Diagnosis Of Myelopathy Research Articles

Enfermedades de la médula espinal. Síndromes medulares

Spinal cord diseases or myelopathies are a heterogeneous collection of pathological processes that directly or indirectly affect this anatomical structure. Although these diseases are uncommon, they entail severe sequela that result in major disability. A rapid diagnosis and appropriate therapeutic intervention is therefore essential. In general, the pathophysiology of spinal damage is complex and not entirely understood except for spinal cord trauma. The clinical manifestations of myelopathies are limited and can be grouped into a series of syndromes that can be associated with specific etiologic processes. Depending on the level of damage to the craniocaudal plane, there are a series of peculiarities or symptoms superadded to the classical spinal syndromes. The differential diagnosis of myelopathy should consider other diseases that have similar presentations. These processes can affect the brain or peripheral nervous system; however, we should also consider muscle, autoimmune and psychiatric diseases that can clinically mimic a myelopathy.

Incidental Dural Tear in Cervical Spine Surgery

This was a retrospective study. To report the incidence of incidental dural tear (DT) in cervical spine surgery, risk factors, and in-hospital patient outcomes on a national level. DT during cervical spine surgery is not as common as that during lumbar spine surgery; however, DT is still a difficult complication. Clinical data were obtained from the US Nationwide Inpatient Sample for 2009. Patients who underwent cervical spine surgery were identified and divided into those with and without DT according to the International Classification of Diseases, 9th revision, Clinical Modification codes. The patient and health care system-related demographic data were retrieved. The incidence of DT and patient outcomes were analyzed. A multivariate logistic regression analysis was performed to identify the risk factors for DT. The incidence of DT was 0.45% (855/190,021). The multivariate analysis revealed that a diagnosis of myelopathy and ossification of the posterior longitudinal ligament; posterior approach, anterior and posterior approach; and insurance status were the significant risk factors for DT. Comparison between patients with and without DT showed that those with DT had significantly higher overall in-hospital complications (21.6% vs. 7.3%), longer hospital stays (6.0 vs. 3.2 d), a lower proportion who were discharged home routinely (66.3% vs. 83.9%), increased total hospital costs ($96,424 vs. $62,416), and similar in-hospital mortality (0.6% vs. 0.4%). The incidence of DT in cervical spine surgery was 0.45% in the United States. The risk of DT was highest with a primary diagnosis of the ossification of the posterior longitudinal ligament (58.4 times). DT significantly increased the rate of in-hospital complications and health care burden.

CN-02 * MYELOPATHY FOLLOWING INTRATHECAL CHEMOTHERAPY: A CASE SERIES IN ADULTS

Intrathecal (IT) chemotherapy in combination with systemic chemotherapy is an effective treatment modality used in the prophylaxis and treatment of CNS disease in hematological malignancies. IT agents commonly used in various chemotherapeutic regimens include methotrexate and cytarabine arabinoside (Ara-C).Side effects from IT chemotherapies described in the literature vary from mild asymptomatic forms of arachnoiditis diagnosed on MRI to leukoencephalopathy and myelopathy. These complications have been reported more frequently in the pediatric literature than in adults. We here describe 7 adult patients treated at a single institution for hematological malignancies that developed myelopathy following intrathecal chemotherapy. 5 out of our 7 patients demonstrated longitudinal hyperintenities involving mostly the dorsal columns and to varying degrees the lateral corticospinal tracts; a picture suggesting methotrexate induced toxicity. In the 2 cases where myelobasic protein was checked in the CSF, it was significantly elevated supporting the role of a potential CSF biomarker to diagnose cord injury and distinguish the pathology from leukemic infiltration. Median survival was 3.1 months from the time of myelopathy diagnosis despite various treatment strategies employed. We did not find any correlation between number of IT methotrexate doses given and development of myelopathy indicating a potential individual sensitivity to methotrexate. Based on what is known, immediate discontinuation of intrathecal methotrexate treatment would be recommended once a diagnosis of IT induced melopathy is made with consideration of methionine or S-adenosylmethionine supplementation for patients who received IT methotrexate.

Differential diagnosis of myelopathies

We present a review on myelopathies. We introduce each category of etiologies by a case study, followed by a short review of the different causes of myelopathies in this category. We elaborate on clinical presentation, laboratory workup, imaging and treatment. This extensive review elaborates on myelopathies caused by demyelinating diseases, infectious agents, connective tissue diseases and vasculopathies, neoplasms, toxic substances, metabolic derangements and the idiopathic myelopathies. Interesting images are incorporated in this review. Keywords: myelopathies, spinal cord, demyelinating, infectious, neoplasm, idiopathic.

Lower extremities paresis due to Ossification of the posterior longitudinal ligament

Ossification of the posterior longitudinal ligament (OPLL) is a condition caused by new bone developing in the posterior longitudinal ligament within the spinal canal. OPLL is a common cause of myelopathy in East Asian countries. Here, we report a case with OPLL in thoracic and lumbar spine in Kermanshah, West of Iran. Case presentation: A 40 years old man gradually developed lower extremities paresis with defecation or voiding difficulties. Radiographic evaluation by computed tomography (CT) and magnetic resonance imaging (MRI) confirmed the mass of ossification at the posterior aspect of the T2-T4 and T12-L1 of vertebral body with spinal cord compression. Although OPLL is a common cause of myelopathy in the East Asian countries, it should be included in differential diagnosis of myelopathy in other regions.

Thirty-day readmissions after elective spine surgery for degenerative conditions among US Medicare beneficiaries

Readmissions within 30 days of hospital discharge are undesirable and costly. Little is known about reasons for and predictors of readmissions after elective spine surgery to help plan preventative strategies. To examine readmissions within 30 days of hospital discharge, reasons for readmission, and predictors of readmission among patients undergoing elective cervical and lumbar spine surgery for degenerative conditions. Retrospective cohort study. Patient sample includes 343,068 Medicare beneficiaries who underwent cervical and lumbar spine surgery for degenerative conditions from 2003 to2007. Readmissions within 30 days of discharge, excluding readmissions for rehabilitation. Patients were identified in Medicare claims data using validated algorithms. Reasons for readmission were classified into clinically meaningful categories using a standardized coding system (Clinical Classification Software). Thirty-day readmissions were 7.9% after cervical surgery and 7.3% after lumbar surgery. There was no dominant reason for readmissions. The most common reasons for readmissions were complications of surgery (26%-33%) and musculoskeletal conditions in the same area of the operation (15%). Significant predictors of readmission for both operations included older age, greater comorbidity, dual eligibility for Medicare/Medicaid, and greater number of fused levels. For cervical spine readmissions, additional risk factors were male sex, a diagnosis of myelopathy, and a posterior or combined anterior/posterior surgical approach; for lumbar spine readmissions, additional risk factors were black race, Middle Atlantic geographic region, fusion surgery, and an anterior surgical approach. Our model explained more than 60% of the variability in readmissions. Among Medicare beneficiaries, 30-day readmissions after elective spine surgery for degenerative conditions represent a target for improvement. Both patient factors and operative techniques are associated with readmissions. Interventions to minimize readmissions should be specific to surgical site and focus on high-risk subgroups where clinical trials of interventions may be of greatest benefit.

Myélopathie àSchistosoma mansoni

IntroductionNeurological complications of schistosomiasis remain exceptional even in hyperendemic area. Case reportWe report a 26-year-old Senegalese man, without past medical history, who was admitted for spastic paraplegia, acute retention of urine, and pain in low back and lower limbs. The final diagnosis was spinal cord schistosomiasis. Diagnosis was based on the endemic context, MRI medullar conus imaging, schistosoma serology in cerebrospinal fluid and blood, and the absence of other cause of myelopathy. Treatment was based on praziquantel, corticosteroids and physiotherapy. The outcome was favorable after a 2-year follow-up. ConclusionSchistosomiasis should be included in the differential diagnosis of myelopathy in patients living actually, or even traveled in the past, in endemic tropical areas.

Acute Myelopathy With Normal Imaging

A 17-year-old girl presented with rapidly progressive quadriparesis and ventilatory failure. The clinical findings indicated a spinal level, but the diagnosis of myelopathy was not supported by her initial spinal imaging and cerebrospinal fluid studies. She had completed treatment for Guillain-Barré syndrome before a follow-up spinal imaging study showed interval expansion and enhancement of the cervical cord.

Clinical presentation of a patient with thoracic myelopathy at a chiropractic clinic

IntroductionThe purpose of this case report is to describe the clinical presentation, examination findings, and management decisions of a patient with thoracic myelopathy who presented to a chiropractic clinic. Case Report/MethodsAfter receiving a diagnosis of a diffuse arthritic condition and kidney stones based on lumbar radiograph interpretation at a local urgent care facility, a 45-year-old woman presented to an outpatient chiropractic clinic with primary complaints of generalized low back pain, bilateral lower extremity paresthesias, and difficulty walking. An abnormal neurological examination result led to an initial working diagnosis of myelopathy of unknown cause. The patient was referred for a neurological consult. ResultsComputed tomography revealed severe multilevel degenerative spondylosis with diffuse ligamentous calcification, facet joint hypertrophy, and disk protrusion at T9-10 resulting in midthoracic cord compression. The patient underwent multilevel spinal decompressive surgery. Following surgical intervention, the patient reported symptom improvement. ConclusionIt is important to include a neurologic examination on all patients presenting with musculoskeletal complaints, regardless of prior medical attention. The ability to recognize myelopathy and localize the lesion to a specific spinal region by clinical examination may help prioritize diagnostic imaging decisions as well as facilitate diagnosis and treatment.

Cervical myelopathy due to chronic overshunting in a pediatric patient: case report and review of the literature

We present a rare cause of cervical myelopathy produced by an engorged suboccipital epidural venous plexus due to chronic cerebrospinal fluid (CSF) overdrainage. A 17-year-old boy with obstructive hydrocephalus due to a retrocerebellar cyst and secondary implantation of a ventricloperitoneal shunt (VP-shunt) presented with progressive spastic tetraparesis. MRI imaging revealed myelopathy due to significant compression of the cervical spinal cord by engorged epidural veins. Further assessment at a low-pressure setting revealed a broken shunt valve. The VP-shunt valve was changed with an additional anti-siphon device leading to a gradual increase of the intracranial pressure (ICP). After intensive physiotherapy, the patient showed slight clinical improvement. Follow-up imaging within nine days showed distinct regression of the dilated venous plexus at the cranial-cervical junction (CCJ) with the resolution of cord compression. Engorgement of the epidural venous plexus should always be considered in the differential diagnosis of myelopathy in long-term shunt patients even when classical clinical and radiological signs of overshunting are missing.

Evaluation of the rate of decompression in anterior cervical corpectomy using an intra-operative computerized tomography scan (O-Arm system)

The purpose of this study was to evaluate the efficacy of intra-operative computerized tomography (CT) scanning in the analysis of bone removal accuracy during anterior cervical corpectomy, in order to allow any necessary immediate correction in the event of inadequate bone removal. From September 2009 to December 2010 we performed an intra-operative (CT) scan using the O-Arm(™) Image system to assess the rate of central and lateral decompression in all patients treated for cervical spondylotic myelopathy by anterior cervical corpectomy and fusion. Out of a population of 187 patients admitted to our department, with a diagnosis of myelopathy due to spondylotic degenerative cervical stenosis, 15 patients underwent a surgical treatment with anterior cervical corpectomy and fusion. There were nine males (60%) and six females (40%); the mean age was 52.4 years, ranging from 41 to 57 years. The pre-operative radiologic investigations (MRI and CT scans) revealed in the nine patients (60%) the extent of the compression to one vertebral body (C4 one case, C5 four cases, C6 four cases), while in the six cases (40%) the compression regarded two vertebral body (C3 and C4 one case, C4 and C5 two cases, C5 and C6 three cases). During surgery, when the decompression was judged completely, a CT scan was performed: in 11 cases (73.3%) the decompression was considered adequate, while in four cases (26.7%) it was deemed insufficient and the surgical strategy was changed in order to optimize the bone removal. In these cases an additional scan was taken to prove the efficacy of decompression, achieved in all patients. Intra-operative CT scan performed during cervical corpectomy is a really useful tool in helping to ensure complete bone removal and the adequacy of surgery. The O-arm(™) Image system grants optimal image quality, allowing correctly assessing the rate of decompression and, in any case of doubt, allows an intra-operative evaluation of the final correct positioning of the graft.

The cutaneous silent period is preserved in cervical radiculopathy: significance for the diagnosis of cervical myelopathy

Electromyographic (EMG) activity from voluntarily contracting hand muscles undergoes transient suppression following nociceptive fingertip stimulation. This suppression is mediated by a spinal inhibitory reflex designated the cutaneous silent period (CSP). The CSP is abolished or altered in a variety of myelopathic conditions. However, before the CSP can gain acceptance as an aid in the diagnosis of myelopathy, the contribution of non-myelopathic conditions that can interrupt the afferent pathways responsible for the CSP needs to be considered. Accordingly, we examined the effect of radiculopathy on the CSP. Nociceptive stimulation was applied to thumb (C6 dermatome), middle (C7) and little (C8) fingers of 23 patients with cervical radiculopathy. Four or more CSP responses were recorded in abductor pollicis brevis muscle following digital stimulation. The patients had C6 (n = 10), C7 (n = 7), or C8 (n = 6) radiculopathy documented by EMG. A complete CSP was elicited in 21 of 23 patients with comparable latencies and durations irrespective of digit stimulated. We conclude that the CSP is preserved in radiculopathy, probably because afferent impulses are carried by smaller, slower conducting 'injury-resistant' A-delta fibers. These results provide important missing evidence that ensures specificity of CSP alterations in the diagnosis of cervical myelopathy. The finding that the CSP is spared in radiculopathy should open the door for investigators and clinicians to adopt this simple spinal inhibitory reflex as a physiologic aid in the diagnosis of spinal cord dysfunction.

Quantitative Assessment of Myelopathy Patients Using Motor Evoked Potentials Produced by Transcranial Magnetic Stimulation

In the diagnosis of myelopathy, conventional diagnostic methods such as neurologic findings, image study such as MRI and myelograms are usually performed, but conclusive diagnosis is sometimes difficult because many symptoms tend to be separate from the existing disease. And the MR images demonstrate morphological abnormalities of the cord but not functional impairment, and not all cord compression shown by MR images is associated with cord dysfunction. Transcranial magnetic stimulation (TMS) is applied as a quick and noninvasive technique to study conduction in the descending corticospinal pathways.

Prevalence of Physical Signs in Cervical Myelopathy

Prospective case-control study. To determine the prevalence and utility of commonly tested myelopathic signs in surgically treated patients with cervical myelopathy (CM). Although physical signs are sought in making the diagnosis of CM, their importance remains unclear, as patients with CM may have normal examinations while those without CM can demonstrate "myelopathic" signs. Patients presenting with cervical complaints and advanced imaging were evaluated over a 6-month interval in a single surgical practice. The CM group consisted of those with (1) a history of myelopathic symptoms and (2) correlative spinal cord compression on imaging, who then (3) underwent surgery and (4) improved Nurick score by > or = 1 grade after surgery. The controls consisted of patients with neck/radicular complaints but no myelopathic symptoms and no cord compression on imaging. Myelopathic signs included hyperreflexia or provocative signs (Hoffman inverted brachioradialis reflex, clonus, Babinski). There were 39 CM patients and 37 controls. Myelopathic signs were more prevalent in the CM group (79% vs. 57%; P = 0.05), with significantly higher rates of all provocative signs but not hyperreflexia. Overall, myelopathic signs were not highly sensitive in diagnosing the presence of CM, as 21% of CM patients failed to demonstrate any myelopathic signs. There was no correlation between the presence of myelopathic signs and diabetes or preoperative Nurick score. However, those with cord signal changes were significantly more likely to demonstrate myelopathic signs. Although myelopathic signs are significantly more common in CM patients, they may be negative in approximately one-fifth and can not be relied on to make the diagnosis. In patients who lack myelopathic signs but otherwise seem myelopathic with no alternative explanations, symptoms combined with correlative imaging studies must be used to base treatment decisions, as the absence of signs does not preclude the diagnosis of myelopathy nor its successful surgical treatment.

Reliability and Diagnostic Accuracy of Clinical Special Tests for Myelopathy in Patients Seen for Cervical Dysfunction

Case control study. Myelopathy is a clinical diagnosis based largely on initial examination findings during a clinical screen, followed by imaging verification of cord injury or compression. At present, few studies have examined the reliability and diagnostic accuracy of clinical examination measures. To determine the reliability and diagnostic accuracy of neurological tests associated with the diagnosis of myelopathy. Reliability and diagnostic accuracy of 7 frequently used tests and measures and subjective findings associated with myelopathy were examined on consecutive patients with cervical pain. Interrater reliability and diagnostic accuracy values, including posttest probability, based on a pretest probability of 40%, were calculated for each test and for combinations of tests and measures. Four of the 7 diagnostic tests were found to have a substantial interrater reliability. None of the single or clusters of tests yielded low negative likelihood ratios. Of the individual tests, the Babinski sign demonstrated the highest positive likelihood ratio (LR+, 4.0; 95% CI: 1.1-16.6) and posttest probability (73%) for diagnosis, but yielded only a moderate negative likelihood ratio (LR-, 0.7; 95% CI: 0.6-0.9). Combinations of tests did not yield improved accuracy values over single test results. This study demonstrated that 4 of 7 tests used to screen for myelopathy offered substantial levels of interrater agreement when used on individuals with cervical dysfunction. None of the tests when performed individually or in combinations are effective for screening; however, the Babinski sign did alter posttest probability more significantly than combinations of test findings. Diagnosis, Level 2b.

Symptomatic thoracic spinal cord compression caused by postsurgical pseudomeningocele

We report the first case of symptomatic thoracic spinal cord compression caused by postsurgical pseudomeningocele. A 49-year-old man sought treatment for progressive loss of strength in the lower extremities ten months after full neurological recovery for a thoracic (T11) intradural-extramedullary schwannoma. Magnetic resonance imaging revealed a postsurgical thoracic (T11-T12) pseudomeningocele. The surgical approach showed an inadequate dural closure with spontaneous cerebrospinal fluid fistula. The defect was sealed with suture, muscle and biological glue covering. The patient had a good recovery. Pseudomeningocele must take part of the differential diagnosis of myelopathy after thoracic spine surgery.

Spinal epidural lipomatosis: a manifestation of HAART-associated lipodystrophy

Spinal epidural lipomatosis: a manifestation of HAART-associated lipodystrophy

Paraparesia espástica tropical/mielopatía asociada al HTLV-I en la infancia. Caso clínico y revisión bibliográfica

HTLV-I associated myelopathy is characterised by a clinical picture of slowly progressive spastic paraparesis that generally presents when the patient is at an age somewhere between his or her thirties and sixties; few cases have been reported involving children. It is a pathology that is prevalent in tropical regions that are endemic for HTLV-I (southern Japan, the Caribbean, Central and South America, and some areas of Africa). The authors report the case of a 9-year-old child from Guinea who was admitted to the Paediatric Neurology Unit in the Hospital de Santa Maria with a two-year-old clinical history of spastic paraparesis. Computerised tomography and magnetic resonance imaging did not show any alterations to the spinal cord. Somatosensory evoked potentials revealed a lesion in the posterior dorsolumbar spinal cord. The exclusion of other (infectious, metabolic and demyelinating) pathologies and the confirmation of infection by HTLV-I (by means of PCR) led to a diagnosis of myelopathy associated to this virus. Therapy was established with interferon alfa, but no appreciable significant improvement was observed. This case stands out because of the uncommonness of this pathology at the paediatric age. We review the most relevant aspects of this disorder at the earliest ages, above all with regard to its epidemiology, transmission, clinical symptoms and complementary diagnostic examinations. Known therapeutic options (corticoids, interferon alfa, antiretroviral agents, among others) and prognosis are also discussed.

Clinical and Radiographic Features of Dural Arteriovenous Fistula, a Treatable Cause of Myelopathy

To assess presentation, imaging, treatment, and outcome of patients with myelopathy due to a dural arteriovenous fistula (DAVF). This retrospective review identified 94 patients with DAVF surgically treated at our institution between June 1985 and December 1999. The mean ages of the 75 men and 19 women were 62.6 years and 63.0 years, respectively (range, 31-83 years). Magnetic resonance imaging was performed in 87 patients, computed tomography-myelography was performed in 37 patients, and spinal angiography was performed in all patients. Initial examination findings were retrospectively adjusted to a modified Aminoff-Logue myelopathy scale. Of the 94 patients, 47 presented with symptoms that worsened with erect posture or Valsalva maneuver. As myelopathy progressed, patients' symptoms increased, and 6 patients had paraplegia at presentation. The mean time from symptom onset to diagnosis was 23 months (range, 2-120 months). Magnetic resonance imaging confirmed the diagnosis in 86 patients; computed tomography-myelography was needed to confirm the fistula in 1 patient. Spinal angiography detected the fistula in all patients. Surgical obliteration of the DAVF was successful in 93 patients; in 1 patient surgery failed because the DAVF was not localized, but acrylic endovascular embolization was successful. No patient experienced permanent morbidity or mortality. Of the 94 patients, 93 improved postoperatively 1 or 2 levels based on a modified Aminoff-Logue scale. Older patients with severe long-term deficits had poor outcomes. The diagnosis of a DAVF seems to be delayed considerably because DAVF is not included in the differential diagnosis of myelopathy and because of clinicians' unfamiliarity with suggestive or revealing findings on diagnostic imaging. Neurodiagnostic imaging confirms the diagnosis, and spinal angiography localizes the fistula. Surgical intradural disconnection of the DAVF clinically reverses the pathophysiology. Additionally, surgical treatment is associated with low short-term morbidity, no permanent morbidity, and no mortality. If the diagnosis is made early and treatment initiated in such patients, they generally do well.

THE ROLE OF SOMATOSENSORY EVOKED POTENTIALS IN THE DIAGNOSIS OF AIDS‐ASSOCIATED MYELOPATHY

BACKGROUND: Although AIDS‐associated vacuolar myelopathy is detected in> 50% of autopsy cases, it is often unrecognized during life. The clinical assessment is often difficult because of concurrent peripheral neuropathy and lack of specific diagnostic markers. Somatosensory evoked potentials (SEPs) have been successfully used to evaluate central conduction in a number of diseases involving the spinal cord. OBJECTIVES: To assess the diagnostic yield of SEPs in AIDS‐associated myelopathy. METHODS: We recorded tibial and median nerve SEPs in 69 HIV‐infected subjects referred for evaluation of lower extremity neurologic abnormalities. Stimulation of the peroneal nerve at the popliteal fossa was performed in patients with absent response to ankle stimulation. RESULTS: HIV‐infected subjects had significantly delayed latencies of both peripheral and central potentials, suggesting a combination of peripheral and CNS abnormalities. Analysis of peripheral and central latencies allowed us to discriminate between neuropathy and myelopathy in individual patients. Abnormalities of tibial central conduction time (CCT) correlated with clinical diagnosis of myelopathy. There was no significant difference in median CCTs between patients and controls, suggesting that conduction abnormalities were restricted to the thoracolumbar spinal cord. A derived spinal conduction time was a sensitive indicator of central conduction abnormalities in AIDS patients with myelopathy. CONCLUSIONS: The combination of median, posterior tibial, and peroneal SEPs is a valuable tool in the diagnosis of AIDS‐associated myelopathy, particularly when myelopathy and peripheral neuropathy coexist. The use of a derived spinal conduction time improves the diagnostic yield of SEPs in AIDS‐associated myelopathy.