Compressive Thoracic Myelopathy Research Articles

Differentiation Between Compressive Cervical and Thoracic Myelopathy Using the Central Motor Conduction Time Ratio.

Thoracic myelopathy is a rare condition whose diagnosis is often missed or delayed. This study aimed to differentiate between cervical and thoracic myelopathy using motor-evoked potential testing. The authors included 835 patients with compressive cervical myelopathy and 94 patients with compressive thoracic myelopathy. Myelopathy using motor-evoked potentials were recorded from the bilateral abductor digiti minimi and abductor hallucis muscles through transcranial magnetic stimulation. The peripheral conduction time was measured through electrical stimulation of the ulnar and tibial nerves; moreover, the central motor conduction time (CMCT) was calculated by subtracting the peripheral conduction time from the myelopathy using motor-evoked potential latency. The most accurate differentiation between compressive cervical myelopathy and compressive thoracic myelopathy was achieved by the CMCT ratios (CMCT-ADM:CMCT-AH; cutoff value of 0.490, sensitivity of 83.0%, and specificity of 80.5%). After excluding patients with compressive cervical myelopathy who had spinal cord compression at C6-7, the cutoff value was 0.490, with a sensitivity of 83.0% and specificity of 87.3%. Determining the CMCT ratio (cutoff value of 0.490) through motor-evoked potential testing could facilitate differentiation between compressive cervical myelopathy and compressive thoracic myelopathy.

Inter-dural spinal cyst with acute thoracic compressive myelopathy: anatomical aspects of spinal dura, case report and literature review

Introduction Inter-dural juxta-facet spinal cysts occur rarely. They form as part of the degenerative spinal disease process and can be misdiagnosed as synovial cysts or ganglion cysts. We report the case of a thoracic inter-dural juxta-facet spinal cyst causing acute compressive thoracic myelopathy. Methods The data was collected retrospectively from patient records. The literature review was performed in PubMed. Results We report a case of symptomatic inter-dural juxta-facet thoracic spinal cyst. The literature review showed a variety of different spinal cysts including arachnoid cyst, discal cyst, ganglion cyst, epidermoid cyst and synovial cysts. Micro-instability and repeated microtrauma associated with degenerative changes are most likely contributors to its formation. Asymptomatic cysts can show spontaneous resolution. When symptomatic, they can be managed with surgical excision with good patient outcome. Conclusion Inter-dural spinal cysts can be diagnosed and surgically excised to produce excellent post-operative outcome. High pre-operative index of suspicion of this diagnosis together with good understanding of the intraoperative anatomy are essential to avoid inadvertent dural breach.

Posttraumatic Arachnoid Cyst in the Thoracic Spine with Medullary Compression: Case Report.

Arachnoid cysts are rare; they can occur at all levels of the dural sac, and can have a congenital, traumatic, iatrogenic or inflammatory origin. In the present article, we report a patient presenting a compressive thoracic myelopathy due to an unusual intradural arachnoid cyst with posttraumatic manifestation and its resolution, in addition to a literature review on the subject. These cysts mainly occur at the thoracic spine, followed by the lumbar, lumbosacral and thoracolumbar spines. Traumatic cysts are caused by an injury to the inner dural layer. These lesions produce neurological deficits through a mass effect on the spinal cord. Concomitant compressive myelopathy is even rarer. In case of myelopathy, cyst resection or drainage is the treatment of choice, and it must be performed immediately. Although rare, arachnoid cysts can be a complication of spine fractures; as such, orthopedists and neurosurgeons, who commonly see these injuries, must be prepared for this unusual situation.

Electrophysiological Assessment and Classification of Motor Pathway Function in Patients With Spinal Dural Arteriovenous Fistula.

The diagnosis of spinal dural arteriovenous fistula (SDAVF) is difficult and often delayed because clinical features are often nonspecific. We assessed the motor function electrophysiologically in patients with SDAVF. Motor-evoked potentials after transcranial magnetic stimulation and compound muscle action potentials and F-waves after electrical stimulation in the ulnar and tibial nerves were measured from the abductor hallucis (AH) muscles in 14 patients with SDAVF (SDAVF group), 12 patients with compressive thoracic myelopathy (CTM group), and 16 normal subjects (control group). The peripheral conduction time determined from abductor hallucis muscles (PCT-AH) and the central motor conduction time determined from abductor hallucis muscles (CMCT-AH) were calculated. According to the neurological findings, patients in the SDAVF group were classified to upper motor neuron (UMN) sign and lower motor neuron (LMN) sign categories. CMCT-AH in the SDAVF and CMT groups were significantly longer than those in the control group. PCT-AH in the SDAVF group was significantly longer than that in the control and CMT groups. Twelve patients in the SDAVF group showed abnormal CMCT-AH and/or PCT-AH. Abnormal CMCT-AH and PCT-AH were detected in five cases that exhibited UMN sign and/or LMN sign. Three cases with abnormal CMCT-AH and normal PCT-AH exhibited UMN sign. LMN sign without UMN sign was observed in four cases with abnormal PCT-AH and normal CMCT-AH. Our study revealed abnormalities in the corticospinal tract and/or lower motor neurons, and classified the patients with SDAVF into three types: the UMN type, LMN type, and mixed type.

Progressive compressive thoracic myelopathy

Progressive compressive thoracic myelopathy

Progressive compressive thoracic myelopathy

Extramedullary hematopoiesis is a possible complication in patients with beta-thalassemia, due to ineffective erythropoiesis, producing remote sites of hematopoiesis in multiple and very variable anatomic locations [1Gatto I. Terrana V. Biondi L. Compression of the spinal cord due to proliferation of bone marrow in epidural space in a splenectomized person with Cooley's disease.Haematologica. 1954; 38: 61-76PubMed Google Scholar, 2Haidar R. Mhaidli H. Taher A.T. Paraspinal extramedullary hematopoiesis in patients with thalassemia intermedia.Eur Spine J. 2010; 19: 871-878Crossref PubMed Scopus (126) Google Scholar]. Among these sites, spinal epidural extramedullary hematopoiesis carries potential risk and may lead to acute irreversible neurological deficits [[3]Salehi S.A. Koski T. Ondra S.L. Spinal cord compression in beta-thalassemia: case report and review of the literature.Spinal Cord. 2004; 42: 117-123Crossref PubMed Scopus (47) Google Scholar]. Surgery has been used as a treatment option, however there have been reports of significant blood loss [3Salehi S.A. Koski T. Ondra S.L. Spinal cord compression in beta-thalassemia: case report and review of the literature.Spinal Cord. 2004; 42: 117-123Crossref PubMed Scopus (47) Google Scholar, 4Lau S.K. Chan C.K. Chow Y.Y. Cord compression due to extramedullary hemopoiesis in a patient with thalassemia.Spine. 1994; 19: 2467-2470Crossref PubMed Scopus (35) Google Scholar, 5Garg K. Singh P.K. Singh M. et al.Long segment spinal epidural extramedullary hematopoiesis.Surg Neurol Int. 2013; 4: 161Crossref PubMed Google Scholar]. In our case, after multidisciplinary discussion, emergency surgical decompression was chosen due to the rapidly progressive paraparesis during the preceding48 hours since admission. It was felt that this would provide speedier decompression over radiotherapy. Additionally, appropriate preoperative hematologic optimization (tranexamic acid, blood and platelet transfusions) was also instigated. After induction of general anesthesia, left T5-T9 hemilaminectomies) were performed (Fig. 2). Total intraoperative blood loss was estimated at 200cc. No supplementary hematologic treatment was needed in the postoperative period. We underline the need for surgical management in cases of progressive spinal cord compression [2Haidar R. Mhaidli H. Taher A.T. Paraspinal extramedullary hematopoiesis in patients with thalassemia intermedia.Eur Spine J. 2010; 19: 871-878Crossref PubMed Scopus (126) Google Scholar, 4Lau S.K. Chan C.K. Chow Y.Y. Cord compression due to extramedullary hemopoiesis in a patient with thalassemia.Spine. 1994; 19: 2467-2470Crossref PubMed Scopus (35) Google Scholar]. It can be performed safely and without excessive hemorrhagic risk. In our case we used a unilateral approach which allowed complete decompression. This approach also limits blood loss and preserves soft tissue and bony structures on the contralateral side. Adequate preoperative hematologic status is essential in these cases. Radiation therapy was used as an adjuvant treatment postoperatively to prevent recurrence of epidural extramedullary hematopoiesis. Follow-up was performed at 6 weeks and 3 months. Complete neurologic recovery was observed, with no recurrence at 3 months MRI (Fig. 3). In conclusion, the optimal management for extramedullary hematopoiesis with neurological impairment remains unproven and is currently based on case-by-case situations. We suggest that surgical management can be safely performed with optimal hematologic preparation without incurring excessive intraoperative blood loss. Note 1: A signed patient consent form has been supplied for publication. Note 2: Posthumous authorship for Dr Christian Wider.

Single-stage surgery for compressive thoracic myelopathy associated with compressive cervical myelopathy and/or lumbar spinal canal stenosis.

The clinical impact of the coexistence of compressive cervical myelopathy (CM) and/or lumbar spinal canal stenosis (LCS) with compressive thoracic myelopathy (TM) remains unknown. The purpose of this study was to examine the incidence, clinical pictures, and surgical outcomes of patients with compressive TM and the coexistence of compressive CM and/or LCS. We retrospectively reviewed 50 patients (18 women and 32 men; mean age 68.4years) who underwent decompression surgery for TM. Mean follow-up period was 44months. The incidence and clinical features of the coexistence of CM and/or LCS were investigated. The surgical outcomes after single-stage multilevel decompression surgery were also examined using the Japanese Orthopedic Association (JOA) scores. Of 50 patients, 35 had concurrent CM and/or LCS (combined group), and the remaining 15 only had TM (T group). No significant differences were found with regard to sex, the etiology of TM, or the level of thoracic stenosis between the groups; however, the patients' age and preoperative JOA scores in the combined group were significantly higher than those in the T group. In both groups, the JOA score at the final follow-up significantly improved compared to the preoperative JOA score. About 70% of patients who underwent surgery for TM had concurrent CM and/or LCS, and they were initially diagnosed with CM or LCS. Single-stage multilevel decompression surgery for TM with concurrent CM and/or LCS is comparable to thoracic only surgery with regard to complications and surgical results, and it is well tolerated in elderly patients.

Compressive Thoracic Myelopathy Caused by Combined Ossification of the Posterior Longitudinal Ligament and Ossified Ligamentum Flavum: A Series of Four Cases in Southern Chinese

Introduction Compressive thoracic myelopathy caused by combined ossification of the posterior longitudinal ligament (OPLL) and ossification of the ligamentum flavum (OLF) at the same level(s) is a rare condition. Clinical diagnosis is usually delayed because of the vague and nonspecific symptoms at the early stage, particularly to the unwary. While CT and MRI confirm the level of involvement readily, surgical decompression not only is risky but improvement is never guaranteed. Majority of the case reports and case series are from North Eastern Asia with sporadic reports from the Indian subcontinent. We hereby report our case series consisting of four patients, all are ethnic Southern Chinese. Material and Methods Four patients, three females and one male, average age 54.3 years (range, 49–63) were treated in our institution between 2004 to 2009. All of them presented with acute paraplegia after very trivial injuries. Two were totally asymptomatic before the injury while the other two were waiting for elective decompressive surgery before their sudden deterioration. Japanese Orthopaedic Association (JOA) score for the thoracic spine (full points = 11), which measures truncal sensory function, lower limb motor, and sensory function and bladder function was used as the evaluation tool throughout the follow-up period. Results The mean extend of laminectomy was 3.25 levels (range, 2–5 levels). The average follow-up was 4.5 years. The average JOA score improvement ratio was 36%. In the first case only 5-level laminectomy was performed, there was cerebrospinal fluid (CSF) leakage intraoperatively and she became total paraplegic postoperatively. At final follow-up 7.5 years later the Cobb angle of the operated level remained same as preoperation, and JOA score improved from 0 to 3, constituting an improvement ratio of 27%. In the other three cases pedicle screws and rods were added for dekyphosis and stabilization together with average 3.3 levels of laminectomy (range, 3–4 levels). One case had CSF leakage intraoperatively. Despite all of them had significant neurological deterioration immediately after operation, the recovery was rapid and all could walk with support on discharge 2.3 months (range, 2–3 months) after the index operation. At final follow-up 3.5 years postoperation (range, 2.5–5 years) the kyphotic Cobb angle reduced from 23.80 (range, 140–31.20) to 16.50 (range, 5.80–23.10), and the JOA score improved from 2.7 (0–4) to 8.7 (8–10), constituting an improvement ratio of 72%. There were no implant-related complications. All these four cases had concomitant cervical spine OPLL detected perioperatively with significant cervical spinal canal stenosis on imaging studies. Throughout the follow-up periods none of them developed any clinically significant cervical myelopathic symptoms and signs. Conclusion Thoracic myelopathy due to same level compression by OPLL and OLF is rare and challenging to the spine surgeon. From our small case series it is suggestive that the addition of posterior instrumentation on top of the posterior decompression for dekyphosis and stabilization of the thoracic spine apparently give a more certain clinical improvement. Intraoperative CSF leakage and postoperative transient neurological deterioration are the two particular risks that need to be conveyed to the patient before surgery.

Compressive Thoracic Myelopathy Caused by Combined Ossification of the Posterior Longitudinal Ligament and Ossification of the Ligamentum Flavum: A Report of Four Cases and a Literature Review

We describe here the rare condition of compressive thoracic myelopathy and its management in four patients with combined thoracic ossification of the posterior longitudinal ligament and ossification of the ligamentum flavum. One of the four patients underwent decompressive laminectomies only, whereas the other three patients had posterolateral fusion with posterior instrumentation (pedicle screws and rods system) in addition to decompressive laminectomies. All four patients developed transient complete paraplegia after surgery. The three patients who received decompressive laminectomies and posterior instrumentation with posterolateral fusion had improved sensation, motor, and sphincter functions compared with their preoperative neurological state. The patient who underwent laminectomy only showed no neurological gain after 7.5 years. A dural tear was noted in two patients and they recovered without complications after intraoperative repair. Posterior instrumentation with posterolateral fusion in addition to decompression laminectomies and excision of the ossification of the ligamentum flavum seems to have a better outcome than simple decompression laminectomies for this rare cause of compressive thoracic myelopathy.

Calcification of the ligamentum flavum in the thoracolumbar spine: an unusual cause of compressive myelopathy

The focal calcification or ossification of the ligamentum flavum is a rare cause of thoracic myelopathy and most often occurs among individuals of Japanese descent. It is rare in other ethnic groups and in individuals below the age of 50. It is most often described at the lower thoracic level, being uncommon in the lumbar region and rare in the cervical region. Here, we present the case of a 44-year-old White female patient who sought medical attention with an eightmonth history of paraesthesia of the lower limbs and progressive difficulty in walking. The clinical profile, together with computed tomography and nuclear magnetic resonance imaging of the spine, led to a diagnosis of compressive thoracic myelopathy due to ossification of the ligamentum flavum in the thoracic and lumbar spine. The patient underwent laminectomy and dissection of some of the affected ligamentum flavum, without any intraoperative complications. After three months of clinical follow-up, the patient had progressed favorably, having no sensory complaints and again becoming ambulatory.

Thoracic Myelopathy Secondary to Seizure Following Scoliosis Surgery

The incidence of spinal injuries is increased in people with epilepsy although compressive thoracic myelopathy has not been reported. We describe a 15-year-old girl with SCN1A mutation (Dravet syndrome), refractory generalized tonic-clonic seizures, and prior posterior instrumentation and fusion for scoliosis, who presented with progressive lower extremity weakness. Junctional kyphosis with disc herniation and spinal cord compression directly rostral to the instrumentation was apparent on imaging. On history, the patient had suffered a particularly severe convulsive seizure just before developing symptoms. Surgical decompression and stabilization led to a complete neurologic recovery. This unusual presentation of myelopathy illustrates the need to consider this complication in patients with epilepsy and spinal instrumentation.

Assessment of Central Motor Conduction Time in the Diagnosis of Compressive Thoracic Myelopathy

Prospective clinical study. The objective of this study was to investigate central motor conduction time (CMCT) values in patients with compressive thoracic myelopathy (CTM) and analyze its power to diagnose this condition. CTM is rare and its diagnosis is often difficult, when other spinal disorders such as cervical or lumbar degenerative spondylosis supervene. Measurement of CMCT following transcranial magnetic stimulation is a useful means to evaluate the electrophysiological functions of the corticospinal tract; however, there are few reports describing CMCT values among patients with CTM. Motor-evoked potentials following transcranial magnetic stimulation, and compound muscle action potentials and F-waves following electrical stimulation in the ulnar and tibial nerves were measured from the abductor digiti minimi (ADM) and abductor hallucis (AH) muscles in 20 patients with CTM, 92 patients with compressive cervical myelopathy (CCM), and 18 control subjects. The CMCT detected from the ADM (CMCT-ADM), the AH (CMCT-AH), and the CMCT-ADM/AH ratio (CMCT-ADM/CMCT-AH) were calculated. The CMCT-AHs in patients with CTM were significantly longer than in control subjects, although there were no significant differences in the CMCT-ADMs. In contrast, both the CMCT-ADMs and CMCT-AHs in the CCM group were significantly longer than those of the control group. The CMCT-ADM/AH ratios in the CTM group were significantly lower than those of the other groups. Among the CTM and CCM groups, when the cutoff point of the CMCT-ADM/AH ratio was set at equal to or lower than 0.52, i.e., the mean CMCT-ADM/AH ratio in the control group, the odds ratio for CTM was 68.4 (95% confidence interval: 8.62-543; P < 0.001). Our data showed a significant pattern of CMCT parameters and low CMCT-ADM/AH ratios in patients with CTM. The measurement of CMCT is valuable as a noninvasive technique for screening patients with CTM or CCM before magnetic resonance imaging.

A case of congenital kyphosis misdiagnosed as cerebral palsy

Congenital kyphosis is an uncommon spinal deformity that needs prompt recognition and early surgery due to its progressive nature, which can lead to neurological compromise. An 11-year-old boy presented with deteriorating ambulatory function after bilateral Achilles tendon lengthening and calcaneal osteotomies. He previously had a series of orthopedic surgeries of the lower extremities, having been diagnosed with spastic diplegic cerebral palsy based on clinical features and history of prematurity. His computed tomography (CT) scan and magnetic resonance imaging (MRI) revealed compressive thoracic myelopathy due to the fusion of vertebral bodies from T2 to T5. He was treated with anterior decompression and anteroposterior fusion of the thoracic spine. Neurological impairment such as spastic paraplegia in children can lead to an erroneous diagnosis of cerebral palsy, resulting in unnecessary surgeries with their attendant potential complications. This report alerts clinicians to the presentation and progression of congenital vertebral anomalies and highlights the importance of a thorough neurological examination and radiological evaluation.

Delayed Diffuse Upper Motor Neuron Syndrome after Compressive Thoracic Myelopathy

A 54-year-old man developed progressive spastic paraparesis beginning 2 weeks after a back injury caused by a subacute compressive thoracic myelopathy attributable to a post-traumatic arachnoid cyst. Three to 18 months after surgical decompression of the thoracic arachnoid cyst, the patient developed a diffuse predominantly upper motor neuron syndrome characterized by spastic quadriparesis, pseudobulbar paresis, and pseudobulbar affect. Retrograde corticospinal tract degeneration and upper motor neuron death after spinal cord injury is recognized. This case suggests that focal upper motor neuron injury can occasionally precipitate diffuse upper motor neuron dysfunction.

Granulomatous compressive thoracic myelopathy as the initial manifestation of Wegener's granulomatosis

Wegener's granulomatosis (WG) is a multisystem disorder characterized by glomerulonephritis and necrotizing granuloma formation and vasculitis in the upper airways and lungs.1,2 Neurologic complications occur in 22% to 54% of patients, including mononeuritis multiplex, symmetric distal sensorimotor neuropathy, cranial neuropathies, external ophthalmoplegia, cerebral infarction, or seizures.2-4 Spinal cord involvement is rare but at least five cases have been reported.5,6 Pathologic examination in one patient revealed dural vasculitis.6 We describe a patient with WG who presented with a gradually progressive spastic paraparesis secondary to thoracic cord compression by meningeal granuloma. Case report. A 58-year-old Brazilian woman presented with a 4-week history of gradually progressive gait difficulty, a sensation of tightness in the midthoracic region, and a 12-hour history of urinary retention and lower extremity paresthesia. She also complained of a dry cough, nasal stuffiness, and epistaxis, which occurred shortly after presentation. Neurologic examination revealed a spastic gait, with weakness (Medical Research Council [MRC] grade 4/5) in both lower extremities; bilateral lower extremity hypertonia; hyperreflexia and extensor plantar responses; reduced rectal tone; and a midthoracic sensory level to pinprick testing. General examination revealed a left knee effusion but no fever, rash, or oropharyngeal or pulmonary abnormalities. Gadolinium-enhanced thoracic MRI revealed a circumferential enhancing soft-tissue mass extending from T2 to T8, with compression of the thecal sac and cord (figure, A). Figure. (A) Sagittal T1-weighted MRI of thoracic cord with gadolinium shows cord compression with circumferential meningeal thickening and enhancement from T2 to T8 vertebral levels. (B) Transverse section of resected dura shows marked thickening by …