Compression syndromes due to hypertrophic nerve roots in hereditary motor sensory neuropathy type I

Original Surgical Treatment and Long-term Follow-up for Chronic Inflammatory Demyelinating Polyradiculoneuropathy Causing A Compressive Cervical Myelopathy

Chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) is a chronic relapsing disease of unknown aetiology. The diagnosis of this disease is still very complicated. The treatment is medical but, in some cases, a surgical decompression might be required. In rare cases it develops a radicular hypertrophy that can cause a cervical myelopathy; this pathology should be put in differential diagnosis with neurofibromatosis 1 (NF-1) and Charcot Marie Tooth (CMT) syndromes. The cases of CIDP cervical myelopathy reported in the literature are rare and even more rarely a surgical decompression was described. Here we report a first and unique case of CIDP cervical myelopathy treated with an open-door laminoplasty technique with 10-years post-operative follow-up (FU). The surgical decompression revealed to be effective in stopping the progression of myelopathy without destabilizing the spine. The patient that before surgery presented a severe tetra-paresis could return to walk and gained back his self-care autonomy. At 10-years FU he didn't complain of neck pain and didn't develop a cervical kyphosis. In case of cervical myelopathy caused by radicular hypertrophy CIDP should be kept in mind in the differential diagnosis and an open-door laminoplasty is indicated to stop myelopathy progression.

Effective cauda equina decompression in two siblings with Charcot-Marie-Tooth disease type 1B

Two siblings with Charcot-Marie-Tooth (CMT) 1B due to a c.517G>C (p.Gly173Arg) mutation in the MPZ gene both developed an acute cauda syndrome with unbearable back pain radiating to both legs, progressive muscle weakness of the legs, and saddle hypesthesia with fecal and urinary incontinence. MRI showed in both patients a lumbar spinal canal totally filled with hypertrophic caudal nerve roots. We performed acute decompression. Postoperatively, in both patients, the back pain resolved immediately, there was a significant improvement of both the paresis of the legs and the hypesthesia, and there was a full return of continence. There was no recurrence of acute symptoms during respectively 19 years and 1.5 years of follow-up. We conclude that in patients with CMT and a related cauda syndrome because of hypertrophic caudal nerve roots, acute decompression can be an effective and safe treatment with long-term efficacy.

Could Spinal Canal Compression be a Cause of Polyneuropathy?

Causality between spinal cord compression and polyneuropathy is difficult to define, especially under the circumstances that polyneuropathy can have many causes.

Seven patients with spinal cord compression and electrophysiological signs of polyneuropathy were treated surgically on decompression of their spinal canal stenosis in the time from April 2010 to January 2013. Median follow up time was 9 months (2-23 months).

Causes of polyneuropathy were: 1 patient with methotrexate-induced polyneuropathy, 1 endocrine-dysfunction-induced, 2 with diabetic-polyneuropathy, and 3 patients had unknown reasons. The localization of the spinal canal stenosis was also varying: 2 patients suffered of cervical spinal canal stenosis and 5 of lumbar. Decompressive surgery led to pain relieve in all patients initially. Surprisingly, also symptoms of polyneuropathy seemed to regress in all 7 patients for the first 5 months after surgery, and in 5 patients for the time of 9 months after surgery.

There are two points we would like to emphasize in this short report. Since 5/7 patients with polyneuropathy and spinal canal stenosis improved clinically after surgery, surgery has a place in the treatment of such a combined pathology. Since it seems to be a possible causality between polyneuropathy of unknown origin and spinal cord stenosis, decompression of the spinal canal could also be a therapeutic step in a specific kind of polyneuropathy. Which patients could possibly have a spinal canal stenosis induced polyneuropathy remains a subject of further studies.

Demyelinating hypertrophic inferior alveolar nerve mimicking a nerve tumor

We herein report a patient with demyelinating inferior alveolar nerve hypertrophy, which was initially suspected to have a nerve tumor. A 39-year-old woman with childhood-onset polyneuropathy presented with tooth pain and visited a dental clinic. An X-ray examination of the mandible revealed enlargement of the mandibular canal, and a nerve tumor was suspected. CT scan and MRI showed hypertrophy of the inferior alveolar nerve along its entire length. We diagnosed the patient with chronic inflammatory demyelinating polyradiculoneuropathy (CIDP), which was supported by the spontaneous recovery reported in her childhood, the results from a nerve conduction study and MRI data. CIDP should be considered in the differential diagnosis of mandibular canal enlargement.

A case of cauda equina syndrome in early-onset chronic inflammatory demyelinating polyneuropathy clinically similar to charcot-marie-tooth disease type 1

To present a case of cauda equina syndrome (CES) caused by chronic inflammatory demyelinating polyneuropathy (CIDP) which seemed clinically similar to Charcot-Marie-Tooth disease type1 (CMT1). CIDP is an immune-mediated polyneuropathy, either progressive or relapsing-remitting. It is a non-hereditary disorder characterized by symmetrical motor and sensory deficits. Rarely, spinal nerve roots can be involved, leading to CES by hypertrophic cauda equina. A 34-year-old man presented with low back pain, radicular pain, bilateral lower-extremity weakness, urinary incontinence, and constipation. He had had musculoskeletal deformities, such as hammertoes and pes cavus, since age 10. Lumbar spine magnetic resonance imaging showed diffuse thickening of the cauda equina. Electrophysiological testing showed increased distal latency, conduction blocks, temporal dispersion, and severe nerve conduction velocity slowing (3 m/s). We were not able to find genetic mutations at the PMP 22, MPZ, PRX, and EGR2 genes. The pathologic findings of the sural nerve biopsy revealed thinly myelinated nerve fibers with Schwann cells proliferation. We performed a decompressive laminectomy, intravenous IgG (IV-IgG) and oral steroid. At 1 week after surgery, most of his symptoms showed marked improvements except foot deformities. There was no relapse or aggravation of disease for 3 years. We diagnosed the case as an early-onset CIDP with cauda equine syndrome, whose initial clinical findings were similar to those of CMT1, and successfully managed with decompressive laminectomy, IV-IgG and oral steroid.

Clinical and imaging findings in three patients with advanced inflammatory demyelinating polyradiculoneuropathy associated with nerve root hypertrophy

OBJECTIVES

Chronic inflammatory demyelinating polyradiculoneuropathy is a treatable neuropathy that is challenging to diagnose and has a broad spectrum of presentations. We report the clinical, electrodiagnostic, and radiographic presentations in three patients whose workup revealed hypertrophic nerve roots.

METHODS

We retrospectively reviewed the clinical, electrodiagnostic, and imaging data for patients diagnosed with chronic inflammatory demyelinating polyradiculoneuropathy over a 3-year period.

RESULTS

All patients had features of proximal and distal neuropathy with progressive or recurrent courses. Diagnosis and management were significantly altered by the concomitant clinical findings and/or radiographic findings.

CONCLUSIONS

Our cases highlight the use of magnetic resonance imaging to evaluate for nerve root hypertrophy as an additional tool to electrodiagnostic testing in the setting of refractory or atypical neuropathy condition. Awareness of the radiographic features will assist in confirmation of the diagnosis, institution of the appropriate therapy, and prevention of inadequate or delay of treatment.

[Case of Charcot-Marie-Tooth disease type 1A with increased cerebrospinal fluid proteins and nerve root hypertrophy]

We report herein a 54-year-old man who first noticed muscle weakness of the hands and legs and hypesthesia of the legs at 20-years-old. Symptoms gradually worsened. Charcot-Marie-Tooth disease type 1A (CMT 1A) was diagnosed on the basis of a nerve conduction study and PMP22 gene duplication. Increased levels of cerebrospinal fluid proteins were identified and cervical and lumbosacral nerve root hypertrophy was evident on magnetic resonance imaging (MRI). CMT 1A with increased CSF proteins and nerve root hypertrophy was carefully evaluated clinically and electrophysiologically to rule out other motor sensory neuropathies such as CIDP. Increased levels of CSF proteins in this case might have resulted from circulatory disturbance of CSF in hypertrophic nerve roots.

Chronic inflammatory demyelinating polyradiculoneuropathy: two cases with cervical spinal cord compression

Chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) is a peripheral nerve disorder probably due to an immunological disturb. It evolves either in a steadily progressive or in a relapsing and fluctuating course. Weakness is mainly in the lower limbs proximally and distally. The electromyography is demyelinating. The cerebral spinal fluid protein is most of times elevated. Sometimes enlarged nerves are found. There are few cases described with spinal cord compression due to hypertrophic spinal nerve roots. Two patients (females, 66 and 67 years old) with diagnosis of a long standing CIDP are described. In the first one, the evolution was characterized by remission and relapsing course. The second patient had a chronic and progressive course. These patients presented after a long evolution a cervical spinal cord compression syndrome due to hypertrophic cervical roots. Neurologists must be aware of the possibility of development of spinal cord compression by enlarged spinal roots in patients with a long standing CIDP.

Hereditäre motorische und sensorische Neuropathie (HMSN) mit Hypertrophie der Cauda equina und demyelinisierenden Läsionen der weißen Substanz

Hereditary motor and sensory neuropathy (HMSN) is thought to almost exclusively affect the peripheral nervous system. We report the case of a 48-year-old patient with a longstanding history of HMSN type I who developed signs and symptoms of a cauda equina compression and of a central nervous system relapsing-remitting demyelinating white matter disease. Gross enlargement of the cauda equina fibers was detected by MR imaging of the lumbar spine. Cranial MR imaging revealed demyelinating white matter lesions. This case suggests that peripheral neuropathic mechanisms may also affect the central myelin in HMSN type I.

[Charcot-Marie-Tooth disease associated with syringomyelia revealed by urinary disorders]

PURPOSE

Charcot-Marie-Tooth (CMT) disease is characterized by genetic and clinical heterogeneity. The occurrence of urinary disorders is unusual and requires further investigation. CMT disease and syringomyelia are not usually associated. Moreover, primary urinary signs in syringomyelia are not frequent.

CASE REPORT

An 11-year-old girl with CMT disease 1A duplication presented with motor deficit of the leg associated with urinary disorders. Urodynamic study revealed neurogenic detrusor overactivity, and magnetic resonance imaging confirmed syringomyelia extending from T11 to an L1 located conus.

DISCUSSION

Review of the literature confirmed the possibility of primary urinary signs in syringomyelia, with only one case of CMT and urinary signs described. In this case, the diagnosis was radicullar and medullar compression by a hypertrophic nerve formation called an "onion bulb" reflecting the demyelinisation and remyelinisation cycle.

CONCLUSION

Urinary signs in CMT disease are exceptional and require investigation into the possibility of a central lesion.

17p duplicated Charcot-Marie-Tooth 1A: characteristics of a new population

The most frequent type of Charcot-Marie-Tooth (CMT) neuropathy is that associated with the 17p11.2-p12 chromosome duplication, whose characteristics have been well described in European and North American populations. In this study, we analyzed a Brazilian population exhibiting the mutation, found in 57 patients from 42 families (79%) of a cohort of 53 families with demyelinating CMT. Almost 20% of the duplicated cases were sporadic. In 77% of the duplicated families the mutation event occurred in the hot spot area of the CMT1A-Rep region. Forty-five percent of patients were females, 84% were Caucasians and 13% of African descent. Distal limb weakness was the most frequent abnormality, appearing in 84% of patients, although uncommon manifestations such as severe proximal weakness, floppy baby syndrome, diaphragmatic weakness and severe scoliosis were also observed. One patient was wheelchair-bound, and three suffered severe hand weakness. Sensory abnormalities were detected in 84% of the cases, but 80% were unaware of this impairment. Twelve patients complained of positive sensory manifestations such as pain and paresthesias. Progression was reported by 40%. Motor conduction velocities in the upper limbs were always less than 35 m/s, and less than 30.4 m/s in the peroneal nerve. The findings of this study expand the clinical spectrum of the disease.

Hypertrophic Neuropathy of the Cauda Equina: Case Report

OBJECTIVE AND IMPORTANCE

Hypertrophic neuropathy of the cauda equina (HNCE) is a rare form of peripheral neuropathy. The diagnosis is complicated by an insidious clinical presentation and complex radiographic images. We present a case of HNCE caused by chronic inflammatory demyelinating polyneuropathy with symptomatic improvement after decompressive lumbar laminectomy and dural expansion.

CLINICAL PRESENTATION

A 54-year-old woman with a history of back pain since she was in her 20s presented with low back and radicular pain that had increased during a period of 6 months, bilateral lower-extremity weakness, and sensory loss in the right thigh. Magnetic resonance imaging of the lumbosacral spine revealed multiple, poorly enhancing mass lesions and apparent intrathecal nerve root thickening from L1 to L5.

INTERVENTION

An L1-L5 decompressive laminectomy, performed with continuous somatosensory evoked potential and electromyographic monitoring, revealed multiple segmentally enlarged nerve roots. One nerve root that did not respond to high levels of stimulation was identified. This root was resected and submitted for pathological analysis. The dura was expanded with an 11-cm-long dural patch. The pathological examination revealed hypertrophic neuropathy, with extensive S-100-positive “onion bulb” formation. The patient's symptoms improved postoperatively.

CONCLUSION

HNCE is a rare disorder that can cause radicular pain and lower-extremity weakness, sensory loss, and hyporeflexia. One possible cause is demyelinating polyneuropathy. Although medical management is typically effective in the treatment of demyelinating polyneuropathy, it has little effect on compressive symptoms caused by intradural nerve root enlargement. As this case demonstrates, surgical management of symptomatic radiculopathy by lumbar laminectomy is a reasonable and effective approach to the treatment of HNCE.

Conus medulla-cauda compression from nerve root hypertrophy in a child with Dejerine-Sottas syndrome: improvement with laminectomy and duraplasty. Case report

This 7-year-old boy with Dejerine-Sottas syndrome caused by a mutation in the myelin protein zero gene began to suffer rapid deterioration with increasing leg weakness, loss of the ability to ambulate, and bowel and bladder incontinence. Magnetic resonance imaging of the spine revealed nerve root hypertrophy resulting in compression of the conus medullaris and cauda equina. Decompressive surgery was successful in reversing some of his deficits.

Chronic demyelinating hypertrophic brachial plexus neuropathy

A patient with unilateral, painless, chronic progressive upper limb sensorimotor deficit showed electrophysiological evidence of a focal demyelinating neuropathy with almost complete conduction block across the brachial plexus. Magnetic resonance imaging disclosed marked brachial plexus hypertrophy. Intravenous immunoglobulin led to fast and complete recovery, maintained by intermittent perfusions. Hypertrophic brachial plexus neuropathy can be a presentation of focal chronic inflammatory demyelinating polyradiculoneuropathy. Objective and quantitative assessment of hand function is useful to evaluate treatment results and to optimize treatment regimens.

Hypertrophied cauda equina presenting as intradural mass: case report and review of literature

BACKGROUND

Hereditary motor and sensory neuropathy types I and III usually lead to enlargement of peripheral nerves. Rarely, spinal nerve roots may also be involved, leading to radiculopathy and/or myelopathy.

METHODS

This 44-year-old man with back and lower extremity radicular pain and distal lower extremity weakness and numbness was found to have a nonenhancing intradural mass that caused a nearly complete myelographic block from L1-L4. He underwent a decompressive laminectomy with intradural exploration.

RESULTS

Hypertrophic but otherwise normal-looking nerve roots were observed. Subsequent electrodiagnostic testing and sural nerve biopsy confirmed that this patient had a previously unsuspected hereditary motor and sensory neuropathy (HMSN). His pain resolved, but at latest follow-up his weakness and numbness persisted.

CONCLUSIONS

Nonenhancing spinal intradural mass lesions may represent enlarged nerve roots, which have a number of potential etiologies. Electrodiagnostic studies and peripheral nerve biopsy are instrumental in establishing the diagnosis of HMSN.

Low back pain due to hypertrophic roots as presenting symptom of CIDP

Attention has recently been drawn to chronic inflammatory demyelinating polyneuropathy (CIDP) with symptomatic nerve root hypertrophy. A 31-year-old woman had fluctuating and worsening low back pain. Absent tendon jerks and a slight weakness of the hand interossei muscles suggested a diffuse neuropathy. The electrophysiological and histological findings were diagnostic for CIDP. Lumbar spine MRI showed marked nerve root enlargement with gadolinium enhancement. This case widens the range of the clinical presentations of CIDP. Further studies are warranted to ascertain whether cauda equina gadolinium enhancement may be a useful tool in the diagnosis of CIDP and a marker of disease activity for monitoring response to therapy.

Nerve root hypertrophy as the cause of lumbar stenosis in chronic inflammatory demyelinating polyradiculoneuropathy

Two patients with chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) developed signs of lumbar stenosis. Radiologic, intraoperative, and pathologic findings demonstrated lumbar stenosis secondary to nerve root hypertrophy. This syndrome has been demonstrated in hereditary but not acquired demyelinating neuropathies. CIDP should be considered in the differential diagnosis of sciatica and nerve root hypertrophy.

Focal posterior interosseous neuropathy in the presence of hereditary motor and sensory neuropathy, type I

A 30-year-old male with hereditary motor and sensory neuropathy, type I (HMSN I), presented with asymmetric weakness of finger extension and radial deviation with left wrist extension, previously felt to be a manifestation of the peripheral neuropathy. Nerve conduction studies confirmed HMSN I; however, needle EMG revealed marked, ongoing axonal loss in muscles innervated by the left posterior interosseous nerve (PIN) only. At surgery there was focal fusiform swelling in the PIN at exit from the supinator muscle, compatible with localized hypertrophic neuropathy, which has not been reported before in HMSN I. A concomitant focal mononeuropathy should be considered in cases of hereditary neuropathy with marked asymmetry of weakness.

Chronic inflammatory demyelinating polyneuropathy mimicking a lumbar spinal stenosis syndrome

A patient with chronic inflammatory demyelinating polyneuropathy (CIDP) established by biopsy developed cauda equina symptoms due to swelling of the nerve roots in the lumbar spinal canal. Magnetic resonance imaging of the lumbar spine showed profoundly thickened nerve roots from the level of the conus medullaris, filling the caudal thecal sac. Immunosuppressant treatment produced partial clinical and radiological resolution. This case shows that spinal compressive syndromes may occur in acquired hypertrophic neuropathies as well as in hereditary motor and sensory neuropathy and expands the range of the clinical presentation of CIDP.