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CASE REPORT

A Case Of OPLL Presenting With Acute Onset Quadriplegia Treated With Delayed Suspension Laminoplasty :A Case Report

Shiju Majeed*,  JKBC Parthiban#

*Fellow in Spine Surgery
#Senior consultant Neuro and Spine Surgeon
, Kovai Medical Centre and Hospital, Coimbatore, India

Address for Correspondence
Dr. Shiju Majeed A.
Fellow in Spine Surgery, Kovai Medical Center and Hospital,
Coimbatore 641 014
Email :Shiju1690@yahoo.com 

Abstract:

Ossification of Posterior Longitudinal Ligament (OPLL) is a well recognized cause of Cervical Spondylotic Myelopathy. However, the incidence and management of  acute traumatic spinal cord injury in a patient with unrecognized OPLL is not well documented in literature 1. OPLL, in itself, is a treatment challenge and  is further complicated by the setting of acute spinal cord trauma. We present our experience in the management of a 54 year old man who became quadriplegic following a trivial fall and was found to have severely stenotic cervical spinal canal due to OPLL. The management strategy and the importance of a delayed laminoplasty is emphasized. 
Keywords: Ossification of Posterior Longitudinal Ligament, quadriplegia;  Cervical Spondylotic Myelopathy;  Methyl Prednisolone;  suspension Laminoplasty.

J.Orthopaedics 2007;4(2)e9

Case report:

A 54 year old man presented to our Emergency department, with history of accidental fall in his home. He had facial abrasions and was taken to a nearby hospital where the initial management was done. He was admitted for observation. Second day, he developed weakness of both upper and lower limbs with paresthesias predominant in the upper limb.Then he was referred to our centre. On examination, the patient had Grade 1/5 power of both fingers and toes, elbow and shoulder. Hip and knee were grade zero. He was hypotonic with absent DTRs. Anal Reflex was absent. Sensory dulling present from C5 downwards. Patient had urinary retention. Respiration and vitals were good.

The patient gives a history of progressive difficulty in walking for the last 6 months for which he had taken some form of indigenous treatment. 

CT Brain was normal study.

Xray of Cervical spine showed a significantly narrow canal with Ossified Posterior Longitudinal Ligament  (OPLL ) (Fig1)

CT Cervical Spine showed Cervical Canal Stenosis with characteristic Posterior Logitudinal Ligament Ossification.(Fig2)

MRI showed Cervical Canal Stenosis with diffuse form of OPLL extending from C2 to C6 vertebra producing impingement of the Cervical Cord. Cord contusion was seen at C4-6 levels (Fig 3 & 4) 

Fig.1. Cervical Spine Lateral
 view showing the ossified PLL

Fig.2.Axial CT showing the narrowed Cervical Canal with OPLL

Fig.3. Sagittal MRI showing 
the extremely narrow Cervical
Canal with OPLL impinging 
the dura

Fig. 4 Postoperative X-ray showing the widened canal.

A diagnosis of Flaccid Quadriparesis, Spinal Shock and OPLL was made. 

Patient was given Injection Methyl Prednisolone  30mg/kg loading dose in 15 minutes followed by a pause of 45 minutes after which a maintenance dose of 5.4 mg/kg/hr was given (Recommendations of  NASCIS III trial)2.. He was given Philadelphia collar. High flow Oxygenation and hyperperfusion was given to maintain the Mean Arterial BP at around 120mm Hg. 

He was started on rigorous physiotherapy. Third day after admission, anal reflex returned suggesting incomplete cord injury. Progressively he had improvement of power in both upper limbs to Gr 3/5. Knee Power increased to Grade 3/5 bilaterally. Ankle and  Toe powers remained at Gr 1/5. Both upper and lower limbs became spastic. 

He underwent Suspension Laminoplasty from C3-C6 on the 14th day after injury.

The laminae from C3-C6 were detached enbloc and reattached to the  paraspinal muscles. He showed progressive improvement. Over a period of 1 month, he attained near normal power of both upper limbs, and was able to stand with support.

Discussion :

OPLL is a very well recognized cause for Cervical Spondylotic Myelopathy3. Although, various procedures in the form of anterior corpectomy and fusion, posterior laminectomy or laminoplasty have been described for management of myelopathy associated with OPLL, the treatment protocol in a case of acute spinal cord injury in the setting of a preexistant myelopathy due to OPLL is not clear.         The study by Koyanagi et al 1 gave varying timings for surgical decompression. 

Difficulty in walking experienced by the patient  prior to the fall could be attributed to the myelopathy. However, lack of space in cervical spinal canal and sudden flexion and extension of the cervical spine during the fall could have resulted in sudden stretch of dura against the rigid PLL resulting in Quadriplegia. Such patients need to be managed as a case of acute spinal cord injury with High dose Methyl Prednisolone and Hyperoxygenation and hyperperfusion 4. The return of anal reflex indicates a better prognosis. 

In this patient , the decompression was done electively after 14 days because of our previous experience which showed that early decompression in these cases can worsen the neurology due to surgical insult to the already compromised cord.  Prospective studies have not shown any appreciable difference in early versus late decompression in acute cervical spinal cord injury 5.Hence, in these cases, we wait for the natural mechanisms to halt the cord edema supplemented with other supportive medications. Of course, there are proponents for early decompressive surgery. However, Albert TJ et al 6 have suggested that a spinal cord with preexistent myelopathy does not behave in the same way as a non myelopathic cord which sustains acute injury. They have suggested initial conservative management followed by delayed decompression. 

 Laminoplasty helps to prevent or lessen the chances of similar event occurring in the future because the canal diameter is widened. Laminoplasty helps in posterior shifting of spinal cord. A posterior shift of spinal cord of 3.5mm is shown to give optimal results following laminoplasty 7.  Suspension  laminoplasty is a safer procedure for diffuse OPLL compared to anterior procedures which are fraught with danger of injuring the dura when the ossified ligament is adherent to the dura or when the disease is associated with dural calcification.

Reference :

  1. Koyanagi I; Iwasaki Y; Hida K ; Imamura H ; Fujimoto S; Akino M  : Acute Cervical Cord Injury associated with Ossification of Posterior Longitudinal Ligament  ;  Neurosurgery ; 53 (4);887-891.

  2.  Bracken MB, Shepard MJ   ,Holford TR, Leo-Summers L ,et al : Administration of methylprednisolone for 24 or 48 hours or tirilazad mesylate for 48 hours in the treatment of acute spinal cord injury. Results of the Third National Acute Spinal Cord Injury Randomized Controlled Trial. National Acute Spinal Cord Injury Study.; JAMA 1997, May.

  3. Ramani PS ; Textbook of Cervical Spondylosis : Jaypee Publications

  4. Bernhard M; Gries A; Kremer P; Martin-Villalba A; Prehospital management of spinal cord injuries; Anaesthetist, 2005; 54(4):357-76.

  5. Vaccaro A ; Daugherty, Reza J; Sheehan, Terrence P :  Neurological outcome of Early versus Late Surgery for Cervical Spinal Cord Injury ; Spine, 1997;, 22 (22); 2609-2613

  6. Albert TJ. Management of central cord syndrome: conservative or delayed surgical decompression and stabilization. From the 67th annual meeting of the American Academy of Orthopaedic Surgeons (Federation of Spine Associations, Section II); March 18, 2000

  7. Kohno K, Kumon Y, Oka Y, et al. Evaluation of prognostic factors following expansive laminoplasty for cervical spinal stenotic myelopathy. Surg Neurol 1997;48:237-45.

 

This is a peer reviewed paper 

Please cite as : Shiju Majeed: A Case Of OPLL Presenting With Acute Onset Quadriplegia Treated With Delayed Suspension Laminoplasty - A Case Report

J.Orthopaedics 2007;4(2)e9

URL: http://www.jortho.org/2007/4/2/e9

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