Thoracic cord compression caused by disk herniation in Scheuermann's disease: a case report and review of the literature

Degenerative Thoracic Myelopathy: A Scoping Review of Epidemiology, Genetics, and Pathogenesis

STUDY DESIGN

Literature Review.

OBJECTIVE

Myelopathy affecting the thoracic spinal cord can arise secondary to several aetiologies which have similar presentation and management. Consequently, there are many uncertainties in this area, including optimal terminology and definitions. Recent collaborative cervical spinal research has led to the proposal and subsequent community adoption of the name degenerative cervical myelopathy(DCM), which has facilitated the establishment of internationally-agreed research priorities for DCM. We put forward the case for the introduction of the term degenerative thoracic myelopathy(DTM) and degenerative spinal myelopathy(DSM) as an umbrella term for both DCM and DTM.

METHODS

Following PRISMA guidelines, a systematic literature search was performed to identify degenerative thoracic myelopathy literature in Embase and MEDLINE.

RESULTS

Conditions encompassed within DTM include thoracic spondylotic myelopathy, ossification of the posterior longitudinal ligament, ossification of the ligamentum flavum, calcification of ligaments, hypertrophy of ligaments, degenerative disc disease, thoracic osteoarthritis, intervertebral disc herniation, and posterior osteophytosis. The classic presentation includes girdle pain, gait disturbance, leg weakness, sensory disturbance, and bladder or bowel dysfunction, often with associated back pain. Surgical management is typically favoured with post-surgical outcomes dependent on many factors, including the causative pathology, and presence of additional stenosis.

CONCLUSION

The clinical entities encompassed by the term DTM are interrelated, can manifest concurrently, and present similarly. Building on the consensus adoption of DCM in the cervical spine and the recent proposal of degenerative cervical radiculopathy(DCR), extending this common nomenclature framework to the terms degenerative spinal myelopathy and degenerative thoracic myelopathy will help improve recognition and communication.

Can MRI Predict Flexibility in Scheuermann Kyphosis Patients?

STUDY DESIGN

Retrospective, blinded analysis of imaging studies.

OBJECTIVE

The aim of this study is compare the use of magnetic resonance imaging (MRI) to lateral radiograph using bolster in the evaluation of Scheuermann kyphosis (SK) curve flexibility measurement.

SUMMARY AND BACKGROUND DATA

The flexibility of the thoracic curve [thoracic kyphosis (TK)] in SK is of primary importance in its preoperative planning. Several methods have been described for SK curve flexibility measurement. The most commonly used method is lateral hyperextension radiography on hard bolster [hyperextension radiograph (HE)]. No current methods use MRI for flexibility assessment.

MATERIALS AND METHODS

Flexibility of TK in SK patients was measured as a difference between standing radiograph and bolster-assisted lateral HE or supine MRI. The sagittal Cobb angle of the TK was measured between the superior endplate of T4 and the inferior endplate of T12 vertebral body. Flexibilities measured by these 2 methods were compared and analyzed using the generalized estimating equation analysis and the correlation analysis.

RESULTS

We assessed 18 SK patients (14 males and 4 females) with mean age of 20.06±6.03 years. The standing TK x-rays showed 83.8±6.1 degrees. On HE, TK curve reduced by 39.3 degrees (95% confidence interval, 35.8-42.9) to 44.5±6.2 degrees (P<0.001). Preoperative MRI images showed TK of 53.8±5.9 degrees which means reduction by 30 degrees (95% confidence interval, 26.6-33.4) from the standing radiographs (P<0.001). Linear dependency between HE and MRI flexibility with a mean difference of 9.3 degrees was found (R=0.61, P<0.001).

CONCLUSIONS

Our study shows that preoperative MRI can be used for SK flexibility assessment with similar predictive value as routinely used bolster-assisted hyperextension lateral radiograph. Consequently, patient exposure to preoperative hyperextension ionizing radiation may be reduced.

Spinal cord ischemia in Scheuermann disease: A report of three cases

BACKGROUND

Neurological complications in Scheuermann's disease are rare but serious.

CASE REPORTS

We report three cases of severe neurological deficit due to medullar ischemia attributable to the compression of a radiculomedullar artery by thoracic (two cases) and lumbar (one case) disc herniations associated with Scheuermann's disease. They were not treated surgically because of the absence of direct spinal cord compression or definitive spinal cord ischemia. Those young patients still have severe neurological damage. An earlier management could have prevented them.

CONCLUSION

When doubting about any compressive sign, MRI should be performed with diffusion weighted imaging (DWI) and apparent diffusion coefficient (ADC) sequences in emergency.

MRI Screening in Operative Scheuermann Kyphosis: Is it Necessary?

STUDY DESIGN

Patients with preoperative spine magnetic resonance imaging (MRI) studies from a prospective multicenter study of operative adolescent Scheuermann kyphosis (SK).

OBJECTIVES

To investigate the usefulness of MRI screening in operative planning for SK surgeries.

SUMMARY OF BACKGROUND DATA

Neural axis abnormalities in operative SK have not been previously studied with MRI screening, despite its use.

METHODS

One orthopedic surgeon and two radiologists evaluated all images retrospectively. Radiographs were evaluated for kyphosis apex and magnitude. MRIs were evaluated for spinal cord abnormalities, epidural lipomatosis, location and number of vertebral wedging, Schmorl nodes and posterior disc herniations, frequency of spondylolysis, etc. The relationship of these pathologies to the kyphosis apex was explored. This group was compared to a surgical SK group without preoperative MRIs.

RESULTS

Eighty-six patients with MRIs, mean age 16.3 years, 64% male, and a mean preoperative kyphosis of 75.9° were evaluated. There were 17 spinal cord abnormalities. Low-lying conus was found in 2 patients, and syrinx in 15 (no Chiari malformations). Epidural lipomatosis was found in 49 patients, average of 5.7 levels. Anterior vertebral wedging occurred in all (mean 4.7 levels). Posterior disc herniations averaged 5.2 levels/patient and 1.8 levels caudad to the apex. Spondylolysis was reported in 8.1%. Four cases (4.7%) had the operative plan changed as a result of the preoperative MRI: two due to neural compression, one due to disc herniation and one due to a spinal cord draped over the apex. Thirty-one patients did not receive an MRI; there were no significant differences between the two groups. The rate of postoperative neurologic change was 3.5% in the MRI group and 3.2% in the no-MRI group.

CONCLUSIONS

Based on 4.7% of cases requiring a change in the operative plan as a result of preoperative MRI, the authors recommend considering performing screening MRI in operative SK patients.

Radiological imaging findings of scheuermann disease

AIM

To find accompanying anomalies of typical and atypical Scheuermann’s disease (SD) is reported in the present study.

METHODS

Study included 20 patients (16 men and 4 women) who had radiological imaging radiography, magnetic resonance imaging (MRI) and computed tomography, if available, due to back pain, curved back and low back pain in November 2011-February 2016 period. Patients were categorized into typical and atypical patterns based on the region involved. Thoracic kyphosis values were measured using real Cobb angle. Accompanying disc degeneration, herniations and spinal cord pathologies were studied using MRI.

RESULTS

Age of the patients ranged from 11.0 to 23.0 (mean 17.2 ± 3.0). Typical pattern of SD were detected in 15 patients while atypical pattern were detected in 5 patients. Cobb angle range was 40.2-67.2 (mean 55.5 ± 8.7) in typical Scheuermann’s patients and 24.7-49.9 (mean 36.7 ± 10.8) in atypical ones. Intervertebral level was affected and had the measures of 3-8 (mean 5.3 ± 1.6) and 7-9 (mean 8.2 ± 0.8) in typical and atypical Scheuermann’s patients, respectively. Level of degenerative disc disease in MRI was 1-7 discs (mean 4.1 ± 1.7) in typical patients and 5-10 discs (mean 7.6 ± 1.9) in atypical patients.

CONCLUSION

SD can be seen in typical and atypical patterns, typical being more frequent. Because degenerative disc diseases, herniations and cord pathologies such as syringomyelia can accompany SD (albeit more common in atypical pattern), it is necessary to evaluate these patients with plain radiography and MRI together.

Spinal Cord Stroke Presenting With Acute Monoplegia in a 17-Year-Old Tennis Player

BACKGROUND

Acute monoplegia is a rare presentation for spinal cord stroke, which usually presents with paraplegia or paraparesis.

PATIENT DESCRIPTION

We describe an athletic girl who presented after a week of heavy athletic activity complaining of back and left leg pain, followed by flaccid left leg paralysis.

RESULTS

The prothrombotic evaluation was unremarkable. Cerebrospinal fluid studies demonstrated elevated myelin basic protein but no oligoclonal bands. Magnetic resonance imaging revealed a lesion in the anterior cord from T9 to T11 with T2 hyperintensity, contrast enhancement, and diffusion restriction, suggesting infarction. There was a herniated disc at T10-T11 contacting the spinal cord and Schmorl's nodes at T11 and T12. Magnetic resonance angiography of the spinal cord was limited by movement artifact.

CONCLUSIONS

The combination of our patient's clinical presentation, imaging studies, and laboratory evaluation suggests that our patient had a spinal cord infarct. A fibrocartilaginous embolism was the likely mechanism of infarct due to the presence of Schmorl's nodes and disc herniation on imaging. In addition to spinal cord stroke, other possible mechanisms leading to presentation with monoplegia, such as transverse myelitis, neuromyelitis optica, and multiple sclerosis, are discussed.

Scheuermann's disease: an update

Scheuermann's disease is a juvenile osteochondrosis of the spine. It is a disease of the growth cartilage endplate, probably due to repetitive strain on the growth cartilage weakened by a genetic background. The radiographic aspects are related to the vertebral endplate lesions and include vertebral wedging, irregularity of the vertebral endplate, and Schmorl's node (intraossous disk herniation). Disc alterations are frequent and may be secondary to dysfunction of the disc-vertebra complex. The definitions of Scheuermann's disease are varied; it can refer to the classical form of juvenile kyphosis, described by Scheuermann as well as asymptomatic radiographic abnormalities. Lumbar involvement is probably as frequent as the thoracic form and might be more painful. The first-line treatment is medical and includes rehabilitation and bracing. The earlier the start of treatment, the better the outcome, which highlights the importance of early diagnosis. Surgery is uncommon and must be limited to severe involvement after failure of conservative treatment. The natural history of Scheuermann's disease is unknown, but it might be associated with increased risk of back pain. The evolution of thoracolumbar and lumbar disease is unknown.

Degenerative alterations of the spine in an Early Mediaeval population from Mannheim-Seckenheim, Germany

Palaeopathological and palaeoepidemiological analyses of human skeletal remains are some of the most important bases for the reconstruction of life of past populations. The assessment of frequency and degree of pathological alterations contributes to conclusions of a population's health status, labour conditions, and environmental influences. Degenerative diseases of the spine are among the most common lesions observed in archaeological human remains. The large number of excavated Early Mediaeval cemeteries in Germany enables the comparison of contemporary populations increasing the reliability of conclusions regarding their living conditions. In this study, 112 adult individuals with largely complete and well preserved spines from the Early Mediaeval population of Mannheim-Seckenheim were analysed for pattern and degree of degenerative changes of the spine. The severity of degeneration was recorded using modified categories originally presented by Lutter (1984) for spondylosis deformans and spondylarthrosis deformans scaling from 0 to 4. In addition, the presence of Schmorl's nodes was recorded and the vertebrae were examined for signs of Scheuermann's disease. In general, there was a high prevalence of degenerative diseases of the spine and males were affected more often and to a greater degree than females. The frequency of spondylosis deformans and spondylarthrosis deformans increased with age. In comparison with other Early Mediaeval series there was a much higher prevalence of degenerative diseases in Mannheim-Seckenheim, although most instances were mild manifestations. No cases of Scheuermann's disease (defined as three adjacent vertebrae with wedging of 5° or more and anterior extensions) were identified in the studied sample.

Acutely progressing paraplegia caused by traumatic disc herniation through posterior Schmorl's node opening into the spinal canal in lumbar Scheuermann's disease

STUDY DESIGN

A case report.

OBJECTIVE

To report an unusual neurologic complication caused by traumatic disc herniation through atypical posterior Schmorl's node (SN) opening into the spinal canal in lumbar Scheuermann's disease.

SUMMARY OF BACKGROUND DATA

Neurologic complications in Scheuermann's disease are rare and disc hernia has been reported as one of the causes of neural compression. However, there has been no report on acutely progressing paraplegia caused by traumatic disc herniation through an atypical posterior SN opening into the spinal canal in lumbar Scheuermann's disease.

METHODS

A clinical and radiologic review of such a case of traumatic disc herniation through an atypical posterior SN that resulted in acutely progressing paraplegia in Scheuermann's disease was performed.

RESULTS

The patient presented with severe back pain after a fall, without any neurologic abnormalities. Computed tomographic scan revealed lumbar Scheuermann's disease, acute compression fracture of T12, and a large posterior SN with "trough-like" indentation of the lower endplate of T12 opening into the spinal canal. Abruptly progressing paraplegia occurred in less than 24 hours after the first visit and the magnetic resonance imaging revealed severe spinal cord compression by large disc extrusion with superior migration at T12-L1 through the atypical posterior SN at the lower endplate of T12. The patient underwent posterior decompression and discectomy at T12-L1 through transfacet pedicle-sparing approach. Postoperatively, the patient showed immediate improvement in the sensory deficit on L1 dermatome and the perianal area and motor function of the hip flexors to grade 2 without further neurologic improvement, at 2-year follow-up.

CONCLUSION

The case report highlights the clinical significance of the atypical posterior SN that could be a channel for large disc extrusion after a traumatic event in Scheuermann's disease and the clinical importance of surgeon's close attention to the possibility of abruptly progressing neurologic compromise in this situation.

Scheuermann’s kyphosis; current controversies

This review of the literature presents the current understanding of Scheuermann’s kyphosis and investigates the controversies concerning conservative and surgical treatment. There is considerable debate regarding the pathogenesis, natural history and treatment of this condition. A benign prognosis with settling of symptoms and stabilisation of the deformity at skeletal maturity is expected in most patients. Observation and programmes of exercise are appropriate for mild, flexible, non-progressive deformities. Bracing is indicated for a moderate deformity which spans several levels and retains flexibility in motivated patients who have significant remaining spinal growth.

The loss of some correction after the completion of bracing with recurrent anterior vertebral wedging has been reported in approximately one-third of patients. Surgical correction with instrumented spinal fusion is indicated for a severe kyphosis which carries a risk of progression beyond the end of growth causing cosmetic deformity, back pain and neurological complications. There is no consensus on the effectiveness of different techniques and types of instrumentation. Techniques include posterior-only and combined anteroposterior spinal fusion with or without posterior osteotomies across the apex of the deformity. Current instrumented techniques include hybrid and all-pedicle screw constructs.

Adolescent disc dysplasia and back pain

PURPOSE

Adolescent disc dysplasia can be a cause of significant back pain and functional impairment in patients. We present a case series of patients inflicted with adolescent disc dysplasia (ADD).

METHODS

A retrospective search was performed identifying patients presenting with ADD. Radiographic studies and advanced imaging were described. We documented presenting symptoms and clinical course.

RESULTS

Six patients were identified. All patients presented with mechanical back pain, which worsened with flexion and extension. Magnetic resonance imaging was most accurate imaging modality.

CONCLUSION

Among our patient cohort, treatment for adolescent disc dysplasia consisted of a combination of physical therapy and bracing. Neither approach proved to be very effective, with only one patient asymptomatic at follow-up.

Posterolateral transforaminal interbody fusion for thoracic disc herniation: a retrospective study of 38 cases

OBJECTIVE

To evaluate the clinical results of posterolateral transforaminal interbody fusion (PTIF) for the treatment of thoracic disc herniation (TDH).

METHODS

Thirty-eight patients with TDH were treated with PTIF in our hospital from November 1999 to November 2003. The mean follow-up period was 5.8 years (range, 4.2 to 6.5 years). There were 24 men and 14 women, ranging from 30.5 to 67.5 years, with an average of 46.5 years. The interval between onset of symptoms and surgery ranged from 5 to 12 months with an average of 9 months. In this group, the disc herniation involved T(9-10) or T(10-11) in 26 (68.5%) patients, T(8-9) in 4 (10.5%), T(11-12) in 4 (10.5%) and T(12)L(1) in 4 (10.5%). All patients underwent X-ray and magnetic resonance imaging (MRI) examination. Twenty-two patients underwent myelography, while 25 patients underwent computer tomography (CT) or CT myelography (CTM) examination. The clinical results were evaluated using the Otani scoring system.

RESULTS

The outcome according to the Otani scoring system was excellent in 16 patients, good in 18, fair in 2 and poor in 2. No neurological symptoms, wound infection or clinical or radiographic evidence of instability were found; and the fusion rate was 100% by final follow-up. An excellent or good outcome was achieved in 89.5% of patients.

CONCLUSION

PTIF is an effective strategy for the treatment of TDH.