Lumbar spinal stenosis in a patient with complex spinal dysraphism caused by a supplementary midline muscle: A case report

Sem M M Hermans; Jasper van Aalst; Jan Beckervordersandforth; Tim A M Bouwens van der Vlis

doi:10.25259/SNI_85_2022

Lumbar spinal stenosis in a patient with complex spinal dysraphism caused by a supplementary midline muscle: A case report

Surg Neurol Int. 2022 Mar 31:13:121. doi: 10.25259/SNI_85_2022. eCollection 2022.

Authors

Sem M M Hermans¹, Jasper van Aalst¹, Jan Beckervordersandforth², Tim A M Bouwens van der Vlis¹

Affiliations

¹ Department of Neurosurgery, Maastricht University Medical Center, Maastricht, Netherlands.
² Department of Pathology, Maastricht University Medical Center, Maastricht, Netherlands.

Abstract

Background: The clinical tethered cord syndrome (TCS) can become symptomatic during adulthood, known as adult tethered cord syndrome (ATCS). Distinguishing ATCS from neurogenic claudication attributed to lumbar spinal stenosis may pose a clinical challenge.

Case description: A 66-year-old male with an underlying complex occult spinal dysraphism (OSD) presented with new onset of lower back and bilateral leg pain plus neurogenic claudication. Magnetic resonance imaging documented OSD, and lumbar spinal stenosis (LSS) attributed to a supplementary midline muscle. Following decompressive surgery for LSS without untethering the ATCS, the patient's symptoms resolved.

Conclusion: A patient with OSD and ATCS with LSS due to a supplementary midline muscle presented with new onset of neurogenic claudication. Surgical decompression of the LSS by removing the supplementary midline muscle resolved patients' symptoms.

Keywords: Decompressive surgery; Neurogenic claudication; Spinal dysraphism; Spinal stenosis; Supplementary midline muscle; Tethered cord.

Publication types

Case Reports