Working Diagnosis:
T7-T8 spinal cord herniation (drawn through defect in thecal sac) with thoracic radicular pain

Treatment:
Rowing and excessive activity involving left arm discontinued for 6 months. Physical therapy initiated. Meloxicam and trazodone partially improved pain. Pain mildly decreased; no longer affecting sleep and ADLs were less painful. With the start of rowing season pain significantly increased, particularly with rowing, typing, trunk or left shoulder movement, coughing, and push-ups. No radicular arm or leg pain. Scapular and core strength were normal, with full active ROM in her thoracic spine and ribs. It was particularly concerning that manual strength testing exacerbated pain and that despite improvement in strength and resolution of rib dysfunction, her pain continued. This prompted the aforementioned MR of the thoracic spine.

Outcome:
She failed (due to side effects), trials of: NSAIDs, trazodone, metaxalone, gabapentin, and cyclobenzaprine. Lidocaine patches have helped pain, topiramate has helped dural headache. She has received substantial relief of pain from paravertebral nerve blocks, of which she has had four.

Clinical Progression:
She is now a year and a half from diagnosis. Symptoms progressed to include left lower extremity weakness, paresthesia, and dyscoordination with tripping, which is now improving (twice weekly tripping currently). She plans to move out of state for a new job this summer. She will continue to have close monitoring with Anesthesia and PM&R.

Return to Play:
She has retired from crew, given that any maneuvers requiring increased intrathoracic pressure put her at risk for progressive myelopathy. Participating in yoga has helped coordination and proprioception. She is tolerating jogging up to 6 miles.

References:
1. Berg-Johnsen J, Ilstad E, Kolstad F, Zuchner M, Sundseth J. Idiopathic ventral spinal cord herniation: an increasingly recognized cause of thoracic myelopathy. Journal of central nervous system disease. 2014;6:85-91.
2. Groen RJ, Middel B, Meilof JF, et al. Operative treatment of anterior thoracic spinal cord herniation: three new cases and an individual patient data meta-analysis of 126 case reports. Neurosurgery. Mar 2009;64(3 Suppl):ons145-159; discussion ons159-160.
3. Hawasli AH, Ray WZ, Wright NM. Symptomatic thoracic spinal cord herniation: case series and technical report. Neurosurgery. Sep 2014;10 Suppl 3:E498-504; discussion E504.

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