Unexpected intradural disc herniation instead of space-occupying tumor at L3-L4 level: a case report and literature review

Background: Lumbar disc herniation (LDH) is a common disease, with a conventional treatment method, as well as well-established surgical procedure, when necessary. However, some rare cases of LDH, such as intradural disc herniation (IDH), accounting for a very small proportion (approximately 0.3%) of all LDH cases, could lead to intra-operation or post-operation complications, which requires a more circumspect pre-operational radiology analysis and overall management. Herein, we reported a case with L3-L4 IDH identified by pathological examination. Recent studies on PubMed were reviewed to summarize the unique characteristics of IDH, as well as diagnosis and treatments. Case introduction: A 69-year-old male was admitted to our department due to complaints of chronic low back pain for the past one month, along with radiating pain along the left lower hip and posterolateral left lower extremity. Disk herniation and space-occupying mass inside the canal at the L3-L4 level were confirmed by both lumbar CT and MRI. In surgery, after resection of the disc at L3-L4, further exploration revealed unsatisfactory volume of disk tissue and local eminence posterior to ventral dura, which emphasized the need for preoperatively identifying the mass inside the spinal canal. The tumor-like mass was found inside the dura. Finally, transforaminal lumbar interbody fusion (TLIF) was performed followed by resection of the mass. However, the histology examination showed a disc-like fibrocartilage tissue. The symptoms were immensely improved after the operation. Conclusion: IDH has a low incidence and is sporadically reported. Misdiagnosis is very common preoperatively as well as intraoperatively. IDH usually develops more rapidly compared with intradural tumors. Adhesion between dura mater and posterior longitudinal ligament may play a critical role in the disease onset.