Declined Spinal Decompression following Severe Acute Myelopathy: A Case Report

Case Diagnosis: 26-year-old with severe myelopathy due to disc protrusion

Case Description or Program Description: A patient presented with acute, severe, and rapidly progressive bilateral lower extremity weakness, hypoesthesia, and new-onset back pain. On admission, the patient was non-ambulatory. Thoracic MRI demonstrated a large central disc protrusion at T9-T10 resulting in severe canal stenosis. Emergent decompressive surgery was recommended, but the patient declined due to rapid and significant clinical improvement. An outside second opinion agreed with emergent decompression. The patient ultimately refused surgery and was discharged to acute inpatient rehabilitation six days from symptom onset.

Setting: Comprehensive Inpatient Rehabilitation

Assessment/Results: On admission, the patient had mild weakness in bilateral hip flexion and great toe extension, as well as sensory change consistent with Brown-Sequard at T9-T10. There was no bladder or bowel incontinence, and deep anal pressure and voluntary anal contraction were preserved. The patient was discharged after 14 days of comprehensive rehabilitation, ambulating without an assistive device. 11 days later, the patient had an acute recurrence of symptoms progressing to complete paralysis. Thoracic MRI demonstrated worsened disc protrusion at T9-10 with severe canal stenosis. The patient underwent T8-L1 fusion with improvement in muscle strength and was re-admitted to inpatient rehabilitation. The patient was discharged home 21 days later, ambulating with a four-wheeled-walker.

Discussion (relevance): Previous research demonstrates that mild myelopathy can improve, whereas severe myelopathy has a high risk of progressing to irreversible nerve damage. This case serves as a warning against non-operative management of myelopathy due to disc protrusion with initial clinical improvement. While disc resorption can occur, its predictability remains uncertain, particularly in the thoracic spine. Physiatrists must provide thorough counseling on the potential for acute neurological decline in patients opting for conservative treatment.

Conclusions: Patients with myelopathy from disc protrusion may experience temporary improvement but remain at risk for sudden deterioration.