A unique case of pure lateral spinal cord herniation

BackgroundSpinal cord herniation (SCH) remains a challenging diagnosis for neuroradiologists and may require treatment challenging for neurosurgeons. Most cord herniations are usually found at anterior thoracic levels.Clinical presentationA 28-year-old woman presented at our department with a 7-year history of progressive myelopathy. MR analysis showed a displacement of the spinal cord in a lateral thoracic dural defect. The herniated cord was released using a microscope and the patient significantly recovered 6 months after surgery.ConclusionWe present a unique case of pure lateral SCH. In the light of reviewed literature and operative findings, the underlying pathophysiological mechanisms are discussed.     

How common is repeat surgery and multi-level treatment in Degenerative Cervical Myelopathy? Findings from a patient perspective survey

Degenerative Cervical Myelopathy (DCM) is a common condition which causes significant disability and reduces health-related quality of life. The only evidence-based treatment and current management guidance is surgery to decompress the spinal cord and stop further damage in moderate to severe cases. However, this guidance is mainly informed by studies that only include first time surgery and/or single level disease, but DCM can reoccur after primary surgery and affect multiple levels of the spine. It is unclear whether patients in these subgroups; repeat surgery and multi-level DCM, differ significantly in their baseline and disease characteristics from those with single-level, single-operation disease. To investigate this, we conducted an online survey of people with DCM looking at key demographic, disease (e.g. mJOA) and treatment characteristics. We received a total of 778 respondents, of which 159 (20%) had undergone surgery for DCM. Around 75% of these respondents had a single operation and 65% at a single level. We found no statistically significant difference in key participant and disease characteristics between respondents with single-level or single-operation and those with multi-level DCM or multiple operations. These data support generalisability of research to these subgroups but also warrants further investigations as these subgroups are underrepresented in current research.     

Acute and subacute myelopathy

Myelopathy is a term referring to any pathologic process affecting the spinal cord, and encompasses a broad spectrum of etiologies. The first step is to categorize myelopathy, according to the time to reach maximum deficit. Myelopathies are commonly classified as acute, subacute or chronic, for which the etiologies are totally different. Myelopathy is considered acute when the symptoms progress to their nadir in maximum 21 days after onset. Due to heterogeneity in pathogenesis, and the overlap in the clinical and imaging presentation among etiologies, acute myelopathy is considered as a diagnostic dilemma. A simple and efficient algorithm for timely identification of the underlying cause is thus useful. In this review, we provide a simplified approach for the differential diagnosis among all causes of acute myelopathies, and describe the principal clinical and imaging features of the main etiologies in adults, including recently characterized antibody-mediated myelitis, and its mimics.     

Rationale and efficacy of CD52 targeting in HTLV-1-associated myositis

We retrospectively analysed two selected patients, referred to our Haematology Department for refractory HTLV-1 associated myositis with circulating pathologic T-cell population with ATL phenotype. They respectively presented also HTLV-1 associated Crohn-like disease and myelopathy. Muscle biopsy of both patients was analysed to determine the pathologic infiltrate. Alemtuzumab was proposed as salvage therapy. Targeting CD52 with alemtuzumab showed good efficacy on myopathy of both patients for respectively 11 and 10 months. Interestingly, this treatment showed also efficacy on circulating pathologic T-cell population and on concomitant digestive and neurological diseases. The double infected cells ablation and immunosuppressive propriety of alemtuzumab probably explains its interest in this infectious and dysimmunitary disorder. Even though alemtuzumab probably remains a suspensive treatment, its place should be assessed in controlled trial in this difficult to treat rare disease.     

Post-laminectomy rotokyphoscoliosis causing paraplegia in long term: case report

CONTEXT: Childhood laminectomy can lead to spinal deformity. This is a report of a case of paraplegia caused by rotokyphoscoliosis, a late complication of laminectomy. FINDINGS: A 55-year-old woman developed paraplegia due to post-laminectomy kyphoscoliosis. She had surgery for a spinal tumor at age 13 years. She developed kyphosis 2 years after the laminectomy, which has been gradually progressing over the years. She experienced weakness of lower limbs that progressed to paraplegia. There was no evidence for tumor recurrence. To our knowledge, this is the first reported case of post-laminectomy kyphoscoliosis causing late-onset paraplegia. Conclusions/clinical relevance: This case highlights a possible long-term complication of laminectomy without stabilization or untreated kyphoscoliosis. Children should be followed closely after laminectomy because development of spinal deformity is very common. Without intervention, the kyphosis might progress and in the long term, serious neurological complications may result, including paraplegia.     

Surgical outcomes in patients with mild symptoms,but severely compressed spinal cord from cervical ossification of the posterior longitudinal ligament

Surgical treatment is indicated in patients with moderate to severe myelopathy from cervical ossification of the posterior longitudinal ligaments (OPLL), but undertaking prophylactic surgery for asymptomatic or mildly symptomatic patients with a severely compressed spinal cord is debatable.Patients with <8 mm space available in the spinal canal on CT scan, were divided into groups I (mild symptoms, Japanese Orthopedic Association (JOA) score range 15–16) and II (moderate to severe symptoms, JOA score <14). Medical charts including operative records were reviewed to obtain preoperative, perioperative, and final postoperative follow-up data.Group I included 24 patients (20 men, mean age 52.42 years), and Group II included 46 patients (33 men, mean age 54.67 years). Compared to Group II, Group I had a shorter preoperative symptom duration (19.21 vs. 38.23 months, p = 0.046) and a more favorable JOA score at final follow-up (p = 0.007). The mean numbers of OPLL-involved segments were similar (Group I 2.96, Group II 3.09; p = 0.773) as were the mean numbers of operated segments (Group I 2.71, Group II 3.35; p = 0.076). Perioperative blood loss, operation duration, and hospital stay duration were significantly more favorable in Group I than in Group II. The numbers of surgery-related complications in the two groups were similar.Early surgical treatment for a favorable neurologic recovery with a low perioperative risk can be recommended in patients with severely compressed spinal cord from cervical OPLL who present with mild arm numbness. Surgery-related complications, however, should be carefully monitored regardless of symptom severity.     

Spinal Cord Kinking in Thoracic Myelopathy Caused by Ossification of the Ligamentum Flavum

Background:

Ossification of the ligamentum flavum (OLF) is being increasingly recognized as a cause of thoracic myelopathy. This study was to describe a rare clinical entity of spinal cord kinking (SK) in thoracic myelopathy secondary to OLF.

Methods:

The data of 95 patients with thoracic myelopathy secondary to OLF were analyzed retrospectively. The incidence and location of SK were determined using preoperative magnetic resonance imaging (MRI). The clinical presentation and radiological characteristics in patients with SK were analyzed. Posterior en bloc laminectomy with OLF was performed, and the surgical results were evaluated.

Results:

SK was found in seven patients (7.4%) based on preoperative MRI. The patients included one male and six females with an average age of 55.6 years (range, 48–64 years). Five patients presented with radiculomyelopathy and two presented with typical thoracic myelopathy of spastic paraparesis. In all cases, the kinking was located just above the end of the spinal cord where the conus medullaris (CM) was compressed by the OLF. The degree of SK varied from mild to severe. The tip of the CM was located between the upper third of T11 to the lower third of L1, above the lower edge of L1. With an average follow-up of 30.4 months, the modified Japanese Orthopedic Association score significantly improved from 5.7 ± 1.8 preoperatively to 8.9 ± 1.4 postoperatively (t = 12.05; P < 0.0001) with an improvement rate of 63.1 ± 12.3%.

Conclusions:

SK is a rare radiological phenomenon. It is typically located at the thoracolumbar junction, where the CM is compressed by the OLF. Our findings indicate that these patients may benefit from a posterior decompressive procedure.     

The use of a novel tablet application to quantify dysfunction in cervical spondylotic myelopathy patients

Background Context

Despite the prevalence and importance of myelopathy, there is a paucity of objective and quantitative clinical measures. The most commonly used diagnostic tools available are nonquantitative physical exam findings (eg, pathologic reflexes, and gait disturbance) and subjective scoring systems (eg, modified Japanese Orthopaedic Association [mJOA]). A decline in fine motor coordination is a hallmark of early myelopathy, which may be useful for quantitative testing.