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BACKGROUND: Anterior thoracic spinal cord herniation (ATSCH) is a rare cause of progressive myelopathy. Early surgery is essential, but there is no agreement about the best surgical approach. OBJECTIVE: To identify factors that determine surgical results, and to find evidence for the most favorable technique to correct ATSCH. METHODS: To find relevant literature, computerized databases of PubMed, EMBASE, and ISI Web of Science were searched. The current study comprised case-reports published between 1974 and 2018, and the data-set was completed with 12 cases treated in our own institute. Patient characteristics were analyzed following the principles of an individual participant data (IPD) meta-analysis. RESULTS: Brown-Séquard-like neurological deficit prior to surgery was associated with postoperative motor-function improvement when compared to patients with para-paresis (P=0.04). In the univariate analysis, widening of the dura defect (WDD) was more prevalent among improved patients, whereas anterior dura patch (ADP) and application of Intra Operative Neurophysiological Monitoring (IONM) were not. In the multivariate analysis the favorable association with WDD disappeared, which is explained by the dominant influence of a Brown-Séquard-like deficit on outcome. CONCLUSIONS: In general, postoperative results after surgery for ATSCH are favorable, with a high percentage of patients experiencing postoperative improvement. Postoperative motor function improvement is more likely to occur in patients with a Brown-Séquard-like neurological deficit. The WDD should be favored above the application of a patch as the technique of choice in surgical treatment of ATSCH.

BACKGROUND: Anterior thoracic spinal cord herniation (ATSCH) is a rare cause of progressive myelopathy. Early surgery is essential, but there is no agreement about the best surgical approach.OBJECTIVE: To identify factors that determine surgical results, and to find evidence for the most favorable technique to correct ATSCH.METHODS: To find relevant literature, computerized databases of PubMed, EMBASE, and ISI Web of Science were searched. The current study comprised case-reports published between 1974 and 2018, and the data-set was completed with 12 cases treated in our own institute. Patient characteristics were analyzed following the principles of an individual participant data (IPD) meta-analysis.RESULTS: Brown-Séquard-like neurological deficit prior to surgery was associated with postoperative motor-function improvement when compared to patients with para-paresis (P=0.04). In the univariate analysis, widening of the dura defect (WDD) was more prevalent among improved patients, whereas anterior dura patch (ADP) and application of Intra Operative Neurophysiological Monitoring (IONM) were not. In the multivariate analysis the favorable association with WDD disappeared, which is explained by the dominant influence of a Brown-Séquard-like deficit on outcome.CONCLUSIONS: In general, postoperative results after surgery for ATSCH are favorable, with a high percentage of patients experiencing postoperative improvement. Postoperative motor function improvement is more likely to occur in patients with a Brown-Séquard-like neurological deficit. The WDD should be favored above the application of a patch as the technique of choice in surgical treatment of ATSCH.

Contains fulltext : 177990.pdf (Publisher’s version ) (Open Access) Idiopathic ventral herniation of the spinal cord (SC) is not often encountered in daily practice. Its clinical prevalence, however, will increase through increasing awareness and more frequent use of MRI. A clear explanation of its pathophysiology has never been formulated. It was hypothesized that the findings during surgery might indicate the real causative mechanism. An extensive literature search was performed, using Embase, PubMed, and Google Scholar. Titles and abstracts were screened by two investigators, using strict inclusion and exclusion criteria. Reference lists of the full paper versions of each included article were checked. The following data were registered for the articles included: age, gender, level of herniation, relation to intervertebral disk, duration of symptoms, findings from surgery, and outcomes. Nine cases treated at our department were added. A total of 117 articles reporting on 259 patients were included. Including our cases, 268 patients were reviewed. Females outnumbered males (160/100). The mean age was 51.3 +/- 12.0 years. In 236 patients, the duration of symptoms was reported: 55.5 +/- 55.6 months. In 178 patients, the intraoperative findings for the herniated part of the SC were not mentioned. In 59 patients, a tumor-like extrusion was seen, without any alteration to the SC. Deformation of the SC itself was never observed. Biopsies of these structures were without clinical consequence. Based on the intraoperative findings reported in literature and the cases presented, acquired causes, such as trauma and erosion of the dura due to a herniated disk, were not plausible. We hypothesize that a non-functioning appendix to the SC can only develop during an early embryologic phase, in which several layers separate. We propose renaming this entity as congenital transdural appendix of the SC.