Neurological deterioration due to missed thoracic spinal stenosis after decompressive lumbar surgery

Abstract

There have been a few reports of patients with a combination of lumbar and thoracic spinal stenosis. We describe six patients who suffered unexpected acute neurological deterioration at a mean of 7.8 days (6 to 10) after lumbar decompressive surgery. Five had progressive weakness and one had recurrent pain in the lower limbs. There was incomplete recovery following subsequent thoracic decompressive surgery. The neurological presentation can be confusing. Patients with compressive myelopathy due to lower thoracic lesions, especially epiconus lesions (T10 to T12/L1 disc level), present with similar symptoms to those with lumbar radiculopathy or cauda equina lesions. Despite the rarity of this condition we advise that patients who undergo lumbar decompressive surgery for stenosis should have sagittal whole spine MRI studies pre-operatively to exclude proximal neurological compression.

Single-stage surgery for compressive thoracic myelopathy associated with compressive cervical myelopathy and/or lumbar spinal canal stenosis

“…Hyperreflexia in the lower extremities is masked by the coexistence of LCS; thus, a thoracic lesion is easily overlooked, because surgeons can be deceived by the imaging findings of the lumbar lesion. Failure to detect thoracic lesions in patients presenting predominantly with LCS may be associated with a significant risk of injury to the spinal cord during positioning for lumbar Eur Spine J decompression surgery [7]. Since 88 % (44/50) of the thoracic lesions developed in the lower thoracic spine, careful attention should be paid to these areas on MRI and myelography in LCS patients to avoid missing thoracic lesions.…”

“…In Japan, this syndrome is known as disseminated spinal canal stenosis, which is diffuse spinal canal stenosis through the cervical spine to the lumbar spine with at least two lesions [5]. In disseminated spinal canal stenosis, it is difficult to determine which level is most involved during the preoperative diagnosis [6,7]. In patients with clinical signs of CM, such as clumsiness of the hands and gait spasticity, diagnosis of associated TM is difficult since we cannot discriminate the symptoms of the lower extremities between CM and TM.…”

“…There are few reports regarding TM combined with CM and/or LCS, and little is known about its clinical features and the surgical strategy [7][8][9].…”

Tandem compression of medulla spinalis and cauda equina

“…According to the published data, the variety of clinical symptoms typical of the tandem compression of the spinal cord and cauda equin can lead to incomplete diagnosis (2,3,7). In these cases, the detection of the thoracic compression can be omitted due to different factors:…”

Degenerative Scoliosis

“…Additionally, studies have shown that asymptomatic thoracic stenosis is present in approximately 30% of patients undergoing lumbar decompressive surgery with the potential for significant impairment if missed [26].…”