2. Patient 1
Ref. : JBJS Case Connect 2022;12:e21.00822
• Sex: male
• Age: 45-years-old
• Injury cause :
Falling heavy object on back leading to paraplegia
3. Brief history
Injury day :
• Patient sent to emergency room after 19 hours
• T11/12 fracture-dislocation
4. Brief history
Injury day :
• CT of brain and neck was normal
• PE :
T8 ASIA A
Preserved upper limb strength and sensation
Tx :
• high-dose methylprednisolone treatment (30 mg/kg 15-
minute bolus followed by 24-hour infusion at 5.4
mg/kg/hour) – National Acute Spinal Cord Injury studies
(NASCIS) – III protocol
5. Brief history
Post-injury day 1 :
• Sensory level progressed to T4 on next day morning.
• Methylprednisolone was continued
Post-injury day 4(OP day) :
• Neurological level
stabilized
• Percutaneous pedicle
screw-rod on T10 ~L1
6. Brief history
Post-injury day 4(OP day) :
• After surgery : sudden decrease in both C7 and T1
myotomes
• Bilateral triceps : grade 2/5, poor hand grip strength
• Methylprednisolone was again started
• Post-operative MRI arranged
7.
8. Brief history
Post-injury day 4(OP day) :
• Rapid neural worsening on the next 8 ~ 10 hours after
surgery
• Bilateral triceps, biceps and deltoid : grade 1-2 /5
• Respiratory distress intubation with mechanical
ventilation
9. Brief history
• Both trapezii involved and sensory level loss of C2
• Tetraplegic with neurological level of C2 with
respiratory paralysis
Post-OP day 2 :
• Methylprednisolone
• low-molecular-weight heparin
• mannitol 20% 100 mL IV thrice daily
• Broad-spectrum antibiotics were continued
Treatment
• Elevated CSF pressure
• CSF analysis not consistent with infection, culture
showed no growth
Lumbar puncture
10. Brief history
Post-OP day 6~15 :
• Inotropic support
• Tracheostomy was done
• No improvement in the neurology
• Cardiorespiratory function continued to decline
• Patient die on post-op day 15 due to severe
respiratory distress with pneumonia, hypotension
and bradycardia
11. Patient 2
Ref. :Br J Neurosurg. 2020 Oct 19:1-4.
• Sex: male
• Age: 15-years-old
• Injury cause :
motor vehicle accident
12. Brief history
In ER :
• Incomplete loss of sensation below T10 and ASIA B
paraplegia
• Upper extremity sensation / strength were
completely preserved
• CT of the head and neck were normal
14. Therapy course
• High dose steroid was used for acute SCI in ER
• ORIF within 7 hours
• T9-L1 bilateral pedicle screw fixation with laminectomy
and reduction
• Surgical time : 137 min / blood loss : 190 ml
• Course smooth, no hypotension episode
• Post-op 4th day
• Patient transfer to wheelchair and start rehab program
15. Therapy course
• Post-op 7th day
• Bilateral upper extremity numbness
• higher sensor level loss to T4 level
• Post-op 11th day
• Tetraplegia
• Respiratory distress and need mechanical ventilation
16. MRI T2 weighed :
• Hyper intensity
extending from T11 to
C3 with enlargement
of cord
17. Therapy course
• End of the 1st month
• Weaning from mechanical ventilator
• Hemodynamic parameter got stable
• Discharge and transfer to rehab facility
• One year later
• Improved to initial SCI status
• Upper limb strength recovered to 5/5
18. Subacute posttraumatic
ascending myelopathy (SPAM)
Patient 1 Patient 2
Age / sex 45 / male 15 / male
Injury level T11/12 fracture-dislocation T11/12 fracture-dislocation
Neurological level T8 T10
ASIA score ASIA A ASIA B
Onset of worsen Right after surgery Post-op day 7
Upmost involved
level
C3 C3
MRI finding Both showed extended spinal cord swelling
21. History
• Frankel. (1969) :
• The first to report this
type of neurological
deterioration
• Aito et al (1999)
Epidemiology
• Incidence : 0.42% ~ 1%
• Mortality rate : 10%
22. Etiological mechanism of SPAM
• Alteration of CSF circulation
• Greater artery of Adamkiewicz thrombosis
• Venous thrombosis and congestive ischemia
• Infection
• Apoptosis
23. Alteration of CSF circulation
• SCI CSF pressure elevation , subarachnoid space
occlusion neurological dysfunction
• Swollen cord fill subarachnoid space despite
adequate epidural decompression (1992)
24. • Intramedullary hemorrhage, oedema or debris
occlusion of central canal
• Interstitial fluid in cord insterstitium progressive
post-trauma myelomalacia, presyrinx or SPAM
25. GAA thrombosis
• Greater artery of Adamkiewicz
• Thoracolumbar junction blood
supply
• Largest single medullar artery
• Possible etiological cause
• Most SPAM cases were injured
on the T-L junction
• Ruptured Fibrocartilage /
nucleus pulposus
26. Venous thrombosis and
congestive ischemia
• 68% SCI showed reversal of
normal hemodynamic
gradient increased vena
pressure block the flow from
paravertebral system
• Autopsy : venous stasis /
infarction located on the
central and posterior cord
region (accordance with MRI
finding)
27. Infection
• Findings that support infection :
Temporal progression of the ascending myelopathy
Fever
Lack of significant recovery
• Symptoms similar to acute transverse myelitis
• Response to steroid, also improvement in radiology
Apoptosis
• Apoptotic cell can be observed in the remote area
from the injury site
28. Pathological findings
• Only 2 articles reported
• Al-Ghatany et al
• Soft with dusky and patchy
hemorrhagic appearance (A)
• Microscopy : infarction, swelling with
necrotic change and macrophagic
infiltration
• Immunostaining showed caspase-3
(+)
• Meagher et al
• Cyst formation
• Cord adhere to injured dura sac
• Loss of myelin with vacuolation
change
• Microscopy : no B-/T-cell infiltration
but with macrophage
29. Risk factor
for SPAM
Complete spinal
cord injury
(nearly all cases)
Thoracolumbar
junction injury
(about 1/3 of cases)
Asymptomatic low
blood pressure
(sit upright)
Early post- op
orthostatic
mobilization
Non-surgical
treatment
30. Clinical evaluation
• Typical SPAM character :
• Neurological deterioration after few days or weeks of
clinical stability
• Pain in arms, shoulder, scapula, neck, chest or trunk
before motor weakness
• Paresthesia, weakness in upper limb and ascending
numbness in trunk
• Various grade of fever
• Neurological assessment
• Motor / sensory, DTR and perineal evaluation
• Dysesthesia of trunk, arm and hand
• Ascending paraplegia
31. Radiological evaluation
• MRI - Gold standard
• Central area : high intensity in T2 sequence
• Ascending > 4 segment cephalad ( sometime migrate
into medulla oblongata)
• High intensity signal tapered in the end of lesion
32.
33. • On day 23 after surgery
a. Increased signaling up to C2 (T2WI)
b. Heterogenous intramedullary signal (T1WI)
c. C5 cord swelling
34. CSF examination
• To exclude acute transverse myelitis
• Content : pleocytosis, elevated IgG index or normal to
slightly increased protein
• SPAM – CSF
• Content : increased protein percent and neutrophils
• Appearance : dishwater
• Microscopy : debris
35. Other investigation
• EMG and motor-evoked potential to detect
denervated muscle
• Selective angiogram to check artery system,
thrombosis, vascular anomaly and AV-fistula
36. Supportive
treatment
Monitor and
maintain BP in
acute phase SCI
Observation of
neurological fxn /
paraplegic level
Bedrest to
prevent
orthostatic
hypotension
Oxygen and
mechanical
ventilation
38. Surgical treatment
• Goal : to decrease the elevated CSF pressure
• Epidural decompression by laminectomy
• improve the block of CSF at the injured site
• Expansive duraplasty and cordectomy
• allow drainage of interstitial fluid into the epidural
space
39. Prognosis
• Varies greatly according to the ascending myelopathy
• Slight improvement of > 1 level below the maximal
level after weeks or months treatment
• Patient rarely recover to neurological level before
deterioration
• Clinical recovery is not accord with MRI finding
40. Conclusion
• SPAM is relatively rare disorder after SCI (~1%)
• Young and middle-aged patient are the majority of
SPAM (90.6%) with sex-related significance (male :
female = 5 : 1)
• Several hypothesis was provided but remains elusive
• Patient rarely recover to previous state or even fatal
The 1st patient is referred from the JBJS case report in 2022
It is
The patient was presented to ER 19 hrs after injury
the X-ray and CT showed T11/12 frx-dislocation, and from the MRI, we can see
1. significant posterior ligamentous complex injury
2. and cord compression with cord signal changes up to T10.
Arrows show the site of initial injury
The initial brain and neck CT was normal
Neurological assessment was T8 level with ASIA score A and the upper limb muscle power and sensation were preserved
Because of episode of acute SCI , steroid was given according to NASCIS III protocol
However, the injury still progress after one day
Sensory level progress to T4 so the steroid was kept use
On day 4 after injury , the condition is stable so the surgeon performed percutaneous pedicle screw –rod construct for the patient, from T10~L1
Picture A showed the initial injury with spinal cord compression and signal change up to T10 but the cervical and thoracic cord was normal
Picture b and c showed the cord swelling extend to C3 level and hyperintensity change
On the following 8-10 hrs, the condition got worse rapidly
Upper limb muscle power downgrade to 1-2 points
Due to the involvement of high-cervical level, respiratory distress occurred and the patient was intubated with
The 2nd case is referred from br j ns
This is a 15 year old male suffered from MVA
The patient presented to ER with paraplegia with incomplete sensation loss , the ASIA score is B
Upper limb strength and sensation were preserved initially
Head and neck CT showed no abnormality
MRI and CT showed T11/12 frx-dislocation with PLC injury and cord compression
High dose steroid treatment was also used
And within 7 hours, the patient received the surgery of pedicle screw fixation with laminectomy and reduction from T9 to L1
The course was smooth and there was no hypotension during surgery
On the day 4 after surgery, ….
However, on the day 7 after surgery, the patient started to complaint upper limb numbness
neurological assessment showed higher sensor loss of T4 level
After 4 days, patient progress to tetraplegia and complicated with respiratory distress
From the MRI, we can see there was hyper intensity signal change from T11 to C3 with cord swelling
And fortunately , the patient was successful weaning from the ventilator, due to the stable hemodynamic condition, he discharged at the end of 1st month
After one year, the condition improved to the initial sci state and upper limb muscle power recover to full
So when we review these 2 patients , we can find that there was an rapid progression and involved distant uninjuried spinal cord
This rare condition is subacute posttraumatic ascending myelopathy, or so called SPAM
My discussions is about SPAM
The definition of SPAM include
SPAM was first provided in 1969 by Dr.Frankel with 7 cases
However, on the following 30 years, there was no other literature about spam until 1999
There are several possible hypothesis to explain the mechanism of SPAM
In terms of …, SCI can lead to … and result in neurological dysfxn
Even after adequate epidural decompression, the cord still fill the subarachnoid space
Just like the picture showed, patient with cervical myelopathy received the surgery, after 3 months, the MRI still showed swelling cord and high signal intensity
Intramedullary hemorrhage, oedema and debris occlusion of central canal (圖AB)
Delayed SPAM may result from gradual tethering of the arachnoid blocking the spinal canal also affect the imbalance of CSF
The 2nd is GAA thrombosis
The greater artery of adamkiewicz is responsible for blood supply to TL junction and it is also the largest single medullar artery
And most SPAM cases
MRI picture showed the distended venous marking
And because of these concerns, UPSF was developed for lumbar fusion
Biomechanical studies showed that it can provide initial stability after fusion and decreased the stress shielding effect on fixed or adjacent level
Some clinical studies showed
And because of these concerns, UPSF was developed for lumbar fusion
Biomechanical studies showed that it can provide initial stability after fusion and decreased the stress shielding effect on fixed or adjacent level
Some clinical studies showed
And because of these concerns, UPSF was developed for lumbar fusion
Biomechanical studies showed that it can provide initial stability after fusion and decreased the stress shielding effect on fixed or adjacent level
Some clinical studies showed
Picture showed a T12 burst fracture and the central canal is severely compressed
After receiving anterior decompression and fixation, we can see the canal is still compromised
On day 23
And because of these concerns, UPSF was developed for lumbar fusion
Biomechanical studies showed that it can provide initial stability after fusion and decreased the stress shielding effect on fixed or adjacent level
Some clinical studies showed
And because of these concerns, UPSF was developed for lumbar fusion
Biomechanical studies showed that it can provide initial stability after fusion and decreased the stress shielding effect on fixed or adjacent level
Some clinical studies showed
Prognosis of SPAM varies….
In general , there is usually
