Compressive Myelopathy Research Articles

Evaluation of bone strength using finite-element analysis in patients with ossification of the posterior longitudinal ligament

BACKGROUND CONTEXTPatients with ossification of the posterior longitudinal ligament (OPLL) are often reported to have increased bone mineral density (BMD). The bone strength of the proximal femur measured by quantitative computed tomography-based finite element analysis (QCT/FEA) is reportedly comparable between healthy subjects with and without OPLL. However, the bone strength in symptomatic OPLL patients remains unknown. PURPOSETo investigate bone strength measured by QCT/FEA in symptomatic patients with OPLL. STUDY DESIGN/SETTINGA single-center prospective observational study. PATIENT SAMPLEA total of 157 patients with cervical or thoracic compressive myelopathy were included in the study. OUTCOME MEASURESWe analyzed patients’ characteristics, Japanese Orthopedic Association (JOA) score, serum laboratory tests including calcium (Ca), inorganic phosphate (Pi), and bone turnover markers, BMD of the proximal femur and lumbar spine measured using dual-energy X-ray absorptiometry, and predicted bone strength (PBS) of the proximal femur and lumbar spine measured using QCT/FEA. METHODSEligible patients were divided into the non-OPLL and OPLL groups. We compared the patients’ characteristics, JOA scores, laboratory data, BMD, and PBS of the proximal femur and lumbar spine between the non-OPLL and OPLL groups among total, male, and female patients by performing Fisher's exact test for categorical variables and the unpaired t test for continuous variables. Then, we used the inverse probability weighted logistic regression model after calculating propensity scores to compare the bone metabolism-associated markers, BMD, and PBS measurements between the groups. RESULTSAmong the eligible 157 patients, 68 were in the non-OPLL group and 89 were in the OPLL group. Compared with the non-OPLL group, the OPLL group had a significantly younger age and higher BMI in the total, male, and female patients. The JOA scores in the total and female patients were significantly higher in the OPLL group than in the non-OPLL group. The OPLL group showed significantly lower Ca levels in the female patients and significantly lower Pi levels in the total or male patients compared with the non-OPLL group in the inverse probability weighting method. The BMD of the proximal femur and lumbar spine and the PBS of the proximal femur were significantly higher in the OPLL group than in the non-OPLL group. There were no significant differences in the PBS and BMD between the male subgroups. However, the BMD and PBS of the proximal femur and lumbar spine were significantly higher in the OPLL females than in the non-OPLL females. CONCLUSIONSHyperostosis of the posterior longitudinal ligament in OPLL was associated with higher bone strength by QCT/FEA, especially in female OPLL patients.

A sheep model of chronic cervical compressive myelopathy via an implantable wireless compression device

PurposeThis study aimed to establish an animal model in which we can precisely displace the spinal cord and therefore mimic the chronic spinal compression of cervical spondylotic myelopathy.MethodsIn vivo intervertebral compression devices (IVCDs) connected with subcutaneous control modules (SCCMs) were implanted into the C2-3 intervertebral disk spaces of sheep and connected by Bluetooth to an in vitro control system. Sixteen sheep were divided into four groups: (Group A) control; (Group B) 10-week progressive compression, then held; (Group C) 20-week progressive compression, then held; and (Group D) 20-week progressive compression, then decompression. Electrophysiological analysis (latency and amplitude of the N1-P1-N2 wave in somatosensory evoked potentials, SEP), behavioral changes (Tarlov score), imaging test (encroachment ratio (ER) of intraspinal invasion determined by X-ray and CT scan), and histological examinations (hematoxylin and eosin, Nissl, and TUNEL staining) were performed to assess the efficacy of our model.ResultsTarlov scores gradually decreased as compression increased with time and partially recovered after decompression. The Pearson correlation coefficient between ER and time was r = 0.993 (p < 0.001) in Group B at 10 weeks and Groups C and D at 20 weeks. And ER was negatively correlated with the Tarlov score (r = -0.878, p < 0.001). As compression progressed, the SEP latency was significantly extended (p < 0.001), and the amplitude significantly decreased (p < 0.001), while they were both partially restored after decompression. The number of abnormal motor neurons and TUNEL-positive cells increased significantly (p < 0.001) with compression.ConclusionOur implantable and wireless intervertebral compression model demonstrated outstanding controllability and reproducibility in simulating chronic cervical spinal cord compression in animals.

Pearls & Oy-sters: Grisel Syndrome Presenting as Pseudodystonia: A Twist in the Neck.

Pseudodystonia is a term that describes abnormal postures, repetitive movements, or both, where clinical analysis, imaging, laboratory, or electrophysiologic investigations indicate that these movements are not consistent with dystonia. Grisel syndrome (GS), characterized by rotatory subluxation of the atlantoaxial joint (AAJ) due to nontraumatic causes, is a cause of pseudodystonia. GS is seen in children less than 12 years of age and should be suspected in patients with acute onset of painful torticollis. We report 2 girls, aged 9 and 6 years, who developed painful torticollis following upper respiratory tract infection. They were thought to have cervical dystonia and referred to a movement disorder specialist for botulinum neurotoxin therapy (BoNT). MRI of the cervical spine showed type I and type II rotary AAJ subluxation, respectively, which confirmed the diagnosis of GS. Short tau inversion recovery hyperintensity was noted suggesting AAJ edema without any bone erosion or cord compression. Abruptness of onset, presence of severe pain, resistance to passive neck movements, fixed postures present equally in rest and action, absence of sensory trick, and persistence in sleep favor pseudodystonia. Both subjects improved with conservative treatment, which included temporary immobilization of the cervical spine and anti-inflammatory drugs. Early identification and treatment is imperative to avoid neurologic complications, like high cervical compressive myelopathy, which can lead to quadriplegia and respiratory distress. Prominent sternocleidomastoid contraction ipsilateral to the rotated chin helps to clinically identify GS.

Clinical Profile and Treatment Outcome of Spinal Epidural Arachnoid Cysts: A Systematic Review of Case Studies and Reports

Abstract Background A spinal epidural arachnoid cyst (SEAC) is a rare clinical entity. We performed a systematic review of the literature to obtain information regarding demographics, clinical presentation, treatment modalities, and outcome of SEACs. Methods A literature search was performed by using the databases PubMed/Medline, PubMed Central, Embase, Cochrane Library, Ovid MEDLINE, and Ovid Medline In-Process. A total of 170 articles were found on literature search. We found 575 cases of SEAC since 1904 for inclusion in the review including three cases which were operated by us. We studied the patient characteristics, clinical features, and management strategies, and evaluated their outcome. Results The average age of presentation was 30 years with a male:female ratio of 1.03:1. They are commonly seen in the thoracic region (42.3%). The length of cyst was more than two vertebral levels in 85.81%. Mean symptom duration was 29 months, with most common presentation being that of compressive myelopathy. A good clinical outcome was present in symptomatic patients who had a shorter symptom duration and underwent complete surgical excision of the SEAC. Age, sex, length of lesion, and presence of dural defect did not have a bearing on the surgical outcome. Conclusion For thoracic compressive myelopathy in a young patient, SEAC should be kept as a differential diagnosis. Surgical complete excision of the cyst with meticulous closure of the dural defect is the standard in management for a good clinical outcome.

Osteolytic Alteration, Cervical Myelopathy and Dysphonia Associated with Mucoepidermoid Carcinoma: A Case Report

Summary: A vertebral neoplasm of extraosseous origin, is that which affects the vertebra starting from a tissue that has metastized. Clinical diagnosis and imaging only provide an etiopatological approach due to various sources of metastasis, so early obtaining of material for sample analysis and timely treatment becomes important. Objective: This study presents a 62-year-old male patient who manifested dysphonia, respiratory distress, cervical compressive myelopathy syndrome; being as a whole this picture with characteristics of increasing intensity and persistent imaging compatible with osteolysis of the spinous process of the fourth cervical vertebra. Methods: lateral radiographs of preoperative cervical spine and cervical magnetic resonance without contrast in sequences T1 and T2 as well as cervical magnetic resonance without contrast axial cut sequence T2 were evaluated. A week after the diagnosis by image is taken to the operative table where resection of tumor mass associated with cervical paravertebral muscles, C4 laminectomy and exceresis of an extension of the tumor to the spinal canal (extradural) is performed and the anatomopathological study was performed. Results: The patient presented improvement due to recovery of the respiratory bellows in the immediate post-operative period, although dysphonic persisted. The biopsy result reported mucoepidermoid carcinoma. We are interested in highlighting in this case the particular evolutionary association between the respiratory-laryngeal process, cervical osteolytic process and myelopathic manifestations as a regional development of the mucoepidermoid adenocarcinoma tous neoplastic activity.

Compressive Myelopathy Secondary to TRPV4 Skeletal Dysplasia: Spondylometaphyseal Dysplasia, Kozlowski Type.

Transient receptor potential vanilloid 4 channel ( TRPV4 ) gene mutations have been described in skeletal system and peripheral nervous system pathology. The case described here is a 9-year-old male child patient, born to a nonconsanguineous marriage with normal birth history who had difficulty in walking and stiffness of joints for the last 7 years, and progressive weakness of all four limbs and urine incontinence for 1 year following falls. Physical examination showed below-average weight and height and short trunk. Musculoskeletal examination revealed bony prominence bilaterally in the knee joints and contractures in knee and elbow joints with brachydactyly; muscle tone was increased, with brisk deep tendon reflexes. Skeletal survey showed platyspondyly with anterior beaking with metaphyseal dysplasia. Magnetic resonance imaging of the spine revealed atlantoaxial instability with hyperintense signal changes at a cervicomedullary junction and upper cervical cord with thinning and spinal canal stenosis suggestive of compressive myelopathy with platyspondyly and anterior beaking of the spine at cervical, thoracic and lumbar vertebrae. Exome sequencing revealed a heterozygous de novo variant c.2389G > A in exon 15 of TRPV4 , which results in the amino acid substitution p.Glu797Lys in the encoded protein. The characteristics observed indicated spondylometaphyseal dysplasia, Kozlowski type (SMD-K). The child underwent surgical intervention for compressive myelopathy by reduction of atlantoaxial dislocation with C1 lateral mass and C2 pars fusion using rib graft and fixation using screws and rods. To conclude, for any child presenting with progressive kyphoscoliosis, short stature, platyspondyly, and metaphyseal changes, a diagnosis of SMD-K should be considered and the patient and family should be advised to avoid spinal injuries.

Multiple cervical spondylolisthesis and thoracic vertebral malformation in an 11 month-old Chilean Caballo Raza Chilena colt

Compressive myelopathy caused by developmental cervical and thoracic malformation was diagnosed in an 11-month- old Chilean Caballo Raza Chilena colt. The patient evidenced an abnormal wide-based stance, neck muscle atrophy, upside-down neck conformation and tetra ataxia. Ataxia was exacerbated when the colt was walked down and uphill, walked with elevated head, backing and turning in tight circles. The patient showed no improvement following medical therapy, therefore, the colt was euthanised due to a poor prognosis after myelogram findings. Cervical spine malalignment (spondylolisthesis) associated with multi-level compression of the spinal cord was suspected based on cervical radiographs and myelogram findings and was confirmed postmortem. Thoracic vertebral malformation retained cartilage matrix spicules and a flare of the cranial vertebral epiphysis of the first thoracic vertebrae (T1) were also diagnosed at necropsy.

Aortic aneurysm causing compressive myelopathy.

Aortic aneurysm causing compressive myelopathy.

Conus myelitis associated with Covid 19 infection – a rare complication

Covid 19 pandemic has taken away millions of lives. Our understanding of this disease, till to date, is not complete. This disease has a wide variety of neurological manifestations. Acute transverse myelitis is one such rare neurological complication of Covid 19. The exact etiology is not clear. Auto immunity might be one of the possible mechanisms. We report a case of 39-year-old lady, who had recent history of high-grade fever and cough. This was followed by weakness of both legs and in- ability to pass urine. SARS-CoV-2 (PCR) from nasopharyngeal swab was positive. She was found to have features of acute non compressive myelopathy. MRI brain and MRI cervical spine with contrast was normal. MRI dorso lumbar spine with contrast was suggestive of diffuse hyper intensity of conus medullaris with contrast enhancement suggestive of conus myelitis. CSF analysis ruled out infection and autoimmune causes. She was pulsed with high dose steroids. There was some transient improvement in symptoms. Learning points: 1) Physicians should not consider Covid as a respiratory illness only. It can present with a variety of extra pulmonary manifestations. 2) Acute transverse myelitis is a rare complication of Covid 19 infection. Timely recognition and treatment can prevent permanent neurological damage and residual disability. 3) Conus myelitis might not present with classic upper motor neuron signs. Any new onset bladder dysfunction in a setting of a recent covid infection should be taken seriously and requires urgent imaging of the spine.

C2 intraspinal osteochondroma causing spinal cord compression in a patient with multiple hereditary exostoses

Intraspinal osteochondroma causing neurological manifestations is a rare condition and can present as either solitary osteochondroma or more commonly as a part of multiple hereditary exostoses. We report a case of osteochondroma arising from lamina of C2 in a 21-year-old patient with multiple hereditary exostoses causing spinal cord compression and cervical myelopathy. The patient presented with worsening neurological deficit and an inability to walk. Immediate laminectomy and surgical decompression were done after accurately localizing the lesion through computed tomography and magnetic resonance images. Following excision of the lesion, the patient recovered completely. The case report is followed by a review of literature highlighting the incidence of spinal osteochondroma, location preferences, clinical presentation, diagnosis, and results of decompression.

Compressive cervical myelopathy in patients presenting to the emergency department with subacute tetraparesis: sensory nerve action potentials in diagnosis

Compressive cervical myelopathy in patients presenting to the emergency department with subacute tetraparesis: sensory nerve action potentials in diagnosis

Degenerative occipitocervical dislocation – Uncommon entity at extreme of Life: A case report and review of literature

Traumatic occipitocervical dislocation (OCD) has been reported numerous times both in children and adults. Nontraumatic OCD is rare. An 85-year-male referred with 2 months history of motor and sensory complaints in all four limbs. There was no history of trauma. Neck movements were restricted. A lateral radiograph of the cervical spine was suggestive of extensive degenerative changes in the cervical spine. Computed tomography scan of the cervical spine revealed posterior OCD with degenerative changes. Magnetic resonance imaging revealed compressive myelopathy at the cervico-medullary junction. Posterior occipitocervical fixation was performed. His neurological symptoms significantly improved. The procedure resulted in an excellent immediate and long-term clinical outcome.

Unusual cause of dorsal compressive myelopathy - Double butterfly vertebra mimicking vertebral fracture

Structural developmental anomalies affecting the vertebral column resulting in malformed vertebrae are numerous. It can arise secondary to errors of vertebral formation, fusion and/or segmentation and developmental variation. These anomalies can occasionally mimic acute trauma and predispose the affected individual to compressive myelopathy. A butterfly vertebrae is a rare form of congenital vertebral segmentation anomaly resulting from symmetric fusion defect. It can easily be confused with burst fracture, hence though rare, we should be aware of this anomaly for a correct diagnosis while treating a patient.

Physiotherapy in Neurological Conditions: AB No: 150: Effect of bioenergy LASER along with activity-based therapy and surface spinal stimulation in sub-acute cervical compressive myelopathy in middle-aged population: A Randomised Controlled Trial

Physiotherapy in Neurological Conditions: AB No: 150: Effect of bioenergy LASER along with activity-based therapy and surface spinal stimulation in sub-acute cervical compressive myelopathy in middle-aged population: A Randomised Controlled Trial

The Utility of COMPASS-31 Questionnaire to Predict Autonomic Dysfunction in Patients With Cervical/Upper Thoracic Compressive Myelopathy.

Patients with cervical/upper thoracic compressive myelopathy may have autonomic dysfunction. The composite autonomic severity score (CASS) is the gold standard test to detect autonomic dysfunction, and the self-rated composite autonomic system scale (COMPASS-31) questionnaire is a screening tool to diagnose autonomic dysfunction. This study compared the COMPASS-31 and modified CASS scores for the detection of autonomic dysfunction in patients with compressive myelopathy. Patients with cervical/upper thoracic compressive myelopathy scheduled for decompressive surgery completed a COMPASS-31 questionnaire and underwent autonomic function tests to calculate the modified CASS score before surgery. Forty-two patients were included in the study; 19 (45.2%) had mild autonomic dysfunction, 5 (11.9%) had moderate autonomic dysfunction, and 18 (42.9%) had severe autonomic dysfunction. Median (interquartile range) of modified CASS and COMPASS-31 scores were 19 (6.33) and 3 (2.5), respectively. There was a positive correlation between modified CASS and COMPASS-31 scores ( r =0.43; P =0.004). Receiver operating characteristic curve analysis confirmed that COMPASS-31 had fair accuracy for prediction of moderate to severe autonomic dysfunction (area under the curve, 0.74; 95% confidence interval, 0.64-0.82; P =0.009). A cut-off of 30 for total COMPASS-31 score had a sensitivity of 52.2% and specificity of 89.5% to detect moderate to severe autonomic dysfunction, with positive and negative predictive values of 85.7% and 60.7%, respectively. Patients with cervical/upper thoracic compressive myelopathy had varying degrees of autonomic dysfunction based on the modified CASS. There was a positive correlation between the modified CASS and COMPASS-31 questionnaire. A COMPASS-31 score of >30 30 could be utilized to predict moderate to severe autonomic dysfunction in patients with compressive myelopathy.

Syringomyelia From Extramedullary Compression: Resolution After Microsurgical Resection of a High-Cervical Spine Schwannoma: 2-Dimensional Operative Video.

Syringomyelia with compression at the foramen magnum is a well-studied subject with a pathophysiological hypothesis explaining syrinx development and treatment.1,2 However, compression of the cervical cord, as in cervical spondylosis, can also lead to cavitation in the spinal cord.3,4 Although the association of intramedullary spinal cord tumors with syringomyelia is well known,5 the association of extramedullary tumors with syringomyelia is scarcely reported, and it is of unknown mechanism and uncertain outcomes regarding syrinx resolution. Syringomyelia is reported to be associated with intramedullary spinal schwannoma.6 However, spinal schwannomas are by and large extramedullary tumors that produce deficits through compressive radiculopathy or myelopathy. The association of extramedullary schwannomas with syringomyelia is extremely rare. In this article, we present a patient with an extramedullary high-cervical schwannoma causing significant syringomyelia who underwent microsurgical resection of the schwannoma, with subsequent total resolution of the syringomyelia. The patient consented for surgery. Images from Lancet 1969 at 6:36 in video Reprinted from The Lancet, Vol. 294, Bernard Williams, The Distending Force in the Production of "Communicating Syringomyelia," Pages 189-193, Copyright 1969, with permission from Elsevier.

Computed tomographic myelography for assessment of the cervical spinal cord in ataxic warmblood horses: 26 cases (2015-2017).

To quantify the degree of dural compression and assess the association between site and direction of compression and articular process (AP) size and degree of dural compression with CT myelography. 26 client-oriented horses with ataxia. Spinal cord-to-dura and AP-to-cross-sectional area of the C6 body ratios (APBRs) were calculated for each noncompressive site and site that had > 50% compression of the subarachnoid space. Site of maximum compression had the largest spinal cord-to-dura ratio. Fisher exact test and linear regression analyses were used to assess the association between site and direction of compression and mean or maximum APBR and spinal cord-todura ratio, respectively. Mean ± SD spinal cord-to-dura ratio was 0.31 ± 0.044 (range, 0.20 to 0.41) for noncompressive sites and 0.44 ± 0.078 (0.29 to 0.60) for sites of maximum compression. Sites of maximum compression were intervertebral and extra-dural, most frequently at C6 through 7 (n = 10), followed by C3 through 4 (6). Thirteen horses had dorsolateral and lateral compression at the AP joints, secondary to AP (n = 7) or soft tissue proliferation (6). Site significantly affected direction of compression, and directions of compression from occiput through C4 were primarily ventral and lateral, whereas from C6 through T1 were primarily dorsal and dorsolateral. No linear relationship was identified between mean or maximum APBR and spinal cord-to-dura ratio. CT myelography may be useful for examination of horses with suspected cervical compressive myelopathy. Degree of compression can be assessed quantitatively, and site of compression significantly affected direction of compression.

Magnetic Resonance Imaging in Co-Occurrence of Thoracic Spinal Dural Arteriovenous Fistula and Compressive Myelopathy

Magnetic Resonance Imaging in Co-Occurrence of Thoracic Spinal Dural Arteriovenous Fistula and Compressive Myelopathy

Using Smartphones for Clinical Assessment in Cervical Spondylotic Myelopathy a Feasibility Study.

Degenerative cervical myelopathy (DCM) is characterized by a progressive deterioration in spinal cord function. Its evaluation requires subjective clinical examination with wide interobserver variability. Objective quantification of spinal cord function remains imprecise, even though validated myelopathy-grading scales have emerged and are now widely used. We created a Smartphone Application, the N-Outcome App, with the aim of quantifying accurately and reliably spinal cord dysfunction using a 5-minute Test. A patient suffering from DCM was clinically evaluated before surgery, at 3 and 6 months follow-up after surgical decompression of the cervical spinal cord. Standard scores (Nurick grade, modified Japanese Orthopedic Association (mJOA) score) were documented at these time points. A 5-minute motor and proprioceptive performance test aided by a smartphone with the N-outcome App was also performed. Motor performance in rapid alternating movements and finger tapping improved in correlation with improvements in standard grading scale scores. Clinical improvements were seen in maximum reflex acceleration and in Romberg testing which showed less closed/open eyes variation, suggesting pyramidal and proprioceptive function recovery. We demonstrate that using the N-Outcome App as an adjunct to clinical evaluation of compressive myelopathy is feasible and potentially useful. The results correlate with the results of clinical assessment obtained by standard validated myelopathy scores.

Teaching NeuroImage: Pontine Owl-Eyes Lesions in a Case of Neuroborreliosis.

Brain MRI in a 65-year-old woman with headache, sensory ataxia, and tick exposure revealed leptomeningeal and cranial nerve enhancement and T2-hyperintense symmetrical pontine lesions resembling the “owl-eyes” sign, a radiologic finding described in ischemic or compressive myelopathy (Figure, A–C).1 CSF analysis revealed pleocytosis (163/µL) and intrathecal production of anti- Borrelia IgG (CSF/serum index 21, N < 2). Workup was negative for alternative causes. The patient fully recovered after 21 days of ceftriaxone (Figure, D–F).