Treatment for Paraplegia Due to Thoracolumbar Expansile Compressive Myelopathy
Immediate surgical decompression is the primary treatment for paraplegia due to thoracolumbar expansile compressive myelopathy, as it offers the best chance for neurological recovery even in cases with profound deficits. 1
Initial Management
- Begin high-dose dexamethasone therapy immediately upon diagnosis of spinal cord compression to reduce inflammation and potentially preserve neurological function 2
- Obtain MRI of the thoracic spine without IV contrast as the initial imaging modality to identify the cause and extent of compression 2
- If MRI is contraindicated or unavailable, CT myelography can be used to assess the patency of the spinal canal/thecal sac and provide high-resolution images of the spinal cord compression 2
Surgical Intervention
Timing and Approach Selection
- Surgery should be performed emergently, as delay can lead to irreversible neurological damage 1
- The surgical approach depends on the cause and location of compression:
- For compression due to bone fragments, surgical decompression is indicated 2
- For compression due to disc herniation, an anterior transthoracic approach (such as thoracoscopic microdiscectomy) is preferred to avoid manipulation of the already compromised spinal cord 1
- For ossification or calcification of the ligamentum flavum, a decompressive laminectomy and medial facetectomy with careful removal of the affected ligamentum is recommended 3, 4
Surgical Considerations
- Avoid intraoperative hypotension to prevent further spinal cord ischemia 1
- For patients with multiple levels of compression, address all levels during surgery 4
- If the compression is due to vertebral collapse, kyphoplasty may be considered to restore vertebral height 2
- Post-surgical radiotherapy should be administered once healing has occurred if the compression was caused by a tumor 2
Medical Management
- Administer intravenous methylprednisolone during surgery to reduce inflammation 1
- Implement thromboprophylaxis to prevent deep vein thrombosis, which is common in patients with paraplegia 2
- Consider combined pharmacologic and mechanical prophylaxis for DVT prevention 2
- Monitor for potential complications such as CSF leak, infection, and neurological deterioration 1
Post-Surgical Care
- Implement early rehabilitation to maximize functional recovery 4
- Monitor neurological status closely for signs of improvement or deterioration 1
- Provide supportive care for bladder and bowel dysfunction 1
Prognosis Factors
- Recovery is possible even with profound neurological deficits, delayed treatment, advanced age, and presence of myelomalacia, provided adequate decompression is achieved 1
- Pretreatment neurological status is the main determinant of recovery - only 30% of non-ambulatory patients and 2-6% of paraplegic patients regain the ability to walk 2
- Patients with paraplegia from thoracic disc herniation can have favorable outcomes when managed correctly with surgical intervention 1
Important Considerations
- Thorough imaging of the entire spine is crucial, as missed thoracic compressive lesions can cause paraplegia even after lumbar decompression surgery 5
- Thoracic disc herniations causing acute myelopathy are often located between T9-10 and T11-12, and are frequently large or calcified 1
- Dorsalgia (back pain) frequently precedes profound myelopathy and may help with early diagnosis 1
- Even without a precipitating traumatic event, acute myelopathy can develop from enlargement of a disc herniation or other compressive pathology 1, 6