gms | German Medical Science

Objective: Progressive cervical myelopathy sometimes represents a quite challenging condition. Spinal imaging as MRI, myelography and angiography can help to distinguish between degenerative, compressive, nutritive, hypoxic, adhesive or posttraumatic damages, but their informative value is sometimes limited. Additional flow-sensitive 4D phase contrast imaging and cine sequences offer non-invasive prospects for a better visualization of CSF flow dynamics and mobility of the spinal cord.

Method: We present a case of a 65-year-old male suffering from progressive ataxia, spastic hemiparesis of his left arm and leg and neuropathic pain since 2005. MRI showed a cervical myelopathy, proceeding in the subsequent examinations, although its origin remained unclear. In 1968 our patient had sustained cervical injury with a complete symptomatic restitution after 6 months. To rule out a late posttraumatic adhesive lesion we performed a conventional 1.5 T MRI of the cervical spine with additional cardiac-gated 4D phase contrast imaging and cine sequences.

Results: A broad cervical myelopathy from C1 to C3 was shown with a spinal stenosis of C1/2 with changes suspicious of a ventral adhesion of the spinal cord. The flow-sensitive 4D MRI and especially the cine-sequences revealed a dorsal cystic formation with pulsatile filling and compression of the spinal cord. The flow velocity was increased with flow disturbances on the level of the dens axis. This diagnosis could be confirmed during surgery, showing a large arachnoidal cyst with only a small connection to the lower spinal canal. The cyst was resected to the greatest possible extent.

Conclusions: Arachnoidal cysts can represent post-traumatic changes, although an onset of symptoms more than 30 years after the trauma is exceptional. In this case the repetitive compression of the spinal cord for years was causal for the slowly proceeding impairment of the spinal cord. The progressive myelopathy could easily have been misinterpreted as a result of adhesive or degenerative changes, missing the underlying, treatable pathology. As our observations show, flow-sensitive 4D MRI and cine sequences can be helpful devices distinguishing between different forms of post-traumatic or post-interventional CSF flow-changing lesions.