Non-compressive Myelopathies Research Articles

Spinal shock in severe SCI dogs and early implementation of intensive neurorehabilitation programs

Spinal shock is complex, paradoxical with sudden presentation, possibly leading to a guarded prognosis. Thus, it is suggested the need for early implementation of intensive neurorehabilitation. This prospective controlled blinded cohort study aims to understand the implication of spinal shock in neurorehabilitation of severe SCI dogs and the importance of its evaluation thought a spinal shock scale (SSS). 371 dogs were randomized by stratification according the presence of spinal shock in the SG (n = 245) or CG (n = 126). The SSS, a punctuation scale (0–7), was evaluated at admission and each 6 h for 3 days, each day for 15 days, each week for 6 weeks, each month until 3 months, followed by 3 monthly follow-ups. All dogs had similar land and underwater treadmill training with functional electrical stimulation. Observational dataset allowed an approximate level of power (1-β) of 0.90 and an α (Type I error) of 0.01, with a total of 11,088 SSS observations between two blinded observers and 18% of disagreement. 75% of the dogs were admitted in 24-48 h after injury, allowing early detection of spinal shock, and dogs admitted at 72 h with SSS ≥ 4 were not able to achieve ambulation. Regarding ambulation rate, there was a significant difference between groups, with 66.9% of ambulation in the SG and 97.6% in the CG. Also, there was a difference in regard to time until ambulation, with a mean of 31.57 days for the SG and 23.02 for the CG. The SSS estimated marginal means had an exponential decrease within the first 6 h, followed by a slower decrease, but always faster in spinal shock dogs diagnosed with non-compressive myelopathies. Thus, early intensive neurorehabilitation in dogs after severe SCI may benefit from SSS classifications at admission and during treatment to establish different therapeutic protocols according to each patient's needs, especially in deep pain negative dogs.

A Comparison Between Somatosensory Evoked Potentials and Spine MRI in the Diagnosis of Non-compressive Myelopathy: Which Is More Accurate?

Non-compressive myelopathy is a neurological disorder due to pathological processes affecting the spinal cord in the absence of clinical and radiological evidence of spinal cord compression. Two commonly used diagnostic tools for non-compressive myelopathy are somatosensory evoked potentials (SSEPs) and magnetic resonance imaging (MRI). SSEPs are a neurophysiological tool used to assess the functional integrity of the spinal cord. MRI, on the other hand, is the mainstay imaging modality used for identifying compressive lesions and other structural abnormalities in the spinal cord.The aim of this study was to test the diagnostic accuracy of SSEPs versus spine MRI in the diagnosis and assessment of the severity of non-compressive myelopathy using the Modified Japanese Orthopaedic Association (mJOA) clinical severity score. Our study included 63 subjects. Whole spine MRI and SSEPs (median and tibial SSEP bilaterally) were done for all subjects; their results were compared according to their relation to the mJOAscore and classified into mild, moderate, and severe. The control group was examined to establish normative data for SSEPresults and compared with cases. Blood investigations such as complete blood count, thyroid function test, A1C, HIVtests, venereal disease research laboratory test, erythrocyte sedimentation rate, C-reactive protein, and antinuclear antibodytests were done. Blood tests for vitamin B12 levels were done for patients who were suspected of sub-acute combined degeneration of the spinal cord; cerebrospinal fluid (CSF) analysis was done for patients suspected of multiple sclerosis (MS), acute transverse myelitis (ATM), or other inflammatory/infectious diseases. CSF was analyzed for cell count, cytology, protein, and oligoclonal bands (if indicated). No mild categories were registered in this study; 30%of patients were moderateand 70%were severe. Causes for non-compressive myelopathy in this study werehereditary degenerative ataxias in 12 (38.71%), ATM in 8 (25.81%), and MS in 5 (16.13%); other causes included vitamin B12 deficiency in 2 (6.45%), ischemia in 2 (6.45%), and an unknown cause in 2 (6.45%). SSEPs showed abnormal results in all patients (31; 100%) whereas MRI showed abnormality in only seven patients (22.6%). SSEPsensitivity for detecting severe cases was around 63.6% while that for MRI was 27.3%. The study concluded that SSEPs were more reliable for the detection of non-compressive myelopathies rather than MRI and correlated better with clinical severity. Performing SSEPs is recommended for all patients with non-compressive myelopathy, especially those with negative imaging.

Relation of fibrocartilaginous embolism and acute and non-compressive nucleus pulposus extrusion with imaging tests - case report

ABSTRACT Fibrocartilaginous embolism (FCEM) and acute, non-compressive nucleus pulposus extrusion (ANNPE) are non-compressive myelopathies that are difficult to differentiate. The definitive diagnosis is obtained only with histology, but the presumptive diagnosis is made through clinical signs and imaging tests. The aim of this study is to report the imaging tests performed for the diagnosis of a neurological clinical case and discuss the best diagnostic method. After attending the patient, complementary tests were requested. Radiography results showed no change. The computed tomography diagnostic impression indicated distal protrusion between C6-C7, T11-T12, T13-L1 followed by mild spinal cord compression defined by the presence of a ventral hyperattenuating region. Magnetic resonance (RMI), showed a slight T2W hypersignal, well delimited in the gray matter, lateralized to the right, over the cranial third of C7. Concluding that the magnetic resonance is the method that brought more information for the diagnosis, in which the others were not described medullary alterations pertinent to FCEM and ANNPE. With their fair prognosis, the absence of histological diagnosis of these diseases may be a limiting factor in this study and, in relation to the RMI alterations being very similar between FCEM and ANNPE it is not possible to diagnose fully accurately.

Clinico-Radiological Spectrum of Non-Compressive Myelopathies

Objective: To study the etiology and clinico-radiological profile of non-compressive myelopathies. Methods: 40 consecutive admissions of non-compressive myelopathy were studied for clinical and radiological profile. Statistical methods: Descriptive statistics, linear regression and independent t-test using SPSS 20. Results: Age of the studied population ranged from 2 years to 55 years with a median age of 32.35 years and male:female ratio of 2:1. 87.5% of cases had an acute to subacute presentation. Complete cord syndrome was the most common presentation followed by anterior cord syndrome, central cord syndrome and mixed pattern. LETM was seen in nearly two-thirds of cases. Lesions involving more than two-thirds of the cross section of spinal cord were seen in more than 60% of cases, thereby accounting for significant disability at onset. Most of the lesions were hyperintense on T2 and STIR images and isointense on T1 with only 18.91% showing contrast enhancement. Optic neuritis was recorded with an overall prevalence of 28.26%. EDSS at presentation varied among the subgroups with ADEM, NMOSD and LETM form of ITM having EDSS scores of 9.5,8.0 and 7.5 respectively whereas in MS and Non-LETM form of ITM, EDSS score was 4.0 and 2.5 respectively. Conclusion: Demyelinating disorders contribute to nearly 80% cases of non-compressive myelopathies with NMOSD being the most common pathology. CSF cell count, cross-sectional involvement of spinal cord, pattern of myelitis and aquaporin-4 seropositivity were found to be predictive of the severity at onset i.e., EDSS at presentation with the initial 3 factors also showing predictability of EDSS at last visit.

Acute Onset Quadriplegia as a Complication of Hepatitis a Infection: A Case Report

Acute onset quadriplegia is a potentially treatable neurological emergency. Common etiologies include radiculoneuropathies, compressive and non-compressive myelopathies. Spontaneous non traumatic spinal epidural hematoma is a relatively uncommon phenomenon. Here we report an interesting patient who developed coagulopathy related spinal epidural hematoma resulting in acute painful quadriplegia as a complication of hepatitis A infection.

Evaluation of Cases of Non-Compressive Myelopathies- A Clinical Study

Evaluation of Cases of Non-Compressive Myelopathies- A Clinical Study

Imaging of other encephalitis and of noncompressive acute transverse myelopathies

Acute encephalitis syndrome (AES) is characterised with acute onset of fever and altered sensorium. Flavivirus infections (West Nile, Dengue, Zika and Japanese encephalitis) are common causes of AES. Subacute sclerosing panencephalitis can present acutely as AES. Bacteria, fungi and parasites are other causes of encephalitis. Autoimmune encephalitis describes a group of brain disorders associated with antineuronal autoantibodies Neuroimaging in various encephalitis is often distinctive. Herpes simplex virus type 1, for example, preferentially affects the mesial temporal lobes. In flavivirus brain infections deep grey matter and periventricular white matter involvement are common. In autoimmune limbic encephalitis, there is preferential involvement of the amygdala and hippocampus. In bacterial, fungal and parasitic disorders, single or multiple enhancing lesions of brain are demonstrated. The term “transverse myelopathies” defines a group of disorders that involves few segments of spinal cord. It clinically manifests with motor, sensory, and bladder involvement. Acute transverse myelopathies, most frequently, are autoimmune in nature. Next, common causes are demyelinating like multiple sclerosis or neuromyelitis optica (NMO) spectrum disorders. A variety of infections, like virus, can directly affect the spinal cord. Acute flaccid myelitis is a polio-like illness. MRI demonstrates a longitudinal lesion in the spinal grey matter. In endemic regions, Mycobacterium tuberculosis is a common cause of transverse myelitis. In transverse myelitis, T2-weighted spinal cord images typically demonstrates hyperintense signals. Pattern of imaging abnormalities differs in different diseases, in multiple sclerosis <2 segments of spinal cord are typically partially involved. In other transverse myelopathies like NMO >3 segments are involved.

A Study on Etiological Profile of Non-Compressive Myelopathies in a Tertiary Care Hospital in Central Tamilnadu

A Study on Etiological Profile of Non-Compressive Myelopathies in a Tertiary Care Hospital in Central Tamilnadu

Medullar Kock without Pott: 13 cases observed at the university hospital center of Conakry, Guinea

Background: The diagnostic certainty of medullar tuberculosis (TB) without Pott disease is difficult to establish in a tropical environment with the large group of infectious, parasitic, and systemic myelopathies, despite the increasing availability of magnetic resonance imaging (MRI) data and improvement of biological exploration platforms. Methods: We retrospectively analyzed the files of 186 patients hospitalized in the Department of Neurology and Neurosurgery of the University Hospital Center of Conakry, Guinea, between 2008 and 2016 for the management of non-compressive and compressive myelopathy. Biological evidence of TB infection was demonstrated for 13 (6.9%) patients. Results: Infectious clinical picture prior to the development of neurological signs was reported in 11 patients (84.6%). The neurological signs were summed up by the existence of a sensitivo-motor semiology of progressive evolution (100% of cases) with sphincter disorders in 11 patients (84.6%) and a medullary compression symptomatology with a lesion and under lesion syndrome from the outset in 4 patients (30.8%). Medullary MRI revealed an extensive intramedullary hypersignal in 9 patients with non-compressive myelopathy and in 4 cases, the lesions appeared in T1 hypersignal and T2 isosignal were localized. Lumbar puncture (LP) revealed lymphocytic pleocytosis, hypoglucorrhage (0.3 to 0.5 g/l), and leukocytosis. Conclusion: This study reveals a classic clinical, biological, neuroradiological, and evolutionary profile of compressive and non-compressive myelopathies. These results are important for the therapeutic and evolutionary discussion of TB myelopathies for good management.

Epidemiological andEtiological Characteristics ofMyelopathies intheNeurology Department oftheUniversity Hospital Center ofCocody, Abidjan (Ivory Coast)

The term myelopathy defines a suffering of the spinal cord whatever the etiologies. They often represent real therapeutic emergencies and are burdened by serious functional sequelae. The aim of this work was to describe the epidemiological, clinical, and etiological aspects of all myelopathies. We have conducted a prospective and descriptive study from January1, 2015 to December31, 2016 at the Neurology department of the Cocody University Hospital in Abidjan. Seventy-one patients out of 1,006 were included, that is, a prevalence of 7.06%. The sex ratio was 1.7. The average age was 49years old. HIV was associated with myelopathy in 24.7% of cases. Medullary compression syndrome was predominant. Pott's disease was the etiology of compressive myelopathies (43.9%) followed by bone metastases (26.8%). Tuberculous myelitis was the most common etiology of non-compressive myelopathies (30%). Myelites of undetermined causes account for 50% of non-compressive myelopathies.

Etiological Diagnosis of Non-Traumatic Myelopathies: Experience in a Tertiary Health Care Center in Bangladesh

Background: The relative frequency of non-traumatic compressive and non-compressive myelopathies and their etiologies have not been evaluated extensively in Bangladesh. This study was aimed to identify the etiological diagnosis of non-traumatic myelopathies.Methods: One hundred cases of non-traumatic myelopathic admitted patients were prospectively studied during 2009- 2012 in the neurology ward of Sir Salimullah Medical College and Mitford Hospital, Dhaka, Bangladesh. Patients underwent a detailed clinical evaluation followed by laboratory investigations and neuroimaging studies.Results: Among 100 cases, 46 patients (male 41 and female 5) presented with quadriparesis and 54 patients (male 30 and female 24) presented with paraparesis. Duration of symptoms before presentation to the hospital was considerably higher in quadriparesis compared to paraparesis (230.09 ± 31.16 days VS 136.82 ± 21.77 days; p value = 0.016). There were no significant differences in the number of patients admitted between compressive and non-compressive groups (p value – 0.4035). Common etiologies observed in this study were vertebral disc disease (23%), spinal cord tumor (15%), Pott’s disease (15%), acute transverse myelitis (13%) and motor neuron disease (11%).Conclusion: Vertebral disc disease, spinal cord tumors, infection (Pott’s disease), post infectious condition (ATM), and neurodegenerative disease (MND) are mostly responsible for myelopathies.J Bangladesh Coll Phys Surg 2018; 36(2): 53-58

Etiologic spectrum and prognosis in noncompressive acute transverse myelopathies: An experience of 80 patients at a tertiary care facility.

We evaluated the spectrum of acquired demyelinating and inflammatory disorders in patients presenting with an acute transverse myelopathy. We also studied differences between an acute idiopathic transverse myelitis and myelitis resulting from other etiologies. Eighty consecutive patients with acute transverse myelopathy were included. At inclusion, clinical profile, serum and cerebrospinal fluid parameters, brain and spinal cord magnetic resonance imaging, and visual evoked potentials were obtained. All patients were given methylprednisolone therapy. Patients were followed up for 6 months. Outcome was assessed using modified Barthel index. A modified Barthel index score of ≤12 indicated a poor prognosis. Majority (n = 49; 61.25%) of patients had idiopathic acute transverse myelitis. Eleven cases had neuromyelitis optica spectrum disorders (8 had anti-aquaporin antibody positivity). Multiple sclerosis was diagnosed in 7 cases. Eight cases had infectious or parainfectious myelitis. Longitudinally extensive transverse myelitis was noted in 66 (82.5%) patients. Seventeen patients had abnormalities in the brain. Majority of patients improved following methylprednisolone therapy. On univariate analysis, delay in administering methylprednisolone therapy, poor modified Barthel index at discharge, and extensive cord involvement were associated with severe residual disability. On multivariate analysis, delayed initiation of methylprednisolone was identified as a poor prognostic factor. A variety of inflammatory, infective, demyelinating, and autoimmune disorders present with acute transverse myelopathy. Early institution of methylprednisolone reduces the disability in these patients.

A Systematic Review of Non-Traumatic Spinal Cord Injuries in Sub-Saharan Africa and a Proposed Diagnostic Algorithm for Resource-Limited Settings.

Non-traumatic myelopathy is common in Africa and there are geographic differences in etiology. Clinical management is challenging due to the broad differential diagnosis and the lack of diagnostics. The objective of this systematic review is to determine the most common etiologies of non-traumatic myelopathy in sub-Saharan Africa to inform a regionally appropriate diagnostic algorithm. We conducted a systemic review searching Medline and Embase databases using the following search terms: "Non traumatic spinal cord injury" or "myelopathy" with limitations to epidemiology or etiologies and Sub-Saharan Africa. We described the frequencies of the different etiologies and proposed a diagnostic algorithm based on the most common diagnoses. We identified 19 studies all performed at tertiary institutions; 15 were retrospective and 13 were published in the era of the HIV epidemic. Compressive bone lesions accounted for more than 48% of the cases; a majority were Pott's disease and metastatic disease. No diagnosis was identified in up to 30% of cases in most studies; in particular, definitive diagnoses of non-compressive lesions were rare and a majority were clinical diagnoses of transverse myelitis and HIV myelopathy. Age and HIV were major determinants of etiology. Compressive myelopathies represent a majority of non-traumatic myelopathies in sub-Saharan Africa, and most were due to Pott's disease. Non-compressive myelopathies have not been well defined and need further research in Africa. We recommend a standardized approach to management of non-traumatic myelopathy focused on identifying treatable conditions with tests widely available in low-resource settings.

Etiological profile of noncompressive myelopathies in a tertiary care hospital of Northeast India.

Background:The discovery of antibodies against aquaporin-4 and evolving concepts of noncompressive myelopathies in the 21st century have made a major impact on the etiological profile of these diseases, with few cases turning out to be idiopathic.Objective:To find causes of noncompressive myelopathy in a tertiary care hospital of Northeast India.Materials and Methods:An observational study was carried out in the Neurology Department of Gauhati Medical College, Guwahati, from September 2013 to February 2016. Patients of noncompressive myelopathies who underwent magnetic resonance imaging (MRI) of the spine were segregated into two categories: acute-to-subacute myelopathy (ASM) and chronic myelopathy (CM). In addition to routine blood tests, chest X-ray, urinalysis, and visual evoked potentials, investigations included MRI of the brain, cerebrospinal fluid analysis, and immunological, infectious, and metabolic profile based on the pattern of involvement.Results:The study had 151 patients (96 ASM and 55 CM) with a median age of 35 years and male: female ratio 1.4:1. The causes of ASM were neuromyelitis optica spectrum disorder (23), multiple sclerosis (MS) (8), systemic lupus erythematosus (1), Hashimoto's disease (1), postinfectious acute disseminated encephalomyelitis (6), postinfectious myelitis (8), infections (9), spinal cord infarct (5), and electrocution (1). The causes of CM were MS (1), probable or possible sarcoidosis (7), mixed connective tissue disease (1), Hashimoto's disease (2), infections (9), Vitamin B12 deficiency (4), folate deficiency (2), hepatic myelopathy (2), radiation (11), and paraneoplastic (1). No etiology could be found in 48 (31.8%) patients (34 ASM and 14 CM). In 21/96 (21.9%) patients of ASM, acute transverse myelitis was idiopathic based on current diagnostic criteria.Conclusion:Underlying etiology (demyelinating, autoimmune, infectious, vascular, metabolic disorder, or physical agent) was found in 68% patients of noncompressive myelopathy.

Etiological profile of noncompressive myelopathies in a tertiary care hospital of Northeast India

Etiological profile of noncompressive myelopathies in a tertiary care hospital of Northeast India

The challenge of acute non-compressive transverse myelopathies

The challenge of acute non-compressive transverse myelopathies

An Approach to the Diagnosis of Acute Transverse Myelitis

The differential diagnosis of acute inflammatory transverse myelitis (ATM) is broad. Therefore, physicians must be aware of the many potential etiologies for acute myelopathy, and should pursue an ordered, efficient, and cost-effective approach to the diagnosis based on the patient's clinical history, examination, and magnetic resonance imaging (MRI) findings. Clinical, immunological, and radiological findings of non-compressive myelopathies are reviewed, as are how these findings can be used to distinguish between demyelinating, infectious, other inflammatory, vascular, neoplastic, and paraneoplastic etiologies. We also review predictors of further episodes of ATM in patients with demyelinating disorders. We discuss the diagnostic clues and pitfalls of the not uncommon clinical scenario of a presumed "myelopathy with normal MRI." Finally, we suggest an algorithm for the diagnosis and management of acute myelopathies.

Acute transverse myelitis

Acute noncompressive myelopathies were first recognized in the 19th century, and early pathologic studies identified both inflammatory and vascular etiologies.1–3 The terms acute transverse myelitis (ATM) and acute transverse myelopathy have been used interchangeably to describe a syndrome characterized by anterior and posterior (hence transverse) spinal cord impairment resulting in weakness, a sensory level, and autonomic dysfunction. Possible causes include vascular, infectious, neoplastic, collagen vascular, iatrogenic, and autoimmune etiologies.4 In addition, the syndrome can occur as part of CNS demyelinating disease such as neuromyelitis optica (NMO) or, uncommonly, typical multiple sclerosis (MS). Once such recognized causes are excluded, the question remains as to whether there exists a unique disease entity “idiopathic ATM.” Based on expert opinion, the Transverse Myelitis Consortium Working Group (TMCWG) proposed diagnostic criteria for idiopathic ATM.5 The clinical requirements include bilateral sensory, motor, or autonomic dysfunction referable to the spinal cord, with a clearly defined sensory level that progresses to the nadir over 4 to 21 days from onset. Neuroimaging, preferably MRI, is used to eliminate structural causes. …

Role of MRI in differentiating various causes of non-traumatic paraparesis and tetraparesis.

To assess the frequency of various causes of non-traumatic paraparesis and tetraparesis in adults based only on the findings of magnetic resonance imaging (MRI). Non-interventional descriptive study carried out from May 2001 to October 2002 at Radiology Department, CMH, Rawalpindi. A total of 100 adult patients who presented with non-traumatic paraparesis or tetraparesis, were studied. MRI spine of all the patients and MRI brain of selected patients, was carried out. Based on MRI findings alone causes of non-traumatic paraparesis and tetraparesis were categorized. Paraparesis was more frequent than tetraparesis. Cord compression was found in 72% cases. Neoplastic compression, infective spondylitis and non-compressive myelopathies were the main causes of paraparesis while spondylotic myelopathy was the main cause of tetraparesis. Based upon MRI findings causes of non-traumatic paraparesis or tetraparesis can be subcategorized into spondylotic, infective or neoplastic cord compression and non-compressive myelopathies. Further subcategorization of neoplastic lesions according to their compartment of origin can also be done.

A prospective study of “undiagnosed” isolated myelopathy: II. Value of magnetic resonance imaging, evoked potentials and CSF analysis

We aimed to determine the sensitivity of available "diagnostic" tests in detecting subclinical abnormalities characteristic of multiple sclerosis (MS) in patients with unexplained isolated myelopathy, and any relationship between test results and level of disability. The trial investigations were carried out in 69 prospectively selected patients with acute or chronic noncompressive myelopathies. Magnetic resonance scans were the most sensitive individual tests, revealing asymptomatic brain lesions in 51 patients (74%, C.I. 64-84). An abnormal IgG/albumin ratio (IgG/A) was present in 29 (42%, C.I. 30-54), oligoclonal bands (OCB) in 27 (39%, C.I. 17-39) and abnormal evoked potentials (EP) (visual and/or auditory brain stem) in 19 cases (28%, C.I. 17-39). OCB and abnormal EP were found significantly less often than in control patients with clinically definite MS (CDMS) and significantly more often than in patients with myelopathy due to other conditions. The number of anatomical brain areas with lesions on magnetic resonance imaging (MRI) was significantly associated with CSF abnormalities; abnormal EP were correlated with abnormal MRI and elevated CSF immunoglobulins. Clinical classifications, age, symptom duration, disability levels and genetic factors did not appear to influence the prevalence of abnormal MRI or CSF. For the exclusion of compressive and structural diseases of the spinal cord, myelography has been superceded by cervical and thoracic MRI. In addition, MRI of the brain is the investigation of choice in patients with myelopathies that remain unexplained after spinal MRI. However, whether used alone or in combination with other tests, the specificity and predictive value of brain MRI abnormalities for the risk of developing MS, as well as the associated "false positive" rates, remain to be defined by long-term follow-up of prospectively ascertained and representative cases.