- Department of Radiodiagnosis, GSVM Medical College, Kanpur, India
- Department of Orthopaedic Surgery, GSVM Medical College, Kanpur, India
Department of Radiodiagnosis, GSVM Medical College, Kanpur, India
DOI:10.4103/2152-7806.76148Copyright: © 2011 Kumar P This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
How to cite this article: Kumar P, Gupta A, Sood S, Verma AK. Fluorotic cervical compressive myelopathy, 20 years after laminectomy: A rare event. Surg Neurol Int 24-Jan-2011;2:11
How to cite this URL: Kumar P, Gupta A, Sood S, Verma AK. Fluorotic cervical compressive myelopathy, 20 years after laminectomy: A rare event. Surg Neurol Int 24-Jan-2011;2:11. Available from: http://sni.wpengine.com/surgicalint_articles/fluorotic-cervical-compressive-myelopathy-20-years-after-laminectomy-a-rare-event/
Background:Spinal cord compression in flourosis is a common complication. These complications are mainly due to compression of the spinal cord by thickening and ossification of posterior longitudinal ligament and ligamentum flavum. Surgical decompression is the treatment of choice for fluorotic spinal cord compression. The recurrence of spinal cord compression after surgical decompression in flourosis is a rare event.
Case Description:We are presenting a case of a 63-year-old man who belonged to Kanpur, an endemic fluorosis region in India, with symptoms of cervical cord compression cranial to the operative site, 20 years after laminectomy for cervical fluorotic myelopathy. Urinary and serum fluoride levels were elevated. The patient underwent a skeletal survey: computed tomography and magnetic resonance imaging of the cervical spine showed a postoperative defect of laminectomy, osteosclerosis, osteophyte formation, calcification of the intraosseus membrane in the forearm, thickening and ossification of the posterior longitudinal ligament at C1, thickening and ossification of the residual ligamentum flavum at C1/C2, and dural calcification at the C2 vertebral level and compressive myelopathy. The patient refused surgical decompression and was managed with tizanidine HCl (an antispasticity medicine), a sublingual single night dose, 8 mg for symptomatic relief.
Conclusion:The recurrence of spinal cord compression in the fluorotic spine 20 years after laminectomy is a very unusual event and hence the patient should be kept under observation for a long duration. This case report contributes to the literature associated with the management of fluorotic spine.
Keywords: Fluorosis, compressive myelopathy, laminectomy, magnetic resonance imaging, cervical
Chronic fluoride intoxication (fluorosis) is endemic in areas where fluoride content is high in drinking water. Endemic skeletal fluorosis is widely prevalent in India, China, and many countries around the world.[
We are reporting a case of a 63-year-old man, who hailed from the Kanpur district, Uttar Pradesh, India, an endemic fluorosis region. He presented with numbness and weakness in all four limbs 20 years back. Skeletal survey and computed tomography (CT) [
Now, he presented with recurrence of symptoms. The weakness had increased in severity to the point that he was unable to sit or stand without support. There was no associated bladder or bowel dysfunction.
Higher mental functions and cranial nerves were intact. Motor examination revealed positive pyramidal signs and decreased power (4/5) in all four limbs without any atrophy/fasciculation. On sensory examination, pain, temperature, and joint position sense were impaired at C1 and C2 dermatomes areas.
Laboratory tests showed raised serum fluoride and urinary fluoride levels. However, complete blood count, erythrocyte sedimentation rate, electrolytes including calcium, magnesium and phosphorus were normal.
The patient underwent a skeletal survey, CT scan and magnetic resonance imaging (MRI) of the cervical spine. The skeletal survey showed osteosclerosis, postoperative changes of laminectomy at the C2-C7 vertebral level, large osteophyte formation, soft tissue calcification, and calcification of the interosseous membrane in the forearm [Figures
MRI revealed severe compression on the dorsal spinal cord at the C1 and C2 vertebral level with T2 hyperintensity in the cervical spinal cord suggestive of severe compressive myelopathy [
Fluorosis is a disease caused by an excessive intake of fluoride. Fluorosis is endemic in at least 25 countries across the world being more widespread in India and China.[
Fluorosis in humans predominantly has dental and skeletal manifestation. Dental fluorosis is an early and sensitive manifestation in children presenting as white chalky opacities or pitting on the enamel. It is seen only if the child has resided in the endemic area during the eruptive period of the teeth and it has been taken as an index of endemicity in epidemiological surveys.[
In the advanced stages, skeletal fluorosis causes crippling deformities and neurological complications. Neurological complications occur in 5-10% of cases of skeletal fluorosis.[
Spinal cord involvement is common in the cervical region followed by thoracic and lumbar region.[
There is a linear relation between urinary fluoride levels and fluoride intake, and a 24-h sample of urine is a good indicator of the fluoride intake.[
In skeletal fluorosis, technetium-labeled methylene diphophonate (99mTc-MDP) bone scanning shows mostly a superscan appearance with a diffuse linear tracer activity along the ligamentous attachments.[
Characteristic radiological changes of a fluorotic spine include osteophyte formation, calcification of ligaments, and ossification of the posterior longitudinal ligament and ligamentum flavum and sclerotic bone.[
Gupta et al. reported that compressive myelopathy in fluorosis is due to thickening with the ossification of the posterior longitudinal ligament and ligamentum flavum.[
Experiments showed that calcium, magnesium, and aluminum salts could reduce fluoride absorption and also increased its excretion from the body. Serpentine was used to increase fluoride excretion in human fluorosis with some success.[
Prevention is the best possible approach to tackle fluorosis, since no cure at present is possible once disease sets in.[
In fluorosis, the recurrence of compressive myelopathy can occur at different levels, but is an uncommon phenomenon. We are reporting a case of compressive myelopathy due to fluorosis, recurred cranial to a previous cervical laminectomy site, laminectomy done 20 years ago.
Mohindra et al. reported five patients of Indian origin with the ossification of the thoracic yellow ligament. Neurologic improvement followed decompressive laminectomy and excision of the ligamentum flavum though persistent spasticity due to irreversible changes within the cord was seen in some patients. One patient was followed up over a span of 10 years. Though the disease was progressive, no mention of recurrent compressive myelopathy had been made.[
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