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Table of Contents    
LETTER TO EDITOR
Year : 2016  |  Volume : 64  |  Issue : 6  |  Page : 1363-1365

Cervical cord compression secondary to epidural fibrous scar tissue around the spinal cord stimulation electrode


1 Department of Neurosurgery, Hospital Universitario Central de Asturias, Oviedo, Spain
2 Department of Radiology, Hospital Universitario Central de Asturias, Oviedo, Spain

Date of Web Publication11-Nov-2016

Correspondence Address:
Sayoa de Eulate-Beramendi
Department of Neurosurgery, Hospital Universitario Central de Asturias, Oviedo
Spain
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.193812

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How to cite this article:
de Eulate-Beramendi S, Santamarta-Liébana E, Leon RF, Saiz-Ayala A, Seijo-Fernandez FJ. Cervical cord compression secondary to epidural fibrous scar tissue around the spinal cord stimulation electrode. Neurol India 2016;64:1363-5

How to cite this URL:
de Eulate-Beramendi S, Santamarta-Liébana E, Leon RF, Saiz-Ayala A, Seijo-Fernandez FJ. Cervical cord compression secondary to epidural fibrous scar tissue around the spinal cord stimulation electrode. Neurol India [serial online] 2016 [cited 2019 Oct 17];64:1363-5. Available from: http://www.neurologyindia.com/text.asp?2016/64/6/1363/193812


Sir,

Spinal cord stimulation is a treatment for serious and chronic painful conditions such as failed back surgery syndrome (FBSS), the complex regional pain syndrome (CRPS), refractory angina, limb ischemia, phantom limb pain, chronic intractable pain, or lumbar stenosis in patients who are not surgical candidates. Early complications such as dural puncture, cerebral cerebrospinal fluid (CSF) leak, infection, epidural hematoma, spinal cord injury, and seroma or hematoma formation may be found at the pulse generator site. In addition, delayed complications include undesirable fluctuations in stimulation, loss of pain relief over time (tolerance phenomenon), erosion through the skin, latent infection, and complications due to technical problems may also be seen. Neurological postoperative complications are exceptional.

We report the case of a 35-year-old man who presented with a 4-year history of type 1 CRPS secondary to car accident. The pain remained refractory to pain treatment and an epidural quadripolar electrode implantation at the C4–C6 level brought about 80% pain relief. The tolerance to pain relief started appearing 6 months later, with progressively increasing intensity of the pain. Seven years after electrode implantation, he developed dysesthesias of the lateral 3 fingers of his left hand; and, neurological examination revealed motor deficit associated with sensory impairment and hypoalgesia in the left C5–C6 dermatomes, without pyramidal syndrome, and severe hypoesthesia of both lower limbs. Cervical MRI demonstrated compression of the posterior aspect of the cord with an artifact caused by the metallic components within the electrode. Myelography [Figure 1] and computed tomographic myelography [Figure 2] confirmed severe spinal cord compression from C4 to C6 levels with the presence of an epidural soft tissue mass. Surgery was proposed under neurophysiological control, to remove the electrode which was embedded in a thick and solid fibrotic mass, 5 centimeters long and 0.8 mm thick [Figure 3]. Partial removal of the fibrotic mass causing cord compression brought about neurological improvement as well as improvement in both motor and sensory evoked potentials despite remnants of fibrosis present on postoperative MRI.
Figure 1: Myelography performed after contrast infusion using a lumbar puncture and its displacement by the Trendelenburg manoeuvre. The contrast column reached C6 cord segment level

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Figure 2: Obstruction of the cervical spinal canal due to a posterior epidural scar tissue (white arrow) which surrounded the four electrodes. This was compatible with the finding of chronic hematoma around the fibrosis. The electrode extended from the C3–C4 to C6–C7 cord levels. Hyperdense contrast column is also seen (black arrows)

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Figure 3: Intraoperative image of the fibrous tissue removed along with the electrode under neurophysiological control

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To our knowledge, there have been five reports (six cases) of epidural fibrosis discovered during surgical exploration.[1],[2],[3],[4],[5] All six cases had an age range from 26 to 66 years; five of them were treated for a CRPS and one had spinal cord stimulation for torticollis.[1] The interval period from the placement of spinal cord electrodes for the initial stimulation to the development of spinal cord compression symptoms can range from 3 months to 17 years. In most of these reports, the stimulation level was found at C4–C5. The cord compression, however, resulted in paresthesias and loss of sensations instead of quadriparesis and gait disorder.

It is interesting to note that all five patients increased the amplitude of the spinal cord stimulation as early as 6 months after surgery due to the development of tolerance phenomenon. This reaction would be more profound in those patients who underwent more than one surgery or those who developed infections.

Symptomatic spinal cord compression by a scar tissue associated with placement of epidural electrodes should be considered even several years after the spinal cord stimulation procedure. Physicians should be aware of this complication and a magnetic resonance imaging scan should be performed before electrode implantation is undertaken to rule out preexisting spinal stenosis. Tolerance phenomenon and new onset sensory or motor deficit should prompt a search for epidural fibrosis. Following surgery, these patients usually have a good functional recovery after proper localization of the epidural fibrotic tissue of the upper cervical segment and its excision.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Reynolds AF, Shetter AG. Scarring around cervical epidural stimulating electrode. Neurosurgery 1983;13:63-5.  Back to cited text no. 1
    
2.
Dam-Hieu P, Magro E, Seizeur R, Simon A, Quinio B. Cervical cord compression due to delayed scarring around epidural electrodes used in spinal cord stimulation. J Neurosurg Spine 2010;12:409-12.  Back to cited text no. 2
    
3.
Wada E, Kawai H. Late onset cervical myelopathy secondary to fibrous scar tissue formation around the spinal cord stimulation electrode. Spinal Cord 2010;48:646-8.  Back to cited text no. 3
    
4.
Wloch A, Capelle HH, Saryyeva A, Krauss JK. Cervical myelopathy due to an epidural cervical mass after chronic cervical spinal cord stimulation. Stereotact Funct Neurosurg 2013;91:265-9.  Back to cited text no. 4
    
5.
Lennarson PJ, Guillen FT. Spinal cord compression from a foreign body reaction to spinal cord stimulation: A previously unreported complication. Spine (Phila Pa 1976) 2010;35:E1516-E1519.  Back to cited text no. 5
    


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