[Sacral insufficiency, unexpected clinical entity as a cause of low back pain. Report of two cases]. / Insuficiencia sacra, entidad nosológica insospechada como causa de dolor lumbar bajo. Descripción de dos casos.

BACKGROUND: sacral insufficiency fractures are a cause of debilitating pain in the elderly. These fractures were first described as a clinical entity in 1982. The bone in these patients is structurally weakened and often associated with diseases such as osteoporosis, cancer and immunological processes. This translates into back and pelvic pain unrelated to trauma. These fractures are usually caused by fatigue in most cases. Bone scans and MRI are the imaging studies with the most sensitivity for detecting sacral insufficiency. CLINICAL CASES: two patients with sacral insufficiency fractures who were studied by MRI and bone scan, in whom the diagnosis of sacral insufficiency was made, were treated by sacroplasty. CONCLUSIONS: sacral insufficiency is an underdiagnosed disease, caused by wide range of diseases, mainly osteoporosis. The studies of choice for diagnosis are MRI and bone scans. Techniques, such as percutaneous sacroplasty, produce significant improvements in pain scores and seem a suitable alternative for managing this disease.

Idiopathic transdural spinal cord herniation: report of two cases and literature review.

BACKGROUND: Idiopathic transdural spinal cord herniation (ISCH) is a rare entity with postsurgical and post-trauma forms. ISCH is often omited in the preoperative evaluation. It often affects the thoracic segment and presents clinically as a rare cause of progressive myelopathy or Brown-Séquard syndrome, whose diagnosis is established by magnetic resonance imaging (MRI). We report on this rare entity due to its difficult diagnosis, making optimal management difficult. CLINICAL CASE: We present the cases of two patients with ISCH who were misdiagnosed and operated on in other spinal segments without reaching an accurate diagnosis. In our institution, patients with clinical suspicion were evaluated by imaging studies in order to rule out other pathologies. Laminectomy was performed on the involved levels, reducing herniation and with the placement of a synthetic spinal patch to the duramater. CONCLUSIONS: ISCH has been attributed to congenital weakness of the duramater or the dural ventral duplication with herniation through the inner layer due to continuous pressure from cerebrospinal fluid that pushes the marrow out of the subdural space. It is estimated that presurgical diagnosis is done only in one third of the cases, confirmed by MRI. Surgery is performed on patients with symptom progression. Surveillance in those patients with mild symptoms is recommended. Treatment may allow recovery of the neurological deficit, improving motor affection in 80% of patients and sensory affection in 35%.

Herniación medular transdural idiopática: informe de dos casos y revisión de la literatura / Idiopathic transdural spinal cord herniation: report of two cases and literature review

Introducción: La herniación medular transdural idiopática es una entidad rara cuyas formas son la postraumática y posquirúrgica; es omitida en la valoración preoperatoria y con frecuencia afecta al segmento torácico. Clínicamente puede causar mielopatía progresiva o síndrome de Brown-Séquard, cuyo diagnóstico se establece por resonancia magnética. La finalidad de informar esta entidad es su dificultad diagnóstica y, por lo tanto, para establecer un manejo óptimo. Casos clínicos: Dos pacientes mal diagnosticados al inicio e intervenidos en otros segmentos del raquis. Finalmente fueron valorados por sospecha clínica de herniación medular transdural idiopática y por exclusión de otras patologías. Se les realizó laminectomía en los niveles afectados, reducción de la hernia medular y colocación de parche sintético en duramadre. Conclusiones: La herniación medular transdural idiopática se ha atribuido a debilidad congénita de la duramadre o duplicación dural ventral con herniación a través de la capa interna debido a la presión continua del líquido cefalorraquídeo que empuja la médula fuera del espacio subdural. Se estima que el diagnóstico preoperatorio se realiza en una tercera parte de los casos, confirmándose con resonancia magnética. El tratamiento quirúrgico se efectúa en pacientes con progresión de los síntomas; los pacientes cuyos síntomas son leves o ausentes se mantienen bajo monitoreo. El tratamiento oportuno puede permitir la recuperación del déficit neurológico, mejorando la afección motora en 80% y la afección sensitiva en 35%.

BACKGROUND: Idiopathic transdural spinal cord herniation (ISCH) is a rare entity with postsurgical and post-trauma forms. ISCH is often omited in the preoperative evaluation. It often affects the thoracic segment and presents clinically as a rare cause of progressive myelopathy or Brown-Séquard syndrome, whose diagnosis is established by magnetic resonance imaging (MRI). We report on this rare entity due to its difficult diagnosis, making optimal management difficult. CLINICAL CASE: We present the cases of two patients with ISCH who were misdiagnosed and operated on in other spinal segments without reaching an accurate diagnosis. In our institution, patients with clinical suspicion were evaluated by imaging studies in order to rule out other pathologies. Laminectomy was performed on the involved levels, reducing herniation and with the placement of a synthetic spinal patch to the duramater. CONCLUSIONS: ISCH has been attributed to congenital weakness of the duramater or the dural ventral duplication with herniation through the inner layer due to continuous pressure from cerebrospinal fluid that pushes the marrow out of the subdural space. It is estimated that presurgical diagnosis is done only in one third of the cases, confirmed by MRI. Surgery is performed on patients with symptom progression. Surveillance in those patients with mild symptoms is recommended. Treatment may allow recovery of the neurological deficit, improving motor affection in 80% of patients and sensory affection in 35%.