Acute Quadriplegia after Lumbar Puncture in a Patient with Misdiagnosed Cervical Myelopathy

Prevalence of idiopathic normal pressure hydrocephalus in patients with degenerative cervical myelopathy

PURPOSE

Degenerative cervical myelopathy (DCM) and idiopathic normal pressure hydrocephalus (iNPH) share symptoms such as gait disturbance and urinary dysfunction, especially in the elderly. While the incidence of DCM in patients with iNPH is reported, the prevalence of iNPH in patients with DCM remains unclear. This study investigates the prevalence of iNPH in DCM patients.

METHODS

This retrospective cohort study included 83 patients undergoing decompression surgery for DCM between April 2018 and March 2023. Brain MRI performed within three years prior to surgery was analyzed. Patients were categorized into two groups based on the Evans Index (EI): those with EI > 0.3 were classified as the Suspected-iNPH group, and those with EI ≤ 0.3 as the Non-iNPH group. Pre- and postoperative Japanese Orthopedic Association (JOA) scores and Patient-Reported Outcomes (PROs), including the Neck Disability Index (NDI), EuroQOL-5D (EQ-5D), Core Outcome Measure Index (COMI), and Numerical Rating Scale (NRS) for pain, were compared. Suspected-iNPH cases underwent further analysis to identify disproportionately enlarged subarachnoid space hydrocephalus (DESH).

RESULTS

Thirty-one patients (37%) were classified as Suspected-iNPH, who were significantly older (p = 0.01). No significant differences were found in pre- or postoperative JOA scores, and PROs. DESH was identified in 6 patients (7%), with 2 diagnosed as probable-iNPH based on cerebrospinal fluid tap tests.

CONCLUSIONS

A notable proportion of elderly DCM patients exhibit ventricular enlargement and DESH, suggesting a potential overlap with iNPH. Brain MRI should be considered for elderly DCM patients, particularly when neurological symptoms deviate from typical patterns.

Dural Puncture Complications

Dural puncture, commonly referred to as lumbar puncture (LP), carries the risk of rare but serious complications including post-dural puncture headache, hemorrhage, herniation, and infection. These complications can lead to suboptimal patient outcomes including significant morbidity and mortality in some instances. This review comprehensively examines potential LP complications, including their incidence, pathophysiology, risk factors, clinical presentations, imaging findings, preventative measures, and treatment strategies. Familiarity with these complications will equip clinicians to effectively manage these complications through prompt recognition, timely diagnosis, and implementation of appropriate preventative measures.

A New Framework for Investigating the Biological Basis of Degenerative Cervical Myelopathy [AO Spine RECODE-DCM Research Priority Number 5]: Mechanical Stress, Vulnerability and Time

STUDY DESIGN

Literature Review (Narrative).

OBJECTIVE

To propose a new framework, to support the investigation and understanding of the pathobiology of DCM, AO Spine RECODE-DCM research priority number 5.

METHODS

Degenerative cervical myelopathy is a common and disabling spinal cord disorder. In this perspective, we review key knowledge gaps between the clinical phenotype and our biological models. We then propose a reappraisal of the key driving forces behind DCM and an individual's susceptibility, including the proposal of a new framework.

RESULTS

Present pathobiological and mechanistic knowledge does not adequately explain the disease phenotype; why only a subset of patients with visualized cord compression show clinical myelopathy, and the amount of cord compression only weakly correlates with disability. We propose that DCM is better represented as a function of several interacting mechanical forces, such as shear, tension and compression, alongside an individual's vulnerability to spinal cord injury, influenced by factors such as age, genetics, their cardiovascular, gastrointestinal and nervous system status, and time.

CONCLUSION

Understanding the disease pathobiology is a fundamental research priority. We believe a framework of mechanical stress, vulnerability, and time may better represent the disease as a whole. Whilst this remains theoretical, we hope that at the very least it will inspire new avenues of research that better encapsulate the full spectrum of disease.