor recovery was observed. After ten months, the patient still has had a distal deficit of both lower limbs, bladder sphincter disorders for which it is under self-intermittent catheterization.

Posterior epidural migration of extruded lumbar disc fragment mimicking epidural mass: A case report

Abstract Introduction Posterior epidural migration of the lumbar disc fragment is a very rare pathological entity. The pathomechanisms remain unclear. Case presentation The authors present the case of a 78-year-old Germans male with refractory low back pain. Contrast-MRI showed an epidural mass at the level L1–2 with rim contrast enhancement. The preoperative diagnosis based on the clinical and history of the patient was most probably sequestrated disc fragment migrated posteriorly; differential diagnosis included all other causes of posteriorly located epidural mass. A left interlaminar approach L1–2 was performed. A sticky, capsulated, semi-hard and mobile mass was removed from the posterior epidural spaces. Intraoperative a lateral till the ventral disc fragments were found. An annular tear was found and discectomy was performed. Pathological examination showed a disc tissue with degenerative changes. The patient was pain-free until the last follow-up at 5 months. Conclusions Correlation between relevant clinical information and radiological finding may help to detect the posterior migrated disc fragment.

Posterior epidural migration of a sequestered lumbar disc - Two cases report

Posterior migration of a sequestered disc fragment to the posterior epidural space is extremely rare due to the natural anatomical barriers of the thecal sac. Only cases were reported in the literature. It often causes severe neurological impairment, such as cauda equine syndrome. Accurate diagnosis is difficult because magnetic resonance images may mimic those of other more common posterior epidural mass lesions. We reported two cases of posterior epidural migration of sequestered discs. Both two patients responded well to operation with complete relief of symptoms.

Discography aids definitive diagnosis of posterior epidural migration of lumbar disc fragments: case report and literature review

BackgroundPosterior epidural migration of lumbar disc fragments (PEMLDF) is extremely rare. It is often confused with other posterior lesions and is usually diagnosed intraoperatively. We here describe the use of preoperative discography in the diagnosis of PEMLDF.Case presentationA 78-year-old man presented with acute low back pain, gait disturbance, and paresthesia in both legs. Magnetic resonance imaging showed a mass located posteriorly and laterally to the left aspect of the dural sac at the L3 level. The initial diagnosis indicated PEMLDF, malignancy, spontaneous hematoma, or epidural abscess. L3/4 discography clearly showed leakage of the contrast medium into the posterior dural space, indicating PEMLDF. The lesion was identified intraoperatively as a herniated-disc fragment, consistent with the preoperative discography.ConclusionPEMDLF is difficult to diagnose preoperatively. Discography is useful for the definitive diagnosis of PEMDLF prior to surgery.

Ultrasound-guided thoracic paravertebral injection in dogs: a cadaveric study

ObjectiveTo describe ultrasound-visualized anatomy and the spread characteristics of a dye injected in the thoracic paravertebral (TPV) space under ultrasound guidance. Study designAnatomic cadaver study. AnimalsSeven dog cadavers. MethodsOne cadaver was used to observe, identify, and describe the relevant TPV anatomy. In the remaining six, the left fifth TPV space was randomly assigned to be injected with either a low volume (LV; 0.05 mL kg−1) or high volume (HV; 0.15 mL kg−1) of dye. Subsequently, the contralateral side was injected with the alternative volume. Anatomic dissections were conducted to determine the incidence of complete spinal nerve staining (>1 cm circumferential coverage), number of contiguous spinal nerves dyed and the absence or presence of solution in particular locations. ResultsThe ultrasound-visualized anatomy of the TPV space was defined as the intercostal space abaxial to the vertebral body, delimited by the parietal pleura ventrally and the internal intercostal membrane dorsally. The endothoracic fascia divides the paravertebral space into dorsal and ventral compartments. The target nerve was completely dyed in five of six and six of six injections in the LV and HV conditions, respectively. In one LV injection, the nerve was partially dyed. No multisegmental spread affecting contiguous spinal nerves was found in either treatment. Multisegmental spread was found in the ventral compartment of the TPV space, affecting the sympathetic trunk on 3 (0–3) and 3.5 (1–6) vertebral spinal levels in the LV and HV conditions, respectively, but differences between volumes were not significant. No intrapleural, ventral mediastinal or epidural migration was observed. Conclusions and clinical relevanceUltrasound-guided TPV block is a potentially reliable technique. The LV appeared sufficient to dye a single spinal nerve and multiple sympathetic trunk vertebral levels. Multiple TPV injections may be needed to provide adequate thoracic analgesia in dogs undergoing thoracic surgery.

Posterior epidural migration of herniated lumbar disc fragment

Joint Bone Spine - In Press.Proof corrected by the author Available online since samedi 28 janvier 2017

Posterior intraductal lombar tumor : About a migration disc

To talk through our observation and a review of the literature about radiological features and diagnostic difficulties of this particular form of disk migration. We report the case of a 29 year-old patient who presented following the wearing of a heavy load bilateral acute lombosciatalgies associated with a deficit of both lower limbs and urinary incontinence. Clinical examination revealed a motor deficit of sural triceps and foot relievers estimated1 in bilateral, hypoesthesia of the anterolateral side of the two legs and the feet, low bone tendon reflexes were abolished, anesthesia in the saddle, hypotonic anal sphincter and bladder distension. MRI of the lumbar spine showed a herniated disc L3-L4 excluded with right posterior epidural migration compressing the dural sheath. Surgical treatment (decompression and herniectomie) was undertaken in emergency. Partial sensorimotor recovery was observed. In two months of decline, the patient still has a distal deficit of both lower limbs, bladder sphincter disorders for which he is under self-intermittent catheterization. Posterior epidural disc herniation migration is exceptional. Its diagnosis is difficult and often takes the form of an intraspinal tumor lesion. Its clinical manifestations are varied to the extreme with a cauda equina syndrome. MRI with injection is the best diagnostic tool. We may always consider this diagnosis in front of a posterior epidural mass with taking a device contrast. Emergency surgery is necessary to prevent serious neurological deficits.

Dorsal Lumbar Disc Migrations with Lateral and Ventral Epidural Extension on Axial MRI: A Case Series and Review of the Literature.

Dorsal epidural migration of lumbar disc extrusion is rare and commonly misdiagnosed. Our purpose was to retrospectively analyze soft-tissue abnormalities on axial MR imaging in both the ventral and lateral epidural space in such dorsal epidural migrations. The presence of each component required complete concordance by 3 independent neuroradiologist readers. In a case series (n = 6) of surgically proved dorsal lumbar disc migrations, in which the radiologist's favored prospective diagnosis had not been correct, each case demonstrated epidural soft-tissue abnormality that had components both laterally and ventrally, abutting the parent disc. Similarly, in previously published cases for which axial MR imaging was available, the lateral component was demonstrated in 23/24 cases (96%). Ventral abutment of the parent disc was evident, in addition, in 17/18 cases (94%) with available disc-level axial images. Both ventral and lateral epidural soft-tissue abnormalities are typically present in dorsal lumbar disc herniations and may help radiologists suggest this rare diagnosis in appropriate cases.

Epidural Catheter Migration in a Patient with Severe Spinal Stenosis.

Establishment of appropriate neuraxial catheter positioning is typically a straightforward procedural undertaking. It can, however, lead to deception of even the most experienced clinician and occur despite the most meticulous attention to detail. Written and verbal consent were obtained from the patient to prepare, discuss, and publish this case report; we describe the occurrence of what we believe was the intraoperative migration of an epidural catheter in the setting of significant tissue changes resulting from a previous spinal fusion.