Surgical Treatment of Idiopathic spinal cord herniation: A Case Report under Neuromonitoring and Meta-analysis of 211 reviewed Cases

Idiopathic spinal cord herniation (ISCH) is a rare condition caused by a ventral or ventrolateral dural defect. Two surgical strategies are used: non-closure (Group I), consisting of reduction and adhesiolysis with or without enlargement of the defect, and closure (Group II), involving reduction followed by direct or indirect dural repair. This study compared these approaches. We reported a case of ISCH treated under neuromonitoring. We conducted a systematic review and meta-analysis including surgically treated cases confirmed by MRI or CT myelography, excluding traumatic, iatrogenic, and discogenic etiologies. Outcomes included neurological status at final follow-up, recurrence, and surgical complications. A 50-year-old patient with progressive Brown–Séquard syndrome underwent surgery; neuromonitoring deterioration during attempted closure prompted conversion to non-closure. At the final follow-up, a clinical improvement without recurrence or complications was observed. Through the review, we identified 211 patients, including our case (mean age 50.99±13.25 years; 58.7% female). Median follow-up was 24.16 months. In Group I, 53 improved, 4 were unchanged, and 2 worsened; in Group II, 114 improved, 27 were unchanged, and 9 worsened. Non-closure was associated with higher odds of improvement in the unadjusted analysis (POR 2.74, 95% CI 1.09–6.90, p=0.032), but this association attenuated after adjustment (adjusted POR 2.53, 95% CI 0.69–9.31, p=0.16). Complication rates were 3.38% vs 8.00% (OR 0.40, 95% CI 0.04–1.90); recurrence occurred once in each Group. Both strategies are comparable. The non-closure could be a better choice, since it requires less manipulation. Intraoperative neuromonitoring is a valuable decision-making tool in ISCH surgery. • Idiopathic spinal cord herniation is a rare condition treated surgically through two comparable surgical strategies: non-closure and closure approaches. • The non-closure approach could provide a better choice through less spinal cord manipulation. • Intraoperative neuromonitoring provides valuable guidance for tailoring surgical strategy.