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Contained Thecal Sac Indentation

Dr. Lisa S. Apfel MD - Spine and Neurosurgery Dr. Lisa S. Apfel MD - Spine and Neurosurgery
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Degenerative Bones, Joints, and Spine Care (A - Z)

Contained thecal sac indentation, also known as contained dural sac effacement, refers to a focal compression or “flattening” of the thecal sac—the membranous sheath of dura mater that surrounds the spinal cord and cauda equina—by a lesion that remains within the confines of the spinal canal (i.e., the outer annulus fibrosus or posterior longitudinal ligament remains intact). On MRI, this appears as a subtle inward molding of the normally oval thecal sac without rupture of the annular fibers SpineInfoRadiology Key.

Anatomy

Structure & Tissue Type
The thecal sac is the tubular sheath of dura mater—the tough outer meningeal layer—that envelops the spinal cord and cauda equina, containing cerebrospinal fluid (CSF) WikipediaSpineInfo.

Location
It extends from the foramen magnum at the base of the skull down to approximately the second sacral vertebra (S2), running centrally within the bony vertebral canal and separated from the vertebral periosteum by the epidural space Wikipedia.

Origin & “Insertion”

  • Origin: Adheres to the margins of the foramen magnum at the skull base.

  • Insertion: Tapers over the filum terminale at S2, anchoring the dural sac to the sacral canal Wikipedia.

Blood Supply
The spinal dura receives arterial blood principally from:

  1. Posterior meningeal branches of the vertebral arteries.

  2. Radicular (segmental) arteries accompanying spinal nerve roots (including the artery of Adamkiewicz) WikipediaKenhub.

Nerve Supply
Sensory innervation arises from small meningeal branches of the spinal nerves (sinuvertebral nerves) and contributions from upper cervical nerves and vagal meningeal branches; cranially, branches of the trigeminal nerve supply the dura of the foramen magnum region WikipediaRadiopaedia.

Functions

  1. Protection & Cushioning: Encloses CSF, which buffers the spinal cord against mechanical shocks Wikipedia.

  2. Nutrient Delivery: CSF carries nutrients and removes waste from neural tissue Wikipedia.

  3. Structural Support: Maintains the spinal cord’s position within the canal.

  4. Dural Root Sheaths: Extends along exiting nerve roots, forming protective sleeves (dural root sheaths) Wikipedia.

  5. Barrier to Pathogens: Acts as a defense against infections reaching neural tissue.

  6. Pressure Regulation: Helps sustain normal intracranial and intraspinal pressure dynamics.

Types of Indentation

  1. Mild vs. Moderate vs. Severe: Graded by depth of sac molding on MRI.

  2. Focal vs. Generalized Effacement: Localized point indentation versus circumferential flattening.

  3. Ventral (anterior) Indentation: Commonly from disc protrusion Radiology Key.

  4. Lateral Indentation: May narrow neural foramina.

  5. Contained Protrusion: Disc bulge/annular protrusion not breaching all annular layers Radiology Key.

  6. Disc Extrusion without Sequestration: Annulus breached but fragment remains attached.

  7. Sequestrated Fragment: Free fragment indenting sac.

  8. Ligamentum Flavum Hypertrophy: Thickened ligament pressing on sac SpineInfo.

  9. Osteophytic Spurs: Bony outgrowths indent the sac SpineInfo.

  10. Epidural Lipomatosis: Excess fat within epidural space.

  11. Tumoral Indentation: Benign or malignant masses.

  12. Arachnoid Web/Cyst: Dural sac compression by arachnoid pathology Optimal Wellness Health Center (UT).

  13. Epidural Hematoma: Acute blood collection.

  14. Epidural Abscess: Infectious compression.

  15. Congenital Stenosis: Developmental canal narrowing.

  16. Spondylolisthesis: Vertebral slippage indenting the sac SpineInfo.

  17. Diffuse Idiopathic Skeletal Hyperostosis (DISH): Bony overgrowths.

  18. Paget’s Disease: Bone remodeling leading to canal narrowing.

  19. Post-surgical Scar Tissue: Fibrosis after spine surgery.

  20. Metastatic Disease: Epidural spread of cancer.

Causes

Any process that narrows the spinal canal or exerts inward pressure can indent thecal sac. Common causes include:

  1. Lumbar or cervical disc herniation SpineInfo

  2. Broad-based disc bulge (contained) Radiology Key

  3. Disc extrusion (breached annulus) Radiology Key

  4. Disc sequestration Radiology Key

  5. Ligamentum flavum hypertrophy SpineInfo

  6. Osteophyte formation (bone spurs) SpineInfo

  7. Spinal stenosis (degenerative) SpineInfo

  8. Spondylolisthesis SpineInfo

  9. Traumatic vertebral fracture or dislocation SpineInfo

  10. Spinal tumors (primary or metastatic) SpineInfo

  11. Arachnoid webs or cysts Optimal Wellness Health Center (UT)

  12. Epidural hematoma (bleeding) SpineInfo

  13. Epidural abscess (infection) SpineInfo

  14. Epidural lipomatosis (excess fat) SpineInfo

  15. Congenital spinal canal narrowing SpineInfo

  16. Diffuse Idiopathic Skeletal Hyperostosis (DISH) SpineInfo

  17. Paget’s disease of bone SpineInfo

  18. Post-surgical epidural fibrosis SpineInfo

  19. Rheumatoid arthritis with pannus formation SpineInfo

  20. Inflammatory spondyloarthropathies (e.g., ankylosing spondylitis) SpineInfo.

Symptoms

Symptoms depend on location and severity:

  1. Localized back or neck pain SpineInfo

  2. Radicular pain (sciatica, cervical radiculopathy) SpineInfo

  3. Numbness or tingling in limbs SpineInfo

  4. Muscle weakness SpineInfo

  5. Gait disturbances SpineInfo

  6. Neurogenic claudication (leg pain on walking) SpineInfo

  7. Hyperreflexia SpineInfo

  8. Hyporeflexia SpineInfo

  9. Muscle spasm or cramps SpineInfo

  10. Balance or coordination problems SpineInfo

  11. Bladder dysfunction (urgency, retention) SpineInfo

  12. Bowel dysfunction SpineInfo

  13. Sexual dysfunction SpineInfo

  14. Saddle anesthesia SpineInfo

  15. Sleep disruption due to pain SpineInfo

  16. Radicular fatigue (profound limb tiredness) SpineInfo

  17. Postural intolerance SpineInfo

  18. Cold or heat sensitivity in limbs SpineInfo

  19. Unexplained weight loss (tumor-related) SpineInfo

  20. Fever, chills (infection-related) SpineInfo.

Diagnostic Tests

  1. MRI (Magnetic Resonance Imaging): Gold standard for soft-tissue detail Orthobullets

  2. CT scan: Useful for bone and calcified lesions Orthobullets

  3. CT myelogram: Contraindicated for MRI-ineligible patients; shows filling defects Orthobullets

  4. X-ray: Initial screening for alignment, fracture SpineInfo

  5. Discogram: Pain provocation test using contrast SpineInfo

  6. Electromyography (EMG): Assesses nerve root irritation SpineInfo

  7. Nerve Conduction Studies (NCS): Differentiates peripheral neuropathy SpineInfo

  8. Bone scan (nuclear medicine): Detects infection or metastasis SpineInfo

  9. CT-guided biopsy: For suspected neoplasm/infection SpineInfo

  10. Blood tests: CBC, ESR, CRP for infection/inflammation SpineInfo

  11. CSF analysis: Lumbar puncture if infection or hemorrhage suspected SpineInfo

  12. Somatosensory Evoked Potentials (SSEP): Assesses dorsal column function SpineInfo

  13. Motor Evoked Potentials (MEP): Evaluates corticospinal tract integrity SpineInfo

  14. Ultrasound: Rare, for accessible epidural masses SpineInfo

  15. Functional MRI: Research use, maps neural activity under load SpineInfo

  16. Plain Myelography: Historical, uses iodinated contrast SpineInfo

  17. Flexion-extension X-rays: Assesses instability SpineInfo

  18. DEXA scan: Bone density for osteoporotic risk SpineInfo

  19. PET scan: Staging metastatic disease SpineInfo

  20. Physical exam: Neurological exam, straight leg raise, reflex testing SpineInfo.

Non-Pharmacological Treatments

  1. Physical therapy: targeted strengthening & stretching SpineInfo

  2. McKenzie lumbar/cervical exercises SpineInfo

  3. Posture training & ergonomic adjustments SpineInfo

  4. Core stabilization programs SpineInfo

  5. Aquatic therapy (hydrotherapy) SpineInfo

  6. Yoga SpineInfo

  7. Pilates SpineInfo

  8. Tai Chi SpineInfo

  9. Spinal traction therapy SpineInfo

  10. Manual therapy/chiropractic manipulation SpineInfo

  11. Massage therapy SpineInfo

  12. Heat therapy SpineInfo

  13. Cold therapy SpineInfo

  14. Transcutaneous Electrical Nerve Stimulation (TENS) SpineInfo

  15. Ultrasound therapy SpineInfo

  16. Acupuncture SpineInfo

  17. Cognitive Behavioral Therapy (CBT) for pain coping SpineInfo

  18. Mindfulness & relaxation techniques SpineInfo

  19. Biofeedback SpineInfo

  20. Orthotic bracing (e.g., lumbar brace) SpineInfo

  21. Activity modification & pacing SpineInfo

  22. Weight management programs SpineInfo

  23. Ergonomic workplace assessment SpineInfo

  24. Sleeping position optimization SpineInfo

  25. Smoking cessation support SpineInfo

  26. Dietary counseling for bone health SpineInfo

  27. Vitamin D & calcium supplementation (non-drug supportive) SpineInfo

  28. Support groups & patient education SpineInfo

  29. Thermal and mechanical modalities (e.g., waxing, paraffin) SpineInfo

  30. Neural mobilization techniques SpineInfo.

Drugs

  1. Ibuprofen (NSAID) SpineInfo

  2. Naproxen (NSAID) SpineInfo

  3. Diclofenac (NSAID) SpineInfo

  4. Celecoxib (COX-2 inhibitor) SpineInfo

  5. Acetaminophen (analgesic) SpineInfo

  6. Tramadol (weak opioid) SpineInfo

  7. Oxycodone (opioid) SpineInfo

  8. Morphine (opioid) SpineInfo

  9. Cyclobenzaprine (muscle relaxant) SpineInfo

  10. Tizanidine (muscle relaxant) SpineInfo

  11. Methocarbamol (muscle relaxant) SpineInfo

  12. Gabapentin (anticonvulsant/neuropathic) SpineInfo

  13. Pregabalin (anticonvulsant/neuropathic) SpineInfo

  14. Duloxetine (SNRI) SpineInfo

  15. Amitriptyline (TCA) SpineInfo

  16. Prednisone (oral corticosteroid) SpineInfo

  17. Methylprednisolone (injection) SpineInfo

  18. Epidural steroid injection SpineInfo

  19. Capsaicin cream (topical) SpineInfo

  20. Lidocaine patch (topical) SpineInfo.

Surgeries

  1. Laminotomy (removal of part of lamina) SpineInfo

  2. Laminectomy (complete lamina removal) SpineInfo

  3. Microdiscectomy (minimally invasive disc removal) SpineInfo

  4. Open discectomy SpineInfo

  5. Foraminotomy (enlargement of neural foramen) SpineInfo

  6. Posterior lumbar interbody fusion (PLIF) SpineInfo

  7. Transforaminal lumbar interbody fusion (TLIF) SpineInfo

  8. Anterior cervical discectomy and fusion (ACDF) SpineInfo

  9. Artificial disc replacement SpineInfo

  10. Kyphoplasty/vertebroplasty (for compression fractures) SpineInfo.

Preventions

  1. Maintain good posture (sitting/standing) SpineInfo

  2. Ergonomic workstation setup SpineInfo

  3. Regular core-strengthening exercises SpineInfo

  4. Healthy body weight management SpineInfo

  5. Proper lifting techniques (bend knees) SpineInfo

  6. Smoking cessation SpineInfo

  7. Adequate hydration & nutrition for bone health SpineInfo

  8. Frequent movement breaks when seated SpineInfo

  9. Use supportive footwear SpineInfo

  10. Regular medical check-ups for early detection SpineInfo.

When to See a Doctor

Seek prompt medical attention if you experience any of the following red-flag signs:

  • Severe, unrelenting back or neck pain, especially after trauma SpineInfo

  • Progressive neurological deficits (weakness, numbness) SpineInfo

  • Bowel or bladder dysfunction SpineInfo

  • Saddle anesthesia (perineal numbness) SpineInfo

  • High fever or signs of infection SpineInfo

  • Unexplained weight loss SpineInfo

  • Cancer history or immunosuppression SpineInfo

  • Pain at rest or nighttime pain SpineInfo.

Early evaluation—including imaging and neurological examination—ensures timely diagnosis and management.

FAQs

  1. What exactly is contained thecal sac indentation?
    It’s a focal compression of the dura-lined sac around your spinal cord by a lesion that remains “contained” within the annulus, seen on MRI as inward molding of the sac without annular rupture SpineInfo.

  2. How does it differ from thecal sac effacement?
    “Effacement” simply means flattening; “contained indentation” emphasizes that the compressing lesion is still held within the disc’s outer layers SpineInfo.

  3. What causes it?
    Most often disc herniations, spinal stenosis, osteophytes, ligamentum flavum hypertrophy, tumors, cysts, and trauma SpineInfo.

  4. Can it resolve on its own?
    Mild indentation without nerve involvement often remains stable or improves with conservative care (PT, lifestyle changes) SpineInfo.

  5. Is surgery always required?
    No—surgery is reserved for severe cases with refractory pain or neurological deficits. Most manage well with non-surgical treatments SpineInfo.

  6. What lifestyle changes help?
    Ergonomic adjustments, weight management, core strengthening, smoking cessation, and regular exercise reduce spinal load SpineInfo.

  7. Can contained indentation cause paralysis?
    Rarely—only if severe compression impinges neural elements long enough to cause irreversible injury SpineInfo.

  8. What symptoms are most concerning?
    Saddle anesthesia, bowel/bladder dysfunction, or rapidly progressive weakness warrant immediate evaluation SpineInfo.

  9. How is it diagnosed?
    MRI is the gold standard; CT myelogram if MRI contraindicated; supported by neurological exam and electrophysiology Orthobullets.

  10. What tests might my doctor order?
    MRI, CT, CT myelogram, X-ray, EMG/NCS, blood work for infection or inflammation SpineInfo.

  11. What non-drug treatments are effective?
    Physical therapy, traction, TENS, manual therapy, yoga, Pilates, acupuncture, bracing, and ergonomic changes SpineInfo.

  12. Which medications ease symptoms?
    NSAIDs, muscle relaxants, neuropathic pain agents (gabapentin), short-term opioids, and corticosteroids (oral or epidural) SpineInfo.

  13. What exercises should I avoid?
    Heavy lifting, high-impact sports, forward-bending under load, and extreme spinal rotations until cleared by a therapist SpineInfo.

  14. How long does recovery take?
    With conservative care, mild cases often improve over 4–12 weeks; severe cases or surgery may require 3–6 months for full recovery SpineInfo.

  15. How can I prevent recurrence?
    Maintain spinal health with core strengthening, good ergonomics, a healthy weight, and regular exercise SpineInfo.

Disclaimer: Each person’s journey is unique, treatment plan, life style, food habit, hormonal condition, immune system, chronic disease condition, geological location, weather and previous medical  history is also unique. So always seek the best advice from a qualified medical professional or health care provider before trying any treatments to ensure to find out the best plan for you. This guide is for general information and educational purposes only. Regular check-ups and awareness can help to manage and prevent complications associated with these diseases conditions. If you or someone are suffering from this disease condition bookmark this website or share with someone who might find it useful! Boost your knowledge and stay ahead in your health journey. We always try to ensure that the content is regularly updated to reflect the latest medical research and treatment options. Thank you for giving your valuable time to read the article.

The article is written by Team Rxharun and reviewed by the Rx Editorial Board Members

Last Updated: May 03, 2025.

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PDF Document For This Disease Conditions

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References

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