CLINICAL REPORT

Incidental Diagnosis of Intradural

Lumbar Disc Herniation During
Discography: A Case Report
Ramsin Benyamin, MD, FIPP, DABIPP*; Ricardo Vallejo, MD, PhD, FIPP*;
Naveed Yousuf, MD; Anobel Tamrazi, PhD; Jeffery Kramer, PhD*,**
*Millennium Pain Center, Bloomington, Illinois; Illinois State University, Department of
Biological Sciences, Normal, Illinois; Department of Surgery, College of Medicine, University
of Illinois, Urbana-Champaign, Illinois; Bloomington Radiology, Normal, Illinois; Medical
Scholars Program, College of Medicine, University of Illinois, Urbana-Champaign, Illinois;
**University of Illinois College of Medicine at Peoria, Department of Cancer Biology and
Pharmacology, One Illini Drive, Peoria, Illinois, U.S.A.

Abstract: We describe an incidental finding of intradural

lumbar disc herniation diagnosed radiographically during
discography. A patient was referred to our center for discography with symptoms of worsening, intractable low back
pain radiating to both hips and the left leg which was exacerbated when standing and walking. Magnetic resonance
imaging of the lumbar spine revealed multiple disc bulges
and lumbar facet arthroses with ligamentum flavum hypertrophy producing moderate central canal and lateral recess
stenosis. Discography was performed at three levels (L3-4,
L4-5, L5-S1). During fluoroscopically guided injection into
L4-5 it was noted that contrast was not contained within the
disc and spread intrathecally with a myelographic appearance. Computerized tomography confirmed accurate needle
placement and a spread of contrast into the intrathecal
space. To the best of our knowledge, this is the first report
describing a finding of intradural disc herniation while
Address correspondence and reprint requests to: Ramsin Benyamin,
MD, FIPP, DABIPP, Millennium Pain Center, 1015 South Mercer Avenue,
Bloomington, IL 61701, U.S.A. E-mail: benyamin@millenniumpaincenter.
com.
Submitted: May 23, 2007; Revision accepted: July 31, 2007
DOI. 10.1111/j.1533-2500.2007.00159.x

2007 World Institute of Pain, 1530-7085/07/$15.00

Pain Practice, Volume 7, Issue 4, 2007 332336

performing discography. Physicians should be aware of this

potential finding while performing this technique.
Key Words: intradural disc herniation, discography,
discogram, intervertebral disc, fluoroscopy, computerized
tomography, degenerative disc disease, magnetic resonance
imaging

INTRODUCTION
Lumbar degenerative disc disease (LDDD) is a highly
common finding in the general population and is a
major contributor to the estimated 6080% lifetime
low-back pain incidence.1 LDDD is typically further
classified into annular tear, herniation, and degeneration
because of spondylosis deformans and intervertebral
osteochondrosis.2 The symptoms of herniated nucleus
pulposus (HNP) have been attributed to the herniation
of nucleus pulposus through a weakened annulus fibrosis or from the mechanical tearing of the annulus,3
which can lead to chronic low-back pain with radiculopathy secondary to nerve root compression or the
sequelae of inflammatory events activating the nociceptive pathways within the nerve roots of the spinal cord.3

Incidental Diagnosis of Intradural Lumbar Disc Herniation 333

In terms of location, HNPs most commonly occur in the

posterior or posterolateral regions of the intervertebral
disc.4
Clinically HNPs are described as either extradural or
intradural. Furthermore, extradural disc herniations are
considered extramedullary, whereas intradural disc herniations (IDHs) are either intramedullary or extramedullary.2 With IDH the architecture of the dura mater and
thecal sac are compromised by the HNP with disc material within the intrathecal space (Figure 1). In this article
we will refer to the intradural space as the intrathecal
space to maintain simplicity of nomenclature. Fortunately, IDHs are far less common than extradural herniations with an overall incidence of 0.260.3% of all
herniated discs5 and up to 1.5% of lumbar disc herniations.6 The location of IDHs include 5% in thoracic, 3%
in cervical, and 92% in lumbar region (usually L4-L5).5
The first reported case of IDH was described by Dandy
in 1942.7 There have been more than 100 reported cases
of IDHs,8,9 however, an overwhelming majority of the

Dura Mater
PLL

A
1

23

C
Spinal
Nerves

Figure 1. Schematic of normal disc anatomy (A), intradural disc

herniation (B) and extradural disc herniation (C). The herniated
disc is shown within the intrathecal space in the intradural disc
herniation (B) and within the epidural space in the extradural
disc herniation (C). The white lines in panel B represent the
openings through which the contrast might flow. PLL-posterior
longitudinal ligament; 1-vertebral body; 2-epidural space;
3-intrathecal space; 4-intervertebral disc space; 5-intervertebral
disc.

positive diagnoses were made during surgery,8 and only

eight reported cases were diagnosed preoperatively with
various imaging modalities (two with computerized
tomography [CT]-Myelography and six with contrast
enhanced magnetic resonance imaging [MRI]).8 It is of
note, that if IDH is overlooked and missed during
surgery, it can necessitate the need for a second surgical
procedure with potential sequelae including complications and longer recovery period.9 These limitations
suggest the need for affirmative diagnosis of IDH on
preoperative imaging studies.
Here we report a case of a patient with chronic
low-back pain and radicular left leg pain and numbness
with equivocal MRI findings for internal disc disruption. During a routine provocation discography, an
intradural lumbar disc herniation was incidentally diagnosed preoperatively at the L4-L5 level. The diagnosis
was made upon visualization of contrast agent flowing
from the nucleus pulposus of the L4-5 disc into the
thecal sac within the intrathecal space. To our knowledge, this is the first reported case of IDH diagnosed
during discography with intrathecal extrusion of contrast. This case was subsequently reported at a local
neuro case conference where multiple neuroradiologists, neurosurgeons, and pain management physicians
looked at the results and agreed on the findings that are
presented in this article.

CASE REPORT
A 54-year-old man with a history of hypertension,
emphysema and diabetes was referred to our pain center
for evaluation and treatment of intractable low-back
pain. His past surgical history included a cervical fusion
and bilateral carpal tunnel surgeries. The patient presented with a gradually worsening intractable low-back
pain (15-month history) radiating to both hips and left
leg along with numbness and tingling in his left foot.
The patient reported his back pain to be worse than his
left leg pain and quantified the pain as 7 out of 10 on a
numerical rating scale. His symptoms increased in the
standing position and walking would cause tingling paresthesias in his left leg. Conservative management with
medications and physical therapy had not improved his
condition. Neurological exam was within normal limits
and there was no gross neuromuscular weakness noted.
MRI scan of lumbar spine without contrast revealed
a prominent disc bulge at L4-5 with degeneration
(Figure 2) and lumbar facet arthroses with ligamentum
flavum hypertrophy producing moderate central canal
and lateral recess stenosis with possible nerve root com-

334 benyamin et al.

fluoroscopic guidance up to the lateral border of the disc

annulus. A 22-gauge 6-inch spinal needle was then
guided through the 18-gauge needle and advanced to the
middle of the nucleus pulposus under continuous realtime fluoroscopic guidance. Placement of the needle into
the disc was uneventful. Upon placement of all the
spinal needles in the nucleus pulposus the fluoroscopy
unit was placed in the lateral position and provocation
injections of Iohexol mixed with antibiotic proceeded.
Injections (2 ml) into L3-4 and L5-S1 discs produced
maximum pressures of 7080 PSI with no pain provocation. During injection into the L4-5 nucleus pulposus,
it was noted that contrast was not contained inside the
disc. Under real-time fluoroscopic visualization extrusion of contrast was noted posteriorly and intradurally
into the intrathecal space (Figure 3). Furthermore, the
disc could not be pressurized above 25 PSI despite contrast injection (4 ml), which did not provoke pain. In
order to clarify the findings, the patient was moved to
the CT suite with the needle in situ at L4-5. The images
showed an annular fissure and extrusion of injected
contrast into the intrathecal space (Figure 4). A postdiscography MRI was also obtained that demonstrated
contrast flowing intradurally into the intrathecal space
(Figure 5). The patient was transferred to the recovery
room in stable condition and was discharged. The
patient did not develop a headache or other sequelae
from the intradural penetration.
Figure 2. Pre-procedural magnetic resonance imaging demonstrating a prominent bulge with mild degeneration at L4-5 level.

pression. In light of the disc bulge with degeneration and

negative MRI findings for internal disc disruption, the
patient was scheduled for a provocation discography to
identify and diagnose the painful intervertebral discs.
This patient was determined to be a candidate for spinal
fusion by the spine surgeon. Therefore, the rational for
discography was to determine if fusion should proceed
with or without discectomy.
Prophylactic antibiotics were administered intravenously 30 minutes prior to procedure. Discography was
performed utilizing standard approach and sterile technique. Lidocaine 1% was used for skin and subcutaneous anesthesia. The side opposite to the patients pain
region was chosen for skin penetration. The procedure
under fluoroscopic guidance was performed using a
double needle technique with a posterolateral approach.
The initial penetration through the skin was performed
with an 18-gauge spinal needle and was advanced under

DISCUSSION
Here we report a case of intradural lumbar disc herniation (L4-L5) incidentally diagnosed during a routine
discography10,11 as evidenced by contrast extrusion into
the intrathecal space. Clinically IDH in the lumbar
region presents with intractable low back pain with or
without radiculopathy, which does not resolve spontaneously.8 Anatomically, IDH is defined as the extrusion
of the nucleus pulposus into an intradural site, which
can be considered as a complication of intervertebral
disc herniation.8 Extrusion of the nucleus pulposus into
the intradural site requires the perforation of the annulus fibrosus, posterior longitudinal ligament (PLL)
and the dura mater.8 Lumbar IDHs are frequently
located at the L4-L5 location, and although the exact
mechanism for this relatively selective location is
unknown, it has been reported that the ventral dura is
most frequently and firmly attached to the PLL at this
level and these adhesions could be congenital in
nature.8,12,13 The pathophysiology of IDH is typically
attributed to three general mechanisms: (i) congenital

Incidental Diagnosis of Intradural Lumbar Disc Herniation 335

Figure 4. Computerized tomography image demonstrating that

the discography needle was accurately placed within the nucleus
pulposus and did not penetrate the posterior longitudinal ligament and therefore did not facilitate the extrusion through the
dura into the intrathecal space.

Figure 3. Anterior-posterior (top) and lateral (bottom) fluoroscopy views of multilevel provocation discography. Contrast was
injected into each disc. Note that the top and bottom levels (L3-4
and L5-S1, respectively) have contrast within the disc. During
injection in the middle (L4-5) level contrast leaked from the disc
into the intrathecal space. The intrathecal contrast simulates a
myelographic appearance.

thickness of the dura mater, and/or a union between the

dura mater and the PLL; (ii) local inflammation secondary to DDD can contribute to the formation of adhesions between the dura mater and PLL, leading to
spontaneous perforation into the intrathecal site; and
(iii) postoperative, iatrogenic adhesions between the
annulus fibrosus, PLL and the dura mater can lead to
perforation.8,9
The differential diagnosis for IDH includes hemorrhage, meningeal cysts, infections, inflammatory processes, neurinoma and meningioma, ependymoma,
epidermoid and dermoid cysts.8,9 Although various

Figure 5. Post-discography axial computerized tomography scan

at the level of L4-5, demonstrating contrast in the intrathecal
space and around the left L5 nerve root sleeve (left arrow).
Please note some contrast in the extradural space as well (right
arrow).

imaging modalities have been used in an attempt to

preoperatively diagnose IDH, affirmative diagnosis of
almost all described IDH cases in the literature were
made intraoperatively.8 MRI with contrast and the combination of epidural gas and an intradural mass on CT,
appear most promising as preoperative diagnostic
tools,8,9 although the fraction of IDH cases diagnosed

336 benyamin et al.

preoperatively with imaging modalities remains extremely low.8 It is of note that the need for effective
preoperative IDH diagnosis has lead to the use of intraoperative ultrasonography to help identify loose intradural fragments.9
In the case of our patient with chronic low-back pain
and no history of previous lower back surgery, a routine
discography showed contrast within the intrathecal
region after injection at L4-L5. Interestingly, there is
one published report of a patient who was diagnosed
with IDH during surgery and had undergone a routine
discography preoperatively.14 However, that IDH case
showed contrast in the epidural space outside of the
thecal sac and was, thus, preoperatively nondiagnostic.
In our case, contrast spread was seen within the intrathecal space on CT, while the needle placement was perfectly positioned within the nucleus pulposus and clearly
away from the PLL. Therefore, the needle was not the
cause of the opening within the PLL and dura mater.
This report highlights IDH as a potential incidental
finding during discography and discographers should be
aware that intrathecal spread of contrast injected into
the nucleus pulposus may indicate an IDH. To a lesser
extent these findings suggest that discography may be a
possible preoperative diagnostic tool for IDH, but
clearly further studies are needed to validate discography as a preoperative diagnostic tool for IDH.

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