Acute spontaneous cervical disc herniation causing rapidly progressive myelopathy in a patient with comorbid ossified posterior longitudinal ligament: Case report and literature review

INTRODUCTION:We report a case of acute tetraplegia, without any trauma or symptoms prior to onset, who presented with ossification of the posterior longitudinal ligament (OPLL) in the cervical spine with concomitant spinal cord infarction. CASE PRESENTATION: A 64-year-old man with a number of risk factors for vascular disease was admitted to our hospital with progressive motor weakness in the bilateral upper and lower extremities. He had initially felt numbness in his left upper extremity and had no previous neurological symptoms or trauma. The night after the initial symptoms, he developed spastic tetraplegia requiring respiratory support. Computed tomography images of the cervical spine demonstrated the segmental type of OPLL. Spinal cord compression and signal intensity changes were identified at the level of C3/4 on magnetic resonance imaging (MRI). He underwent emergency surgery consisting of posterior decompression with laminoplasty of C3-6. Despite the surgery, the patient's tetraplegia did not improve and he continued to require respirator support. There was still no improvement in his neurological status at 10 days postoperatively, and MRI demonstrated evidence of marked spinal cord infarction. DISCUSSION: Mechanical compression of spinal arteries by OPLL and pre-existing vascular compromise had a role in the pathogenesis of spinal cord infarction. Chronic spinal compression may be characterized by 3 important factors, namely an uncommonly devastating clinical course, vascular risk factors and persistent findings on MRI, and these might lead to early diagnosis of spinal cord infarction.

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Spinal cord infarction at the level of ossification of the posterior longitudinal ligament

Tanida

Kamimura

Tanishima

et al. 2016

Spinal Cord Ser Cases

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Rapidly Progressive Tetraparesis with Ossification of the Posterior Longitudinal Ligament (OPLL)

Sawagashira

Watari

Tokuda

2016

J of Gen and Family Med

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Case ReportOssification of the posterior longitudinal ligament (OPLL) is a common cervical disease that can cause stenosis in the spinal canal and consequent cervical myelopathy, especially in middle-to-high aged Asian men. Typically, patients with cervical OPLL complain of neck pain in their daily lives but lack any significant neurologic symptoms. However, it can cause myelopathy through even minor trauma, such as falls and blunt head injuries, like reported in the following case.A 50-year-old man living in the nursing home due to mental retardation presented with a sudden onset tetraparesis without prior history of injury. Though he had difficulty in moving the right lower extremity for a long time a diagnosis had not been made, and the patient could walk by himself five days before admission. Physical examination showed weakness in all extremities, most significant in the right lower extremity (grade 1/5 by manual muscle testing). It was difficult to appropriately conduct the neurological examination for sensory disturbance due to the mental retardation. His tendon reflexes of bilateral triceps brachii, biceps brachii and brachioradialis muscle were normal and his patellar and Achilles tendon reflexes were slightly diminished. Bladder and rectal dysfunction were not detected. There was no episode of prior infection and serum potassium level was within normal limits. Cerebrospinal fluid examination showed mild cytoalbuminic dissociation, so we had a suspicion of Guillain-Barré syndrome as one of the differential diagnosis. But on Day 11 we found hyperreflexia of his patellar and Achilles tendon, so cervical CT and MRI scans were performed immediately, demonstrating segmental OPLL (C2-C6) and the cervical spinal cord compression at C3/4. The patient received a diagnosis of cervical myelopathy with OPLL and he was transported to another hospital for surgical intervention. However golden time had passed, so he did not receive operative therapy.An accurate and immediate diagnosis for myelopathy from OPLL based on history, physical exam, and plain radiograph, along with CT and MRI findings is very important to assess the development of myelopathy and to make quick decisions regarding a treatment plan.

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Degenerative Cervical Myelopathy: A Case Report of Delayed Diagnosis in a Younger Man

Wood,

Dunstan,

Davies

2022

JOSPT Cases

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BACKGROUND: Degenerative cervical myelopathy is most caused by degenerative cervical stenosis in an over 55-year age group. However, it may occur in younger ages, most commonly due to large cervical disc protrusions. CASE PRESENTATION: The case report describes a 42-year-old male, who presented with progressive ataxia and upper limb discoordination over a 4-year period. He was initially diagnosed and treated for bilateral carpal tunnel releases. Following his persistent symptoms, cervical magnetic resonance imaging was performed, which confirmed a large cervical C4/5 disc protrusion. OUTCOME AND FOLLOW-UP: Although initially managed with observation, his continuing decline resulted in emergency cervical decompression. Surgery for myelopathy aims to prevent further deterioration, and timely treatment is therefore critical to restoring function. DISCUSSION: This case highlights the difficulties faced by people with degenerative cervical myelopathy to obtain a diagnosis and treatment, and the consequences. Myelopathy is an important differential diagnosis to consider irrespective of age. Where suspected, a cervical spine MRI should be requested. JOSPT Cases 2022;2(4):220–225. Epub: 12 October 2022. doi:10.2519/josptcases.2022.11088

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Acute spontaneous cervical disc herniation causing rapidly progressive myelopathy in a patient with comorbid ossified posterior longitudinal ligament: Case report and literature review

Cited by 4 publications

References 20 publications

Spinal cord infarction at the level of ossification of the posterior longitudinal ligament

Spinal cord infarction at the level of ossification of the posterior longitudinal ligament

Rapidly Progressive Tetraparesis with Ossification of the Posterior Longitudinal Ligament (OPLL)

Degenerative Cervical Myelopathy: A Case Report of Delayed Diagnosis in a Younger Man

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