Herniation of spinal cord into nerve root avulsion pseudomeningocele: A rare cause of delayed progressive neurological deficit
A 40-year-old male patient presented with history of progressive weakness of the right lower limb. Four years back, he had sustained injuries in a road traffic accident and was admitted with head trauma. He had profound weakness of the right upper limb. Clinically, brachial plexus injury was suspected and nerve conduction studies suggested involvement of right C5–D 1 nerve roots. Patient recovered from his head injuries and was left with residual right monoplegia. Four years later, the patient developed progressive weakness of the right lower limb and started walking with a limp. On examination, there was wasting and weakness of the right upper limb muscles. Mild wasting of the right thigh and calf muscles was noted. The power in the right hip and knee flexors was Grade 4/5 Medical Research Council (MRC). The power in dorsiflexor and plantarflexors of ankle was Grade 4/5 MRC. The right knee and ankle jerks were exaggerated and right plantar reflex was extensor. There was no sensory loss in either lower limbs or left upper limb. Clinically, myelopathy was suspected and MRI of the cervical spine was suggested. MRI of the patient was done on Magnetom Avanto 1.5 T MRI (Siemens, Erlangen, Germany). Axial, sagittal, and coronal T1- and T2-weighted images of the cervical spine were acquired, which revealed the presence of lateral pseudomeningoceles at C7–D1and D1–D2 levels []. Dedicated 3-D SPACE sequence and oblique coronal inversion recovery sequence of the right brachial plexus were also acquired. There was lateral herniation of a knuckle of cord into the pseudomeningocele at D1–D2 neural foramen [Figures and ]. Reconstruction of data set in any specified plane and superior spatial resolution of the 3-D sequence resulted in better appreciation of dura, dural defect, and the cord herniation.\nDue to progressive neurological deficit, a decision to treat the patient surgically was made. Through a posterior approach, laminectomies were performed at D1 and D2 levels. Herniation of the cord was seen into the pseudomeningocele through a dural defect. The herniated cord was reduced and the dural defect repaired. After surgery, there was slight improvement in the right lower limb power.