TITLE:
Thoraco-Lumbar Junction Disc Herniation and Tight Filum: A Unique Combination?
AUTHORS:
Erwin M. J. Cornips, Emile A. M. Beuls, Biene W. Weber, Johannes S. H. Vles
KEYWORDS:
Clinical Presentation, Disc Herniation, Tethered Cord, Therapy, Thoraco-Lumbar Junction, Tight Filum
JOURNAL NAME:
International Journal of Clinical Medicine,
Vol.5 No.12,
June
26,
2014
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.