Mielopatía aguda compresiva por absceso pulmonar. Presentación de un caso / Compressive acute myelopathy by pulmonary abscess. A case report

Las mielopatías constituyen un conjunto heterogéneo de procesos patológicos que directa o indirectamente afectan a la médula espinal. Son poco frecuentes y pueden ser producidos por variadas causas y vías de afectación, que conllevan a grandes secuelas y elevada discapacidad. Se describe un caso de mielopatía aguda compresiva desencadenada por un absceso pulmonar como causa y mecanismo de producción inusual. Hombre de 48 años, con antecedentes de salud y cuadro clínico de inicio brusco de paraparesia fláccida e hiporreflexia osteotendinosa de miembros inferiores asimétrica, con predominio derecho, nivel sensitivo dorsal a nivel de D4 y dolor a la percusión en procesos espinosos dorsales en D3-D6. Los estudios sanguíneos, inmunológicos y de líquido cefalorraquídeo resultaron irrelevantes, excepto muestra de signos indirectos de infección. La radiografía de tórax mostró la presencia del absceso pulmonar primario derecho y la afectación medular se corroboró a través de la realización de la resonancia magnética medular dorsal. Presentó pobre respuesta ante los esteroides parenteral, hasta que se inició la terapia antibiótica, de forma paulatina y con apoyo rehabilitador. Transcurridos tres meses se investigaron y fueron descartadas otras etiologías no compresivas. Las mielopatías agudas representan un grupo heterogéneo de trastornos con distintas etiologías y mecanismos de producción, a través de su estudio se evidenció como causa un absceso pulmonar con afectación medular, por lo que debe ser considerado en la extensa lista de diagnósticos diferenciales (AU).

Myelopathies are a heterogeneous group of pathological processes that directly or indirectly affect the spinal cord. They are rare and can be produced by different causes and affectation pathways leading to major consequences and high disability. A case of acute compressive myelopathy triggered by a lung abscess as unusual cause and production mechanism is described. It is the case of a man, aged 48 years, with a clinical history and symptoms of acute onset of flaccid paraparesis and asymmetric osteotendinous hyporeflexia of lower limbs, with right predominance, dorsal sensitive level at D4, and pain at percussion in D3-D6 dorsal spinal processes. Blood, immune and cerebrospinal fluid (CSF) studies were irrelevant, but showing indirect signs of infection. Chest radiography showed the presence of the right primary lung abscess and spinal cord involvement was confirmed by performing dorsal medullar magnetic resonance (MRI). The patient had poor response to parenteral steroids until antibiotic therapy began, gradually and with rehabilitation support. After three months, other non-comprehensive etiologies were studied and ruled out. Acute myelopathies represent a heterogeneous group of disorders with different etiologies and production mechanisms. The study evidenced a lung abscess with spinal cord involvement as a cause, so it should be considered in the extensive list of differential diagnoses (AU).

Assessment of the diagnostic value of diffusion tensor imaging in patients with spinal cord compression: a meta-analysis

We investigated the diagnostic value of the apparent diffusion coefficient (ADC) and fractional anisotropy (FA) of magnetic resonance diffusion tensor imaging (DTI) in patients with spinal cord compression (SCC) using a meta-analysis framework. Multiple scientific literature databases were exhaustively searched to identify articles relevant to this study. Mean values and standardized mean differences (SMDs) were calculated for the ADC and FA in normal and diseased tissues. The STATA version 12.0 software was used for statistical analysis. Of the 41 articles initially retrieved through database searches, 11 case-control studies were eligible for the meta-analysis and contained a combined total of 645 human subjects (394 patients with SCC and 251 healthy controls). All 11 studies reported data on FA, and 9 contained data related to the ADC. The combined SMDs of the ADC and FA showed that the ADC was significantly higher and the FA was lower in patients with SCC than in healthy controls. Subgroup analysis based on the b value showed higher ADCs in patients with SCC than in healthy controls at b values of both ≤500 and >500 s/mm2. In summary, the main findings of this meta-analysis revealed an increased ADC and decreased FA in patients with SCC, indicating that DTI is an important diagnostic imaging tool to assess patients suspected to have SCC.

Compressão medular / Medular compression

Este artigo abordará a investigação diagnóstica e tratamento de mielopatias causadas por compressões medulares agudas, com enfoque nas etiologias neoplásicas.

This article aims to review the diagnostic approach and treatment of myelopathies caused by acute spinal cord compression, focusing on neoplasic etiologies.

Accuracy of Diffusion Tensor Imaging for Diagnosing Cervical Spondylotic Myelopathy in Patients Showing Spinal Cord Compression

OBJECTIVE: To assess the performance of diffusion tensor imaging (DTI) for the diagnosis of cervical spondylotic myelopathy (CSM) in patients with deformed spinal cord but otherwise unremarkable conventional magnetic resonance imaging (MRI) findings. MATERIALS AND METHODS: A total of 33 patients who underwent MRI of the cervical spine including DTI using two-dimensional single-shot interleaved multi-section inner volume diffusion-weighted echo-planar imaging and whose spinal cords were deformed but showed no signal changes on conventional MRI were the subjects of this study. Mean diffusivity (MD), longitudinal diffusivity (LD), radial diffusivity (RD), and fractional anisotropy (FA) were measured at the most stenotic level. The calculated performance of MD, FA, MD∩FA (considered positive when both the MD and FA results were positive), LD∩FA (considered positive when both the LD and FA results were positive), and RD∩FA (considered positive when both the RD and FA results were positive) in diagnosing CSM were compared with each other based on the estimated cut-off values of MD, LD, RD, and FA from receiver operating characteristic curve analysis with the clinical diagnosis of CSM from medical records as the reference standard. RESULTS: The MD, LD, and RD cut-off values were 1.079 × 10⁻³, 1.719 × 10⁻³, and 0.749 × 10⁻³ mm²/sec, respectively, and that of FA was 0.475. Sensitivity, specificity, positive predictive value and negative predictive value were: 100 (4/4), 44.8 (13/29), 20 (4/20), and 100 (13/13) for MD; 100 (4/4), 27.6 (8/29), 16 (4/25), and 100 (8/8) for FA; 100 (4/4), 58.6 (17/29), 25 (4/16), and 100 (17/17) for MD∩FA; 100 (4/4), 68.9 (20/29), 30.8 (4/13), and 100 (20/20) for LD∩FA; and 75 (3/4), 68.9 (20/29), 25 (3/12), and 95.2 (20/21) for RD∩FA in percentage value. Diagnostic performance comparisons revealed significant differences only in specificity between FA and MD∩FA (p = 0.003), FA and LD∩FA (p < 0.001), FA and RD∩FA (p < 0.001), MD and LD∩FA (p = 0.024) and MD and RD∩FA (p = 0.024). CONCLUSION: Fractional anisotropy combined with MD, RD, or LD is expected to be more useful than FA and MD for diagnosing CSM in patients who show deformed spinal cords without signal changes on MRI.

Primary dorsal spine hydatid cyst

Primary dorsal hydatid cyst is rare and one of the important health conditions to be addressed in endemic countries and nations where the affected individuals may migrate. A twenty-seven years old female presented with gradual onset of mid-back pain and progressive numbness and weakness of both legs. MRI dorsal spine images showed multiple peripherally enhancing cystic lesions located in the posterior mediastinum with extension to adjacent vertebrae D4-5 causing destruction with kyphotic deformity and extension to posterior element. A small cystic lesion is extending to right aspect intra-spinal canal causing displacement and compression of spinal cord at D4-5 level. The clinical presentation, diagnosis and treatment of this case are discussed and review of the literatures is presented

Actinomycosis affecting the spinal cord: a case report / Actinomicose comprometendo a medula espinhal: um relato de caso

Actinomycosis is a rare, chronic, suppurative, granulomatous infection caused by a group of gram-positive anaerobic bacteria belonging to the natural flora of the oral cavity and gastrointestinal and urogenital tracts. It may involve several organs. This case study refers to pulmonary actinomycosis with chest wall involvement and cord compression in a 29-year-old male who presented with fever, cough, hemoptysis, neck pain, and paresis and plegia of the lower limbs of 5-month duration.

A actinomicose é uma infecção rara, crônica, supurativa e granulomatosa, causada por um grupo de bactérias anaeróbias Gram-positivas que pertencem à flora natural da cavidade oral, do aparelho gastrointestinal e urogenital. Pode envolver diversos órgãos. O estudo refere-se à actinomicose pulmonar com envolvimento da parede torácica e compressão medular em um paciente masculino com 29 anos que apresentava febre, tosse, hemoptise e cervicalgia, além de paresia e plegia em membros inferiores com cinco meses de evolução.

Médula anclada, dificultad diagnóstica en el adulto: reporte de un caso / Tethered cord, diagnostic difficulty in adult: report of a case

INTRODUCCIÓN: El síndrome de médula espinal anclada es una malformación de la región caudal de la columna vertebral. Es una enfermedad poco frecuente que aparece en el 5 por ciento de la población, de inicio inhabitual y diagnóstico tardío en el adulto. Puede llevar a disfunciones neurológicas, musculoesqueléticas, urológicas o gastrointestinales. PRESENTACIÓN DEL CASO: Paciente de sexo masculino de 50 años, con evidencia clínica e imagenológica de síndrome de médula anclada de inicio sintomático en la vida adulta, con historia de aparente incontinencia urinaria de esfuerzo diagnosticada hace 10 años. Luego de estudio por urología se diagnostica hiperplasia prostática benigna, por lo que se realiza resección transuretral de próstata. Posterior a ello, persiste la incontinencia urinaria y la sintomatología, se solicita interconsulta con neurólogo diagnosticándose médula anclada asociada a lipoma lumbosacro. DISCUSIÓN: Los exámenes de imágenes obtenidos, junto a un examen físico dirigido, orientaron a un síndrome mucho más amplio como lo es el síndrome de médula anclada, en el que la clínica urológica inicial del paciente presentado es una de las muchas formas posibles de debut de un síndrome que a lo largo de la vida pasó desapercibido. La falta de antecedentes previos de disfunción medular en la infancia, es responsable de la complejidad para llegar al diagnóstico con mayor precisión. En adultos, el momento de la cirugía es controversial y no existe consenso neuroquirúrgico al respecto.

INTRODUCTION: The tethered spinal cord syndrome is a malformation of the caudal region of the spine. Is a rare disease that occurs in 5 percent of the population, with an unusual start, and late diagnosis in adult. It can lead to neurological, musculoskeletal, urologic or gastrointestinal disorders. CASE REPORT: Fifty-year old male patient with clinical and imaging evidence of tethered cord syndrome of symptomatic onset in adulthood, with urinary incontinence since 10 years ago. After study by urologist, benign prostatic hyperplasia is diagnosed and transurethral resection of the prostate is done, but urinary incontinence symptoms persist, requesting consultation with a neurologist who diagnosed tethered cord associated with a lumbosacral lipoma. DISCUSSION: The imaging examinations and the led physical examination, directed at a broader syndrome as tethered cord syndrome, in which patient’s initial clinical urological presented is one of the many possible manifestations of a syndrome throughout life go unnoticed. The absence of prior history of spinal cord dysfunction in childhood is responsible for the complexity to make the diagnosis more accurately. In adults, the time of surgery is controversial and no neurosurgical consensus exists.

Estenosis acueductal en acondroplasia: a propósito de un caso / Aqueductal stenosis in achondroplasia: report of a case

Achondroplasia is the most frequent cause of disproportionate short stature. Characterized by abnormal growth of long bones, it renders a short-limbed individual of normal intelligence. A serious potential complication is spinal compression, which can happen at any level but is particularly common at the craniocervical junction. It can cause important morbility during the first few years of life, including sudden death. We present a 22-month-old patient diagnosed with achondroplasia, who developed aqueductal stenosis with symptomatic spinal cord compression, diagnosed during a routine consultation, requiring decompressive surgery with excellent results.

La acondroplasia es la condición asociada a talla baja desproporcionada más frecuente, caracterizada por un crecimiento óseo anormal, que resulta en talla baja con extremidades cortas e inteligencia normal. Una de las complicaciones más habituales es la compresión medular, que puede ocurrir a cualquier nivel, siendo más frecuente en la unión cráneo cervical, generando alta morbimortalidad en los primeros años de vida, principalmente por muerte súbita. Presentamos una paciente de 1 año 10 meses con diagnóstico precoz de acondroplasia, que presentó en su evolución estenosis acueductal con compresión medular, sintomática, pesquisada en control rutinario, que requirió cirugía descompresiva con buena evolución posterior.

Mielopatias agudas não compressivas: [revisão] / Acute non-compressive myelopathy: [review]

Mielopatias agudas são emergências neurológicas. Por serem pouco comuns, muitas vezes há dificuldade no diagnóstico e atraso no início do tratamento destes pacientes. Através de revisão de literatura, descrevemos as características das principais causas de mielopatias não compressivas: 1) mielopatias inflamatórias (doenças desmielinizantes, auto-imunes e para-infecciosas); 2) pós radiação tardia, 3) por alterações vasculares e 4) por deficiência de vitamina B12. Um algoritmo para auxílio na abordagem destes pacientes e posterior investigação etiológica é apresentado.

Prognostic Factors That Affect the Surgical Outcome of the Laminoplasty in Cervical Spondylotic Myelopathy

BACKGROUND: This study examined the prognostic factors that affect the surgical outcome of laminoplasty in cervical spondylotic myelopathy patients by comparative analysis. METHODS: Thirty nine patients, 26 males and 13 females, who were treated with laminoplasty for cervical myelopathy from September 2004 to March 2008 and followed up for 12 months or longer, were enrolled in this study. The mean age of the subjects was 62.4 years (range, 37 to 77 years). The patients' age, number of surgical segments, spinal cord compression ratio, segment number, level, localized marginal pattern of high signal intensity within the spinal cord in the T2 image, preoperative Japanese Orthopaedic Association Scoring System (JOA) score with the recovery ratio were compared respectively. The JOA score was used for an objective assessment of the patients' preoperative and postoperative clinical status. The recovery ratios of surgery were graded using the Hirabayashi equation. Statistical analysis was carried out using Pearson correlation analysis. RESULTS: The patients' JOA score increased from a preoperative score of 11.1 (range, 5 to 16) to a postoperative score of 14.9 (range, 7 to 17). The average recovery ratio was 65.8% (range, 0 to 100%). The number of segments with high signal changes in the T2 image, a localized marginal pattern with high signal change, signal intensity changes in the upper cervical spinal cord were inversely associated with the recovery ratio, whereas the spinal cord compression ratio showed a significant positive correlation. However, the currently known prognostic factors, such as number of surgical segment, age, and preoperative JOA score, showed no statistically significant correlation. CONCLUSIONS: The number of segments, localized marginal pattern, rostral location of signal intensity c hanges with a high signal change in the T2 image and a low spinal cord compression ratio in cervical spondylotic myelopathy patients treated by laminoplasty can indicate a poor prognosis.

Formações císticas epidurais relacionadas a bursite interespinhosa, cisto sinovial e cisto discal / Epidural cystic masses associated with interspinous bursitis, synovial and discal cysts

Os autores apresentam casos de cistos epidurais, dentre eles os cistos sinoviais, discais, do ligamento amarelo e relacionados a bursite interespinhosa, todas essas condições determinando compressão radicular, do saco dural ou estenose do canal vertebral. Descrevem as características de imagem e localização na ressonância magnética nessas diferentes afecções.

The authors describe some cases of epidural cysts, namely synovial, discal, ligamentum flavum cysts, and cysts secondary to interspinous bursitis, all of these conditions determining radicular, dural sac compression or spinal canal stenosis. Magnetic resonance imaging findings and localization of these entities are described.

Mal de Pott: uma doença milenar em um novo século / Pott's disease: an ancient disease in a new century

A tuberculose espinhal, também conhecida como Mal de Pott ou Doença de Pott, caracteriza-se como a forma mais frequente de tuberculose extrapulmonar. Apresentamos aqui o caso de uma paciente encaminhada ao Serviço de Neurologia do Hospital de Clínicas de Porto Alegre com um quadro de dois meses de evolução, apresentando sintomas de compressão medular. O diagnóstico de tuberculose espinhal foi realizado por punção guiada por tomografia computadorizada e a paciente foi submetida à drenagem do abscesso. Concomitantemente, foi iniciado o tratamento com RHZ e a paciente evoluiu com melhora dos sintomas neurológicos. Esse caso ilustra que mesmo pacientes com alterações neurológicas importantes devido à tuberculose medular podem apresentar melhora significativa com tratamento.

Spinal tuberculosis, also known as Pott's disease, is the most common form of extra-pulmonary tuberculosis. We report on a patient referred to the Division of Neurology of Hospital de Clínicas de Porto Alegre presenting with spinal cord compression symptoms for two months. The diagnosis of spinal tuberculosis was rapidly done by a computerized tomography guided biopsy. The patient was submitted to abscess surgical draining and complementary RHZ treatment, with recovery of neurological symptoms. This case illustrates that even patients with severe neurological deficits due to spinal tuberculosis may have a good outcome with the appropriate treatment.

Discopatías lumbares: patología, diagnósticos y tratamiento quirúrgico / Lumbar disc: pathology, diagnostic and surgical treatment

La patología raquídea lumbar degenerativa de la que es una parte la Hernia Discal, es una causa más frecuente de Síndrome Lumbociático. De los pacientes con esta entidad clínica alrededor del 90 por ciento mejora con tratamiento médico consistente en reposo, analgésico antiinflamatorios, fisioterapias, etc, indicado por diferentes especialistas. Sólo alrededor de un 10 por ciento de los pacientes tiene indicación quirúrgica, decisión que debe ser la resultante de una correcta evaluación clínica y de una adecuada correlación clínico radiológica. Por tratarse de una patología frecuente especialmente en nuestra época de gran experiencia física de tipo laboral y deportiva, con mayor incidencia en edades productivas de los pacientes, con un costo social alto y necesidad de una reincorporación precoz a sus actividades, es importante definir el rol del tratamiento quirúrgico, la oportunidad de su indicación, la técnica adecuada, su costo y resultados.

The Disc Hernia witch forms part of the Lumbar Spinal Degenerative Disease is the most frequent cause of the Lumbociatic Syndrome. Ninety percent of the patients with this syndrome get better with medical treatment consisting of rest, analgesics, anti inflammatory drugs, Physiotherapy , Kinesiotherapy, etc, indicated by different specialists. Only around 10 percent of the patients require surgery, decision that should be the result of a correct clinical evaluation and an adequate clinical radiological correlation. As it is a frequent syndrome specially in these days of great physical demand in work and sports, with a high rate of incidence in the productive age of the patients, a high social cost and the need of a pront returne to the work field, it is important to define the role of the surgical treatment, the adequate timing and technique and its cost and results.

Spinal cord hamartoma with pseudopancreatic cyst.

A 2-year-old boy presented with weakness of both lower limbs with bladder and bowel involvement and history of frequent falls. Magnetic resonance imaging of the spine revealed a T2 altered signal intensity enhancing mass lesion seen in the spinal epidural space extending from sixth cervical to fourth thoracic vertebrae, which was compressing the adjacent spinal cord. Histopathology of the lesion was suggestive of hamartoma. A brief review of the literature including its embryogenesis is discussed here. The child subsequently developed pseudopancreatic cysts possibly because of repeated falls leading to blunt trauma abdomen.

Synovial cyst of the thoracic spine: case report

Spinal cord compressing syndrome due to synovial cyst (SC) of the thoracic spine is a rare clinic condition. We report a case of SC located in the thoracic spine causing spastic paraparesis in a 14 year-old female patient. The SC was removed thoroughly by laminectomy. The patient had an excellent recovery. The etiological and therapeutic aspects are discussed.

Síndrome de compressão medular causada por cisto sinovial (CS) da coluna torácica é patologia rara e pouco descrita na literatura. Descrevemos um caso de CS da coluna torácica causando paraparesia espástica em uma paciente de 14 anos de idade. O cisto foi removido através de laminectomia e a paciente apresentou uma excelente recuperação. Discutimos os aspectos etiológicos e terapêuticos.

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.

Relatamos o primeiro caso de compressão medular torácica sintomática causada por pseudomeningocele pós-operatória. Paciente masculino, 49 anos, apresentou perda progressiva de força nas extremidades inferiores dez meses após recuperação neurológica completa de cirurgia para remoção de schwannoma intradural-extramedular torácico. A ressonância magnética dorsal revelou pseudomeningocele (T11-T12). A abordagem cirúrgica mostrou fechamento dural inadequado com fistula liquórica espontânea. O defeito foi corrigido com sutura, músculo e cola biológica. O paciente teve boa evolução pós-operatória. Pseudomeningocele deve fazer parte do diagnóstico diferencial de mielopatia surgida após cirurgia na coluna dorsal.

Tetraparesis secondary to cervical ossification of the posterior longitudinal ligament: case report

Ossification of the posterior longitudinal ligament (OPLL) is a rare cause of myelopathy in non-Oriental populations and relatively unrecognized by general practitioners. A case of an Afro-Brazilian 54-years-old woman presenting with tetraparesis due to cervical OPLL is presented. Emphasis is made for the inclusion of OPLL in the differential diagnosis of compressive cervical myelopathy.

Ossificação do ligamento longitudinal posterior (OLLP) é causa rara de mielopatia na população não Oriental e relativamente subdiagnosticada por clínicos gerais. Relata-se um caso de mulher de 54 anos descendência Afro-Brasileira com tetraparesia associada a OLLP cervical. Enfatiza-se a inclusão da OLLP como diagnóstico diferencial de mielopatia cervical compressiva.