key: cord-0693103-x7ho2yja
authors: Guadarrama-Ortiz, Parménides; Choreño-Parra, José Alberto; Javier Pacheco-Sánchez, Francisco; Ponce-Sánchez, Jesús Manuel; García-Quintero, Gabriela; Rodríguez-Muñoz, Patricia E.; Prieto-Rivera, Ángel Daniel
title: Chronic subclinical spondylotic myelopathy exacerbated by COVID-19: a case report
date: 2020-09-10
journal: Interdiscip Neurosurg
DOI: 10.1016/j.inat.2020.100896
sha: 501322b963aebd69a54db783f2ea0c5cf0e2a055
doc_id: 693103
cord_uid: x7ho2yja

INTRODUCTION: Besides typical respiratory symptoms, the coronavirus disease 2019, also known as COVID-19, is characterized by a wide range of neurological symptoms that result from the injury of the brain and peripheral nerves. Only a few reports have described the involvement of the spinal cord among COVID-19 patients. Furthermore, little is known about the risk of individuals with chronic degenerative conditions of the spine for acute neurological complications of COVID-19. CASE PRESENTATION: Here, we describe the case of a 73-year-old man with a subclinical cervical multifocal spondylotic myelopathy that manifested neurological symptoms of spinal cord injury some days after getting infected with SARS-CoV-2. The patient did not show any data associated with respiratory involvement and improved clinically after decompressive spinal surgery and administration of steroids. CONCLUSIONS: This is the first reported case of an acute exacerbation of a chronic degenerative condition of the spine caused by COVID-19.

The emergence of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the causative agent of the coronavirus disease 2019 (COVID-19), is a global public health crisis.

Although respiratory symptoms mainly characterize this disease 1 , SARS-CoV-2 has the potential to affect the nervous system, causing a wide range of neurological manifestations 2 . The spectrum of neurological findings observed in COVID-19 patients is associated with the affection of the brain and peripheral nerves. In contrast, only a few reports have described the involvement of the spinal cord [3] [4] [5] . Also, little literature exists about the risk of patients with chronic degenerative disorders of the spine for exacerbations of their underlying conditions after SARS-CoV-2 infection.

Here, we report the case of a patient with chronic silent cervical spondylotic myelopathy who manifested neurological symptoms of spinal cord injury only after getting infected with the novel SARS-CoV-2. Our report provides evidence of the potential of COVID-19 to unmask and exacerbate chronic degenerative spinal conditions.

A 73-year-old right-handed man attended our center with a history of sub-acute quadriparesis, urinary retention, and fecal constipation. Six weeks earlier, he tested positive for SARS-CoV-2 infection by real-time polymerase chain reaction (RT-PCR) in a nasopharyngeal swab sample.

He presented a fever that remitted with antipyretics as his only clinical manifestation of illness.

Seven days later, he developed acute urinary retention and fecal constipation, requiring admission to another hospital, vesical catheterization, and evacuating enemas. After three days, the patient developed myoclonic movements in both lower limbs that progressed to paraparesis.

He received unspecified medical management and discharged with minimal clinical improvement. During the following month, he was evaluated by a gastroenterologist and a urologist, who ruled out primary disorders of the gastrointestinal and urinary tracts. Over such a period, he developed irradiated cervical pain and weakness of the upper limbs. Also, he presented a weight loss of 6 kilograms due to reduced food intake as a result of fecal constipation and restrictive abdominal distention. The patient was referred to our center with the clinical suspicion of an upper spinal cord injury.

His past medical history was unremarkable other than occasional alcohol consumption. He was a half-marathon runner (last running six months before symptoms onset) otherwise healthy. On admission, the patient was alert, oriented to person, place, and time. The physical examination was relevant for painful abdominal distention, which also conditioned restrictive respiratory distress. His neurological examination showed general hyperreflexia and muscle weakness of left predominance. Also, he presented the Babinski sign in the left lower limb and hyperalgesia in both left limbs. He was unable to stand and walk unaided, and his gait was ataxic. The cerebellum was not evaluable clinically due to the presence of motor deficits, and meningeal signs were negative. The patient´s clinical findings were consistent with the American Spinal Injury Association (ASIA) impairment scale Grade B 6 .

Due to the recent antecedent of COVID-19, we suspected of an immune-mediated neuropathy vs.

acute non-traumatic myelitis. The results of the laboratory workup showed hemoglobin of 13.3g/dL, platelets 249,000 (10 9 /L), glucose 98.6mg/dL, and normal white blood cell counts.

Also, thyroid, liver, and renal function parameters, as well as the metabolic panel, lipid panel, These compressions conditioned myelopathy manifested as an intramedullary hyperintensity at segments C2-C3, which was not characteristic of acute transverse myelitis (ATM; Figure 3b ).

Also, stenoses at segments L1-S1 of the spine were observed (Figure 3c anesthesiologists, and nurse personnel were required to wear an N95 mask and appropriate personal protective equipment (PPE). After the surgery, we continued the steroid administration for an additional three days. The patient recovered the muscle strength of his upper and lower limbs and was able to stand with assistance seven days after surgery (ASIA Grade B). Also, he presented an improvement of his intestinal motility and was able to pass stool. A postoperative MRI of the cervical spine showed no residual compressions of the spinal cord (Figure 3d ). The decompression of the lumbar canal was postponed. He was discharged with a urinary catheter and scheduled for neurological and bladder rehabilitation. The patient provided informed consent for the publication of the case report.

The COVID-19 pandemic has modified the routine workflow of several areas of medicine, including spine surgery. In many centers, urgent spinal surgery has been reserved only for conditions of high risk for severe neurological sequela, and most procedures have been Here, we described the case of an elderly patient with a chronic subclinical cervical spondylotic myelopathy that developed neurological manifestations of acute spinal cord injury some days after getting infected with the novel SARS-CoV-2. We found particularly important to communicate this case as it illustrates an acute exacerbation of a chronic subclinical degenerative process of the spine/spinal cord induced by COVID-19. In fact, our patient had stable clinical cervical myelopathy and was able to practice high-intensity sports until the SARS-CoV-2 infection precipitated the neurological decline.

This case differs from other reports of COVID-19 patients with acute spinal cord injury. Those cases have been characterized by ATM in individuals with a history of respiratory symptoms and with no demonstrated structural alterations of the spine [3] [4] [5] . Conversely, our case does not resemble a classic ATM, since the T2-weighted MRI of the spinal cord showed an intramedullary hyperintensity occupying only two cervical segments, which coincided with the sites of spondylosis, whereas ATM mostly affects the thoracic spinal cord 8 . Furthermore, we did not observe enlargement of the affected cervical segments, nor enhancement of the leptomeninges and dorsal nerve roots, which are features of parainfectious and idiopathic ATM 8 . Also, the CSF analysis of our patient was not inflammatory, although the delayed diagnostic evaluation of our patient did not allow us to analyze the CSF during the acute phase of the patient´s illness. Furthermore, our patient showed clinical improvement after treatment with steroids and decompressive surgery, even when these interventions were administered six weeks after disease onset.

Interestingly, our patient did not present respiratory symptoms. This supports a possible neurotropism for SARS-CoV-2 and suggests that direct effects driven by the virus could cause the spinal cord injury. The chronic inflammatory process induced by ischemia and mechanical compression could make the spinal cord more prone to the detrimental effects of the infection. In this regard, it has been demonstrated that the expression of the angiotensin-converting enzyme 2 (ACE2), the putative receptor for the "spike" (S) protein of SARS-CoV-2, is overregulated by inflammatory signals 9 .

Finally, segments of the spinal cord under chronic compression display a range of pathological alterations, including ischemia, vascular remodeling, and endothelial dysfunction 10 . These changes contribute to a disruption of the blood-spinal cord barrier (BSCB) and increased vascular permeability, which might result in increased inflammatory infiltration to the spinal cord parenchyma. Hence, the anti-viral inflammatory response could have further exacerbated the local inflammation at sites of compressive myelopathy.

Our report provides evidence about the potential of SARS-CoV-2 to cause disease exacerbations in patients with chronic degenerative conditions of the spinal cord, such as spondylotic myelopathy. 

Presenting Characteristics, Comorbidities, and Outcomes Among 5700 Patients Hospitalized With COVID-19 in the

Neurological Aspects of SARS-CoV-2 Infection: Mechanisms and Manifestations

Acute transverse myelitis after COVID-19

COVID-19-associated acute necrotizing myelitis

Acute myelitis as a neurological complication of Covid-19: A case report and MRI findings

International standards for neurological classification of spinal cord injury (revised

COVID-19 and neurosurgical practice: an interim report

MRI in transverse myelitis

SARS-CoV-2 Receptor ACE2 Is an

Interferon-Stimulated Gene in Human Airway Epithelial Cells and Is Detected in Specific Cell Subsets across Tissues

Pathobiology of cervical spondylotic myelopathy

 A first case report of a patient with cervical spondylotic myelopathy and COVID-19  SARS-CoV-2 can cause a neurological decline in patients with chronic spinal disorders  Sites of compressive myelopathy may be at risk for detrimental effects of the virus  Steroids may be useful for spinal cord injury associated with COVID-19  COVID-19 has a significant impact on the routine workflow at spine surgery centers