|Year : 2016 | Volume
| Issue : 2 | Page : 106-109
Nontraumatic myelopathy at the University of Port Harcourt Teaching Hospital: Magnetic resonance imaging evaluation
Regina Chinwe Onwuchekwa1, Arthur Chukwubike Onwuchekwa2, Emeka Ifedi Emedike1
1 Department of Radiology, University of Port Harcourt Teaching Hospital (UPTH), Port Harcourt, Nigeria
2 Department of Internal Medicine, University of Port Harcourt Teaching Hospital (UPTH), Port Harcourt, Nigeria
|Date of Web Publication||5-Jul-2016|
Regina Chinwe Onwuchekwa
Department of Radiology, University of Port Harcourt Teaching Hospital (UPTH), Port Harcourt
Objective: The aim of the study is to evaluate the etiology of nontraumatic myelopathy on magnetic resonance imaging (MRI) with a view to highlight the most common causes. Materials and Methods: We retrospectively examined the images and reports of patients with nontraumatic spinal cord lesion who presented to the Radiology Department of University of Port Harcourt Teaching Hospital for MRI scan between 2007 and 2012. The following data were collected: age, gender, types of lesions, and location of lesions. Cases with incomplete information were eliminated and cases with conflicting image findings and reports were reviewed. Institutional ethics approval was not necessary for this retrospective study. The data were analyzed statistically using Statistical Package for the Social Sciences (SPSS) 14.0 window evaluation version. Results: Seventy-three patients satisfied the criteria for inclusion in the study. Of these patients, there were 21 females and 52 males giving a female-to-male ratio of 1:2.5. The mean age was 37 years (age range of 15-78 years). The age range of 51-60 years had the highest frequency of lesions, accounting for 29. 17%. Disc degenerative disease was found to rank the highest among the lesions seen on MRI, accounting for 46. 6%. Conclusion: MRI is useful in detecting and localizing the spinal cord lesion responsible for myelopathy. The finding in this study that the commonest cause of myelopathy is spondylosis has contributed to bringing into limelight the burden of degenerative spinal lesion in the environment and the need to provide adequate facilities for management of the condition.
Keywords: Etiology, magnetic resonance imaging, myelopathy, nontraumatic, spondylosis
|How to cite this article:|
Onwuchekwa RC, Onwuchekwa AC, Emedike EI. Nontraumatic myelopathy at the University of Port Harcourt Teaching Hospital: Magnetic resonance imaging evaluation. Trop J Med Res 2016;19:106-9
|How to cite this URL:|
Onwuchekwa RC, Onwuchekwa AC, Emedike EI. Nontraumatic myelopathy at the University of Port Harcourt Teaching Hospital: Magnetic resonance imaging evaluation. Trop J Med Res [serial online] 2016 [cited 2019 Oct 17];19:106-9. Available from: http://www.tjmrjournal.org/text.asp?2016/19/2/106/185428
| Introduction|| |
Myelopathy describes any neurologic deficit related to spinal cord injury (SCI). Damage to the spinal cord results in neurological impairment affecting motor, sensory, and autonomic functions.  Myelopathy is a common neurological disease with high morbidity and mortality ,, though the mortality risk varies widely by country and income status and depends heavily on the availability of quality clinical care and rehabilitation services.  About 79% of patients with myelopathy remain disabled even after rehabilitation.  Myelopathy can result from traumatic or nontraumatic causes. Data on the global prevalence of SCI (traumatic and nontraumatic) are sparse; hence, it is unclear as to how many people are living with SCI globally  but international incidence data suggest that every year between 250,000 and 500,000 people become injured in the spinal cord and the majority of these cases were traumatic.  Global and regional incidence rates of nontraumatic SCI cannot be estimated because existing studies are not representative.  The incidence rate in Canada is estimated to be 68 per million, Australian estimate using data from Victoria reported an incidence of 26 per million. ,, Data from Spain reported an incidence of 11.4 per million. 
In sub-Saharan Africa, the only report on incidence was from Malawi, which gave an incidence rate for nontraumatic spinal cord injury (NTSCI) of 77 per million population per year. 
Studies have shown that communicable diseases such as tuberculosis and noncommunicable diseases such as tumors, degenerative changes, and cardiovascular diseases are common etiologies in myelopathy. Prompt and concise diagnosis of these etiologies and localization of the site of lesion are essential for prediction of neurological and functional outcomes. Magnetic resonance imaging (MRI) is the mainstay in evaluation of myelopathy.  MRI of the spinal cord has improved imaging of the spinal cord lesions to the point that reliable diagnosis of nonexpansile lesion is routinely possible.  MRI best depicts the relation of pathology to the cord, and can help predict which patient may benefit from surgery.  While clinically-based studies abound on nontraumatic spinal cord lesions with a few from Kenya, Uganda, Tanzania, and northern Nigeria, this study is different as it is basically MRI evaluation of nontraumatic myelopathy. The aim of the study is to evaluate the etiology of nontraumatic myelopathy on MRI with a view to highlight the most common causes in our environment.
| Materials and Methods|| |
We retrospectively examined the images and written reports of patients with non-traumatic spinal cord lesion who presented to the Radiology Department of University of Port Harcourt Teaching Hospital for MRI scan between August 2007 and September 2012. The following data were collected: age, gender, types of lesions, and location of lesions.
All the patients were examined with 0.2Tesla MR system (Magneton concerto, Siemens medical system, DEU). T1-weighted, T2-weighted, and proton density images were acquired. The surface coil was used for radio frequency reception from the body. Slice thickness was 3.0 mm in the cervical region and 4.0 mm in the thoracic and lumbar regions. Cerebrospinal fluid motion artifact was inhibited by cardiac gating. Magnevist [gadolinium diethylenetriamine penta-acetic acid (DTPA)] was used for tissue enhancement.
Cases with incomplete information were eliminated and cases with conflicting image findings and reports were reviewed. Institutional ethics approval was not necessary as this was a retrospective study.
Data were analyzed statistically using Statistical Package for the Social Sciences (SPSS) 14.0 window IBM, USA evaluation version.
| Results|| |
Seventy-three patients satisfied the criteria for inclusion in the study [Table 1].
Of these, there were 21 females and 52 males giving a female-to-male ratio of 1:2.5.
The mean age was 37 years (age range of 15-78 years).
The age range of 51-60 years had the highest frequency of lesions, accounting for 29.17%.
Disc degenerative disease was found to rank the highest among the lesions seen on MRI, accounting for 46. 6% [Table 2].
This was followed by Pott's disease, which accounted for 28.8%.
Most of the lesions were located in the thoracolumbar region where 37.0% of the lesions were found [Table 3].
The lumbar region ranked second with 23.3% of the lesions.
Most of the patients presented with paraplegia.
| Discussion|| |
Myelopathies are common neurological diseases with high morbidity and mortality that affect people of all ages and genders. Irrespective of the causes, a specialist multidisciplinary expertise care is required in order to optimize outcomes.  Early and effective rehabilitation may be achieved by prompt and accurate diagnosis and detection of the extent of lesion, which is possible by the effective interpretation of magnetic resonance images.
Previous studies have shown that there is male preponderance in myelopathy globally. , Comparable results were found in the present study. In this study, men represented 71.23% of the cohort. Agarwal in a hospital-based study in India had a similar finding.  He, however, attributed the male preponderance to the increased participation of men in high-risk jobs such as construction work, climbing of heights, and lifting of heavy loads, which are associated with trauma to the spine. Such strenuous activities also predispose to spondylosis and increased disc prolapse that may result in spinal cord compression. Further studies on this may be necessary.
This study shows that over 50% of the sample size were 40 years and above, which is in tandem with the finding in previous studies. , Murray reported that nontraumatic SCI comprises only 31% of the patients under the age of 40 years but 87% of those over that age.  New et al. also showed that most of the patients in his study with nontraumatic myelopathy were 40 years and above. 
The predominance in the etiology of degenerative spinal disease found in this study is a reflection of the aging population demonstrated in the study. Degenerative spinal disease is more common in older age as it is part of the aging process. Its associated disc herniation, osteophyte formation, facet hypertrophy, thickening of the ligamentum flavum, and the posterior longitudinal ligament may result in spinal stenosis and possibly cord impingement. This finding of degenerative spinal disease as the dominant etiology is in agreement with the dominant etiology of myelopathy found in Western countries as demonstrated by the previous studies in that region. , A similar finding was reported by Oguniyi et al.  in an earlier study on the Nigerian population; their finding showed that spondylosis was the commoner cause of myelopathy. However, in developing countries such as Nigeria it is unexpected as most of the studies done in sub-Sahara Africa have shown that tuberculosis of the spine is the dominant etiological factor for myelopathy. ,
The predominance of degenerative spinal disease in this study may be explained by the fact that the evaluation of etiological factors was done using MRI, which is an expensive study. The average cost of a single MRI scan ranges from N=60,000-100,000, which is equivalent to US$340-560. Not many patients can afford this amount in a resource-poor country such as Nigeria. MRI is usually not the first line of investigation if tuberculosis is suspected. Many of the patients would have spinal and chest x-ray radiograph and other laboratory workups for tuberculosis. If these investigations are positive for tuberculosis, the treatment is usually commenced without further investigation. MRI is done if the patient does not respond to antituberculosis treatment or the investigations are negative for tuberculosis.
There are also programs by the government as part of the control for tuberculosis. These include free bacillus Calmette-Guérin (BCG) immunization given to all infants and free treatments given to patients with confirmed tuberculosis; these have also helped in reducing the incidence of tuberculosis though they have not completely eradicated it from Nigeria.
The location of lesions in the study showed that the thoracic and lumbar regions of the spine are the commoner sites of the lesion. This finding has been consistently demonstrated in most of the previous studies as shown in the compilation of studies on nontraumatic lesion by New et al.  The two prevalent lesions in this study occur more commonly in these regions. Degenerative spinal diseases are commoner in the cervical and lumbar regions, which are sites of the highest dynamic and static overload while tuberculosis is commoner in the thoracolumbar region; hence, the predominance of the lesions in the thoracic and lumbar regions is not unexpected.
Some of the limitations of this study include the small sample size, which is due to low turnout of myelopathy patients for MRI as a result of its high cost and regular equipment breakdown.
There are also challenges of poor record keeping. The study is a retrospective one; hence, some data were extracted from the records. The patients with incomplete data were excluded from the study.
Further studies on this topic using a sample size, which is representative of the general population is necessary to ascertain the common causes of nontraumatic myelopathy and its burden in the developing countries.
| Conclusion|| |
Myelopathy is a devastating condition with a wide range of impairments and activity restriction. The burden of myelopathy is enormous for the patient, family, and society at large; hence, prompt diagnosis is necessary to achieve early rehabilitation for the patient. MRI is useful in detecting and localizing the spinal cord lesion responsible for myelopathy. The finding in this study that the commonest cause of myelopathy is degenerative spinal disease has contributed to bringing into limelight the burden of degenerative spinal disease in the environment and the need to provide adequate facilities for management of the condition. The multiplanar imaging capability of MRI and its superior soft tissue definition over other radiologic modalities have made it the modality of choice in radiological evaluation of myelopathy.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
American Spinal Injury Association: International Standards for Neurological Classification of Spinal Cord Injury. Chicago: American Spinal Injury Association; 2006.
Scrimgeour EM. Non-traumatic paraplegia in northern Tanzania. Br Med J (Clin Res Ed) 1981;283:975-8.
Kim RY, Spencer SA, Meredith RF, Weppelmann B, Lee JY, Smith JW, et al
. Extradural spinal cord compression: Analysis of factors determining functional prognosis -0 prospective study. Radiology 1990;176:279-82.
Zenebe G. Myelopathies in Ethiopia. East Afr Med J 1995;72:42-5.
World Health Organization (WHO). International Perspective on Spinal Cord Injury. Geneva, Switzerland: World Health Organization (WHO); 2013. p. 11-32.
Lekoubou Looti AZ, Kengne AP, Djientcheu Vde P, Kuate CT, Njamnshi AK. Patterns of non-traumatic myelopathies in Yaounde (Cameroon): A hospital based study. J Neurol Neurosurg Psychiatry 2010;81:768-70.
New PW, Cripps RA, Bonne Lee B. Global maps of non-traumatic spinal cord injury epidemiology: Towards a living data repository. Spinal Cord 2014;52:97-109.
New PW. Non-traumatic spinal cord injury: What is the ideal setting for rehabilitation? Aust Health Rev 2006;30:353-61.
New PW, Sundararajan V. Incidence of non- traumatic spinal cord injury in Victoria, Australia: A population- based study and literature review. Spinal Cord 2008;46:406-11.
van den Berg ME, Castellote JM, Mahillo-Fernandez I, de Pedro-Cuesta J. Incidence of nontraumatic spinal cord injury: A Spanish cohort study (1972-2008). Arch Phys Med Rehabil 2012;93:325-31.
Brown KG. Non-traumatic paraplegia in Sub-Saharan Africa. East Afr Med J 1979;56:300-10.
Kent DL, Haynor DR, Longstreth WT Jr, Larson EB. The clinical efficacy of magnetic resonance imaging in neuroimaging. Ann Intern Med 1994;120:856-71.
Murray PK, Kusier MF. Epidemiology of nontraumatic and traumatic spinal cord injury. Arch Phys Med Rehabil 1994;65:634.
New PW, Farry A, Baxter D, Noonan VK. Prevalence of non-traumatic spinal cord injury in Victoria, Australia. Spinal Cord 2013;51:99-102.
Agarwal P, Upadhyay P, Raja K. A demographic proﬁle of traumatic and non-traumatic spinal injury cases: A hospital-based study from India. Spinal Cord 2007;45:597-602.
Scivoletto G, Farchi S, Laurenza L, Molinari M. Traumatic and non-traumatic spinal cord lesions: An Italian comparison of neurological and functional outcomes. Spinal Cord 2011;49:391-6.
McKinley WO, Seel R, Hardman JT. Non traumatic spinal cord injury: Incidence, epidemiology, and functional outcome. Arch Phys Med Rehabil 1999;80:619-23.
Ogunniyi A, Shokunbi MT, Oluwole OS, Adenyinka A, Malomo A, Adebiyi AA. Non-traumatic spinal cord diseases in Ibadan, Nigeria: Aetiology and prognostic factors. Cent Afr J Med 1995;41:50-4.
Nyame PK. An aetiological survey of paraplegia in Accra. East Afr Med J 1994;71:527-30.
Osuntokun BO. The pattern of neurological illness in tropical Africa: Experience at Ibadan, Nigeria. J Neurol Sci 1971;12:417-42.
[Table 1], [Table 2], [Table 3]