Delayed Onset of Thoracic SCIWORA in Adults
A 38-year-old male had fallen down from a height of about 1.5 m. The patient had no special medical history other than hepatitis B infection and had not experienced back pain before. Since he did not show other neurological symptoms besides back pain at the time he visited a private hospital, he received conservative treatment such as medication and physical therapy. Afterwards, the patient experienced weakness in lower extremity 7 days after the injury while performing his daily routine. At that time, he felt that his trunk was swaying slightly while he was walking. The gait disturbance symptoms gradually progressed and there was onset of additional symptoms such as impotence and lower extremity hypoesthesia. Consequently, he was admitted to the Department of Neurosurgery by the emergency room on the 30th day of the occurrence of injury. No external wound was observed at the time of the patient's hospitalization, and the pain was only in the back and lower extremity. According to the radiologist's reading of the whole spine MRI examination (), there had been findings of a wedge-shaped vertebral body but no findings of spinal cord damage was observed. From the initial blood test, the white blood cell count was 5,900/ul; the segmented neutrophil was 41.3%; the ESR and CRP was within the normal range; and the VDRL, HIV test, plasma lgG, anticardiolipin antibody (ACA), anti-phospholipid, antinuclear antibody (ANA), and blood bacterial culture test results were found to be negative. There were findings of five types of white blood cells, and no lgG in the CSF based on the cerebrospinal fluid test. On physical examination, the bilateral lower extremity strength was of grade 4/5; hypoesthesia of the bilateral extremity; urinary incontinence; and the bowel function was intact. Steroid therapy had been performed under clinical suspicion of cauda equine syndrome. According to the thoracic vertebral MRI, there were no specific findings. On physical examination on the 7th day of the patient's hospitalization, his lower extremity strength deteriorated to grade 3 without any improvement in the symptoms; his sensory functions had been reduced below the T8 dermatome level; Deep Tendon Reflexes were increased; Babinsks's sign was evoked; and urinary incontinence was presented. The neurological level was T8 with ASIA grade D. Functionally, the patient progressed from independent ambulation using canes at the time of his hospitalization to wheelchair ambulation. On the 13th day of hospitalization, as the symptoms worsened, he was transferred to the Department of Neurology, where the second steroid therapy was performed. There were no abnormal findings from the nerve conduction study, H reflex, and F response tests on the lower extremity. The MR brain also showed no abnormal findings (). Since then, the symptoms were maintained without any further worsening. Around the 40th day of the hospitalization (70 days after the injury), he was transferred to Department of Physical Medicine and Rehabilitation. The result of nerve conduction studies were normal and needle electromyography of the L5 paraspinal muscle revealed abnormal spontaneous activity (). In somatosensory evoked potential obtained by stimulating the tibial nerves, right tibial nerve pathway showed delayed onset latency when compared to left side; while left tibial nerve pathway showed over 50% decrease in amplitude when compared to the right side (). Afterwards, muscle-strengthening, balance-training, and gait-training using a mono-cane had been performed for one hour each twice a day. According to the follow-up test after two weeks, the deep tendon reflexes of lower extremity and the ankle clonus maintained a positive reaction, and the sensory functions were still in the reduced state. However, the muscle strength improved to grade 4 and the neurogenic bladder was in a condition capable of performing normal bladder functions. Even from the functional aspect, the patient was discharged in a condition in which he can ambulate independently indoors over a distance of 30 m with the help of a cane. Since then, no outpatient follow-up has been recorded.