Hoffmann Sign Research Articles

Infinity: A Prospective Trial for Safety and Accuracy of Navigated Posterior Cervical and Thoracic Instrumentation in long-segment Fusions.

Unblinded single-arm prospective clinical trial. Evaluate safety and accuracy of navigation for placement of posterior cervicothoracic instrumentation. Computer assisted stereotactic navigation for placement of spinal instrumentation has been widely studied and implemented in the thoracic and lumbar spine. However less literature exists regarding the use of computer assisted navigation for posterior cervical instrumentation, particularly with lateral mass fixation. Here we present the first prospective study of navigated cervical lateral mass screw placement for cervicothoracic fusion. Patients who met indications for posterior cervical fusion were screened, consented, and enrolled preoperatively for instrumentation with Medtronic Infinity Occipital-Cervical-Thoracic implants, with use of intraoperative O-arm and stereotactic Stealth navigation. Postoperative CTs of the instrumented levels were obtained during the same hospital admission. Primary outcome of the trial was safety. Secondary outcomes were screw accuracy assessed by Gertzbein-Robbins grade, neurologic exams, and patient reported outcomes on the PROMIS 29 questionnaire. A total of 50 patients underwent surgery, and 557 screws were placed. There were no adverse events related to the use of navigation or screw malposition. Gertzbein-Robbins grade A or B placement comprised 95% of navigated screws. There was a decrease in positive Hoffmann sign rate postoperatively, and sensory and motor exams remained stable. There was improvement in patient reported pain and sleep domains. Navigation for cervicothoracic instrumentation is safe overall and leads to high rates of accurately placed screws. Longer term follow up could provide more insight to whether the use of this technology results in durable improvement in spinal alignment parameters and patient reported outcomes. 3.

Hoffmann's sign in cervical spondylotic myelopathy patients: pathological insights from neuroimaging.

Hoffmann's sign testing is a commonly used physical examination in clinical practice for patients with cervical spondylotic myelopathy (CSM). However, the pathophysiological mechanisms underlying its occurrence and development have not been thoroughly investigated. Therefore, the present study aimed to explore whether a positive Hoffmann's sign (PHS) in CSM patients is associated with spinal cord and brain remodeling and to identify potential neuroimaging biomarkers with diagnostic value. Seventy-six patients with CSM and 40 sex- and age-matched healthy controls (HCs) underwent multimodal MRI. Based on the results of the Hoffmann's sign examination, patients were divided into two groups: those with a PHS (n = 38) and those with a negative Hoffmann's sign (NHS; n = 38). Quantification of spinal cord and brain structural and functional parameters of the participants was performed using various methods, including functional connectivity analysis, voxel-based morphometry, and atlas-based analysis based on functional MRI and structural MRI data. Furthermore, this study conducted a correlation analysis between neuroimaging metrics and neurological function and utilized a support vector machine (SVM) algorithm for the classification of PHS and NHS. In comparison with the NHS and HC groups, PHS patients exhibited significant reductions in the cross-sectional area and fractional anisotropy (FA) of the lateral corticospinal tract (CST), reticulospinal tract (RST), and fasciculus cuneatus, concomitant with bilateral reductions in the volume of the lateral pallidum. The functional connectivity analysis indicated a reduction in functional connectivity between the left lateral pallidum and the right angular gyrus in the PHS group. The correlation analysis indicated a significant positive association between the CST and RST FA and the volume of the left lateral pallidum in PHS patients. Furthermore, all three variables exhibited a positive correlation with the patients' motor function. Finally, using multimodal neuroimaging metrics in conjunction with the SVM algorithm, PHS and NHS were classified with an accuracy rate of 85.53%. This research revealed a correlation between structural damage to the pallidum and RST and the presence of Hoffmann's sign as well as the motor function in patients with CSM. Features based on neuroimaging indicators have the potential to serve as biomarkers for assessing the extent of neuronal damage in CSM patients.

Upper motor neuron signs in primary lateral sclerosis and hereditary spastic paraplegia.

The frequency and distribution of upper motor neuron (UMN) signs in primary lateral sclerosis (PLS) are unknown. We aimed to study the spectrum of UMN signs in PLS and compare it with hereditary spastic paraplegia (HSP). We retrospectively analyzed the frequency of different UMN signs, including hyperreflexia (limbs and jaw), limb and tongue spasticity, Babinski, and Hoffman signs, in PLS patients at first observation and compared this respect to onset region and symptom duration. We also compared PLS versus HSP patients. We included 34 PLS and 20 HSP patients, with a median symptom duration at first visit of 3.0 (interquartile range, IQR = 4.0) and 19.0 (IQR = 22.0) years, respectively. In PLS patients, hyperreflexia of upper (UL) (88.2%) and lower (LL) (91.2%) limbs, and LL spasticity (79.4%) were the most common findings. Spasticity of LL was significantly (p = .012) more frequent in LL-spinal onset subgroup, tongue spasticity in bulbar-onset subgroup (p = .021), and Hoffman sign in UL-spinal onset subgroup (p = .024). The PLS subgroup with shorter disease duration had a higher frequency of abnormal jaw jerk reflex (p = .037). Compared with HSP, PLS patients had a higher frequency of UL hyperreflexia (88.2% vs. 42.1%, p < .001) and UL spasticity (44.1% vs. 0.0%, p < .001). Asymmetric distribution of UMN signs was present in PLS and not in HSP. In PLS, UL UMN signs are nearly always present and UMN sign distribution appears to be associated with onset region. At first observation, bulbar involvement, asymmetrical distribution of UMN signs and UL spasticity may indicate PLS versus HSP.

Degenerative Cervical Myelopathy: An Overview.

Degenerative cervical myelopathy (DCM) is a spinal condition of growing importance due to its increasing prevalence within the ageing population. DCM involves the degeneration of the cervical spine due to various processes such as disc ageing, osteophyte formation, ligament hypertrophy or ossification, as well as coexisting congenital anomalies. This article provides an overview of the literature on DCM and considers areas of focus for future research. A patient with DCM can present with a variety of symptoms ranging from mild hand paraesthesia and loss of dexterity to a more severe presentation of gait disturbance and loss of bowel/bladder control. Hoffman's sign and the inverted brachioradialis reflex are also important signs of this disease. The gold standard imaging modality is MRI which can identify signs of degeneration of the cervical spine. Other modalities include dynamic MRI, myelography, and diffusion tensor imaging. One important scoring system to aid with the diagnosis and categorisation of the severity of DCM is the modified Japanese Orthopaedic Association score. This considers motor, sensory, and bowel/bladder dysfunction, and categorises patients into mild, moderate, or severe DCM. DCM is primarily treated with surgery as this can halt disease progression and may even allow for neurological recovery. The surgical approach will depend on the location of degeneration, the number of cervical levels involved and the pathophysiological process. Surgical approach options include anterior cervical discectomy and fusion, corpectomy, or posterior approach (laminectomy ± fusion). Conservative management is also considered for some patients with mild or non-progressive DCM or for patients where surgery is not an option. Conservative treatment may include physical therapy, traction, or neck immobilisation. Future recommendations include research into the prevalence rate of DCM and if there is a difference between populations. Further research on the benefit of conservative management for patients with mild or non-progressive DCM would be recommended.

Hoffman Sign

The Hoffmann sign or reflex is commonly taught as part of the physical examination to detect abstract upper motor neuron pathology. We present a case of a patient with congenital spinal stenosis and a fall who had a positive Hoffmann sign as the result of a central cord syndrome. The materials contain a video of this physical exam finding and briefly review its history, reliability and clinical utility.

The value of Clinical signs in the diagnosis of Degenerative Cervical Myelopathy - A Systematic review and Meta-analysis.

Delayed diagnosis of degenerative cervical myelopathy (DCM) is likely due to a combination of its subtle symptoms, incomplete neurological assessments by clinicians and a lack of public and professional awareness. Diagnostic criteria for DCM will likely facilitate earlier referral for definitive management. This systematic review aims to determine (i) the diagnostic accuracy of various clinical signs and (ii) the association between clinical signs and disease severity in DCM? A search was performed to identify studies on adult patients that evaluated the diagnostic accuracy of a clinical sign used for diagnosing DCM. Studies were also included if they assessed the association between the presence of a clinical sign and disease severity. The QUADAS-2 tool was used to evaluate the risk of bias of individual studies. This review identified eleven studies that used a control group to evaluate the diagnostic accuracy of various signs. An additional 61 articles reported on the frequency of clinical signs in a cohort of DCM patients. The most sensitive clinical tests for diagnosing DCM were the Tromner and hyperreflexia, whereas the most specific tests were the Babinski, Tromner, clonus and inverted supinator sign. Five studies evaluated the association between the presence of various clinical signs and disease severity. There was no definite association between Hoffmann sign, Babinski sign or hyperreflexia and disease severity. The presence of clinical signs suggesting spinal cord compression should encourage health care professionals to pursue further investigation, such as neuroimaging to either confirm or refute a diagnosis of DCM.

Physical Signs and Clinical Features of Cervical Myelopathy in Elderly Patients, Especially 80 Years or Older: Comparison of 100 Consecutive Operative Cases across Three Age Groups.

Retrospective cohort study. The present study aimed to examine the characteristics of physical signs in elderly patients with cervical myelopathy (CM) and to compare the findings in three different age groups. As the global population ages, the incidence of CM in elderly patients is increasing. We evaluated 100 consecutive surgical patients with CM and divided them into the following groups: 80s (34 patients; mean age, 83.9 years), 70s (33 patients; mean age, 73.9 years), and 69 or younger (33 patients; mean age, 60.9 years). The clinical symptoms and physical signs were evaluated and recorded. Although the recovery rate decreased with increasing age, all groups demonstrated a significant improvement in clinical symptoms relative to preoperative values. The Hoffman sign and hyperreflexia of the triceps tendon were, respectively, present in 82% and 88% of patients in the 80s group, 74% and 64% of those in the 70s group, and 69% and 82% of those in the 69 or younger group, with no significant difference among the groups. In contrast, the rates of hyperreflexia of the patellar and Achilles tendons were, respectively, 59% and 32% in the 80s group, 85% and 48% in the 70s group, and 91% and 70% in the 69 or younger group, with significant differences. The positivity rate of the lower extremity hyperreflexia decreased significantly with increasing age in patients with CM. The absence of hyperreflexia, particularly lower extremity, is not uncommon in elderly patients with suspected CM.

The Hoffmann parallax: a prospective study to determine the benefit of Hoffmann's sign.

Degenerative cervical myelopathy (DCM) is the most common cause of age-related spinal cord dysfunction worldwide. Despite the widespread use of provocative physical exam maneuvers in the workup of DCM, the clinical significance of Hoffmann's sign is controversial. The purpose of this study was to prospectively assess the diagnostic performance of Hoffmann's sign for DCM in a cohort of patients treated by a single spine surgeon. Patients were divided into two groups based on the presence of a Hoffmann sign on physical examination. Advanced imaging studies were independently reviewed by four raters for confirmation of a diagnosis of cervical cord compression. Prevalence, sensitivity, specificity, likelihood, and relative risk ratios for the Hoffmann sign were calculated, with subsequent Chi-square and receiver operator characteristic (ROC) analysis to further characterize correlative findings. Fifty-two patients were included - of whom, thirty-four (58.6%) patients presented with a Hoffmann sign, and eleven (21.1%) patients demonstrated cord compression on imaging. The Hoffmann sign demonstrated a sensitivity of 20% and a specificity of 35.7% (LR = 0.32; 0.16-1.16). Chi-square analysis revealed that imaging findings positive for cord compression were proportionally greater for patients lacking a Hoffmann sign than those with a confirmed Hoffmann sign (p =0.032) ROC analysis demonstrated that a negative Hoffmann sign performed moderately well in predicting cord compression (AUC.721; p =0.031). The Hoffmann sign is an unreliable marker for cervical cord compression, and the lack of a Hoffmann sign may be more predictive of cervical cord compression.

A Rare Case of Hereditary Spastic Paraplegia 46 With Novel Compound Heterozygous GBA2 gene variants (P3-8.013)

<h3>Objective:</h3> To present a case of Hereditary Spastic Paraplegia (HSP) 46 with distinct imaging and clinical findings, with two novel variants in <i>GBA2</i>, previously classified as variants of undetermined significance (VUS). <h3>Background:</h3> HSP is an uncommon cause of lower extremity spasticity and weakness. There have been many genetic etiologies identified with various clinical features. HSP 46 is an autosomal recessive, slowly progressive form of HSP caused by biallelic pathogenic variants in <i>GBA2</i>. <h3>Design/Methods:</h3> NA (Case report) <h3>Results:</h3> A 21-year-old man presented with progressive lower extremity weakness and ambulatory dysfunction. Symptom onset was in second grade, when he was found to have difficulty walking and inversion of the right foot. His ambulatory dysfunction continued to progress. Extensive serologic testing was negative, as was MRI of his spinal cord. Brain MRI demonstrated thinning of the corpus collosum. Examination approximately 12 years after his initial presentation was notable for diffuse hyperreflexia, bilateral lower extremity spasticity, and bilateral Hoffmann and Babinski signs. He had excessive lower extremity circumduction in swing phase, hyperextension at the knees, and internal rotation at the hips; consistent with a scissoring gait. There were no cranial neuropathies, sensory deficits, or cerebellar ataxia. The family history was negative. Genetic testing via whole-exome sequencing demonstrated compound heterozygous <i>GBA2</i> variants, both classified as VUS: c.1820 A&gt;G (p.N607S) and c.472 G&gt;A (p.G158R). <h3>Conclusions:</h3> Considering the distinctive clinical features, MRI finding of dysgenesis of the corpus collosum, and absence of an alternative explanation, we propose that the GBA2 variants found in this patient may be causative. Functional studies and/or messenger ribonucleic acid sequencing may confirm our hypothesis. <b>Disclosure:</b> Dr. Gill has nothing to disclose. Dr. Gill has nothing to disclose. Madeline Williamson has nothing to disclose. Dr. Avila has received personal compensation in the range of $500-$4,999 for serving on a Scientific Advisory or Data Safety Monitoring board for Alnylam Pharmaceuticals. Dr. Avila has received personal compensation in the range of $10,000-$49,999 for serving on a Speakers Bureau for Alnylam Pharmaceuticals. Dr. Avila has received personal compensation in the range of $500-$4,999 for serving on a Speakers Bureau for Akcea Therapeutics.

Does chromosome 16p12.1-p12.2 harbor a novel gene for essential tremor? (P5-11.012)

<h3>Objective:</h3> To describe a patient with de novo duplication of 16p12.1-p12.2 associated with severe action tremor and developmental delay, and genetic analysis of candidate genes within the duplicated chromosomal segment. <h3>Background:</h3> A family history of essential tremor (ET) can be found in 30–80% of all affected patients, suggesting a strong genetic contribution to its etiology. However, discovery of disease-causing genes has been largely elusive. Candidate genes can be identified using linkage analysis, whole exome or genome sequencing, and genetic association studies. Detection of genomic rearrangements with gene dosage changes in tremor patients provides another unique opportunity to identify additional candidate genes. <h3>Design/Methods:</h3> Case report and genetic analysis of the candidate chromosomal region. Chromosomal microarray analysis was performed in patient and both parents. We designed PCR primers for all coding exons of selected candidate genes. We included 75 unrelated probands from kindreds with familiar ET. Candidate genes were sequenced in all ET controls. <h3>Results:</h3> The proband is a 20-year-old female with significant developmental delay who developed progressive tremor at age of 15 years. Her tremor was a moderate to severe 4–5 Hz postural and action distal tremor, not present at rest, minimally responsive to propranolol. Additional examination revealed diffusely brisk reflexes with positive Hoffman and cross adductor sign, and upgoing toes. MRI brain did not show evidence of hypomyelination. She underwent chromosomal microarray analysis that identified duplications 12p13.33 and 16p12.2-p12.1. Chromosome 12p duplication was also detected in her father. Duplication of 12p was considered nonpathogenic and duplication 16p was <i>de novo</i>. The duplicated segment on chromosome 16p contained eight genes and six were considered possible candidate for tremor: <i>UQCRC2</i>, <i>CDR2</i>, <i>EEF2K</i>, <i>POLR3A</i>, <i>LOG23117</i>, and c16orf65. No putative deleterious mutations have been identified in ET controls. <h3>Conclusions:</h3> We report identification and genetic analysis of six novel candidate genes on chromosome 16p12.1-p12.2 that may be associated with ET. <b>Disclosure:</b> Dr. D’Aguiar Rosa has nothing to disclose. Dr. Yousaf has nothing to disclose. Dr. Hedera has received personal compensation in the range of $500-$4,999 for serving on a Scientific Advisory or Data Safety Monitoring board for Alexion. Dr. Hedera has received personal compensation in the range of $500-$4,999 for serving on a Speakers Bureau for Abbvie. Dr. Hedera has received personal compensation in the range of $5,000-$9,999 for serving as an Editor, Associate Editor, or Editorial Advisory Board Member for University of Louisville.

664: A RARE CASE OF NEUROPSYCHIATRIC LUPUS VASCULITIS: TREATING A DIAGNOSTIC DILEMMA

Introduction: Fat emboli syndrome (FES) in the setting of sickle cell disease (SCD) occurs secondary to bone ischemia, releasing fatty acids into the blood, and leading to infarct and microhemorrhages to the brain through either pulmonary or cardiac shunt. The characteristic MRI findings of cerebral FES are a “starfield” appearance of scattered micro-infarcts. Cerebral FES is uncommon in pediatrics, in patients without evidence of a shunt and in patients without inciting bone injury. Description: 16 year old male with HbSS presented with low back pain concerning for acute vaso-occlusive pain crisis that progressed to acute chest syndrome, respiratory failure and ARDS requiring intubation. He had respiratory acidosis and prolonged hypoxia on arrival. His initial HgbS fraction was 76%, requiring multiple exchange transfusions. He developed multiorgan dysfunction including acute renal failure, bilateral cortical renal infarcts, and biventricular cardiac dysfunction with ejection fraction of 35-40% and no shunt. He received therapeutic plasma exchange (TPE) in the setting of thrombocytopenia with schistocytes. A week later, his respiratory failure had improved and sedation was lifted for extubation when he was found to have increased tone, myoclonic movements, clonus, extensor posturing, gaze deviation and bilateral Hoffman sign. EEG showed no evidence of seizures. MRI demonstrated diffuse microhemorrhages and diffusion restriction in the white matter of the brain, localized heavily in the corpus callosum, as well as extensive bone ischemia of cervical vertebrae consistent with a microvascular occlusive process. The bony changes and starfield pattern seen on MRI were suggestive of cerebral FES. He tested positive for parvovirus B19, commonly seen in FES. He was extubated 6 days after diagnosis of FES and transferred to rehab facility after a month. Discussion: Although well described in adults, we found only a single other case describing FES with SCD in a child. Also notable are his delayed development of FES after recovery from other organ injuries and in the absence of cardiac shunt, and unknown intrapulmonary shunt. Prognosis for this disease, particularly in pediatrics, is unclear and treatment is mostly supportive aside from exchange transfusions.

P.219 Novel clinical phenotype of early-onset amyotrophic lateral sclerosis and frontotemporal dementia with SNCB mutation

The continuum between amyotrophic lateral sclerosis (ALS) and frontotemporal dementia (FTD) is well known spectrum of disease and genetic variability in this overlap has been previously reported. We report a novel clinical phenotype of early-onset ALS and FTD with a previously reported <i>SNCB</i> (β synuclein) mutation with Lewi body dementia. 45-year-old woman presented to our department complaining of progressive quadriparesis and dysphagia, which had started with right hemiparesis 4 months ago. She had a history of hypothyroidism but denied neurological family history. Neurologic examination revealed Hoffmann sign positive bilaterally and hyperreflexia of both knees. Nerve conduction study and electromyography showed low complex motor action potentials and widespread denervation in four limbs and thoracic paraspinal muscles without abnormal sensory nerve action potentials. CSF study was unremarkable. Diagnosis of probable ALS was established and riluzole 100mg daily was administered. Three months later, she reported a cognitive decline. In the neuropsychologic assessment battery, her language, memory, and frontal/executive function were below the first percentile for her age with relatively intact attention and visuospatial function. Brain MRI showed bilateral temporal atrophy, especially in the left anterior temporal area. SPECT revealed hypoperfusion in both frontal, temporal, and parietal cortices. Targeted next generation sequencing was conducted for ALS and FTD, and we found heterozygous c.208G>A mutation in <i>SNCB</i>. Despite tremendous research elucidating ALS-FTD, early onset case is rare. With this case, we report a new clinical phenotype of ALS-FTD with <i>SNCB</i> mutation, which has been only reported in few cases of Lewy body dementia and is being investigated recently. This case implies <i>SNCB,</i> which is assumed to contribute to neurodegeneration, can be a new candidate of ALS-FTD, especially in young age.

The radiological and electrophysiological characteristics of Hirayama disease with proximal involvement: A retrospective study.

PurposeHirayama disease (HD) has been largely believed to affect only distal muscles. However, the proximal upper extremities have been affected in some cases, which can be confused with motor neuron diseases.MethodsBaseline data, deep tendon reflex, Hoffmann sign, cervical curvature, sagittal Cobb angle, atrophied spinal cord, high signal intensity, loss of attachment, and affected muscles and segments on electromyography (EMG) were retrospectively obtained and compared between patients with HD with proximal involvement and patients with simple distal HD in one center from September 2007 to April 2022.ResultsIn this study, fifteen patients with proximal HD and 30 patients with simple distal HD were included. The proximal group had a larger proportion of patients with decreased biceps reflex, decreased triceps reflex, brisk or hyperactive knee reflex, positive Hoffmann sign, and cervical kyphosis. The curvatures of the upper part of the cervical spine (C2-4) were lost to a greater degree in the proximal group. More affected segments were observed on magnetic resonance imaging (MRI) and electromyography in the proximal group.ConclusionThe injured segments were longer and the upper curvature of the cervical spine was poorer in patients with HD with proximal involvement. These findings indicated that proximal involvement may indicate more serious HD.

Can screening for degenerative cervical myelopathy (SCREEN-DCM) be effectively undertaken based on signs, symptoms and known risk factors? Rationale and research protocol for a prospective, multicentre, observational study

IntroductionDegenerative cervical myelopathy (DCM) is the most common cause of spinal cord impairment. Unfortunately, the condition remains poorly recognised and underdiagnosed. To better identify patients, screening tests that target individuals...

Proposing a Framework to Understand the Role of Imaging in Degenerative Cervical Myelopathy: Enhancement of MRI Protocols Needed for Accurate Diagnosis and Evaluation.

Proposing a Framework to Understand the Role of Imaging in Degenerative Cervical Myelopathy: Enhancement of MRI Protocols Needed for Accurate Diagnosis and Evaluation.

Odontoid fracture complicating ankylosing spondylitis presenting with cervical canal stenosis and quadriparesis: A case report with 5-year follow-up and review of the literature.

Introduction and importanceSpinal fractures, especially cervical fractures, are more common in patients with ankylosing spondylitis in comparison with unaffected patients. However, odontoid fractures are relatively rare in these patients. Also, neurological symptoms are not common in odontoid fractures due to the larger diameter of the spinal canal at this level.Case presentationHere, we presented a 41 year-old man known case of ankylosing spondylitis who develop odontoid fracture and severe cervical stenosis after falling trauma. Quadriparesis and positive Hoffman sign as well as significant thoracolumbar kyphosis were diagnosed in further investigation. Laminectomy and posterior fixation were executed primary and pedicular subtraction osteotomy was performed two years later to manage the kyphosis and sagittal imbalance. On the follow-up period of five years the patient was fully functional.Clinical discussionThere are a few cases of odontoid fractures complicating ankylosing spondylitis in the literature. Neurological symptoms are relatively uncommon in odontoid fractures; however, cases with AS can present with neck pain, weakness, and hyperreflexia when having unstable fractures.ConclusionAlthough there is not any gold standard for the treatment of the odontoid fracture in AS, surgical intervention is preferred.

Buckling of the Ligamentum Flavum as a Rare Complication of Anterior Cervical Corpectomy and Fusion: A Case Report

Abstract Introduction and Importance Neurological deterioration due to buckling of the ligamentum flavum (LF) is an uncommon complication after anterior cervical corpectomy or discectomy with fusion. Case Presentation In this report, we present the case of a 66-year-old male who underwent anterior cervical partial corpectomy of C5 and discectomy of prolapsed C5-C6 with fusion. Postsurgery, the patient displayed signs of neurological deterioration. Upon immediate cervical magnetic resonance imaging (MRI), posterior canal stenosis and severe compression with cord signal due to LF buckling were detected. A posterior laminectomy procedure and canal decompression at the C5-C6 level with bone fusion were performed. Clinical Discussion Patient presented with walking difficulty, then walking disability, followed by bilateral upper and lower limb paresthesia with burning sensation. Examination showed ⅘ muscle strength in both handgrips. Further investigation showed brisk deep tendon reflexes, positive Hoffman sign unilaterally, equivocal Babinski sign, and progressive quadriparesis. Magnetic resonance imaging showed mild and diffuse building of some cervical discs, with spinal cord progression. We performed an anterior cervical corpectomy and fusion (ACCF) and anterior cervical discectomy and fusion (ACDF); a titanium mesh with plates and screws was used for fusion, with removal of a calcified and herniated subligamentous disc. Postoperatively, upper and lower limb strength deteriorated; immediate cervical and thoracic MRI showed LF buckling, which caused canal stenosis and severe compression. Urgent posterior laminectomy and canal decompression with bone fusion was scheduled on the same day. The patient underwent physiotherapy and regained upper and lower limb strength and his ability to walk. Conclusion This indicates the possibility of neurological deterioration as a result of LF buckling, which may be a result of LF thickening accompanied by hyperextension in the cervical region. In this regard, immediate imaging following signs of neurological complications after anterior cervical corpectomy or discectomy warrants early detection, which results in a better prognosis.

Scoliosis Secondary to Lumbar Spine Herniated Nucleus Pulposus in Adolescents: A Case Report

Introduction: Herniated nucleus pulposus (HNP) is infrequent among children and adolescents. The first case of surgical intervention for disc herniation was reported in a 12-year-old child. Since then, very few cases or series of cases have been published. The reactive scoliosis is frequently associated with lumbar HNPs, a compensatory effort to relieve nerve compression. Moreover, reactive scoliosis secondary to lumbar HNP is typically associated with children and usually resolves with effective management of lumbar HNP. Although the surgical intervention is frequently employed among adults, only 0.5% of discectomies are carried out in children &lt;16 years old. The current case report is of a 15-year-old girl, with no history of spinal ailment, who presented with a large disc herniation at L4–L5 region, associated with a reactive secondary scoliosis, which was resolved following a successful surgical intervention.&#x0D; Case Report: A 15-year-old female with known case of scoliosis and a history of lower back pain for nine months following a fall while playing football presented at outpatient clinic. She sought medical opinion after two months of persistent pain with radiculopathy to the right side toward big toe. Similarly, there was normal plantar reflex and no clonus or Hoffman sign. There was positive straight leg raise test as well as positive contralateral straight leg raise test. Scoliosis is idiopathic in majority of young patients. However, it might also arise as a part or complication of a triggering health state. Although scoliosis has been frequently associated with lumbar HNP among adolescents, most patients with lumbar disc ailment in this age group might be underdiagnosed initially. Similarly, in our case study the patient was not diagnosed when medical opinion was sought after two months of persistent pain with radiculopathy to the right side toward big toe. The clinical characteristics of pediatric lumbar HNP are usually comparable to those seen in adults; however, one distinguishing feature is that up to 90% have a positive straight-leg raising test. The most common symptom is lumbar pain; limitation of lumbar motility and lassegue are the most common signs. The etiology, pathophysiology, and patterns of the scoliotic posture in cases secondary to HNP remain debated. It is highly recommended to do CT scan in cases of adolescent lumbar HNP to rule out apophyseal ring fracture; accurate diagnosis helps surgeon in planning the appropriate surgical intervention needed. Scoliosis secondary to lumbar disc herniation is observed occasionally, therefore, its clinical significance and pathophysiology are not well-established. However, it is well-recognized that children’s spines have superior adaptive capacity, which shields nervous tissue. An example of this could be scoliosis in patients with root compression, when they bend to the side contrary to the compression, causing an enlargement of the affected foramen and root release. It has been reported that 80% of the patients with disc herniation and scoliosis had the convexity on the side of the root compression. The MRI findings revealed that the scoliosis widened the foramen. Similarly, in our case report the X-ray depicted scoliotic deformity with convexity toward the right side. MRI is the best imaging technique to indicate disc herniation and eliminate other likelihoods in both children and adolescents. Surgical interventions, such as micro-endoscopy discectomy and percutaneous endoscopic lumbar discectomy, could achieve considerable pain relief and function improvement. Our case finding revealed that microscopic discectomy relieved the pain and improved the scoliosis.&#x0D; Conclusion: Lumbar disc herniation is a rare entity among both children and adolescent and may also result in scoliosis and lumbar pain with or without sciatica. Therefore, lumbar disc herniation in association with scoliosis need vigilant evaluation of signs and symptoms in addition to appropriate diagnostic imaging. Imaging has a vital role in the diagnosis of underlying disease state and helps in clinical management along with surgical planning. The appropriate treatment is discectomy.

Correlation Study Between Clinical Special Tests for Myelopathy and Static MRI Parameters in Patients of Malaysian Population Treated for Cervical Dysfunction

Introduction: Cervical spondylotic myelopathy (CSM) is the most common cause of spinal cord dysfunction. Magnetic resonance imaging (MRI) remains the imaging modality of choice, but its findings are not completely specific for clinically significant CSM. This cross-sectional study aims to determine the pathoanatomy of CSM in patients and analyze the correlations between clinical key symptoms, myelopathic signs, and MRI findings.Methods: Patients with CSM aged 30 to 80 years old with no previous cervical spine disease or injuries were recruited. Clinical parameters include myelopathic hand signs and other clinical-specific tests. The MRI findings were analyzed for level of compression, underlying degenerative pathology, and parameters for cord compression.Results: Thirty patients were recruited. The most common myelopathic signs observed were positive Hoffmann’s sign and the presence of reverse brachioradialis reflex. All patients had either degenerative or prolapse disc changes on MRI. There was a positive correlation between the clinical key features with MRI parameters for canal and cord diameter. The transverse cord diameter, cord compression ratio, and approximate cord area were the only independent variables related to almost all the positive clinical specific tests. All three have a moderate to strong correlation with the clinical findings.Conclusion: The MRI parameters such as canal and cord size of the cervical spine are an objective reflection of compression on the spinal cord. Correlations observed indicate cord compression that plays a major role in the pathophysiology of CSM. These measurements are sensitive indicators of canal stenosis and play a significant role in predicting the severity and outcome of CSM.

Epidemiological study of cervical cord compression and its clinical symptoms in community-dwelling residents.

Degenerative compressive myelopathy (DCM) is caused by cervical cord compression. The relationship between the magnitude and clinical findings of cervical cord compression has been described in the literature, but the details remain unclear. This study aimed to clarify the relationship between the magnitude and clinical symptoms of cervical cord compression in community-dwelling residents. The present study included 532 subjects. The subjective symptoms and the objective findings of one board-certified spine surgeon were assessed. The subjective symptoms were upper extremity pain and numbness, clumsy hand, fall in the past 1 year, and subjective gait disturbance. The objective findings were: Hoffmann, Trömner, and Wartenberg signs; Babinski's and Chaddock's signs; hyperreflexia of the patellar tendon and Achilles tendon reflexes; ankle clonus; Romberg and modified Romberg tests; grip and release test; finger escape sign; and grip strength. Using midsagittal T2-weighted magnetic resonance imaging, the anterior-posterior (AP) diameters (mm) of the spinal cord at the C2 midvertebral body level (DC2) and at each intervertebral disc level from C2/3 to C7/T1 (DC2/3-C7/T1) were measured. The spinal cord compression ratio (R) for each intervertebral disc level was defined and calculated as DC2/3-C7/T1 divided by DC2. The lowest R (LR) along C2/3 to C7/T1 of each individual was divided into 3 grades by the tertile method. The relationship between LR and clinical symptoms was investigated by trend analysis. The prevalence of subjective gait disturbance increased significantly with the severity of spinal cord compression (p = 0.002812), whereas the other clinical symptoms were not significantly related with the severity of spinal cord compression. The magnitude of cervical cord compression had no relationship with any of the neurologic findings. However, subjective gait disturbance might be a better indicator of the possibility of early stage cervical cord compression.