• Cauda equina syndrome(CES)
• Constructive Interference in Steady State(CISS) MRI
• Discectomy
• Intra-operative ultrasonography(IOUS)
• Intradural disc herniation(IDDH)
• Lumbar herniated disc

Lumbar disc herniation (LDH) is prevalent among adults aged 25-55 years who spend a considerable proportion of their time sitting or standing with heavy workloads. We report the case of a 33-year-old male waiter with severe LDH, causing compression of the nerve roots and spinal cord with neurological dysfunction, who presented to a chiropractic clinic. Magnetic resonance imaging (MRI) revealed a radiological differential diagnosis comprising LDH and an epidural mass lesion. To rule out serious pathology, a second MRI with contrast was ordered, which confirmed the diagnosis of severe LDH. Diagnosing large LDH may be challenging, and severe disc herniation often mimics spinal tumors. This study offers insights into the differential diagnosis of LDH and spinal tumors, as well as the design of a treatment strategy for severe LDH in the chiropractic clinic.

• chirpractor
• chiropractic
• chiropractic therapy
• disc prolapse
• lumbar disc herniation

• breast cancer
• cauda equina syndrome
• disc sequestrum
• epidural metastasis
• lumbar disc herniation

• magnetic resonance imaging
• mimicking tumor discs
• reliability
• schwannoma
• sensitivity

• Humans
• Female
• Adult
• Middle Aged
• Aged
• Diagnosis, Differential
• Retrospective Studies
• Water
• Reproducibility of Results
• Neoplasms
• Magnetic Resonance Imaging

• National Natural Science Foundation of China

Disc herniation refers to the displacement of disc material beyond its anatomical space. Disc sequestration is defined as migration of the herniated disc fragment into the epidural space, completely separating it from the parent disc. The fragment can move in upward, inferior, and lateral directions, which often causes low back pain and discomfort, abnormal sensation, and movement of lower limbs. The free disc fragments detached from the parent disc often mimic spinal tumors. Tumor like lumbar disc herniation can cause clinical symptoms similar to spinal tumors, such as lumbar soreness, pain, numbness and weakness of lower limbs, radiation pain of lower limbs, etc. It is usually necessary to diagnose the disease according to the doctor's clinical experience, and make preliminary diagnosis and differential diagnosis with the help of magnetic resonance imaging (MRI) and contrast-enhanced MRI. However, pathological examination is the gold standard that distinguishes tumoral from non-tumoral status. We report four cases of disc herniation mimicking a tumor, and all the pathological results were intervertebral disc tissue.

The first case was a 71-year-old man with low back pain accompanied by left lower extremity radiating pain for 1 year, with exacerbation over the last 2 wk. After admission, MRI revealed a circular T2-hypointense lesion in the spinal canal of the L4 vertebral segment, with enhancement on contrast-enhanced MRI suggesting neurilemmoma. The second case was a 74-year-old man with pain in both knees associated with movement limitation for 3 years, with exacerbation over the last 3 mo. MRI revealed an oval T2-hyperintense lesion in the spinal canal at the L4–5 level, with obvious peripheral enhancement on contrast-enhanced MRI. Thus, neurilemmoma was suspected. The third case was a 53-year-old man who presented with numbness and weakness of the lumbar spine and right lower extremity for 2 wk. MRI revealed a round T2-hyperintense lesion in the spinal canal at the L4–5 level, with obvious rim enhancement on contrast-enhanced MRI. Thus, a spinal tumor was suspected. The fourth case was a 75-year-old man with right lower extremity pain for 2 wk, with exacerbation over the last week. MRI revealed a round T1-isointense lesion in the spinal canal of the L3 vertebral segment and a T2-hyperintense signal from the lesion. There was no obvious enhancement on contrast-enhanced MRI, so a spinal tumor was suspected. All four patients underwent surgery and recovered to ASIA grade E on postoperative days 5, 8, 8, and 6, respectively. All patients had an uneventful postoperative course and fully recovered within 3 mo.

Disc herniation mimicking a tumor is a relatively rare clinical entity and can be easily misdiagnosed as a spinal tumor. Examinations and tests should be improved preoperatively. Patients should undergo comprehensive preoperative evaluations, and the lesions should be removed surgically and confirmed by pathological diagnosis.

• Disc herniation
• Disc sequestration
• Mimicking tumor
• Spinal tumor
• Surgery
• Case reports

Accounting for less than 0.4% of disc herniations, intradural lumbar disc herniations (ILDHs) are a rare occurrence primarily described as a complication after lumbar spine surgery. It is speculated that the herniation may propagate intradurally from either an unrecognized dural defect after initial surgery or as a result of adhesions between the dura and posterior longitudinal ligament. This report explores the etiology, presentation, diagnostic evaluation, and treatment of ILDH along with a case report and microsurgery video.

A 67-year-old patient who 1 year earlier had undergone an L2–5 laminectomy and L2–3 decompression with no known complications presented with low back pain and radiating right leg, buttock, and groin pain for 1 month. Physical examination indicated no numbness or weakness. Magnetic resonance imaging demonstrated a large ILDH. A transforaminal interbody fusion was performed followed by a durotomy, ILDH removal, and dural closure. A ventral dural defect was found and repaired during the procedure.

The treatment for ILDH is laminectomy with dorsal durotomy. Because ILDH has rarely been described in literature, understanding its presentation is crucial for prompt identification and management.

• cauda equina syndrome
• lumbar disc herniation
• ossification of the ligamentum flavum
• ossification of the longitudinal ligament
• schwannoma

• Cerebrospinal fluid leakage
• Durotomy
• Intradural disc herniation
• L1-2 level
• Laminectomy
• Lumbar spine
• Suturing of ventral dura

Intradural disc herniation (IDH) is a rare complication which comprises 0.27% of all herniated intervertebral discs. We are reporting a case of lumbar intradural disc herniation at the L4-L5 levels highlighting challenges in establishing clinical diagnosis and surgical approach involving a transdural microsurgery approach.

A 38-year-old gentleman was presented with left radicular low back pain without motoric and autonomic involvement admitted to our neurosurgical service. Spine MRI showed an intradural, extra-axial spinal mass.

Lumbar IDH is a rare pathology thus often initially diagnosed as other more common conditions. In our case, the IDH diagnosis was confirmed during surgery as the radiological examination results mimic intradural extra-axial tumor. During surgery, a hard irregular white mass was found shortly after dural incision. Histopathological results showed chondrocytes, fibrotic and necrotic appearances consistent with the diagnosis of disc herniation. Postoperatively, the patient showed improvement and pain alleviation.

We observed the beak sign which is one of the important features of IDH imaging. Surgery-wise, the challenge of dissecting the anterolateral part of the duramater from the annulus fibrosus of the intervertebral disc should be noted by the performing surgeon.

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Intradural disc herniation (IDH) is a rare complication and comprises 0.27% of all herniated disc.

• Intradural herniation
• Lumbar herniated disc
• Microsurgery

• Endoscopic diskectomy
• Intradural disk herniation
• Microscopic diskectomy

• Acute disc herniation
• Acute low back pain
• Discitis osteomyelitis
• Epidural hematoma
• Pathologic fracture
• Spinal cord infarct
• Spinal metastases

Since disc sequestration that mimics a tumor is rare and sometimes presents with an atypical appearance upon magnetic resonance imaging (MRI), it is often confused with other more common epidural and intradural neoplasms, particularly neurinoma. Open surgery is necessary due to the difficult of achieving a definitive diagnosis using computed tomography, MRI, and gadolinium- enhanced MRI prior to operation. Herein, we describe the use of coronal MR images of 3D fast-field echo with water selective excitation in the diagnosis of disc sequestration mimicking a tumor.

Two patients were admitted to our hospital with back pain, radiating pain, and hypoesthesia in the right lower limb. MRI revealed tumor-like masses in the lateral recess of L3 and posterior to the body of L4. The initial diagnosis indicated disc sequestration mimicking a tumor and neurinoma. The coronal MR images of 3D fast-field echo with water selective excitation showed a clear boundary between the tumor-like mass and the nerve root. Moreover, the mass was also completely separated from the dura. Therefore, neurinoma was excluded as a possible diagnosis prior to operation. Surgical excision to perform removal of the gross mass was performed in one patient. The histopathological diagnosis was consistent with the 3D fast-field echo with water-selective excitation MRI. Another patient was successfully treated by minimally invasive endoscopic surgery.

Disc sequestration that mimics a tumor is difficult to diagnose preoperatively. As a non–invasive strategy, coronal MR images of 3D fast-field echo with water selective excitation is a helpful imaging tool for differentiating between diagnosis of disc sequestration that mimics a tumor and neurinoma prior to operation. If the disc fragment of mimicking tumor can be identified prior to operation, open surgery may not be necessary for all patients. Minimally invasive endoscopic surgery also is an alternative strategy.

• 3D fast-field echo with water selective excitation
• Disc sequestration
• Lumbar disc herniation
• Mimicking tumor

We present a case series of six cases of intradural disc herniation at L4–L5 level diagnosed on the basis of intraoperative findings.

All our cases, on preoperative magnetic resonance imaging (MRI) were reported as having diffuse annular bulge with large posterocentral extrusion. Our study comprised patients in age group of 30–60 years. Four cases out of six presented with cauda equina syndrome. In three cases, cauda equina was associated with sudden deterioration in the power of lower limb muscle groups.

We suspect that intradural herniation of disc was synchronous with cauda equina syndrome in these cases, which was very well documented in one of the cases. On retrospective analysis, MRI findings of mass effect in the form of displacement of the traversing nerve roots due to large central disc with crumble disc sign were suggestive of early evidence of intradural disc herniation. Y sign in ventral dura due to splitting of ventral dura and arachnoid mater by disc material was a good diagnostic sign to suspect intradural extra-arachnoid disc. The presence of hypointense structure inside the dura with no continuity with the adjacent intervertebral disc on MRI was highly suggestive of an intradural disc.

Intradural disc prolapse remains a diagnostic dilemma as it is very difficult to diagnose all the cases preoperatively. The presence of above-mentioned radiological signs on MRI in patients having the large central disc on MRI, especially at L4–L5 levels, should raise suspicion of intradural herniation of disc.

• Cauda equina
• intradural disc
• lumbar herniated disc

Intradural disc herniation is a very rare condition, and multiple intradural disc herniations have not been reported to date. The latter may be confused with intradural extramedullary (IDEM) spinal tumors. Here, we report a case of multiple intradural disc herniations masquerading as multiple IDEM tumors and review the relevant literature. We retrospectively reviewed the patient's medical chart, reviewed the intraoperative microscopic findings, and reviewed of PubMed articles on intradural disc herniation. The masses considered to be IDEM tumors were confirmed to be multiple intradural disc herniations. A nonenhancing mass was found to have migrated along the intra-arachnoid space. Two enhancing masses could not migrate because of adhesion and showed peripheral neovascularization. We report an extremely rare case of multiple intradural lumbar disc herniations showing diverse enhancing patterns and masquerading as multiple IDEM tumors. In case of multiple enhancing IDEM masses suspected preoperatively, surgeons should consider the possibility of intradural disc herniation.

• Intervertebrtal disc displacement
• Lumbar vertebrae
• Neoplasms