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Case 87: Subacute Combined Degeneration¹

¹ From the Departments of Radiology (M.J.N.) and Neurology (S.U.H.), Feinberg School of Medicine, Northwestern University and Northwestern Memorial Hospital, 676 N St Clair St, Suite 800, Chicago, IL 60611. Received October 31, 2003; revision requested January 20, 2004; revision received January 27; accepted February 24.

Correspondence: Address correspondence to M.J.N. (e-mail: m-naidich{at}northwestern.edu).

	HISTORY

TOP HISTORY IMAGING FINDINGS DISCUSSION References

 
A 59-year-old man with non–insulin-dependent diabetes mellitus underwent laparoscopic cholecystectomy for biliary stones. He was able to return to work 8 days after surgery. The patient started to experience numbness and tingling in all four limbs 2–3 weeks later. The symptoms progressed to the point that he had difficulty driving, walking, and using his hands. Bladder function was intact. The patient was hospitalized for a complete neurologic evaluation 8 weeks after surgery. A cervical spine magnetic resonance (MR) imaging examination was performed at that time.

	IMAGING FINDINGS

TOP HISTORY IMAGING FINDINGS DISCUSSION References

 
The sagittal T2-weighted MR image (Fig 1) demonstrates abnormal hyperintensity within the posterior aspect of the cervical spinal cord extending from the level of C2 to C6. Transverse T2-weighted MR images obtained at these levels (Fig 2) show symmetric abnormal hyperintensity within the posterior spinal cord corresponding to the dorsal columns. The areas of abnormal T2 hyperintensity within the dorsal columns are enhanced on T1-weighted images (Fig 3). This distinctive pattern of abnormal signal intensity was considered characteristic of subacute combined degeneration of the spinal cord. A serum vitamin B₁₂ test was performed and showed a diminished serum B₁₂ level of 43 pg/mL (32 pmol/L); this abnormal result was confirmed with a repeat test, which indicated a B₁₂ level of 51 pg/mL (38 pmol/L) (normal range, 200–1000 pg/mL [148–738 pmol/L]). Intrinsic factor antibody was present, and the serum homocysteine level was elevated. Findings were negative for human immunodeficiency virus and syphilis. These findings confirmed the diagnosis of subacute combined degeneration, and 1000 µg of B₁₂ was administered intramuscularly every day for 1 week and was followed with maintenance injections. At 3-week follow-up, the patient had made substantial clinical improvement. Review of the anesthesia note from surgery showed nitrous oxide was administered for 1 hours during surgery.

View larger version (90K): [in this window] [in a new window] [Download PPT slide]   Figure 1. Sagittal T2-weighted fast spin-echo MR image (repetition time msec/echo time msec, 3894/130) of the cervical spinal cord shows hyperintensity (arrows) in the dorsal aspect of the cord spinal, extending from the level of C2 to the level of C5.

View larger version (117K): [in this window] [in a new window] [Download PPT slide]   Figure 2a. Transverse T2-weighted fast spin-echo MR images (5703/130) obtained through the cervical spinal cord at three separate levels from C3 to C4. (a–c) Images demonstrate bilateral symmetric signal intensity abnormality within the dorsal columns (arrows). All transverse images obtained through the area of posterior signal abnormality provided identical imaging findings.

View larger version (122K): [in this window] [in a new window] [Download PPT slide]   Figure 2b. Transverse T2-weighted fast spin-echo MR images (5703/130) obtained through the cervical spinal cord at three separate levels from C3 to C4. (a–c) Images demonstrate bilateral symmetric signal intensity abnormality within the dorsal columns (arrows). All transverse images obtained through the area of posterior signal abnormality provided identical imaging findings.

View larger version (110K): [in this window] [in a new window] [Download PPT slide]   Figure 2c. Transverse T2-weighted fast spin-echo MR images (5703/130) obtained through the cervical spinal cord at three separate levels from C3 to C4. (a–c) Images demonstrate bilateral symmetric signal intensity abnormality within the dorsal columns (arrows). All transverse images obtained through the area of posterior signal abnormality provided identical imaging findings.

View larger version (149K): [in this window] [in a new window] [Download PPT slide]   Figure 3. Transverse T1-weighted fast spin-echo MR image (747/12) obtained after contrast material administration through the cervical spinal cord at the level of C4 shows symmetric enhancement (arrows) within the dorsal columns.

	DISCUSSION

TOP HISTORY IMAGING FINDINGS DISCUSSION References

Vitamin B₁₂ cobalamin is a required coenzyme for two important enzymatic reactions. In the first reaction, cobalamin facilitates the methylation of homocysteine by methyltetrahydrofolate into methionine and tetrahydrofolate. Tetrahydrofolate is necessary for normal DNA synthesis by all cells, including blood cell precursors and myelin-producing oligodendrocytes. Methionine is subsequently converted to S-adenosyl-methionine. S-adenosyl-methionine is necessary for methylation of myelin sheath phospholipids. In the second reaction, cobalamin is a coenzyme that converts methylmalonyl coenzyme A into succinyl coenzyme A. Failure of this second reaction to occur results in elevated levels of methylmalonic acid. Excessive methylmalonic acid will prevent normal fatty acid synthesis, or it will be incorporated into fatty acid itself rather than normal malonic acid. If this abnormal fatty acid subsequently is incorporated into myelin or if the methylation of the myelin sheath phospholipids fails to occur, the resulting myelin will be too fragile, and demyelination will occur (1–4).

Active vitamin B₁₂ cobalamin exists in a reduced form. Nitrous oxide oxidizes the reduced form to inactive cobalamin, which is excreted. This oxidation is not reversible. Even after relatively short periods of exposure to nitrous oxide, the amount of methionine synthase-vitamin complex is measurably reduced (4). Once inactivated, this complex requires 3–4 days to recover; during this time, new enzyme-vitamin complexes are synthesized. Healthy individuals have sufficient stores of cobalamin to compensate; however, there is no reserve in patients with vitamin B₁₂ deficiency. Thus, nitrous oxide may bring about manifestations of vitamin B₁₂ deficiency in a patient who had yet to experience symptoms of vitamin B₁₂ deficiency, as was the case in this patient (4,5).

Vitamin B₁₂ deficiency may manifest with megaloblastic anemia because of impairment of DNA synthesis or as one of a few neurologic syndromes. These neurologic syndromes include mental status changes (eg, memory impairment, poor attention span, diminished intellectual function, and abnormalities of behavior, mood, or logical thought), optic neuropathy, or subacute combined degeneration. The term subacute combined degeneration was introduced in the late 1800s (6,7) and used to describe myelopathy that develops over the course of a few weeks to a few months. Myelopathy was later found to be associated with vitamin B₁₂ deficiency. Numbness, weakness, and paresthesia of the extremities primarily affects the lower extremities, is often symmetric, and progresses in a distal-to-proximal manner. Later, this myelopathy progresses to unsteady gait, poor coordination, sensory deficits, and bowel or bladder dysfunction. At physical examination, signs of dorsal column involvement include loss of position and vibration sense and ataxia. Lateral column involvement includes spasticity, hyperreflexia, and a positive Babinski sign. There may be involvement of the spinothalamic tracts with a sensory level (2–4,8,9). These neurologic findings may predate the development of anemia. In fact, there may be an inverse relationship between the degree of neurologic deficits and the occurrence of hematologic abnormalities (1,2,7).

Pathologically, there is demyelination involving the dorsal columns, predominately in the lower cervical and upper thoracic region. Focal swelling of the myelin tubes progresses to larger areas of vacuolization of myelin. This process eventually involves the entire dorsal columns symmetrically, with spread in the cranial and caudal directions and into the lateral columns. If uncontrolled, this process may advance to other long fiber tracts (9–13).

This demyelination is seen as hyperintensity on the T2-weighted images and involves the dorsal columns. On sagittal images, there is a vertically oriented segment of variable length at the posterior aspect of the spinal cord, as is seen in this patient. On cross-section images, bilateral paired areas of T2 hyperintensity are seen as an "inverted V" or "inverted rabbit ears" in the expected anatomic location of the dorsal columns. Case reports demonstrate occasional lateral column involvement and enhancement. After treatment for vitamin B₁₂ deficiency, there is interval improvement in the region of signal abnormality (9,14–17).

Patients with acquired immunodeficiency syndrome and vacuolar myelopathy present with clinical symptoms similar to those of patients with subacute combined degeneration. Furthermore, images obtained in patients with this disease show symmetric T2 hyperintensity within the posterior columns that extends for several vertebral segments. The pathologic changes are also nearly identical (11–13,17,18). The cause of vacuolar myelopathy is not known exactly, but research (18) has demonstrated impairment of the methylation pathway, perhaps by the virus itself. Given the complexity of the B₁₂-dependent transmethylation pathway, it is not surprising that errors anywhere along the course can result in identical clinical, gross pathologic, and imaging findings, even in patients with normal levels of B₁₂. Consequently, although imaging findings of vacuolar myelopathy will look identical to those of subacute combined degeneration, this former diagnosis is strictly reserved for those individuals who have the human immunodeficiency virus. In the absence of this clinical data, however, both diagnoses need to be considered.

Authors have suggested that similar findings could be seen in patients with multiple sclerosis (19). Although multiple sclerosis certainly involves the dorsal columns, the exquisite symmetry of the signal abnormality confined to the dorsal columns over several vertebral segments, as in this case, would be unlikely. Tabes dorsalis, with its preferential involvement of the posterior columns, has been postulated to yield similar findings. A search of the literature failed to reveal any magnetic resonance (MR) studies of tabes dorsalis. This is presumably related to the introduction of penicillin predating the development of MR imaging and the number of cases of neurosyphilis having decreased drastically since that time. Although the incidence of tabes dorsalis is increasing, mainly as a consequence of human immunodeficiency virus infection, most new cases are of the meningovascular form (20–23).

The synergistic effect of nitrous oxide in patients with clinically silent or borderline vitamin B₁₂ deficiency is not commonly known. Consequently, it may be the radiologist who is called to evaluate a patient with new-onset myelopathy and a remote postoperative history. Bilateral paired T2 hyperintensity within the dorsal columns, when seen on MR images, is strongly suggestive of subacute combined degeneration, even in the absence of confirmation of the neurologic signs and symptoms.

	FOOTNOTES

 

Part one of this case appeared 4 months previously and may contain larger images.

 

	References

TOP HISTORY IMAGING FINDINGS DISCUSSION References

 

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12. Sartoretti-Schefer S, Blattler T, Wichmann W. Spinal MRI in vacuolar myelopathy, and correlation with histopathological findings. Neuroradiology 1997;39:865–869.[CrossRef][Medline]
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22. Nieman EA. Neurosyphilis yesterday and today. J R Coll Physicians Lond 1991; 25(4):321–324.[Medline]
23. Simon RP. Neurosyphilis. Arch Neurol 1985;42:606–613.[Abstract]

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