Neurological manifestations of thoracic myelopathy in 203 patients

Transcription

1 Neurological manifestations of thoracic myelopathy in 203 patients Shota Takenaka* a, MD; Takashi Kaito b, MD; Noboru Hosono a, MD; Toshitada Miwa c, MD; Takenori Oda d, MD; Shinya Okuda d, MD; Tomoya Yamashita c, MD; Kazuya Oshima b, MD; Kazuo Yonenobu e, MD a Department of Orthopaedic Surgery, Osaka Kosei-nenkin Hospital b Department of Orthopaedic Surgery, Osaka University Hospital c Department of Orthopaedic Surgery, Kansai-Rosai Hospital d Department of Orthopaedic Surgery, Osaka-Rosai Hospital e Department of Orthopaedic Surgery, National Hospital Organization Osaka Minami Medical Center

2 Objective n To identify anatomic-pathology-specific or compressed-segment-specific symptoms of thoracic myelopathy by detailed investigation of the preoperative manifestations Summary of Background Data Detailed investigation of the preoperative manifestations of thoracic myelopathy in a large population has not been reported.

3 Materials & Methods ü Total 203 patients who underwent surgery for degenerative thoracic myelopathy from 2000 to 2010 ü 61 women and 142 men ü Mean age = 62.2 ± 12.3 (range, 21 87) years ü Mean preoperative disease duration = 595 ± 978 (range, ) days

4 Materials & Methods 19% SPD n=39 9 Women & 30 Men OLF+IDH n=3 11% IDH n=22 6 Women & 16 Men OLF n=106 53% 1 Woman & 2 Men 1% OLF+OPLL n=17 9 Women & 8 Men OPLL n=16 25 Women & 81 Men 8% 11 Women & 5 Men IDH = intervertebral disc herniation; SPD = spondylosis. 8% OLF = ossification of the ligamentum flavum; OPLL = ossification of the posterior longitudinal ligament.

5 Clinical Evaluation Deep tendon reflexes (DTR) Lower limb Patellar tendon reflex (PTR) Achilles tendon reflex (ATR) Upper limb Hoffmann s sign Wartenberg s sign DTRs for the biceps, brachioradialis, and triceps tendons Pathological reflexes Ankle clonus, Babinski sign Preoperative lower limb muscle strength Iliopsoas (IP) Quadriceps femoris (QF) Tibialis anterior (TA) Gastrocnemius (GS) Manual muscle testing (MMT 0 5 grades) was used. MMT grades less than four were defined as clinically weak. Bladder dysfunction Bladder dysfunction was evaluated based on the JOA bladder subscore (0 3). A grade of zero or one was considered severe dysfunction.

6 Complaints Complaints were classified by 17 categories. Frequent complaints are highlighted. Neck pain Middle back pain Low back pain Upper limb numbness Trunk numbness Lower limb numbness Upper limb pain Trunk radicular pain Lower limb pain Strange sensation in the sole Other abnormal sensation in the lower limbs Abnormal tightness in the lower limbs Subjective lower limb weakness Muscle atrophy in the lower limbs Foot drop Unsteady gait Other complaints % Complaints (onset) Complaints (pre-op)

7 Multivariate logistic regression analyses Anatomical pathology Age OLF OPLL IDH SPD Diabetes (DM) Potential predictors Compressed segments C7/T1-T9/10 Upper limb hyperreflexia T10/11 /12 / T9 T10 Spinal cord Cauda equina Differences based on anteriorposterior compression Response variables Complaints Lower limb DTR Pathological reflexes Lower limb muscle strength weakness(mmt3 or less) Severe bladder dysfunction(joa subscore 0 or 1)

8 Results Lower limb muscle weakness and T10/11 anterior compression Lower back pain and /12 compression T9 T10 Lower limb pain and /12 anterior compression Hyporeflexia in the PTR / Foot drop and / anterior compression

9 Discussion Schematic showing cross sections at the T10/11levels Lower limb muscle weakness and T10/11 anterior compression T10/11 Wall et al. JBJS-Am, 1990 Patients who had T10/11 anterior compression were more likely to have lower limb muscle weakness. Given the fact that only and nerve roots exist at this level, this muscle weakness is explained by long tract involvement or the involvement of spinal cord segments to L5 if they were located more rostally than previously thought.

10 Discussion Lower back pain and /12 compression Schematic showing cross sections at the /12levels /12 Wall et al. JBJS-Am, 1990 Patients with low back pain were predominantly compressed at /12, regardless of anterior or posterior compression. One explanation is the involvement of upper lumbar nerve roots including the nerve root. Although there are individual differences in the Termination level of the conus medullaris (TLCM) (TLCM in patients who showed low back pain and /12 compression were largely localized at the /2 intervertebral disc level and the upper-third of the vertebra), the to nerve roots flank the spinal cord at the /12 level. Involvement of the nerve root, whose infiltration is proposed to be an effective treatment for low back pain, may explain why patients with /12 compression showed a high prevalence of low back pain. Murata Y et al. Spine, 2009 Ohtori S et al. J Orthop Sci, 2010

11 Discussion Lower limb pain and /12 anterior compression Schematic showing cross sections at the /12 and / levels /12 Hyporeflexia in the PTR / Foot drop and / anterior compression Patients with /12 anterior compression showed a higher rate of lower limb pain, and there was a significant correlation between / anterior compression and foot drop. These correlations also may be explained by involvement of lumbar nerve roots. / anterior compression was implicated as preoperative predictors for hyporeflexia in the PTR, which can be related to lumbar nerve root involvement. L4 L5 L4 L5 / L5 L4 L5 L4 Wall et al. JBJS-Am, 1990 Disclosure declaration None of the authors has any potential conflict of interest.