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Extraforaminal Thecal Sac Indentation

Dr. Tracy L. Ansay, MD - Spine and Neurosurgery Dr. Tracy L. Ansay, MD - Spine and Neurosurgery
2 Views
Degenerative Bones, Joints, and Spine Care (A - Z)

Extraforaminal thecal sac indentation refers to an imaging finding—most commonly on MRI—where the outer (extraforaminal) aspect of the dural (thecal) sac appears indented or pressed in. The thecal sac is the tubular membrane (dura mater) that surrounds the spinal cord and nerve roots, containing cerebrospinal fluid (CSF). “Indentation” means that some structure (such as a herniated disc fragment, bony overgrowth, or soft‐tissue lesion) is pressing against the dural sac, causing it to lose its smooth, rounded contour, yet often without direct nerve compression in the central canal Spine Info.

This finding is distinct from central or foraminal indentations:

  • Central/Sagittal Indentation: Occurs within the spinal canal.

  • Foraminal Indentation: Occurs within the neural foramen, where nerve roots exit.

  • Extraforaminal Indentation: Occurs lateral to the foramen—outside the main canal and foramen—and is less common but clinically significant when present Radiology Assistant.

Anatomy

Structure & Location

  • Thecal Sac (Dural Sac): A sheath of dura mater that encloses the spinal cord (in the cervical and thoracic regions) and the cauda equina (in the lumbar region). It runs from the foramen magnum at the skull base down to approximately the level of S2 vertebra Spine Info.

  • Extraforaminal Zone: The region lateral to the neural foramen (the exit canal for spinal nerve roots). Structures here include the exiting nerve root, dorsal root ganglion (DRG), surrounding fat, and small vessels Radiology Assistant.

Origin & “Insertion”

  • The dura mater originates from mesenchymal tissue during embryogenesis and fuses with the periosteum of the foramen magnum at the skull base. Inferiorly, it tethers to the filum terminale and blends into the periosteum of the sacral canal. Unlike muscles, it does not “insert” but is anchored at cranial and caudal attachments.

Blood Supply

  • Arterial: Branches of the vertebral arteries (cervical region), intercostal arteries (thoracic), and lumbar segmental arteries supply the dura and nerve roots.

  • Venous: The internal vertebral (epidural) venous plexus runs in the epidural space, draining blood from the dura and vertebral bodies into segmental veins.

Nerve Supply

  • The dura mater has somatic fibers from sinuvertebral (Luschka’s) nerves, which convey pain from dural irritation, and autonomic fibers that regulate vasomotor tone.

Key Functions of the Thecal Sac

  1. Protection: Encases and cushions the spinal cord and nerve roots.

  2. Containment of CSF: Maintains the CSF volume that provides nutrients and buoyancy.

  3. Shock Absorption: CSF within the sac dampens mechanical shocks.

  4. Immune Barrier: The dura forms part of the blood–CSF barrier, limiting pathogen entry.

  5. Facilitates Nerve Exit: Guides nerve roots through foramina into peripheral distribution.

  6. Anchoring: Through ligaments (e.g., denticulate ligaments), stabilizes the spinal cord within the canal ScienceDirect.

Types of Extraforaminal Indentation

Indentation may be categorized by location, severity, and laterality:

  1. By Location

    • Level (e.g., L4–L5 extraforaminal indentation).

    • Side (right or left).

  2. By Severity

    • Mild: ≤25% loss of normal sac contour.

    • Moderate: 26–50% loss.

    • Severe: >50% flattening or displacement.

  3. By Laterality

    • Unilateral: One side only.

    • Bilateral: Both sides, often seen with central spinal processes.

Common Causes

  1. Extraforaminal Disc Herniation (far‐lateral herniation) Radiology Assistant

  2. Osteophyte Formation (bone spurs)

  3. Facet Joint Hypertrophy

  4. Ligamentum Flavum Buckling

  5. Epidural Lipomatosis (fat accumulation) jocn-journal.com

  6. Synovial Cysts (from facet joints) PMC

  7. Spinal Tumors (meningioma, schwannoma)

  8. Metastatic Disease (vertebral or epidural)

  9. Trauma (bone fragments)

  10. Spondylolisthesis (slippage of a vertebra)

  11. Disc Degeneration & Bulging

  12. Infections (epidural abscess)

  13. Rheumatologic Conditions (ankylosing spondylitis)

  14. Congenital Canal Narrowing

  15. Iatrogenic Post‐Surgical Scar Tissue

  16. Hemorrhage (epidural hematoma)

  17. Herniated Synovium

  18. Paget’s Disease of Bone

  19. Vascular Malformations (e.g., hemangioma)

  20. Tethered Cord Syndrome (caudal traction).

Symptoms

  1. Localized Back/Lumbar Pain

  2. Radiating Leg Pain (radiculopathy)

  3. Numbness or Tingling in a dermatomal distribution

  4. Muscle Weakness in lower limb

  5. Gait Disturbance

  6. Sensory Deficits (light touch, pinprick)

  7. Reflex Changes (diminished knee‐jerk)

  8. Neurogenic Claudication (pain on walking)

  9. Shooting Pain down the leg

  10. “Electric Shock” Sensations with movement

  11. Bowel/Bladder Dysfunction (rare in pure extrusion)

  12. Paresthesias in foot or thigh

  13. Cold Sensations in extremities

  14. Deep Dull Aching discomfort

  15. Postural Pain (worse when bending)

  16. Pain Relief on Flexion (leaning forward)

  17. Muscle Spasms

  18. Difficulty Standing Upright

  19. Activity‐Related Flare‐Ups

  20. Night Pain/Worsening at Rest.

Diagnostic Tests

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

  2. CT Scan (Computed Tomography): Bone detail & calcified lesions.

  3. X-ray (Standing/AP & Lateral): Alignment, spondylolisthesis.

  4. CT Myelogram: Dye-enhanced canal imaging.

  5. EMG (Electromyography): Nerve conduction studies.

  6. Nerve Conduction Velocity (NCV).

  7. Selective Nerve Root Block (Diagnostic Block).

  8. Provocative Discography.

  9. Ultrasound: Soft tissue masses.

  10. Bone Scan: Tumors, infections.

  11. Blood Tests: Inflammatory markers (ESR, CRP).

  12. CSF Analysis: If infection suspected.

  13. Neurological Examination: Dermatomes & myotomes.

  14. Postural Assessment: Biomechanics.

  15. Gait Analysis.

  16. Dynamic Flexion/Extension X-rays: Instability.

  17. CT Angiography: Vascular lesions.

  18. PET-CT: Metastatic disease.

  19. Biopsy: Tumor/infectious etiology.

  20. Digital Infrared Thermography: Rare for vascular causes.

Non-Pharmacological Treatments

  1. Physical Therapy (Core Stabilization)

  2. McKenzie Exercises

  3. Yoga & Pilates

  4. Aquatic Therapy

  5. Chiropractic Mobilization

  6. Spinal Traction

  7. Acupuncture

  8. Massage Therapy

  9. Ergonomic Assessment

  10. Hot/Cold Packs

  11. TENS (Transcutaneous Electrical Nerve Stimulation)

  12. Ultrasound Therapy

  13. Dry Needling

  14. Manual Therapy

  15. Flexion‐Distraction Table

  16. Postural Training

  17. Weight Management & Nutrition

  18. Mindfulness & Biofeedback

  19. Core Strengthening Classes

  20. Stabilization Belts

  21. Bracing (Lumbar Corset)

  22. Education on Body Mechanics

  23. Aquatic Buoyancy Exercises

  24. Anti-gravity Treadmill

  25. Pilates Reformer

  26. Instrument-assisted Soft Tissue Mobilization

  27. Foam Rolling & Myofascial Release

  28. Balance & Proprioception Training

  29. Low-impact Aerobics (Cycling)

  30. Functional Movement Re-education.

Drugs

  1. NSAIDs (e.g., ibuprofen)

  2. COX-2 Inhibitors (e.g., celecoxib)

  3. Muscle Relaxants (e.g., cyclobenzaprine)

  4. Oral Steroids (short course prednisone)

  5. Gabapentinoids (gabapentin)

  6. Pregabalin

  7. Tricyclic Antidepressants (amitriptyline)

  8. SNRIs (duloxetine)

  9. Opioids (short term, e.g., tramadol)

  10. Topical NSAIDs (diclofenac gel)

  11. Capsaicin Cream

  12. Lidocaine Patches

  13. Steroid Injections (Epidural)

  14. Botulinum Toxin (off-label)

  15. Bisphosphonates (if osteoporotic changes)

  16. Calcitonin (rare)

  17. Vitamin D & Calcium (adjunct)

  18. Anticonvulsants (carbamazepine)

  19. Alpha-2-delta Ligands

  20. Analgesic Combinations (acetaminophen + codeine).

Surgical Options

  1. Microdiscectomy (for disc herniation)

  2. Laminectomy (decompression)

  3. Foraminotomy (foraminal widening)

  4. Far-Lateral Discectomy

  5. Interbody Fusion (PLIF/TLIF)

  6. Facet Joint Resection

  7. Epidural Lipomatosis Debridement

  8. Synovial Cyst Excision

  9. Artificial Disc Replacement

  10. Minimally Invasive Endoscopic Decompression.

Preventive Measures

  1. Maintain Healthy BMI

  2. Regular Core Strengthening

  3. Ergonomic Workstation Setup

  4. Lift with Legs, Not Back

  5. Frequent Posture Breaks

  6. Proper Sleeping Support

  7. Avoid Prolonged Sitting

  8. Flexibility Exercises

  9. Quit Smoking (promotes disc degeneration)

  10. Stay Hydrated & Nutritious Diet.

When to See a Doctor

  • Progressive Neurological Deficits (weakness, loss of reflex)

  • Severe/Unrelenting Pain despite conservative care

  • Bowel or Bladder Dysfunction (possible cauda equina syndrome)

  • Infection Signs (fever, elevated WBC, severe back pain)

  • Trauma with New Symptoms

  • Systemic Signs (weight loss, night sweats—possible malignancy)

  • Intractable Night Pain

  • Failure of 6-week Conservative Trial.

FAQs

  1. What exactly causes extraforaminal indentation?
    Compression from far-lateral disc herniation, osteophytes, or soft-tissue lesions pressing the dural sac outside the foramen Radiology Assistant.

  2. Is indentation always painful?
    Not always—mild indentation may be asymptomatic if nerve roots aren’t directly compressed.

  3. How is it diagnosed?
    MRI is the gold standard; CT myelogram can supplement if MRI contraindicated.

  4. Can it worsen over time?
    Yes, without intervention, bony overgrowth or disc degeneration may progress, increasing indentation.

  5. Are injections helpful?
    Epidural steroid injections can reduce inflammation and pain short term.

  6. Will physical therapy cure it?
    PT focuses on stabilizing the spine and may relieve symptoms but rarely “cures” the structural change.

  7. When is surgery recommended?
    For intractable pain, progressive neurological deficits, or failure of conservative care after 6–12 weeks.

  8. Is it the same as spinal stenosis?
    It is a localized form of stenosis outside the foramen, distinct from central canal stenosis.

  9. Can it cause sciatica?
    Yes, if the exiting lumbar nerve root is irritated by far-lateral indentation.

  10. How can I prevent it?
    Core strengthening, ergonomic lifting, weight control, and posture awareness.

  11. Is bed rest effective?
    Short‐term rest may help, but prolonged inactivity can worsen deconditioning.

  12. What is the recovery time after surgery?
    Microdiscectomy: 4–6 weeks; fusion procedures: 3–6 months.

  13. Are there non-surgical alternatives?
    Yes—NSAIDs, PT, chiropractic therapy, acupuncture, and injections.

  14. Can children get this?
    Rarely; usually related to congenital anomalies or trauma in younger patients.

  15. Does indentation always show up on X-ray?
    No—soft tissue indentations are best seen on MRI; X-rays only show secondary bone changes.

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 02, 2025.

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  40. https://www.fda.gov/files/drugs/published/Acute-Bacterial-Skin-and-Skin-Structure-Infections—Developing-Drugs-for-Treatment.pdf
  41. https://dermnetnz.org/topics
  42. https://www.aaaai.org/conditions-treatments/allergies/skin-allergy
  43. https://www.sciencedirect.com/topics/medicine-and-dentistry/occupational-skin-disease
  44. https://aafa.org/allergies/allergy-symptoms/skin-allergies/
  45. https://www.nibib.nih.gov/
  46. https://www.nei.nih.gov/
  47. https://en.wikipedia.org/wiki/List_of_skin_conditions
  48. https://en.wikipedia.org/?title=List_of_skin_diseases&redirect=no
  49. https://en.wikipedia.org/wiki/Skin_condition
  50. https://oxfordtreatment.com/
  51. https://www.nidcd.nih.gov/health/
  52. https://consumer.ftc.gov/articles/w
  53. https://www.nccih.nih.gov/health
  54. https://catalog.ninds.nih.gov/
  55. https://www.aarda.org/diseaselist/
  56. https://www.ninds.nih.gov/Disorders/Patient-Caregiver-Education/Fact-Sheets
  57. https://www.nibib.nih.gov/
  58. https://www.nia.nih.gov/health/topics
  59. https://www.nichd.nih.gov/
  60. https://www.nimh.nih.gov/health/topics
  61. https://www.nichd.nih.gov/
  62. https://www.niehs.nih.gov
  63. https://www.nimhd.nih.gov/
  64. https://www.nhlbi.nih.gov/health-topics
  65. https://obssr.od.nih.gov/
  66. https://www.nichd.nih.gov/health/topics
  67. https://rarediseases.info.nih.gov/diseases
  68. https://beta.rarediseases.info.nih.gov/diseases
  69. https://orwh.od.nih.gov/

References

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