Is deformity correction essential in a "Myelopathic Cord"? - A case series.

Introduction: The incidence of preoperative neurological deficits in pediatric patients with complex deformities ranges from 15% to 23%. Furthermore, the likelihood of a postoperative neurological deficit can be considerably increased to 83.3% in the presence of a preoperative neurological deficit. Hence, the management of pediatric spinal deformities with neurological deficits is a challenge for every spine surgeon. Here, we describe four consecutive cases of pediatric spinal deformity with myelopathic cord, all of which were managed with decompressive surgery and stabilization without any attempts to correct the deformity. All the patients recovered well neurologically, without any progression of deformity.

Case presentation: The authors obtained the informed written consent from the patient and their parents for the print and electronic publication of the case. All four patients had clinical myelopathy with a progressive, worsening neurological deficit. The pathology was in the thoracic region in all the patients. Of the four cases, two were post-tubercular deformities, and two were congenital deformities. The treatment strategy for all patients was circumferential decompression of the spinal cord with posterior pedicle screw instrumentation. Although all patients had significant neurological deficits (Nurick grade 4 or 5) preoperatively, we used intraoperative neuromonitoring to prevent the worsening of the deficit during the procedure. None of the patients experienced intraoperative signal changes. All patients had significant neurological recovery (Nurick grade 0 to 2) and showed no worsening of deformity at their latest follow-up, up to 4 years. All showed good improvement in all domains of the SRS22r questionnaire.

Discussion: It is challenging for spine surgeons to manage complex spinal abnormalities in pediatric patients with myelopathic cords. Even a minimal manipulation of the cord during surgery might result in severe long-term morbidity. The primary objective in managing such patients should be neurological recovery rather than deformity correction-"First do no harm," and if necessary, the deformity can be corrected at a later stage under neuromonitoring.