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Progressive posttraumatic myelomalacic myelopathy: imaging and clinical features
S Falcone1, R M Quencer, B A Green
1Department of Radiology, University of Miami/Jackson Memorial Medical Center.
Purpose:
To describe the imaging features, surgical management, and clinical outcome of progressive posttraumatic myelomalacic myelopathy (PPMM), a relatively unrecognized but important cause of progressive myelopathy in patients with previous spinal cord injuries.
Methods:
The clinical records, imaging studies, and postoperative outcome of 10 patients with PPMM were reviewed. Fifteen preoperative and five postoperative MRs were analyzed for intramedullary signal abnormalities, the nature of these signal abnormalities, and cord tethering. All patients had intraoperative sonography.
Results:
Neurologic signs and symptoms found in our patients included 1) progressive loss of motor function (6/10), 2) sensory level changes (4/10), 3) increased spasticity (4/10), 4) autonomic dysreflexia (4/10), 5) loss of bowel or bladder control (4/10), and 6) local and/or radicular pain (4/10). Preoperative MR in nine patients revealed intramedullary T1/T2 lengthening (9/9), extramedullary tethering/adhesions (9/9), ill-defined lesional borders (6/9), cord expansion (5/9), and increased signal intensity of the lesion on T1-weighted images compared with CSF (7/9). Proton density images in five patients demonstrated a relative increase in signal intensity over CSF. In all five postoperative MRs, there was evidence of untethering of the spinal cord and a decrease in cord size in two patients. Intraoperative sonography revealed cord tethering and abnormal cord echotexture in all cases. Postoperative clinical evaluation revealed neurologic improvement in nine patients.
Conclusions:
PPMM may clinically and radiographically mimic progressive posttraumatic cystic myelopathy (PPCM). MR provides clues to the diagnosis of myelomalacia preoperatively. Intraoperative sonography confirms the absence of a confluent cyst. These points are crucial in the surgical procedures in PPMM vs PPCM. In PPMM, lysis of intradural adhesions results in an improvement in symptoms in a manner similar to the shunting of PPCM.
Insights
Progressive posttraumatic myelomalacic myelopathy (PPMM) causes worsening spinal cord injury symptoms. Surgical lysis of adhesions improves outcomes, distinguishing it from cystic myelopathy.
Area of Science:
- Neurosurgery
- Neurology
- Radiology
Background:
- Progressive posttraumatic myelomalacic myelopathy (PPMM) is an underrecognized cause of worsening neurological deficits after spinal cord injury.
- It can mimic other post-injury complications, necessitating accurate diagnosis and management.
Purpose of the Study:
- To delineate the imaging features, surgical management, and clinical outcomes of patients with PPMM.
- To differentiate PPMM from progressive posttraumatic cystic myelopathy (PPCM).
Main Methods:
- Retrospective review of 10 patients with PPMM, including clinical data, imaging (MRI), and surgical outcomes.
- Analysis of preoperative and postoperative MRI for signal abnormalities and cord tethering.
- Intraoperative sonography utilized in all cases.
Main Results:
- Common symptoms include motor loss, sensory changes, spasticity, autonomic dysreflexia, and bowel/bladder dysfunction.
- MRI revealed intramedullary signal changes, cord tethering, and ill-defined lesions.
- Postoperative MRI showed spinal cord untethering, and 9/10 patients improved neurologically after surgery.
Conclusions:
- PPMM shares imaging and clinical features with PPCM, but intraoperative sonography can differentiate them.
- Surgical lysis of intradural adhesions in PPMM leads to symptom improvement.
- Accurate diagnosis and surgical approach are critical for managing PPMM.
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