- Department of Surgery, Division of Neurosurgery, Centre Hospitalier de l’Université de Montréal, Hôpital Notre-Dame, Montreal, Quebec, Canada
- Toronto Western Hospital, Division of Neurosurgery, Toronto, Ontario, Canada
- University of Toronto, Department of Surgery, Toronto, Ontario, Canada
Mohammed F. Shamji
Toronto Western Hospital, Division of Neurosurgery, Toronto, Ontario, Canada
University of Toronto, Department of Surgery, Toronto, Ontario, Canada
DOI:10.4103/2152-7806.139671Copyright: © 2014 Westwick HJ. 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: Westwick HJ, Goldstein CL, Shamji MF. Acute spontaneous cervical disc herniation causing rapidly progressive myelopathy in a patient with comorbid ossified posterior longitudinal ligament: Case report and literature review. Surg Neurol Int 28-Aug-2014;5:
How to cite this URL: Westwick HJ, Goldstein CL, Shamji MF. Acute spontaneous cervical disc herniation causing rapidly progressive myelopathy in a patient with comorbid ossified posterior longitudinal ligament: Case report and literature review. Surg Neurol Int 28-Aug-2014;5:. Available from: http://sni.wpengine.com/surgicalint_articles/acute-spontaneous-cervical-disc-herniation-causing-rapidly-progressive-myelopathy-in-a-patient-with-comorbid-ossified-posterior-longitudinal-ligament-case-report-and-literature-review/
Background:Ossification of the posterior longitudinal ligament (OPLL) and cervical disc herniation are commonly encountered neurosurgical conditions. Here we present an unusual case of nontraumatic rapidly progressive myelopathy due to cervical disc herniation with comorbid OPLL and conduct a literature review focusing on the frequency and management of disc herniations with OPLL.
Case Description:A 52-year-old healthy female presented with a 72-h history of rapid progression of dense quadriparesis with sensory deficits, with a precedent 4-week history of nontraumatic midline neck pain. Clinical examination revealed profound motor deficits below the C5 myotome. Spinal neuroimaging revealed OPLL (computed tomography [CT]) and a cervical disc herniation spanning from C4/5 to C5/6 with significant retrovertebral disease (magnetic resonance imaging [MRI]). Operative management involved an anterior cervical corpectomy and instrumented fusion, with removal of both the sequestered disc material and the locally compressive OPLL. The patient recovered full motor function and independent ambulation with no residual signs or symptoms of myelopathy at the time of discharge.
Conclusion:This unique case of a spontaneous cervical disc herniation in the context of OPLL causing rapidly progressive myelopathy illustrates the complementarity of CT and MRI in diagnosing the underlying cause of a rapidly progressive neurologic deficit in the absence of antecedent trauma. Though the optimal surgical management of such pathology remains uncertain; in this case, the anterior approach was motivated by the significant retrovertebral ventrally compressive sequestrum, and provided for excellent neurologic outcome. This article also reviews the occurrence/management of such acute cervical discs with OPLL.
Keywords: Cervical disc herniation, ossified posterior longitudinal ligament, quadriplegia
Ossification of the posterior longitudinal ligament (OPLL) and cervical disc herniation occur in isolation, but their acute comorbid presentation is highly unusual. Cervical disc herniation, although most often asymptomatic can contribute to a spectrum of neurological sequelae, including acute radiculopathy, myelopathy, or, rarely, quadriparesis/plegia.[
A 52-year-old healthy female presented with a rapid, 72-h progression of quadraparesis. She described a prior 4-week history of gradual onset, nontraumatic midline neck pain, requiring narcotic analgesia, without radiculopathy. Immediately prior to admission, she began experiencing a progressive quadriparetic deficit (with sequential numbness of right upper and lower then left lower and upper extremities) without sphincter dysfunction.
Her motor examination revealed weakness in all extremities, most significant in the right lower extremity (grade 1/5 power), diffuse hyperreflexia (positive Hoffman's sign and up-going Babinski sign bilaterally), and a C7 sensory level to light touch, loss of position/vibration sensation in the lower extremities but intact pin sensation. Notably, the digital rectal examination was unremarkable.
A large, contiguous C4-5 disc extrusion extending from the postero-inferior corner of C4 to the C5-6 disc space was identified on magnetic resonance imaging (MRI) [
Preoperative T2-weighted sagittal (a) and proton density weighted axial (b-d) MRI images without contrast. The axial images demonstrate the level of spinal canal compromise at the level of the C4-5 disc (b), mid-C5 vertebral body (c) and C5-6 disc (d). An arrow identifies the cervical disc herniation with extrusion on the sagittal MRI
Preoperative sagittal (a) and axial (b-d) CT images. Images b-d correspond to axial MRI images presented in Figure 1. The extent of bony canal compromise secondary to OPLL posterior to the C4-5 disc (b), mid-C5 vertebral body (c) and C5-6 disc (d) is illustrated. Note the double layer sign on the axial CT images
Literature review of rapidly progressive myelopathy
Acute nontraumatic rapidly progressive myelopathy in the context of cervical disc herniation (with or without comorbid OPLL) is rarely encountered clinically, and a review of cases described in the English literature is summarized in
OPLL is thought to arise from unrestricted osteoblastic overactivity of hypertrophic PLL cells, although the inciting stimulus is uncertain. The typical natural history of OPLL involves asymptomatic progression of the ossification with 71% of patients being free from myelopathy at 30 years and only 17% of patients developing neurologic dysfunction.[
Surgical intervention is not indicated in asymptomatic patients, with controversy existing over the optimal surgical management of symptomatic OPLL.[
The surgical risk for CSF leak has been shown to be associated with ossification of the dural membrane as evidenced by the double layer sign on CT, as seen in
This case is an example of two comorbid conditions, cervical disc herniation and OPLL, leading to a unique clinical presentation of rapidly progressive myelopathy in the absence of trauma. Surgical decompression was successful and lead to complete resolution of symptoms in our patient. The value of complementary types of spinal imaging (CT and MRI) is clear in the context of an acute and rapidly progressive neurological deterioration in the absence of any definable external trauma. Typical imaging findings with OPLL, especially the double layer sign with dural ossification are important in the workup of this condition to determine the cause of neurological deterioration and optimal surgical approach. This case also demonstrates that despite the increased risk of perioperative complications associated with anterior decompression in patients with OPLL, in the setting of comorbid acute cervical disc herniation, this surgical technique is technically feasible and can lead to favorable clinical outcomes.
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