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Título

Cervical Spondylotic Myelopathy Mimicking Subacute Combined Degeneration: A Case Report

RESUMO

A 60-year-old woman with rheumatoid arthritis presented with a 1-year history of difficulty holding objects due to numbness and weakness of the upper limbs. Three months before admission, the symptoms progressed to the lower limbs, and she required support to walk. On physical examination, there was a spastic tetraparesis with extensor plantars and decreased vibratory and position sense in all limbs. The patient also experienced a prominent increase in limb weakness with neck flexion (McArdle sign). The cervical MRI revealed spinal canal stenosis at the level of C2-C8 and symmetric bilateral high signal within the dorsal columns (inverted "V" sign). Serum vitamin B12 was 243 pg/ml (normal 180–500 pg/ml) and serum methylmalonic acid was 0.13 umol/L (normal < 0.40 umol/mL). Flexion–extension radiographs revealed aggravation of cervical misalignment with neck flexion. A standard anterior cervical discectomy was performed and there was a marked improvement in symptoms at 1-month follow-up. The typical MRI finding of subacute combined degeneration (SCD) is a symmetric bilateral high signal of the dorsal columns that begin in the upper thoracic region, with ascending or descending progression. The lateral corticospinal tracts and lateral spinothalamic tract may also be involved. On the other hand, MRI of spondylotic myelopathy reveals a circumferential enhancement sparing spinal cord gray matter on axial images, usually located beneath the site of maximum stenosis (pancake-like sign). We describe a case of compressive myelopathy mimicking clinic and radiologic characteristics of SCD . In addition, our patient also presented with McArdle sign, which is considered highly specific for the diagnosis of multiple sclerosis (MS). In our patient, the normal level of methylmalonic acid and the rapid improvement after surgery ruled out SCD. The clinical features were not compatible with MS. This case report shows that spondylotic myelopathy can have a great spectrum of clinical and radiographic features and can mimic conditions such as SCD.

Palavras Chave

Myelopathy, canal stenosis, Subacute Combined degeneration.