Case 20: progressive paraplegia; thoracic lesion

posted: July 1, 1997

resident: Jack Kruse, MD
attendings: Deepak Awasthi, MD and Mitch Harris, MD

CLINICAL PRESENTATION: This 53 year black woman presented to an outlying hospital with a 3.5 month history of progressive weakness of the legs. She was able to walk previously with a cane and was now wheelchair bound. The patient also complained of midthoracic pain and paresthesias. She had urinary incontinence, but no fecal incontinence. Patient denied any history of diabetes mellitus, cancer, heart disease, infections, hypertension, similar problems in the family. She also denied any history of smoking, drug or alcohol abuse.

Examination revealed profound weakness of the right lower extremity (2/5) with moderate weakness of the left lower extremity (3+/5). Propioception was decreased in both lower extremities (R>L). There was approximately a T6 sensory level to pinprick and ligh touch. Patient had a Foley catheter on admission. Rectal tone was good and there was moderate preservation of perirectal and perineal sensation.

DIAGNOSTIC STUDIES: Initial diagnostic study was a MRI scan of the thoracic spine; select sagital view is shown below:

Note the hypointensities (red pointers) in the dorsal aspect of the spinal canal in this T2W sagital view of the thoracic spine.

We next obtained a CT myelogram:

Above are axial CT- bone window (left); postmyeloCT at the T6 level (middle) and a sagital reconstructed CT scan (right). Note the ossfication of the ligamentum flavum (red pointers) in the three scans. This ossification is more prominent on the right side with cord compression.

STEPS TAKEN AT LSU: A decompressive T3-6 laminectomy was performed without fusion. Ossified ligamentum flavum was resected and the dura was seen to bulge out through the laminectomy defect.

Postoperatively, the patient's sensory symptoms improved as well as the pain. There was no change in the motor function. Patient was transfered to rehab.

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